Swift Air 737-400 Crash Report

[HeyEng]

The preliminary report of the Swift Air 737-400 crash in Vilnius has come out and the report indicates that the Pilot Monitoring (which was the Captain) accidentally  shut off Hydraulic Systems A and B while trying to turn on the Engine Anti-ice.

Both the Anti-ice and Hydraulic systems use the same lever-lock switches instead of red guarded switches for the hydraulics seen on other aircraft and the hydraulic switches are just below the switches for the Engine Anti-ice.

The overhead panel layout shares the legacy design of the first 737 produced which had the option of having a Flight Engineer who would sit in the jumpseat.  The overhead panel allowed easy access to the controls from the jumpseat but can be awkward from either pilot seat.

Furthermore the Captain probably neglected to observe the blue Anti-Ice indicators come on indicating the Anti-ice valves opened and most likely just moved the levers by feel as he was monitoring the approach. Both pilots missed a vital clue as well since they could not engage the Autopilot with both A and B Systems shut down.

 

 

[Smokin]

Yikes.  It is interesting and surprising what switches are guarded and what are not.  Makes me wonder at Boeing's (and Airbus') logic for the guards.  For example on the Boeing plane I fly, the engine fuel cutoff switches are not guarded.  You have to lift them to go to shutoff, but otherwise no red guard.  The stab trim cutoff switches?  Yep, those are guarded.  Makes perfect sense.

[StoleIt]

I've momentarily turned Sys B off when I meant for the Anti-Ice. The master caution light comes on for HYD, you say I'm dumb, and turn it back on.

From your text, Sys A never got turned off, otherwise it would be really weird for the PM to flip 4 switches when he meant to do 2.

New copilot and a weak Captain didn't help this error train, but I will say, from a human factors perspective, that having white colored tips or the same shape for all those switches isn't a great idea.

[disgruntledemployee]

17 hours ago, Smokin said:

Yikes.  It is interesting and surprising what switches are guarded and what are not.  Makes me wonder at Boeing's (and Airbus') logic for the guards.  For example on the Boeing plane I fly, the engine fuel cutoff switches are not guarded.  You have to lift them to go to shutoff, but otherwise no red guard.  The stab trim cutoff switches?  Yep, those are guarded.  Makes perfect sense.

737 Electric hydraulic switches are turned on/off every flight, so red guarding those doesn't make sense.  Also, in the Max, if its hot out the engine pump switches are turned off for engine start. 

I've seen it once where the Capt reached over to turn on the eng heat but fliped the hydraulic switches, kind of a cross cockpit mistake.  The master caution coming on at switch flip is the sign that the wrong switches were flipped, and that happened to this crew, but they reset the MC and didn't look into what or why. 

Yep, what StoleIt said.

Edited yesterday at 07:44 PM by disgruntledemployee
I started the post an hour ago

[FUSEPLUG]

11 minutes ago, disgruntledemployee said:

Also, in the Max, if its hot out the engine pump switches are turned off for engine start. 

Bro, does that reduce the motoring time?  And if so, how has the world's premier operator of the 737 not adopted this procedure?!

[disgruntledemployee]

24 minutes ago, FUSEPLUG said:

Bro, does that reduce the motoring time?  And if so, how has the world's premier operator of the 737 not adopted this procedure?!

No.  Our FM says for the MAX, "This procedure provides an alternate engine start procedures in an effort to avoid a potential EGT exceedance when OAT is 40C/104F or greater."

[HeyEng]

3 hours ago, StoleIt said:

I've momentarily turned Sys B off when I meant for the Anti-Ice. The master caution light comes on for HYD, you say I'm dumb, and turn it back on.

From your text, Sys A never got turned off, otherwise it would be really weird for the PM to flip 4 switches when he meant to do 2.

New copilot and a weak Captain didn't help this error train, but I will say, from a human factors perspective, that having white colored tips or the same shape for all those switches isn't a great idea.

According to Juan Brown’s video both A and B were turned off during descent and prior to flap extension. They immediately punched off the Master Caution light and obviously missed what the Master Caution was for. The Autopilot will not engage with both systems de-powered. 

[StoleIt]

5 hours ago, HeyEng said:

According to Juan Brown’s video both A and B were turned off during descent and prior to flap extension. They immediately punched off the Master Caution light and obviously missed what the Master Caution was for. The Autopilot will not engage with both systems de-powered. 

Where in the video did he say both A & B? The video you posted above the guy basically starts immediately and says Sys B was switched off and then around at 2 minutes he talks only about Sys B again...and again at 5:26 in the video he says Sys B.

If the incident Captain turned off FOUR switches trying to turn on the TWO anti-ice switches...then he really needs to be drug tested.

[Lord Ratner]

17 hours ago, HeyEng said:

According to Juan Brown’s video both A and B were turned off during descent and prior to flap extension. They immediately punched off the Master Caution light and obviously missed what the Master Caution was for. The Autopilot will not engage with both systems de-powered. 

At American Airlines every time we hit the enunciator panel, we say "6 and 6" to indicate checking that all six Amber lights on each panel illuminated. I think this is the absolute dumbest thing imaginable, and has directly led to legitimate Master caution lights being punched out by accident due to the habit pattern of immediately pushing the master caution button after checking the panel. 

 

I've had to change my habit patterns because I do this too. I no longer check for six lights other than during the initial PreFlight when I am checking all the other lights. Now I tap the enunciator panel for half a second, and look at the master caution light itself to see if it remained illuminated. I've got training in May so I'm going to see if there's any appetite amongst the chick airmen for a change here, because it doesn't make sense to be checking all of your lights a bunch of times per flight, but AA is notoriously averse to change.

[Smokin]

20 hours ago, disgruntledemployee said:

737 Electric hydraulic switches are turned on/off every flight, so red guarding those doesn't make sense.  Also, in the Max, if its hot out the engine pump switches are turned off for engine start.

Yes, but the emergency exit lights switch is guarded and we turn that on and off every flight.  While important, I'd say that switch is less important in flight than some others that are not guarded.

[HeyEng]

14 hours ago, StoleIt said:

Where in the video did he say both A & B? The video you posted above the guy basically starts immediately and says Sys B was switched off and then around at 2 minutes he talks only about Sys B again...and again at 5:26 in the video he says Sys B.

If the incident Captain turned off FOUR switches trying to turn on the TWO anti-ice switches...then he really needs to be drug tested.

My bad, I thought the slats were on A and the flaps on B, but both slats and flaps are on B and the flaps can be electrically lowered like on the 727.