Former pilot and I was on that flight on that day. Shortly after TO the pilot slightly retarded the engines. I noticed it but it was subtle. Then we started sinking. The aircraft did not nose over into a dive. It felt like we were hit with a downdraft. Many screamed and the crew increased thrust and recovered and climbed up to FL39 and smooth air. I normally don't get too bothered by turbulence but I knew we were very close to the water having only been in the air for slightly more than a minute.
That's great information. Maybe what you were experiencing was a near stall. Maybe there was an issue with the power setting, but I doubt that (since any engine issues would require an immediate landing). More likely, as someone mentioned above in the comments, the flaps were accidentally retracted to zero when commanded to 1.
I am also a retired pilot. One afternoon flying a Boeing 737-300 on vectors to land at SLC we hit a down draft over the Great Salt Lake that pushed us down. The autopilot was unable to hold altitude so I took over manually added full power pitched nose up and still lost altitude. After about a loss of 700 feet we flew clear of the downdraft and regained our assigned altitude. I was wondering if this was a downdraft and your description fits that scenario.
If it’s true that it didn’t pitch down, and the increased ground speed seen on ADSB is accurate, wind shear could be to blame (big loss of headwind or big increase in tailwind). Would expect to see ground speed decrease in the scenario you described if air was stable.
@Cory Amatuzzo they retard the engines for several reasons. Reduced drag once the aircraft is airborne allows it to accelerate beyond the 250 knot speed restriction (below 10,000 ft). noise abatement reasons as well as engine limitations for continuous max thrust and excessive fuel consumption.
I’m a an ATP CFII in Kahului Maui (my UA-cam is “In the Left Seat” and I have 10,000 hours teaching in the SR22 out of Kahului. I distinctly recall the weather that day. It was a NO FLY day whatsoever. The rain was extremely heavy and the clouds were super dark. I was driving near the airport that afternoon and was thinking to my self who on earth is going flying and why don’t they just delay. This IMO was a microburst event. They are right off shore when weather like this hits. Thank god no one was hurt. All airlines need to change ops specs for this airport. As that on shore flow hits the runway it’s wind shear all day long.
That explains it, I was on an HA Airbus flight from the mainland to Maui about ten years ago and we had one of the hardest landings I have ever experienced in an RPT aircraft. The approach was extremely turbulent, and the aircraft literally crashed on. There were apologies and I understand it did overstress the UC. The pax were relieved to walk away.
Fellow CFII here . MICROBURSTS are NO JOKE. I looked at the weather for that day after I saw that Flight Radar 24 posted this event, and I was thinking the same thing: a Microburst… glad to know there is some first hand witness to that weather for confirmation. Scary stuff .
@@jimgraham6722 yeah I was on a similar flight into Maui once … very turbulent approach- on a clear day, just super windy and wind-shear . I’ve never experienced turbulence like that before nor since !
Microburst doesn’t really make sense to me. United would probably have disclosed this in their press releases were it true. The fact that two experienced ATPs would have failed to make a pirep after such an extreme shear event causing this level of g load and failed to return to the airfield for structural inspection just doesn’t add up. More likely they got into clouds, got distracted, had a loss of SA, maybe a misconfigured system, something like that. But microburst doesn’t hold up here based on what we know. At that decent rate, this aircraft was
I had one "Don't Sink" occurrence in my career. It was so long ago that I do not recall the exact circumstances, other than that the fault was mine, it was minor and easily corrected. The lesson I took from that (after obsessive post-occurrence self-analysis) was that one should always treat the GPWS like a Finnish colleague! If your Finnish colleague voices an opinion, HEED IT! The Finns, like a GPWS, are silent - until the shite is REALLY about to hit the fan. Then they might, quietly, say "don's sink" or something to that effect. I flew with some Finns for the ICRC (the Red Cross) in Africa in the early 1990's and I have been in awe of my fellow Finnish brothers ever since. Whatever we Icelanders manage to do, the Finns take it to another level. No wonder the other Nordics call us the "Edge-finders". We Icelanders are at the mellow west precipice, the Finns are at the very real and violent Russian precipice of existence.
@@bobdobalina838, the Nordics in general are quite introvert, but the Finns take it to another level. Even among friends, if a Finn has nothing meaningful to contribute to a conversation, he/she simply stays silent!
It's been a very busy month for you, Juan. As an armchair pilot, I appreciate your use of clear and concise language, as well as your experience in breaking down what went wrong and how it all unravelled. Thanks again.
those Chuck Yaeger commemorative planes at the end. The sound of the engines, the shiny-ness, the props tricking frame rates into changing direction.. just viewing that video is quite something. Thanks :)
I always brief a “black hole” departure out of the islands. Out of the islands there are no outside references for visual flight on a night departure once you bring the nose up. It’s equivalent to a zero zero departure . You need to be on the gauges and have recency of experience skills in this situation. Pilot Monitoring is essential during the initial climb.
Could it be conversely argued that the pilot would not have the distraction of the beautiful display of city lights below and therefore full attention is on flight instruments?
I had to do the equipment investigation for a black hole arrival crash into the US Virgin Islands. The runway lights weren’t working correctly and the pilot flew into the water. The pilot died but several passengers that did survive said the pilot kept looking up over the dash as if he was confused and looking for something…. (The runway). If things don’t look right climb immediately.
Having done a lot of night takeoffs to the north out of Maui and Kauai (Hawaii's worst black hole departures) I can agree. I describe it as "when you rotate someone just painted the windows black." I also think Kauai is worse because just after takeoff you make a right turn. I think Kona landing south is the worst black hole arrival.
Kaua'i checking in, 200 miles NW of Maui. On 18 Dec 2022, we were experiencing strong, heavy thunderstorms with very gusty winds with heavy rain. Reports of many very bumpy flights that day. May have been a contributing factor.
I was working Dispatch that night on all-cargo flights out of HNL; there was a very deep trough right overhead the Hawaiian Islands - very severe turbulence N and W of the islands. I was loading additional fuel to allow the crews to do what they needed to do route and altitude wise - I remember the weather system was extending almost all the way to the ETP between Hawaii and the Mainland. I ACARS'ed one of my eastbounds about an hour E of Hawaii - and he said at altitude it was very moderate turbulence.
Not sure about other operators, but on ours (B757/767), part of the Before Start checklist says MCP (Mode Control Panel) to verify V2 heading and initial cleared ALTITUDE. Would be surprised if B777 didn't have a similar checklist item. Great review of known facts as always!
I agree with you. I'm retired off the B757/767 but it's common fleetwide at my company. Plus, your Clearance denotes the initial cleared altitude for the Departure.
In the other events where this happened, the other pilot just replied "set" to that checklist item without even looking at it and seeing it was set at 0 ft.
@@llamainternationalairlines9632 Thank you very much for the video. Very intresting difference between the two types. Checking your FMAs is always a must. It is NOT specifically included in the B757/767 generic Normal checklist, however we do have it on our ops preflight checklist under (Challenge) Flight Instruments: ---- (Reply) TO / TO / FD Heading (times 3) Altimeter (QNH times 3).
I'd suggest that any system that creates obvious potential for human error to result in potentially disastrous results is a flawed system. Sure, not all HE can be removed, but if it's so relevant why isn't the SYSTEM preventing attempted take off if that panel reads 00000? Put differently, if I can take off with INAPPROPRIATE settings in the MCP then it's NOT a complete system in my view. Surely there are SOME elements that can be FORCED to at least certain values i.e. not everything has to be allowed to be set at any value? I wrote something asking some questions about it in a post of my own and am hoping some people might answer the questions I posed. Cheers
I retired before the United merger from Continental Airlines flying the 777-200. Our procedure after takeoff was gear up and climb to 3000 ft AGL before accelerating and flap retraction. What ever happened was a serious situation with lots of GPWS noise. Serious rug dance in the Chief Pilots office and a sim visit for sure.
“…these basic skills (of flying) are being lost…” More correctly, these basic skills are not being taught! Very good analysis as always. Blancolirio is the best aircraft accident channel.👍🏻
Juan, so glad you took my seat at DFW; I take what you say to the bank! We've all seen neophytes blanch at that "Flaps 5" callout, that a new FO would park at 15 shouldn't have surprised an old 777 guy. I'm reminded of Jim and Eduardo's GRU departure; even the smartest of us can fall prey to this stuff. We've all known people smarter than ourselves who fell into traps. Super observation, re hand flying: I mean, none of this should've happened if the autopilot were immediately engaged, as us perennial underachievers are prone to do ;) Seriously, I'm glad it ended well. Outstanding work, as always. RIP Terry & Len, gone but never forgotten
Whenever I attend recurrent simulator training, fellow pilots and instructors look at me funny when I hand fly, especially in an emergency. I always say the same thing; we only practice this stuff a few times a year and I want to know I can handle it. We are losing this crucial skill!
@@CFITOMAHAWK Automation dependency and it’s pitfalls have been known for decades; NASA has studied it. But, instead of addressing the problem, we create more automation to be managed and further remove the crew from manipulating the aircraft.
That's a very timely and relevant comment. As a former pilot, most of us hand flew the aircraft up to at least 10,000 or even FL180, if not higher. On approach, in good weather, it was not uncommon to turn OFF all of the autoflight passing FL180 and had fly the approach. Obviously, you had instrument backup but the idea was to maintain proficiency hand flying the aircraft. That was true on the 757 through the 777 aircraft.
