How a Simple Switch Triggered an In-Flight Upset on a 737

[@AirTrafficVisualised]

By way of clarification: I don't intend on moving away from the classic ATC audio/visualisation/breakdown format - there's more of that to come - just wondering if viewers found this interesting enough to justify occasional investigation report overviews in future. The primary difference to my mind is that, with the benefit of a full investigation, a more complete picture can be painted. For example, control wheel positioning and bank angle data were provided in this investigation report - that's not available via ADS-B, as well as crew communications with each other, accurate timelines of events based on flight data recorder information, etc. Thank you all for watching and for your feedback!

[@himethisisme]

I really like this format. I hope you do more as well as the more "traditional" videos.

[@jakint0sh]

Yeah, I’d definitely enjoy one of these once in a while alongside your usual videos. Also, kudos for the insanely good editing, production, etc. Here’s to hoping you get more recognition for it at some point :)

[@bubbleboom1]

Both formats are great

[@less7651]

Loved the addition of the Real-time replay at the end, displays perfectly how quickly these things truly happen.

[@AirTrafficVisualised]

I spent weeks working on the video, creating the visuals, reading the report. But it was only when I watched the real-time replay that it really struck me how quickly the upset occurred - and how quickly the crew reacted to intervene.

[@Anolaana]

For sure! All of a sudden at 8:54 the wings just flip, it's kinda crazy. Trim of all kinds leads to some crazy incidents. My only feedback for ATV is that it was a little unusual hearing the usual uplifting "Midnight Landing" theme music that usually plays after an event has resolved during the event being retold! Something else like the second half of the more dramatic "PvP" track might have fit, or even the rock of "Breaking Through" to signify an event in progress?

[@edgars9581]

I like it a lot! A small thing: I think the replay was lacking the cockpit conversations, they added a lot in the previous segments

[@aeomaster32]

Having years of flying the fully manual B737 200, at a time when engine failure and other emergency training was done in the actual aircraft, not the simulator, the following engine failure procedure became instinctual and second nature. First an explanatory note; the flight spoilers on the wings were there to help the ailerons roll the aircraft into banks by deploying on the down-going wing. Thus, if the roll control wheel was deployed more than a few degrees, the spoiler on the down-going wing would start lifting, decreasing lift and increasing drag on that wing. Now consider an engine failed (say the right), and the aircraft wants to roll right towards the failed engine. The pilot cranks on left aileron to stop the roll, which also deploys the flight spoiler on the left wing increasing its drag. The only way to stop this drag is to centre the control wheel with the left rudder trim until the wheel centers itself. After many practice sessions with engine failures in the real B737 200, it became automatic to check the rudder trim and use it to center the control wheel. Sadly it seems that the old manual skills are fading away, causing pilots to address the automation and not the airplane when seeking an answer.

[@Lachy-o5q]

That real time thing is a great addition. When you watch 10/20/60 minute videos about an incident or accident, you imagine it dragging out over a similar period of time, even when you’re told it was only however many seconds/minutes. Seeing it on the screen in real time really makes you see how fast it can all happen

[@apolloactual7666]

This is probably the best quality production of a flight report.

[@Nalehw]

Aww yeah, new ATV upload! You've always got the highest production value in the genre, I love it. New format is cool! It's great to see the exact controls, and hear exactly what they're for and why the pilots are doing it. The reenactment is great too! Some parts like the Contributing Factors section are a little wordy - feels like you're just reading off the report verbatim - some people who aren't quite as aviation-brained might tune out at that point? I especially appreciate the real-time replay at the end - events can happen so rapidly that it can be hard to keep track of how long each part took, and other creators' aviation vids hardly ever consider that.

[@AirTrafficVisualised]

Thank you for the feedback! There is definitely a more interesting way to present the findings section towards the end, I'll consider that should I make another of this style of video.

[@Destroyer-20000]

Great format! The real time playback was fascinating!

[@Bellonging]

Oooh I like the way you showed the relevant information and I really love how this feels like a combination of the usual stuff with the report overview. I've not read the report but it certainly seemed well summarised.

[@GreenCrim]

Like the new format. Good stuff.

[@TheFlightDoc]

Absolutely phenomenal video!

[@keyszhang356]

New format is fantastic mate, well done!

[@AirTrafficVisualised]

Thanks for the feedback, I'm glad you enjoyed it!

Awesome new format! I would love to see more!

[@desmond-hawkins]

Great video! It could have gone a lot worse, there have been several major crashes due to pilots fighting against extreme trim settings. The MCAS crashes were relatively recent and saw a lot of coverage, but loss of trim control has happened due to a number of factors. Alaska Airlines Flight 261 was also due to runaway trim after a mechanical failure, for example. Having the feeling that the aircraft acts like it has a mind of its own and that you're fighting it to survive has to be terrifying.

[@AirTrafficVisualised]

When you watch the real-time replay, you can see how quickly the bank increased once the autopilot reached it's limit of authority. The crew did well to counteract the roll and bring the aircraft back to approximately level flight. Even another 1 or 2 seconds delay could have been the difference.

