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CH Teo

Wrong Button Sends ANA Jet Upside Down

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In a chilling reminder of how a simple human error can override the highest of high technology, an investigation has shown that All Nippon Airways Co. narrowly escaped a catastrophe earlier this month when its plane almost flipped over after a co-pilot hit the wrong button while trying to open the cockpit door for the plane’s captain, returning from the restroom.

 

The revelation came at an awkward time for the Japanese carrier, just hours after the first of the new-generation Boeing Co. 787 Dreamliner jets on which it has built its future strategy finally landed in Tokyo on Wednesday, more than three years behind schedule.

 

The celebratory mood was quickly over as Shin Nagase, a senior executive vice president at ANA, apologized and bowed deeply in front of TV cameras at a news conference to apologize for the trouble caused by the incident, which took place Sept. 6.

 

According to the Japan Transport Safety Board, two flight attendants were slightly hurt when the Boeing 737-700, with 117 people aboard, tipped more than 130 degrees to the left at one point and dived about 1,900 meters in 30 seconds during a flight from Naha on the southern island of Okinawa to Tokyo. Two flight attendants were slightly injured and six passengers became airsick or reported neck pains.

 

ANA said a 38-year-old co-pilot likely hit the rudder trim controls by mistake instead of pushing the door unlock button to let the captain in after he stepped out of the cockpit to go to the restroom.

 

Computer graphic images compiled by the safety board showed the plane turning almost upside down, but many passengers on board apparently did not realize the gravity of the situation, since it was already dark outside when the incident occurred at around 10:50 pm.

 

The safety board will continue the investigation, while a company spokeswoman said ANA will take preventative measures to make sure that pilots do a double-check on where the controls are located as they leave and return to the cockpit. The company said it will also try to improve its reporting lines, admitting that officials were not aware of the incident until the following day.

 

Sources: - http://blogs.wsj.com/japanrealtime/2011/09/29/wrong-button-sends-ana-jet-upside-down/?mod=google_news_blog

 

Sounds really horrible...B737 family is literally everywhere...

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"... tipped more than 130 degrees to the left at one point and dived about 1,900 meters in 30 seconds ..."

 

That's friggin' awesome!

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I thought the rudder trim switch is a circular knob? Or am I mistaken?

 

It is. And so is the cockpit door unlock switch. And both are located at the rear of the center pedestal.

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I wonder how was the captain outside.?

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This was first reported by NHK 2 weeks ago, 6 people (4 passengers + 2 F/A) suffered neck, spine injuries caused by the resulting 2.3g force (FYI, space shuttle launch asfronauts encounter 3g according to NHK). Majority of passengers didn't even feel or realise about it after it happened.

 

Apparently the F/O twisted the rudder trim knob once but seeing that the captain didn't enter, he twisted that same knob two more times. When the a/c banked, he then realized the mistake and took immediate corrections.

 

Although both switches are round, however, a retired ANA pilot interviewed by NHK stated that is an unbelieveable mistake (own opinion anyway), and he explained that Boeing deliberately designed both of them strickingly different in shape and size, and they are located 18cm apart.

 

1970311.jpg

Edited by Denny Yen

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It is. And so is the cockpit door unlock switch. And both are located at the rear of the center pedestal.

 

Another design flaw be Boeing ....... :rolleyes:

 

 

:hi:

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The two blue knobs as seen in the Airliners.net photo?

They look more like the screw cap tops of drinking water bottles to me :p

 

 

"... tipped more than 130 degrees to the left at one point and dived about 1,900 meters in 30 seconds ..."

 

That's friggin' awesome!

I think this is even more awesome (reporting) :D

..... but many passengers on board apparently did not realize the gravity of the situation, since it was already dark outside when the incident occurred at around 10:50 pm.

Either that or there were many Mr Bean clones on board :)

 

 

I wonder how was the captain outside.?

He was very glad he went to the restroom before the incident :lol:

Edited by BC Tam

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I would say it is very lucky of them not to have crashed and is able to recover in time. An aircraft can impact in a matter of minutes even though from a height of FL330. Most of the cockpit transcripts that I read shows point of realize of a danger to point of impact is within a couple of minutes the most. Shorter still when an aircraft banked sharply during approach, which in this case, a matter of seconds. Hardly any words said before aircraft impacted ground.

 

As for fail-safe feature of the knobs, I think there's not enough after-thought being put to it.

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from CH Teo's post:

 

....ANA said a 38-year-old co-pilot likely hit the rudder trim controls by mistake instead of pushing the door unlock button to let the captain in after he stepped out of the cockpit to go to the restroom.

 

Investigators said the co-pilot was quite experienced, with more than 35,000 total hours of flight time. Nonetheless, according to investigators, the slip-up cause a roll and descent so violent that the jet exceeded certain maximum allowable speeds and also was subjected to stresses beyond its acceleration limits......

 

 

Sources: http://blogs.wsj.com/japanrealtime/2011/09/29/wrong-button-sends-ana-jet-upside-down/?mod=google_news_blog

 

35,000hrs flight time?

 

The two button so different....how can it be?

Edited by LeeTZ

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I don't buy it for a second! the explanation simply doesn't make sense! And I would believe 737NG pilots would agree with me. Here's why!

 

I would only assume, the aircraft was on autopilot, its in cruise, wouldn't make sense to not be on autopilot, but who knows!

 

Turning the rudder trim, for even 5 full seconds continuously, won't be able to provide such a dramatic effect!!!! I'm missing something here!

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..... suffered neck, spine injuries caused by the resulting 2.3g force (FYI, space shuttle launch asfronauts encounter 3g according to NHK). Majority of passengers didn't even feel or realise about it after it happened.

I still can't get my mind past fact that people "didn't even feel or realise about it" !

1,900m drop over 30s is equivalent to 228km/h, vertical

And it wasn't like it was a blink of eye thing either, 30s was quoted

How can anyone fail to notice unless they were temporarily blacked out by the g forces ? :pardon:

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