@@NamelessRider Yep. Lazy pilots will make pilot errors when had to hand fly it on an emergency or bad winds or weather. A Mild Maneuvering Pilot cant be trusted on hard maneuvering weather or turns.
I had a horrific turbulence/ downdraft experience in a 747 circling the NYC area during severe t-storms as all area airports were closed. We’d originated in Los Angeles. We had off and on mild to moderate Intermittent mild turbulence when suddenly a sustained very long ‘free fall’. A momentary leveling off followed by another long free fall. Passengers hitting their heads, then once back in their seats, quickly buckled up. Yes yelling and screaming. Thankfully we had a lot of altitude. 5 minutes later the cabin announced we’re heading to Baltimore as we’re low on fuel. Made it to Baltimore and deplaned. The airline gave us the option of boarding he aircraft and continue our flight to Newark or for those too traumatized, buses were available at no charge. I’d guess 25-33% took the bus. This was early 80’s I believe
Circling EWR Newark NJ in a late summer Noreaster storm is definitely a roller coaster. The hilly terrain immediately west of the airport lends extra sauce
The NTSB has stated that early flap retraction caused this as well as the pilots actions, a preliminary report is coming, this brings me to a concern I had just last weekend, I was on a 737-800 flight from CTG to MIA, and the flight took off with no slats and no flaps, as a pilot I was looking at this as we were taxiing and out and thought to myself this aircraft is not configured correctly but I didn't say anything because as we are taxiing out and I noticed this I did look up the take-off specs and I noticed that it was able to do a no flap no slat takeoff, the flight was not fully loaded so maybe that had something to do with it also but I will say this, the CTG runway is approx 8300 ft, and although we were airborne around 7000 ft, there was a noticeable dip, once we got out of ground effect, also there was an audible "ohhh" from many of the passengers, .... I just thought to myself:"why would a flight crew not use the slats or flaps?" What was to be gained? I also took a video of it , just in case we crashed and they found my phone in the wreckage the NTSB would have all they need to make a determination about what went wrong
It has been 4 weeks and no report published. I wrote the NTSB for the report and no reply Will try again next week. From friends at UA, a fairly new Captain, new FO who had to have additional training multiple times. Agree on the flap retract. Probably a flap 20 TO, and when flying pilot called for flaps 5, he/she either went to flaps 1, or flaps up
From FR24 Take off appears to be at 190049Z. From METARS, it now looks more weather than automation. There is a 180 change in wind direction between last two METARs and TS in overhead moving NE i.e along departure track. METAR PHOG 190054Z 14009KT 3SM +RA BR BKN009 OVC020 19/18 A2977 RMK AO2 SLP085 P0020 T01940183=
I really appreciate your analysis from a professional perspective. This is a flight I’ve taken from Maui many of times. I purposely book the wide body 777 so this is a important issue for many of us.
I read the same article, and your expertise answered many questions. As a layman I would think this should be part of the pre-flight check list. Thanks Juan
I had the absolute pleasure to meet Gen Yeager at Edwards AFB in 1996 on the occasion of the anniversary of breaking the sound barrier. After a very interesting speech to the graduating Test Pilot class he climbed on an F15 and overflew the base at Mach 1 again. He was 73 .. what an incredible life and immense contributions to aviation..
Juan B! Head of AAAR - (the not yet formed: Advocacy for Accuracy in Aviation Reporting) Thanks for all that you do for us and the content you make. Cheers from Texas.
Interesting video, and as always, a great job of professional reporting, Juan. At UAL, the ASAP report is called a "FSAP" (basically the same type of report), which is used internally at UAL, and from that, an ASRS Report is generated, along with FAA notification, if any regs were violated. It's important to mention that even though a crew's anonymity is protected via ASAPs/FSAPs, they can only protect the crew (i.e.: "Get out of jail, free") if the deviation or event was not intentional. I have heard that either the CA & FO, or perhaps both, were new to their respective seats in the triple-7...so, maybe not as much experience in the airplane, as would be desired for this type of mission. If the target altitude erroneously had been set to "00000", I don't believe the automation would cause a descent of over 8,000 FPM, so it is probable that it was being hand-flown (especially given the sudden increase in IAS). I'm also sure that the EGPWS was shouting warnings at the crew, which would have exacerbated the state of confusion that would be present during these types of events. Like the reporter below, to me, it sounds like they encountered a severe downdraft, from which, they fortunately recovered.
Sounds like many flights had uncomfortable rides that day. Especially with the Hawaiian Airlines flight having injuries it would be hard to get the media attention regarding another flight.
Anyone remember Chuck Yeager's Advanced Flight Trainer aircraft simulation computer game, published by Electronic Arts in 1987? I used to play it on the Commodore 64. What the game graphics didn't provide back then, my imagination did,lol Nice one Chuck!🏆👍
I've pulled around 3G out of an intentional vertical dive in a DHC-1 on many occasions, flying aerobatics. It might not be the sort of number that jet fighter pilots pull, but a sustained 2.7G pulling out of a dive would certainly be felt by everyone aboard. It's enough to feel you are being crushed into your seat.
Juan, you're a 777 guy. Get one of your training buds to put this scenario in the sim. See if engaging auto flight at 2200' with zero in the Altitude Select Window gives the same results. Then get them to do the same for a severe microburst at 2200'.
Juan, can’t thank you enough for providing these updates. These events are now getting so much national airplay and the “why” you provide so promptly to fill the information gap is world-class. Appreciate everything you do.
When I lived in Daytona, one of my favorite flights to fly was DAB-SSI (St. Simmons Island, Georgia) for some great barbecue from a famous restaurant on the island. I would often leave DAB in the early evening and leave SSI sometime after dark. The night flight I did out of SSI, it was a moonless night, which required me to rely solely on my instruments during the takeoff from SSI. I feel like the takeaway from this story is the importance of good situational awareness. Although it was in a C-172, it was a great learning experience for me so I can translate those skills and the required situational awareness into a bigger aircraft one day. Thanks for keeping us informed and educated about these stories sir!
This seems like a “hole in the Swiss cheese”: something where, eventually, somebody’s going to be distracted, at night with no visual references, and they’re not going to catch it until it’s too late.
I’m with you Juan! Obviously we don’t have all the data, but as a retired (and extremely experienced) heavy jet captain, this isn’t microburst- for my money this is TOTALLY human error. You must GLUE your eyes to the instruments and ignore what your head tells you. It’s relatively rare, but very severe spatial disorientation (call it vertigo) can happen in this scenario, especially in IMC during acceleration when getting airborne day OR night. Example: One early evening in the early 90’s we were departing KaiTak (the old HongKong) and just after getting airborne and flying into a solid cloud layer whilst accelerating, I was very suddenly hit with extremely severe disorientation. I immediately said “handing over” to the captain (I was FO at the time.) He said “NO- I’m probably worse than you!” Needless to say I immediately engaged autopilot as I knew that it would likely do a better job than me. I probably could have hand flown it without a major drama, but that’s not the time to do it- leave that for the simulator (even though I’ve never had such severe vertigo in the sim.) Within a very short time my disorientation disappeared, and a little while later the captain said he was back to normal too. We discussed it, and agreed that neither of us had experienced anything as sudden (and severe) before. …. Or since. We further believed at the time that landing lights as we intercepted cloud layers made the problem much worse. I’ve subsequently had other mild cases, but nothing ever again remotely like that night out of HongKong.
As I understand it, United has said that both of the crewmembers who were involved in this incident have been "sent for retraining." As I read that, United must have determined that the crew messed up somehow. All of that said, the news stories over the past couple of days appear to have seriously exaggerated the actual attitude of the aircraft during the incident, describing it as a "nose-dive", which most of us would interpret as more than 30 degrees nose-low. My suspicion is that if a Triple-7 entered a dive like that at 2,200 ft., we'd be having a different discussion now.
I live on O’ahu and fly for the hometown team. It was interesting weather that day and night. My guess, backend of microburst with tail windshear resulting in loss of altitude and increase of groundspeed. CVR would reveal likely aural warning. But we just don’t know enough to really say.
Juan outstanding report and I can tell you were qualifying your words very carefully. Although this event is not required to be immediately investigated by the FAA, the PAX on this flight were very fortunate as was the crew that the aircraft was recoverable. With the rate of decent/ground speed and the lack of altitude this aircraft was seconds from a bad outcome. What really surprises me was the lack of coverage in mainstream media. You would think the PAX would have lit them up. Very interesting comments from @mauiflight regarding weather conditions on this day/evening. I'm not being critical of United, not at all they are one of the best domestic airlines in my opinion and in the world today but I fully agree with @mauiflight that not only United but all carriers should review their SOP regarding go/no go as related to weather conditions. We all know you have extremely tenured pilots on the wide body Hawaii hauls but still there is pressure industry wide to go and on time. Again thank you for your outstanding analysis !
If the aircraft lost power at the gate, then MCP will reset to 00000 feet. If the was after the brief and after the preflight check, then it may had been missed after they put the cockpit back together from the power loss.
It'e been reported that this was premature flap retraction from flaps 20, without incremental stops at 15 and 5. Heavy takeoff from the short runway at OGG necessitating a flaps 20 departure.
Juan, having spent more than 10 years in the left seat of the 777 this incident and it's cause has spiked my interest. One of the news stations just had an interview with a frequent flying passenger on that flight who gave an interesting description of what he felt and heard differently from other flights he's been on. 2 things he said immediately stood out to me - 1. That the nose of the airplane seemed to pitch up quickly momentarily just before the descent began and that the engine sound didn't seem to be as high as it normally is when climbing. This would in fact be indicative of a microburst as commented below by poster "In the Left Seat" and which could also explain how the autopilot would react climbing out in VNAV or FLC when entering an huge increase in headwind followed by an immediate loss and matching increase in tailwind. The question then is why did United give the pilots further training? Perhaps that's just company policy after any abnormal event - I don't know. Does United use the same "Escape" maneuvers we were trained to use? Was the autopilot and auto throttles disconnected immediately followed by max power escape maneuver? Considering their altitude, airspeed and weight at the time did a sudden loss of airspeed activate the stick pusher? Certainly a lot more questions here than answers - This is NOT a criticism of the pilots - I well know how quickly things can go south in a situation like this and how task overloaded things can become. However, I also know that training doesn't always answer every scenario - case in point, we were always trained to climb out at V2 up until 191 the DC-10 in Chicago was lost. I would most like to know how long the autopilot was involved after this event started because waiting to see what it's going to do and then playing catch up after isn't the best place to be caught in.
Juan, I’ve never flown a Boeing but I do fly the Global 5000 Vision. If this flight had requested a high speed climb and let’s say 300 knots was selected when the autopilot commanded a decent im assuming the AT go to idle and the plane pitches for 300kts. That would explain the spike in speed and rapid decent. Now as to why the crew didn’t correct this massive change from normal climb immediately is another question.
2.7 G's doesn't sound like much, but a lot of plastic parts (carbon fiber or just plain fiber) are used on modern aircraft, and each over-G has to be analyzed at certain points on the aircraft. Little stress cracks form, and while not very scary, multiple over G's add-up. One aircraft I worked on had over 100 sensors built-in to the wing structure, and software was available to analyze each flight. Everything being stored in a huge database until the plane was retired.
Actually, 2.7Gs is a lot. In a 45 degree banked turn maintaining altitude you will pull 1.5 Gs and that will definitely get your attention, especially non pilots. So nearly doubling that G loading will definitely increase the pucker factor for everyone on that aircraft. You won’t forget it either.
@@FranksMSFlightSimulator First of all, most pilots would NOT engage the autopilot until the aircraft was "clean" and both pilot comfortable they were flying the assigned departure/ flight path or route. Personally, I hand flew the aircraft up through at least 10,000. Secondly, as has been mentioned, there are at least three checklist actions that call for a verification of the MCP set altitude. At United, I know of two prior to starting the takeoff roll.
@@NamelessRider that’s my point, ie after everything you say is done, or supposed to have been done, if it is still set to zero there could/should be a warning. Cheers.
It does sound like pilot selected Level Change for his/her climb mode and then increased MCP speed to 280 knots, while MCP ALT was set to zero. This would cause rapid descent because the autopilot is pitching down for 280 knots.
@@nunya-d2t You can engage the autopilot as soon as 400ft above ground if you want to. The only thing the pilots did wrong was forgetting to set a altitude higher than zero feet in the mode control panel. If they had set a altitude of 10,000ft the plane would have climbed to 10,000ft at a speed of 280knots, instead of descending to zero feet/into the ocean at 280 knots. Normally it's 250 knots max below 10,000ft but ATC can give clearance to fly faster than 250 below 10000ft.
@@ThruAWiderLens if I’m not mistaken, unless you set the altitude hold lower than the field, it’ll break off the glideslope at the set altitude, instead of following it down to the field. Given the field is only fifty four feet above the sea, the only thing lower, is zero.
Thanks Juan! As always, informative and insightful. This is indeed a disturbing trend; I fear it could be as you noted possibly due to heavy turnover in the industry. Hopefully folks will ensure standards are not weakened in the interest of expediency.
All sorts of questions that are left undiscussed in this narrative. If the altitude was set at zero and the auto pilot engaged, the AC will not descend at anything close to 8600 fpm. If the a/p is not engaged, the flight directors would still be following the VNAV climb profile. There is also no mention of the aircraft alpha during the descent or the disposition of the auto throttles. If the aircraft was level or nose high and the thrust levers were at max thrust, that might point to a shear event. Exiting from a shear event with a nose up attitude and max thrust would most definitely increase G loading on the airframe. A pilot who loses SA would have to be ignoring the magenta FD bars along with the CA and the possible third pilot in the cockpit. My best guess would be a shear event. The weather was terrible with heavy rain and thunder storms in the area.
In 1991 our United Airlines 747 took off from HNL to LAX. About 45 minutes into the flight, we hit some terrible wind shear and immediately began to lose altitude. Horrible sensation. We must have lost 5000-8000 feet. It could have been much more. I hope that I never experience that ever again.
Classic wind shear conditions and aircraft reaction. This Boeing 777 is very lucky not to have crashed. That airframe is going to have it's life cut down after this very stressful event. New underwear for crew and all passengers for sure.
Great analysis Juan - I lay these kinds of problems directly at the feet of the airline training departments who are pushing auto flight systems so hard that they are literally training the "pilot" of of people. Not only that, but possibly more important in your explanation of these incidents, how many of these pilots first went to the Auto Flight panel or the FMC to initiate the recovery by trying to "reprogram" auto flight rather than simply clicking the OFF button, pushing the throttles up and recovering the aircraft immediately? It's almost like a lot of these pilots have forgotten that these are still airplanes (sorry Airbus guys - I realize that doesn't necessarily work for you) In my last year before I retired, we were departing in a 787 out of Shanghai late at night, it was the FO's leg. Stormy night - complicated departure - at less than 1000 ft the FO engaged the autopilot right after the gear came up ( a habit from a previous airplane) and to my surprise he immediately turned his attention away from the aircraft to start digging through his kitbag looking for something he bought at the discount mart in Shanghai. This in my opinion is a direct result of the training they are getting. I had Check airman hounding me for my last 5 years or more because flight management had decided that we shouldn't use the Vertical Speed button in liu of Flight Level Change - because of the so called "protections" FLC provided - The same "scenario" that could have very well been the cause of this particular near loss of control, if the altitude had been set incorrectly! BTW - I never quit using the Vertical Speed mode, and they were never able to answer the question "If I'm doing my job - why not?" Thanks again for the great analysis - it will be interesting to see what the investigation, if there is one turns up.
If the altitude being set at 00000 was the cause, as you said yourself, why would the rate of descent be so steep? It's an interesting theory but surely must be excluded as an automated descent would not be that steep? What if the vertical speed had been up at max? Would that cause the steepness of descent?
I think we need some reforms about mandatory retention of data and cockpit recorders for ALL incidents. Pilots' unions fight against this to protect pilots in opposition to safety improvements. Both this and the JFK runway incursion recently are examples where we should get more data.
In 35+ years of flying passenger jets I have NEVER seen the Altitude Select window set to 00,000'. I've seen a lot of other stuff set in there such as 100' above the anticipated SID clearance altitude but never zero.
That's exactly what happened in the fatal Piaggio crash a few months ago. Pilot set zero altitude and the autopilot started taking the plane down into the ocean. But that's not what happened with this United flight. The PM retracted the flaps too much.
Some airlines have a policy that when the flight crew is completing their checklists, the MCP altitude window is set at 0000. Thus the incoming crew knows this and when doing the cockpit setup, the proper initial altitude is set in the window and cross checked at least twice. I simply cannot buy the premise that this crew neglected to set the proper MCP altitude. It's NOT a United SOP.
@@NamelessRider I like that. I don't like how the power on default is 10000' on the plane I am flying. But at the same time forgetting is forgetting and if 10000' is the wrong altitude that isn't good neither is forgetting and leaving it on zero.
Thanks Juan for this professional explanation of this near tragic event. I’ve heard through other sources that the pilots were sent for additional training, which would make sense given your offered possible scenario. Also, if the G-forces exceeded the design limits why did the pilots continue this flight rather than return to their origination point. Isn’t a near 5 hour flight under that circumstance dangerous? I also have to wonder about the CVR. Doesn’t it retain only the last 30 minutes of data? If the pilots knowingly (after the fact) made a mistake wouldn’t continuing the flight overwrite the error the may have made?
I'm curious too about why they didn't return to the departure airport, that is unless they knew how they had screwed up and thought "well, we won't do that again."
Instantaneous G loading can be difficult to feel. It’s possible that with all that adrenaline they may not have noticed they pulled that hard. Since the plane departed SFO about 2.5 hours after they landed I’m guessing they did no real damage to the plane.
@@thractrack but my point is that the FAA has (or should have?) very specific regulations about flight ready status when a performance threshold is exceeded. What is that threshold I wonder?
747 guy here. Maybe the 777 FMC logic is different, but on my Boeing, you can't select an altitude below you while in Vnav climb and have it go down. For example, I cannot takeoff and level at 2200ft then select 0 and go down without forcing the FMC into Descent mode or going to V/S or FLCH. If they had 0 set on takeoff, 0 captured, and were hand flying, the whole climb to 2200ft, the flight director would be indicating a descent. I'm skeptical the whole crew would ignore the command bars for that length of time. Even when we have a guy flying true raw data, no FD's, the other guy leaves his on. My money is on microburst type event. Unless we have another GTI3591 type event.
The news stories here are reporting that the flight crew was given "additional training" after the incident. To me that implies some sort of pilot mistake rather than weather or mechanical problems, but you have to take these news stories with a grain of salt. I was hoping Juan would have more insight into what might have happened, but without an official NTSB report we may never know for sure.
I was at the Oshkosh air show in the 1990s, and we were walking down a line of beautiful P51 Mustangs. My buddy taps me on the shoulder, and says "See that guy over there? That's Chuck Yeager." I turned to look, and there he was next to Glamorous Glen, looking like he was 20 years old again.
I always set the altitude window to what I expect the clearance to be, minus 100. E.G. if the top of the departure is FL230 and that's whats commonly given, then I set it to 229, so that there is at least something close to expected, but also off to alert me that I don't have the clearance yet. Normally on landing the touchdown zone elevation rounded UP to the nearest 100' is set at GS intercept, until 1000' then you set missed approach. This one's a head scratcher for sure until we hear more
Hi Mr Brown,I really enjoy your channel,I saw you on KCRA tonight at the Gen Chuck Yeager 100th,I have a question I wonder if you could comment on,I once watched a documentary on RA Bob Hoover and it said he might of been chosen instead of Gen Yeager to pilot the.X-15 but he had a pervious Indiscretion that cost him the spot,and it said he flew the chase plane on that flight,im a fan of both men,do you know anything further about this,I would be interested, thank you Sir
Some rumors floating around.....take it for what it's worth I suppose......but they indicate that the Captain called for flaps 5, and the FO retracted them to flaps 1 before reaching the lever gate. The low speed may have then caused a loss of lift leading to a stall situation. Any thoughts on the possibility of this scenario in the 777?
If it was due to a microburst, all souls were VERY LUCKY it didn't happen 800 ft lower. Very experienced with Hawaiian microbursts. Poor crew decision to not delay - that DFW microburst crash about 30 years ago got Doppler Radar used.
Interesting, maybe flap retraction too soon after thrust reduction altitude. Wouldn't be the first time. Lets see what comes from it. A 777 did that recently, I think Juan reported on it. Stall warning was on the audio..
Considering the airframe could have been over stressed at +2.7G’s, I am surprised the pilots continued the flight and went up to 39,000ft, rather than immediately diverting.
A design question - what is the recording time on 777 CVR and FDR before they overwrite older data? Question applies to both this incident and the JFK incursion where the AA went ahead and departed.
As a pilot with a few thousand hours of flight time rated on the 727, 737, DC10, 757, 767, 777, and Airbus 320 on Microsoft flight simulator, (LOL) shouldn't this be on a checklist to check the alt select window? I certainly check during my pre-flight. This is way above my aviation knowledge to fully understand what happened. Always great job on the blancolirio channel to provide us great insights on aviation news!
If you look at the flight's FMS SEL box on ADS-B, no altitude is selected until they pass through 6,000 feet. At that time, 16,000 feet is shown on FMS SEL. Therefore it seems very unlikely that this incident was caused by zero altitude being selected and then the autopilot or pilot following the FD flying the plane down to zero altitude. In any event, it's now widely reported that this incident was caused by the flaps accidentally being retracted too much shortly after takeoff.
Hi Juan, really love your channel. Id heard that some of the confusion on this flight was due to a miss communication about the flaps setting and that the captain spent most of his hours flying in a Air Bus.
Wait, engaging the autopilot would engage them in the already active flight director modes, right? If the flight director is centered, the AP wouldn't just start a nosedive, and if the FD bars are way off center, why would you engage the AP in the first place? Normally LNAV and VNAV would be armed, what would happen to VNAV if the alt was set to zero? I don't know the 777, but in the 737, if the autopilot is engaged while in take-off mode (TO/GA on FMA), the system would revert to LVL CHG (MCP SPD on FMA), the A/T would have to reduce thrust to idle. All that would be boxed on the FMA, which would be unusual if VNAV is expected to be active, and should get the attention of the pilots.
I too was on that flight. I am not a pilot and had not been thinking about how close we were to the water. I do however teach Physics and just heard that our story was released to the public with enough data to have the classes do some "High School Physics" calculations. Suffice it to say, thank goodness for air resistance or we would have been in pieces in the water. With said air resistance we had about a second and a half to spare? Cool Physics stuff. Nice to feel 2.7gs but I wouldn't do it again. I agree airlines need to keep planes on the ground in that kind of weather.
Thanks for the report Juan. Due to the potential for over-G, why didn't the aircraft return to Maui for inspection rather than continuing on to the original destination? Seems kinda weird, not to mention that all the pax would've probably been pretty spooked by the event.
@@chrisroberts3963 8600 fpm down is pretty severe, I don't think I'd need to look at the data to consider returning to the airport that I just left to make sure the plane's in one piece.
@@thomaslemay8817 Fly two thousand miles over open ocean rather than land heavy? A 777 can land at MTOW, it just needs to be checked afterward. Or, either dump fuel or circle near land to burn it off, not commit to a two thousand mile crossing if there is doubt about the airplane.
My guess is the G forces they felt most likely did not feel like much. 2.7 gs does not feel like much to pilots that fly all the time. When the pilots did the pull up I imagine they did not think about gs pulled either. If you think you might crash that sort of thing is not high on your list of what is the most important in your brain.
I personally doubt the AP hypothesis suggested. 0 ft would result in a near 0 G bunt over, and would be immediately noticeable by any crew. If the AP was selected on at very low level (as per Emirates incident), that reaction time to disconnect the AP could result in the recovery ending close to the ground. However in this instance there was significant loss of altitude. It may depend on the company, but I would expect a genuine GPWS warning to be reportable and would be investigated by local authorities where I live, and I expect most western jurisdictions.
Do you find it strange that all that was released in terms of pilot flight time was the summation of pikots pilots and not each individual total flight time which is normally done? 777 CAPTS generally have roughly 20-25K hours total flight time before they are senior enough to hold the left seat. Could it be the FO had 3000ish hours? Is there a price to be had for putting new hires in the right seat of large commercial aircraft?
United says that the pilots had to be given some training. So were they trained to negotiate a micro burst or doing the check list properly. One thing we constantly hear on accident reports is of faulty settings . While warnings like bank angle, sink rate etc are built into the aircraft program, why can't incorrect settings be checked during the different stages of flight be monitored and warnings issued.
The rate of descent may have been tied to IAS or some speed hold mode engaging where the nose went down to get to a certain airspeed speed regardless of VS (vertical speed) - when they saw this happening AP/disconnect and pull out of dive
Saw someone post on a local newspaper forum (rather definitively, but anonymously) that the copilot mistakenly moved flaps from 20->1, instead of the "20->15" that the pilot had requested, perhaps because "both were relatively new on-type." I have no flying knowledge... but would that make sense per your scenario, even if unverifiable?
Do you pilots get a warning in the cockpit when you exceed the g forcre limit, like in the United Airlines case? If so would it be a reason to abort the further light, and land as soon as possible? In this case return to Kahului airport?
Those Mustangs look brand new. Beautiful. Could they install an alarm if the altitude is set at zero on TO? Let's face it , not many airports at at zero altitude.
Former pilot and I was on that flight on that day. Shortly after TO the pilot slightly retarded the engines. I noticed it but it was subtle. Then we started sinking. The aircraft did not nose over into a dive. It felt like we were hit with a downdraft. Many screamed and the crew increased thrust and recovered and climbed up to FL39 and smooth air. I normally don't get too bothered by turbulence but I knew we were very close to the water having only been in the air for slightly more than a minute.
That's great information. Maybe what you were experiencing was a near stall. Maybe there was an issue with the power setting, but I doubt that (since any engine issues would require an immediate landing). More likely, as someone mentioned above in the comments, the flaps were accidentally retracted to zero when commanded to 1.
I am also a retired pilot. One afternoon flying a Boeing 737-300 on vectors to land at SLC we hit a down draft over the Great Salt Lake that pushed us down. The autopilot was unable to hold altitude so I took over manually added full power pitched nose up and still lost altitude. After about a loss of 700 feet we flew clear of the downdraft and regained our assigned altitude. I was wondering if this was a downdraft and your description fits that scenario.
If it’s true that it didn’t pitch down, and the increased ground speed seen on ADSB is accurate, wind shear could be to blame (big loss of headwind or big increase in tailwind). Would expect to see ground speed decrease in the scenario you described if air was stable.
Were you asked to give a statement of any kind? As a pilot you would more aware of what is happening. Could shed a lot of light on the situation.
@Cory Amatuzzo they retard the engines for several reasons. Reduced drag once the aircraft is airborne allows it to accelerate beyond the 250 knot speed restriction (below 10,000 ft). noise abatement reasons as well as engine limitations for continuous max thrust and excessive fuel consumption.
I’m a an ATP CFII in Kahului Maui (my UA-cam is “In the Left Seat” and I have 10,000 hours teaching in the SR22 out of Kahului. I distinctly recall the weather that day. It was a NO FLY day whatsoever. The rain was extremely heavy and the clouds were super dark. I was driving near the airport that afternoon and was thinking to my self who on earth is going flying and why don’t they just delay. This IMO was a microburst event. They are right off shore when weather like this hits. Thank god no one was hurt. All airlines need to change ops specs for this airport. As that on shore flow hits the runway it’s wind shear all day long.
That explains it, I was on an HA Airbus flight from the mainland to Maui about ten years ago and we had one of the hardest landings I have ever experienced in an RPT aircraft. The approach was extremely turbulent, and the aircraft literally crashed on. There were apologies and I understand it did overstress the UC. The pax were relieved to walk away.
Very very interesting. Thank you for sharing your thoughts. It makes a lot of sense. Incredible that it was recovered from.
Fellow CFII here . MICROBURSTS are NO JOKE. I looked at the weather for that day after I saw that Flight Radar 24 posted this event, and I was thinking the same thing: a Microburst… glad to know there is some first hand witness to that weather for confirmation. Scary stuff .
@@jimgraham6722 yeah I was on a similar flight into Maui once … very turbulent approach- on a clear day, just super windy and wind-shear . I’ve never experienced turbulence like that before nor since !
Microburst doesn’t really make sense to me. United would probably have disclosed this in their press releases were it true. The fact that two experienced ATPs would have failed to make a pirep after such an extreme shear event causing this level of g load and failed to return to the airfield for structural inspection just doesn’t add up. More likely they got into clouds, got distracted, had a loss of SA, maybe a misconfigured system, something like that. But microburst doesn’t hold up here based on what we know. At that decent rate, this aircraft was
I had one "Don't Sink" occurrence in my career. It was so long ago that I do not recall the exact circumstances, other than that the fault was mine, it was minor and easily corrected. The lesson I took from that (after obsessive post-occurrence self-analysis) was that one should always treat the GPWS like a Finnish colleague!
If your Finnish colleague voices an opinion, HEED IT! The Finns, like a GPWS, are silent - until the shite is REALLY about to hit the fan. Then they might, quietly, say "don's sink" or something to that effect. I flew with some Finns for the ICRC (the Red Cross) in Africa in the early 1990's and I have been in awe of my fellow Finnish brothers ever since. Whatever we Icelanders manage to do, the Finns take it to another level. No wonder the other Nordics call us the "Edge-finders". We Icelanders are at the mellow west precipice, the Finns are at the very real and violent Russian precipice of existence.
GOOD writing skills!
Fascinating Insight Man. I knew nordics were economical with words, but wow.
@@bobdobalina838, the Nordics in general are quite introvert, but the Finns take it to another level. Even among friends, if a Finn has nothing meaningful to contribute to a conversation, he/she simply stays silent!
@@Halli50 An Italian will be like "O MAMA MIA LA MORTE, LA MORTE" (The death).
It's been a very busy month for you, Juan. As an armchair pilot, I appreciate your use of clear and concise language, as well as your experience in breaking down what went wrong and how it all unravelled. Thanks again.
I agree
those Chuck Yaeger commemorative planes at the end. The sound of the engines, the shiny-ness, the props tricking frame rates into changing direction.. just viewing that video is quite something. Thanks :)
In your case maybe a “noise abatement” maneuver…, being it was out over a large city..?
I always brief a “black hole” departure out of the islands. Out of the islands there are no outside references for visual flight on a night departure once you bring the nose up. It’s equivalent to a zero zero departure . You need to be on the gauges and have recency of experience skills in this situation. Pilot Monitoring is essential during the initial climb.
Could it be conversely argued that the pilot would not have the distraction of the beautiful display of city lights below and therefore full attention is on flight instruments?
@@jimrobin watt
@@jimrobin In my opinion no, the lights actually give you some sense of the horizon
I had to do the equipment investigation for a black hole arrival crash into the US Virgin Islands. The runway lights weren’t working correctly and the pilot flew into the water. The pilot died but several passengers that did survive said the pilot kept looking up over the dash as if he was confused and looking for something…. (The runway). If things don’t look right climb immediately.
Having done a lot of night takeoffs to the north out of Maui and Kauai (Hawaii's worst black hole departures) I can agree. I describe it as "when you rotate someone just painted the windows black." I also think Kauai is worse because just after takeoff you make a right turn. I think Kona landing south is the worst black hole arrival.
Enjoy what this channel has become! Your humility and ability to look at these events without judgement, but with suggestion, is really enjoyable.
Lol, missed his last video eh?
@@Boston_Pilot Which one?
Kaua'i checking in, 200 miles NW of Maui.
On 18 Dec 2022, we were experiencing strong, heavy thunderstorms with very gusty winds with heavy rain. Reports of many very bumpy flights that day. May have been a contributing factor.
I was working Dispatch that night on all-cargo flights out of HNL; there was a very deep trough right overhead the Hawaiian Islands - very severe turbulence N and W of the islands. I was loading additional fuel to allow the crews to do what they needed to do route and altitude wise - I remember the weather system was extending almost all the way to the ETP between Hawaii and the Mainland. I ACARS'ed one of my eastbounds about an hour E of Hawaii - and he said at altitude it was very moderate turbulence.
Not sure about other operators, but on ours (B757/767), part of the Before Start checklist says MCP (Mode Control Panel) to verify V2 heading and initial cleared ALTITUDE. Would be surprised if B777 didn't have a similar checklist item.
Great review of known facts as always!
I agree with you. I'm retired off the B757/767 but it's common fleetwide at my company. Plus, your Clearance denotes the initial cleared altitude for the Departure.
I think this video may better explain the MCP/FD situation on takeoff for the 777
ua-cam.com/video/UH4qH2NhqTI/v-deo.html
In the other events where this happened, the other pilot just replied "set" to that checklist item without even looking at it and seeing it was set at 0 ft.
@@llamainternationalairlines9632 Thank you very much for the video. Very intresting difference between the two types. Checking your FMAs is always a must. It is NOT specifically included in the B757/767 generic Normal checklist, however we do have it on our ops preflight checklist under (Challenge) Flight Instruments: ---- (Reply) TO / TO / FD Heading (times 3) Altimeter (QNH times 3).
I'd suggest that any system that creates obvious potential for human error to result in potentially disastrous results is a flawed system. Sure, not all HE can be removed, but if it's so relevant why isn't the SYSTEM preventing attempted take off if that panel reads 00000? Put differently, if I can take off with INAPPROPRIATE settings in the MCP then it's NOT a complete system in my view. Surely there are SOME elements that can be FORCED to at least certain values i.e. not everything has to be allowed to be set at any value?
I wrote something asking some questions about it in a post of my own and am hoping some people might answer the questions I posed.
Cheers
It's 'Climb, Communicate, Confess.' Thanks for all you do!
I retired before the United merger from Continental Airlines flying the 777-200. Our procedure after takeoff was gear up and climb to 3000 ft AGL before accelerating and flap retraction. What ever happened was a serious situation with lots of GPWS noise. Serious rug dance in the Chief Pilots office and a sim visit for sure.
What’s your take on what the cause was?
Yep. 30 years ago you might as well have left your badge and Jeps on the counter and started updating your resume 😂😂
I saw an article about this the other day, and eagerly awaited for your video on the matter... Informative as always Juan.
“…these basic skills (of flying) are being lost…”
More correctly, these basic skills are not being taught!
Very good analysis as always. Blancolirio is the best aircraft accident channel.👍🏻
I like that the husky parked right in sniffers rows next to the vintage metal!! ❤
I knew you’d be on top of this when I saw it in the news. Thank you for keeping those interested in aviation educated.
Juan, so glad you took my seat at DFW; I take what you say to the bank! We've all seen neophytes blanch at that "Flaps 5" callout, that a new FO would park at 15 shouldn't have surprised an old 777 guy. I'm reminded of Jim and Eduardo's GRU departure; even the smartest of us can fall prey to this stuff. We've all known people smarter than ourselves who fell into traps.
Super observation, re hand flying: I mean, none of this should've happened if the autopilot were immediately engaged, as us perennial underachievers are prone to do ;) Seriously, I'm glad it ended well.
Outstanding work, as always.
RIP Terry & Len, gone but never forgotten
Whenever I attend recurrent simulator training, fellow pilots and instructors look at me funny when I hand fly, especially in an emergency.
I always say the same thing; we only practice this stuff a few times a year and I want to know I can handle it.
We are losing this crucial skill!
Like doing circlings with autopilot and not manual. What is the problem ? Cant maneuver it ?
@@CFITOMAHAWK Automation dependency and it’s pitfalls have been known for decades; NASA has studied it. But, instead of addressing the problem, we create more automation to be managed and further remove the crew from manipulating the aircraft.
That's a very timely and relevant comment. As a former pilot, most of us hand flew the aircraft up to at least 10,000 or even FL180, if not higher. On approach, in good weather, it was not uncommon to turn OFF all of the autoflight passing FL180 and had fly the approach. Obviously, you had instrument backup but the idea was to maintain proficiency hand flying the aircraft. That was true on the 757 through the 777 aircraft.
@@NamelessRider Yep. Lazy pilots will make pilot errors when had to hand fly it on an emergency or bad winds or weather. A Mild Maneuvering Pilot cant be trusted on hard maneuvering weather or turns.
Won't be long before they completely automate it.
I had a horrific turbulence/ downdraft experience in a 747 circling the NYC area during severe t-storms as all area airports were closed. We’d originated in Los Angeles. We had off and on mild to moderate Intermittent mild turbulence when suddenly a sustained very long ‘free fall’. A momentary leveling off followed by another long free fall. Passengers hitting their heads, then once back in their seats, quickly buckled up. Yes yelling and screaming.
Thankfully we had a lot of altitude. 5 minutes later the cabin announced we’re heading to Baltimore as we’re low on fuel.
Made it to Baltimore and deplaned.
The airline gave us the option of boarding he aircraft and continue our flight to Newark or for those too traumatized, buses were available at no charge. I’d guess 25-33% took the bus.
This was early 80’s I believe
Circling EWR Newark NJ in a late summer Noreaster storm is definitely a roller coaster. The hilly terrain immediately west of the airport lends extra sauce
As a customer and member of the flying public, I really appreciate the quality of discussion on this channel.
Thanks to all.
The NTSB has stated that early flap retraction caused this as well as the pilots actions, a preliminary report is coming, this brings me to a concern I had just last weekend, I was on a 737-800 flight from CTG to MIA, and the flight took off with no slats and no flaps, as a pilot I was looking at this as we were taxiing and out and thought to myself this aircraft is not configured correctly but I didn't say anything because as we are taxiing out and I noticed this I did look up the take-off specs and I noticed that it was able to do a no flap no slat takeoff, the flight was not fully loaded so maybe that had something to do with it also but I will say this, the CTG runway is approx 8300 ft, and although we were airborne around 7000 ft, there was a noticeable dip, once we got out of ground effect, also there was an audible "ohhh" from many of the passengers, .... I just thought to myself:"why would a flight crew not use the slats or flaps?" What was to be gained? I also took a video of it , just in case we crashed and they found my phone in the wreckage the NTSB would have all they need to make a determination about what went wrong
It has been 4 weeks and no report published. I wrote the NTSB for the report and no reply Will try again next week.
From friends at UA, a fairly new Captain, new FO who had to have additional training multiple times. Agree on the flap retract. Probably a flap 20 TO, and when flying pilot called for flaps 5, he/she either went to flaps 1, or flaps up
From FR24 Take off appears to be at 190049Z. From METARS, it now looks more weather than automation. There is a 180 change in wind direction between last two METARs and TS in overhead moving NE i.e along departure track.
METAR PHOG 190054Z 14009KT 3SM +RA BR BKN009 OVC020 19/18 A2977 RMK AO2 SLP085 P0020 T01940183=
METAR PHOG 182354Z 32010KT 3SM +RA BR BKN009 OVC020 20/18 A2976 RMK AO2 SLP081 TS OHD MOV NE P0027 60140 T02000183 10233 20200 56022=
METAR PHOG 182254Z 34010KT 4SM RA BR BKN009 BKN020 OVC100 21/19 A2977 RMK AO2 TSB2156E50 SLP085 TS OHD MOV NE P0061 T02110194=
METAR PHOG 182251Z 33007G15KT 5SM -RA BR BKN011 BKN020 OVC100 21/19 A2977=
SPECI PHOG 182251Z 33007G15KT 5SM -RA BR BKN011 BKN020 OVC100 21/19 A2977 RMK AO2 TSB2156E50 TS OHD MOV NE P0060=
There are rumblings that this was an accidental Flaps 20 to Flaps UP command on the initial Flaps step.
I really appreciate your analysis from a professional perspective. This is a flight I’ve taken from Maui many of times. I purposely book the wide body 777 so this is a important issue for many of us.
I read the same article, and your expertise answered many questions. As a layman I would think this should be part of the pre-flight check list. Thanks Juan
I had the absolute pleasure to meet Gen Yeager at Edwards AFB in 1996 on the occasion of the anniversary of breaking the sound barrier. After a very interesting speech to the graduating Test Pilot class he climbed on an F15 and overflew the base at Mach 1 again. He was 73 .. what an incredible life and immense contributions to aviation..
Juan B! Head of AAAR - (the not yet formed: Advocacy for Accuracy in Aviation Reporting) Thanks for all that you do for us and the content you make. Cheers from Texas.
Interesting video, and as always, a great job of professional reporting, Juan.
At UAL, the ASAP report is called a "FSAP" (basically the same type of report), which is used internally at UAL, and from that, an ASRS Report is generated, along with FAA notification, if any regs were violated. It's important to mention that even though a crew's anonymity is protected via ASAPs/FSAPs, they can only protect the crew (i.e.: "Get out of jail, free") if the deviation or event was not intentional.
I have heard that either the CA & FO, or perhaps both, were new to their respective seats in the triple-7...so, maybe not as much experience in the airplane, as would be desired for this type of mission.
If the target altitude erroneously had been set to "00000", I don't believe the automation would cause a descent of over 8,000 FPM, so it is probable that it was being hand-flown (especially given the sudden increase in IAS). I'm also sure that the EGPWS was shouting warnings at the crew, which would have exacerbated the state of confusion that would be present during these types of events.
Like the reporter below, to me, it sounds like they encountered a severe downdraft, from which, they fortunately recovered.
Sounds like a wild ride. Surprised that there hasn’t been a few stories on news sources up until now.
Sounds like many flights had uncomfortable rides that day. Especially with the Hawaiian Airlines flight having injuries it would be hard to get the media attention regarding another flight.
Anyone remember Chuck Yeager's Advanced Flight Trainer aircraft simulation computer game, published by Electronic Arts in 1987? I used to play it on the Commodore 64. What the game graphics didn't provide back then, my imagination did,lol Nice one Chuck!🏆👍
PC version was my favorite combat sim!
I had that, either Commodore 64 or Commodore Amiga ..
That was a very important observation, Juan. I'll follow any repercussions with great interest. Thank you for your diligence!
I've pulled around 3G out of an intentional vertical dive in a DHC-1 on many occasions, flying aerobatics. It might not be the sort of number that jet fighter pilots pull, but a sustained 2.7G pulling out of a dive would certainly be felt by everyone aboard. It's enough to feel you are being crushed into your seat.
You read my mind. Thanks for covering this.
Juan, you're a 777 guy. Get one of your training buds to put this scenario in the sim. See if engaging auto flight at 2200' with zero in the Altitude Select Window gives the same results. Then get them to do the same for a severe microburst at 2200'.
Yeah, now your talking!
Juan, can’t thank you enough for providing these updates. These events are now getting so much national airplay and the “why” you provide so promptly to fill the information gap is world-class.
Appreciate everything you do.
When I lived in Daytona, one of my favorite flights to fly was DAB-SSI (St. Simmons Island, Georgia) for some great barbecue from a famous restaurant on the island. I would often leave DAB in the early evening and leave SSI sometime after dark. The night flight I did out of SSI, it was a moonless night, which required me to rely solely on my instruments during the takeoff from SSI. I feel like the takeaway from this story is the importance of good situational awareness. Although it was in a C-172, it was a great learning experience for me so I can translate those skills and the required situational awareness into a bigger aircraft one day. Thanks for keeping us informed and educated about these stories sir!
This seems like a “hole in the Swiss cheese”: something where, eventually, somebody’s going to be distracted, at night with no visual references, and they’re not going to catch it until it’s too late.
I’m with you Juan!
Obviously we don’t have all the data, but as a retired (and extremely experienced) heavy jet captain, this isn’t microburst- for my money this is TOTALLY human error.
You must GLUE your eyes to the instruments and ignore what your head tells you.
It’s relatively rare, but very severe spatial disorientation (call it vertigo) can happen in this scenario, especially in IMC during acceleration when getting airborne day OR night.
Example: One early evening in the early 90’s we were departing KaiTak (the old HongKong) and just after getting airborne and flying into a solid cloud layer whilst accelerating, I was very suddenly hit with extremely severe disorientation. I immediately said “handing over” to the captain (I was FO at the time.) He said “NO- I’m probably worse than you!”
Needless to say I immediately engaged autopilot as I knew that it would likely do a better job than me. I probably could have hand flown it without a major drama, but that’s not the time to do it- leave that for the simulator (even though I’ve never had such severe vertigo in the sim.)
Within a very short time my disorientation disappeared, and a little while later the captain said he was back to normal too. We discussed it, and agreed that neither of us had experienced anything as sudden (and severe) before. …. Or since.
We further believed at the time that landing lights as we intercepted cloud layers made the problem much worse.
I’ve subsequently had other mild cases, but nothing ever again remotely like that night out of HongKong.
As I understand it, United has said that both of the crewmembers who were involved in this incident have been "sent for retraining." As I read that, United must have determined that the crew messed up somehow. All of that said, the news stories over the past couple of days appear to have seriously exaggerated the actual attitude of the aircraft during the incident, describing it as a "nose-dive", which most of us would interpret as more than 30 degrees nose-low. My suspicion is that if a Triple-7 entered a dive like that at 2,200 ft., we'd be having a different discussion now.
I live on O’ahu and fly for the hometown team. It was interesting weather that day and night. My guess, backend of microburst with tail windshear resulting in loss of altitude and increase of groundspeed. CVR would reveal likely aural warning. But we just don’t know enough to really say.
Juan outstanding report and I can tell you were qualifying your words very carefully. Although this event is not required to be immediately investigated by the FAA, the PAX on this flight were very fortunate as was the crew that the aircraft was recoverable. With the rate of decent/ground speed and the lack of altitude this aircraft was seconds from a bad outcome. What really surprises me was the lack of coverage in mainstream media. You would think the PAX would have lit them up. Very interesting comments from @mauiflight regarding weather conditions on this day/evening. I'm not being critical of United, not at all they are one of the best domestic airlines in my opinion and in the world today but I fully agree with @mauiflight that not only United but all carriers should review their SOP regarding go/no go as related to weather conditions. We all know you have extremely tenured pilots on the wide body Hawaii hauls but still there is pressure industry wide to go and on time. Again thank you for your outstanding analysis !
Deserves an upvote just for the P-51 elephant walk outro!
If the aircraft lost power at the gate, then MCP will reset to 00000 feet. If the was after the brief and after the preflight check, then it may had been missed after they put the cockpit back together from the power loss.
News report I read said United was "Retraining" The pilots. and The plane continued in service. So it sounds like pilot error.
Thank You Juan for this update report.
It'e been reported that this was premature flap retraction from flaps 20, without incremental stops at 15 and 5. Heavy takeoff from the short runway at OGG necessitating a flaps 20 departure.
Juan, having spent more than 10 years in the left seat of the 777 this incident and it's cause has spiked my interest. One of the news stations just had an interview with a frequent flying passenger on that flight who gave an interesting description of what he felt and heard differently from other flights he's been on. 2 things he said immediately stood out to me - 1. That the nose of the airplane seemed to pitch up quickly momentarily just before the descent began and that the engine sound didn't seem to be as high as it normally is when climbing. This would in fact be indicative of a microburst as commented below by poster "In the Left Seat" and which could also explain how the autopilot would react climbing out in VNAV or FLC when entering an huge increase in headwind followed by an immediate loss and matching increase in tailwind. The question then is why did United give the pilots further training? Perhaps that's just company policy after any abnormal event - I don't know. Does United use the same "Escape" maneuvers we were trained to use? Was the autopilot and auto throttles disconnected immediately followed by max power escape maneuver? Considering their altitude, airspeed and weight at the time did a sudden loss of airspeed activate the stick pusher? Certainly a lot more questions here than answers - This is NOT a criticism of the pilots - I well know how quickly things can go south in a situation like this and how task overloaded things can become. However, I also know that training doesn't always answer every scenario - case in point, we were always trained to climb out at V2 up until 191 the DC-10 in Chicago was lost. I would most like to know how long the autopilot was involved after this event started because waiting to see what it's going to do and then playing catch up after isn't the best place to be caught in.
Juan, I’ve never flown a Boeing but I do fly the Global 5000 Vision. If this flight had requested a high speed climb and let’s say 300 knots was selected when the autopilot commanded a decent im assuming the AT go to idle and the plane pitches for 300kts. That would explain the spike in speed and rapid decent. Now as to why the crew didn’t correct this massive change from normal climb immediately is another question.
😳 This is not giving me confidence in flight travel. Thanks, JB, for the briefing.
2.7 G's doesn't sound like much, but a lot of plastic parts (carbon fiber or just plain fiber) are used on modern aircraft, and each over-G has to be analyzed at certain points on the aircraft. Little stress cracks form, and while not very scary, multiple over G's add-up. One aircraft I worked on had over 100 sensors built-in to the wing structure, and software was available to analyze each flight. Everything being stored in a huge database until the plane was retired.
Actually, 2.7Gs is a lot. In a 45 degree banked turn maintaining altitude you will pull 1.5 Gs and that will definitely get your attention, especially non pilots. So nearly doubling that G loading will definitely increase the pucker factor for everyone on that aircraft. You won’t forget it either.
How zero can be set in the altitude selector without all sorts of warnings going off, I’ll never know! Cheers.
Yeah that does sound like an easy one.
So the pilots could prevent the aircraft diving down suddenly like the video suggested might have happened and is becoming a bit too common!!!
@@FranksMSFlightSimulator First of all, most pilots would NOT engage the autopilot until the aircraft was "clean" and both pilot comfortable they were flying the assigned departure/ flight path or route. Personally, I hand flew the aircraft up through at least 10,000. Secondly, as has been mentioned, there are at least three checklist actions that call for a verification of the MCP set altitude. At United, I know of two prior to starting the takeoff roll.
@@NamelessRider that’s my point, ie after everything you say is done, or supposed to have been done, if it is still set to zero there could/should be a warning. Cheers.
@@nunya-d2t ok, but always room for improvement! Cheers.
It does sound like pilot selected Level Change for his/her climb mode and then increased MCP speed to 280 knots, while MCP ALT was set to zero. This would cause rapid descent because the autopilot is pitching down for 280 knots.
🤔 very interesting
@@nunya-d2t You can engage the autopilot as soon as 400ft above ground if you want to. The only thing the pilots did wrong was forgetting to set a altitude higher than zero feet in the mode control panel. If they had set a altitude of 10,000ft the plane would have climbed to 10,000ft at a speed of 280knots, instead of descending to zero feet/into the ocean at 280 knots. Normally it's 250 knots max below 10,000ft but ATC can give clearance to fly faster than 250 below 10000ft.
Non-pilot here. Why is it possible for the altimeter to be set at 0000 in this circumstance? It sounds like an accident begging to happen.
@@ThruAWiderLens if I’m not mistaken, unless you set the altitude hold lower than the field, it’ll break off the glideslope at the set altitude, instead of following it down to the field. Given the field is only fifty four feet above the sea, the only thing lower, is zero.
@@702Wolfi Sorry, but you are really speculating. You don't know what was set in the MCP window for altitude.
Thanks Juan! As always, informative and insightful. This is indeed a disturbing trend; I fear it could be as you noted possibly due to heavy turnover in the industry. Hopefully folks will ensure standards are not weakened in the interest of expediency.
All sorts of questions that are left undiscussed in this narrative. If the altitude was set at zero and the auto pilot engaged, the AC will not descend at anything close to 8600 fpm. If the a/p is not engaged, the flight directors would still be following the VNAV climb profile. There is also no mention of the aircraft alpha during the descent or the disposition of the auto throttles. If the aircraft was level or nose high and the thrust levers were at max thrust, that might point to a shear event. Exiting from a shear event with a nose up attitude and max thrust would most definitely increase G loading on the airframe. A pilot who loses SA would have to be ignoring the magenta FD bars along with the CA and the possible third pilot in the cockpit. My best guess would be a shear event. The weather was terrible with heavy rain and thunder storms in the area.
Not weather related.
In 1991 our United Airlines 747 took off from HNL to LAX. About 45 minutes into the flight, we hit some terrible wind shear and immediately began to lose altitude. Horrible sensation. We must have lost 5000-8000 feet. It could have been much more. I hope that I never experience that ever again.
Classic wind shear conditions and aircraft reaction. This Boeing 777 is very lucky not to have crashed. That airframe is going to have it's life cut down after this very stressful event. New underwear for crew and all passengers for sure.
Great analysis Juan - I lay these kinds of problems directly at the feet of the airline training departments who are pushing auto flight systems so hard that they are literally training the "pilot" of of people. Not only that, but possibly more important in your explanation of these incidents, how many of these pilots first went to the Auto Flight panel or the FMC to initiate the recovery by trying to "reprogram" auto flight rather than simply clicking the OFF button, pushing the throttles up and recovering the aircraft immediately? It's almost like a lot of these pilots have forgotten that these are still airplanes (sorry Airbus guys - I realize that doesn't necessarily work for you) In my last year before I retired, we were departing in a 787 out of Shanghai late at night, it was the FO's leg. Stormy night - complicated departure - at less than 1000 ft the FO engaged the autopilot right after the gear came up ( a habit from a previous airplane) and to my surprise he immediately turned his attention away from the aircraft to start digging through his kitbag looking for something he bought at the discount mart in Shanghai. This in my opinion is a direct result of the training they are getting. I had Check airman hounding me for my last 5 years or more because flight management had decided that we shouldn't use the Vertical Speed button in liu of Flight Level Change - because of the so called "protections" FLC provided - The same "scenario" that could have very well been the cause of this particular near loss of control, if the altitude had been set incorrectly! BTW - I never quit using the Vertical Speed mode, and they were never able to answer the question "If I'm doing my job - why not?" Thanks again for the great analysis - it will be interesting to see what the investigation, if there is one turns up.
If the altitude being set at 00000 was the cause, as you said yourself, why would the rate of descent be so steep? It's an interesting theory but surely must be excluded as an automated descent would not be that steep? What if the vertical speed had been up at max? Would that cause the steepness of descent?
when i heard about this early morning news! this is right where I headed for some answers and as expected you came through. Great report thank you
Thanks for your report, RB, Nova Scotia,
Thanks for explaining the procedures that the FAA and Airlines have employed to report troubling incidents.
I think we need some reforms about mandatory retention of data and cockpit recorders for ALL incidents. Pilots' unions fight against this to protect pilots in opposition to safety improvements. Both this and the JFK runway incursion recently are examples where we should get more data.
In 35+ years of flying passenger jets I have NEVER seen the Altitude Select window set to 00,000'. I've seen a lot of other stuff set in there such as 100' above the anticipated SID clearance altitude but never zero.
Agreed. Wrong altitude yeah .... but zero?
That's exactly what happened in the fatal Piaggio crash a few months ago. Pilot set zero altitude and the autopilot started taking the plane down into the ocean. But that's not what happened with this United flight. The PM retracted the flaps too much.
Some airlines have a policy that when the flight crew is completing their checklists, the MCP altitude window is set at 0000. Thus the incoming crew knows this and when doing the cockpit setup, the proper initial altitude is set in the window and cross checked at least twice. I simply cannot buy the premise that this crew neglected to set the proper MCP altitude. It's NOT a United SOP.
@@NamelessRider I like that. I don't like how the power on default is 10000' on the plane I am flying. But at the same time forgetting is forgetting and if 10000' is the wrong altitude that isn't good neither is forgetting and leaving it on zero.
I can hear that little yellow and black taildragger sitting on the flight line saying, "when I grow up, I want to be one of those."
Thanks Juan for this professional explanation of this near tragic event. I’ve heard through other sources that the pilots were sent for additional training, which would make sense given your offered possible scenario. Also, if the G-forces exceeded the design limits why did the pilots continue this flight rather than return to their origination point. Isn’t a near 5 hour flight under that circumstance dangerous? I also have to wonder about the CVR. Doesn’t it retain only the last 30 minutes of data? If the pilots knowingly (after the fact) made a mistake wouldn’t continuing the flight overwrite the error the may have made?
I'm curious too about why they didn't return to the departure airport, that is unless they knew how they had screwed up and thought "well, we won't do that again."
Instantaneous G loading can be difficult to feel. It’s possible that with all that adrenaline they may not have noticed they pulled that hard. Since the plane departed SFO about 2.5 hours after they landed I’m guessing they did no real damage to the plane.
@@thractrack but my point is that the FAA has (or should have?) very specific regulations about flight ready status when a performance threshold is exceeded. What is that threshold I wonder?
747 guy here. Maybe the 777 FMC logic is different, but on my Boeing, you can't select an altitude below you while in Vnav climb and have it go down. For example, I cannot takeoff and level at 2200ft then select 0 and go down without forcing the FMC into Descent mode or going to V/S or FLCH.
If they had 0 set on takeoff, 0 captured, and were hand flying, the whole climb to 2200ft, the flight director would be indicating a descent. I'm skeptical the whole crew would ignore the command bars for that length of time. Even when we have a guy flying true raw data, no FD's, the other guy leaves his on.
My money is on microburst type event. Unless we have another GTI3591 type event.
Should not be just “injuries” that attract FAA attention, but “near misses” as well! Cheers.
i feel like altimeter set to 0 is a near miss.
The news stories here are reporting that the flight crew was given "additional training" after the incident. To me that implies some sort of pilot mistake rather than weather or mechanical problems, but you have to take these news stories with a grain of salt. I was hoping Juan would have more insight into what might have happened, but without an official NTSB report we may never know for sure.
United stated that the flight crew were given “additional training.”
I was at the Oshkosh air show in the 1990s, and we were walking down a line of beautiful P51 Mustangs. My buddy taps me on the shoulder, and says "See that guy over there? That's Chuck Yeager." I turned to look, and there he was next to Glamorous Glen, looking like he was 20 years old again.
Juan, thanks for the analysis! Stay safe!
I always set the altitude window to what I expect the clearance to be, minus 100. E.G. if the top of the departure is FL230 and that's whats commonly given, then I set it to 229, so that there is at least something close to expected, but also off to alert me that I don't have the clearance yet. Normally on landing the touchdown zone elevation rounded UP to the nearest 100' is set at GS intercept, until 1000' then you set missed approach. This one's a head scratcher for sure until we hear more
Hi Mr Brown,I really enjoy your channel,I saw you on KCRA tonight at the Gen Chuck Yeager 100th,I have a question I wonder if you could comment on,I once watched a documentary on RA Bob Hoover and it said he might of been chosen instead of Gen Yeager to pilot the.X-15 but he had a pervious Indiscretion that cost him the spot,and it said he flew the chase plane on that flight,im a fan of both men,do you know anything further about this,I would be interested, thank you Sir
I'm afraid that this will be a continuing trend with the willingness to accelerate pilot learning to get them behind a stick. Any warm body will do.
Some rumors floating around.....take it for what it's worth I suppose......but they indicate that the Captain called for flaps 5, and the FO retracted them to flaps 1 before reaching the lever gate. The low speed may have then caused a loss of lift leading to a stall situation. Any thoughts on the possibility of this scenario in the 777?
Wow, those beautiful P-51’s at the end!
If it was due to a microburst, all souls were VERY LUCKY it didn't happen 800 ft lower. Very experienced with Hawaiian microbursts. Poor crew decision to not delay - that DFW microburst crash about 30 years ago got Doppler Radar used.
Interesting, maybe flap retraction too soon after thrust reduction altitude. Wouldn't be the first time. Lets see what comes from it. A 777 did that recently, I think Juan reported on it. Stall warning was on the audio..
So refreshing to hear someone say “correction” seamlessly as you should. Lost fundamentals these days
Considering the airframe could have been over stressed at +2.7G’s, I am surprised the pilots continued the flight and went up to 39,000ft, rather than immediately diverting.
A design question - what is the recording time on 777 CVR and FDR before they overwrite older data? Question applies to both this incident and the JFK incursion where the AA went ahead and departed.
Juan’s comment at 8:40 - and the way he delivers it - is concerning. I’ve often wondered about a general decline in airmanship over time.
We have cemeteries full of pilots who are too smart to use their checklists
As a pilot with a few thousand hours of flight time rated on the 727, 737, DC10, 757, 767, 777, and Airbus 320 on Microsoft flight simulator, (LOL) shouldn't this be on a checklist to check the alt select window? I certainly check during my pre-flight. This is way above my aviation knowledge to fully understand what happened. Always great job on the blancolirio channel to provide us great insights on aviation news!
Our man Juan is...always... so good!
Turns out today news blips are happening claiming that the autopilot was potentially set incorrectly.
Who knew?
If you look at the flight's FMS SEL box on ADS-B, no altitude is selected until they pass through 6,000 feet. At that time, 16,000 feet is shown on FMS SEL. Therefore it seems very unlikely that this incident was caused by zero altitude being selected and then the autopilot or pilot following the FD flying the plane down to zero altitude.
In any event, it's now widely reported that this incident was caused by the flaps accidentally being retracted too much shortly after takeoff.
Hi Juan, really love your channel. Id heard that some of the confusion on this flight was due to a miss communication about the flaps setting and that the captain spent most of his hours flying in a Air Bus.
Wait, engaging the autopilot would engage them in the already active flight director modes, right? If the flight director is centered, the AP wouldn't just start a nosedive, and if the FD bars are way off center, why would you engage the AP in the first place? Normally LNAV and VNAV would be armed, what would happen to VNAV if the alt was set to zero?
I don't know the 777, but in the 737, if the autopilot is engaged while in take-off mode (TO/GA on FMA), the system would revert to LVL CHG (MCP SPD on FMA), the A/T would have to reduce thrust to idle. All that would be boxed on the FMA, which would be unusual if VNAV is expected to be active, and should get the attention of the pilots.
I too was on that flight. I am not a pilot and had not been thinking about how close we were to the water. I do however teach Physics and just heard that our story was released to the public with enough data to have the classes do some "High School Physics" calculations. Suffice it to say, thank goodness for air resistance or we would have been in pieces in the water. With said air resistance we had about a second and a half to spare? Cool Physics stuff. Nice to feel 2.7gs but I wouldn't do it again. I agree airlines need to keep planes on the ground in that kind of weather.
Wait, ain't tha' the Blanco dude's Husky hangin' with the 51s?..hoowhee, SkyKing!
Thanks for the report Juan. Due to the potential for over-G, why didn't the aircraft return to Maui for inspection rather than continuing on to the original destination? Seems kinda weird, not to mention that all the pax would've probably been pretty spooked by the event.
I would think that it would be in the recorded data which the crew cannot access or see.
Perhaps every airline pilot knows the cockpit voice recorder erases after a certain amount of time....?
@@chrisroberts3963 8600 fpm down is pretty severe, I don't think I'd need to look at the data to consider returning to the airport that I just left to make sure the plane's in one piece.
@@thomaslemay8817 Fly two thousand miles over open ocean rather than land heavy? A 777 can land at MTOW, it just needs to be checked afterward. Or, either dump fuel or circle near land to burn it off, not commit to a two thousand mile crossing if there is doubt about the airplane.
My guess is the G forces they felt most likely did not feel like much. 2.7 gs does not feel like much to pilots that fly all the time. When the pilots did the pull up I imagine they did not think about gs pulled either. If you think you might crash that sort of thing is not high on your list of what is the most important in your brain.
Love all your considered analyses.
Wish main stream media were as good.
Heard the pilots were admonished internally for not returning and have been sent for full requalification training
I personally doubt the AP hypothesis suggested. 0 ft would result in a near 0 G bunt over, and would be immediately noticeable by any crew. If the AP was selected on at very low level (as per Emirates incident), that reaction time to disconnect the AP could result in the recovery ending close to the ground. However in this instance there was significant loss of altitude.
It may depend on the company, but I would expect a genuine GPWS warning to be reportable and would be investigated by local authorities where I live, and I expect most western jurisdictions.
That sounds pretty scary that this new trend seems to be starting. Hopefully the Airlines will jump on it before there's an incident.
Do you find it strange that all that was released in terms of pilot flight time was the summation of pikots pilots and not each individual total flight time which is normally done? 777 CAPTS generally have roughly 20-25K hours total flight time before they are senior enough to hold the left seat. Could it be the FO had 3000ish hours? Is there a price to be had for putting new hires in the right seat of large commercial aircraft?
The Emirates flight mistake you mentioned is similar to when I accidentally set 0 feet in the A/P controls in simulators.
United says that the pilots had to be given some training. So were they trained to negotiate a micro burst or doing the check list properly.
One thing we constantly hear on accident reports is of faulty settings . While warnings like bank angle, sink rate etc are built into the aircraft program, why can't incorrect settings be checked during the different stages of flight be monitored and warnings issued.
The rate of descent may have been tied to IAS or some speed hold mode engaging where the nose went down to get to a certain airspeed speed regardless of VS (vertical speed) - when they saw this happening AP/disconnect and pull out of dive
Were the flaps brought up inadvertently to 0 when flaps 5 was called for?
Saw someone post on a local newspaper forum (rather definitively, but anonymously) that the copilot mistakenly moved flaps from 20->1, instead of the "20->15" that the pilot had requested, perhaps because "both were relatively new on-type." I have no flying knowledge... but would that make sense per your scenario, even if unverifiable?
Do you pilots get a warning in the cockpit when you exceed the g forcre limit, like in the United Airlines case? If so would it be a reason to abort the further light, and land as soon as possible? In this case return to Kahului airport?
Those Mustangs look brand new. Beautiful. Could they install an alarm if the altitude is set at zero on TO? Let's face it , not many airports at at zero altitude.