[@Lachy-o5q]

I like this to the point style. I watch a few air crash/incident type channels and they drag a lot out - obviously there’s more info when there’s a crash, but still, this is informative while being engaging and the animation really helps a complete noob like me understand

[@A320_shrek]

You explained it so well! Great job!

[@zovisapphire]

I'm liking this new format :) This is such high quality that this should be considered official education material :D For example, it has finally clicked what EXACTLY Trim does. I always had a rough idea, but it didn't completely click in my head. Now it does :)

[@Enigma_Kay]

Love the new format, you should definitely do more of it.

[@matsteele6437]

well compiled and presented - thank you :)

[@kodiakwood4924]

Love the new style of video.

[@ozsimulation]

Absolutely loved this video. Watches every second!

[@Rijndael1998]

The real time replay was good. Please add cockpit convos to it :)

[@guybough]

Loved the video format. It was engaging and detailed. Quite different to other channels.

[@AirTrafficVisualised]

Thanks for watching! I'm glad you found it enjoyable.

[@jeffblyth5961]

great presentation

[@AirTrafficVisualised]

Thank you for watching!

[@mitchul]

That photo at 0:44 looks familiar! Awesome video.

[@AirTrafficVisualised]

Thank you for providing your photos under a CC license so that other creators like me can use them. It may seem like a small thing but having real photos of the aircraft that's being discussed definitely adds something to my videos.

[@mitchul]

@@AirTrafficVisualised not a problem - it’s why I licence them that way! Feel free to use them whenever you need.

[@Jimbo-t2h]

More like concerning than fascinating. Great expose and in an excellent and concise format. Thank you.

[@feynthefallen]

This is a classic case of distraction. If you're distracted, your brain turns on it's own autopilot, trying to complete the last commanded action by way of the secondary motor cortex. However, with the consciousness occupied elsewhere, there is no optical feedback via the cerebellum, and the only remaining feedback is haptic and subconscious. That unfortunately only kicks out of automatic if it encounters something truly unexpected. Has the fimgers touched, say, a piece of sushi, he would have jolted back. Since however both knobs had a familiar feel to the captain, the 'grab knob and turn left' subroutine was not interrupted.

[@ellismillr]

Very detailed. Great video. Thanks.

[@Sygulsty]

Bought the midnight landing soundtrack, and made it my ringtone :)

[@AirTrafficVisualised]

I'm glad you enjoyed the music! Thank you for your support, I really appreciate it.

[@Sygulsty]

@@AirTrafficVisualisedofc! Anytime

[@navajojohn9448]

The only thing missing from this crew is the all inspiring comment of confidence " what is this plane doing?"

[@johntu7484]

That quip-“What is this plane doing?”-is a bit of aviator’s gallows humor referring to those moments of automation surprise when a pilot suddenly has to ask why the aircraft is behaving in a way they didn’t expect. It’s something we see in accident reports and cockpit voice recorder (CVR) transcripts where the crew, perplexed by a misbehaving system or inadvertent input, blurts out a variation of “What’s it doing now?” In this Virgin Australia incident, no one actually said it, but the situation certainly fits the kind of confusion pilots sometimes face when automation starts responding to a hidden input (in this case, unintended rudder trim). The joke is that the only thing missing was that classic exasperated line! Why pilots say it (in real life) Automation Surprise: Modern aircraft have multiple layers of automation that can do unexpected things when an unnoticed input (like mis-set trim) conflicts with autopilot logic. Tunnel Vision: High workload or distractions can cause the crew to miss small cues that something is going wrong until it’s very obvious-leading to that “What on earth is happening?” exclamation. Complacency with Routine: In day-to-day operations, everything is usually so seamless that a sudden deviation can catch pilots off guard, prompting an out-loud reaction. While it’s a humorous take in hindsight, it underscores a serious point: Recognizing the aircraft’s unexpected behavior quickly and knowing when to disconnect automation are key to safe recovery.

[@AirTrafficVisualised]

Your comment reminds me of the legendary Warren Vanderburgh “Automation Dependency” presentation. He says: “Let me ask you guys out here in the 757/6 community, A300 guys, et al. What’s the most often asked question in our cockpits? ‘What’s it doin’ now?’ [Audience laughter.]”

[@HeyMatthew303]

The rudder switch should have bumps or a different feel from the door switch. I’m just surprised the captain didn’t put two and two together with him twisting a switch to the left, and the plane reacting to the left… I wonder if there was a complimentary “oops, our bad, but we’re good now. Annnd that’s why we say remain seated with belts fastened” 😂

[@thegoalie5233]

​@mattg30380003 it does, it's bigger for one, round and with indentations in he plastic, it's completely different to the door switch

[@Dont_Gnaw_on_the_Kitty_1]

Looks like a design issue with the rotary door switch being similar and close to the trim switch.

[@darcyschmidt9997]

This video was really enjoyable and informative, I’ll subscribe for more like this 😀

[@AirTrafficVisualised]

Thank you for subscribing, I'm glad you enjoyed the video!

[@navajojohn9448]

Did either of them notice the rudder pedals were offset and not centered before manipulating them?

[@bsbowring]

Just flew on VH-YQR today (LST to MEL)! Feels a bit ick to be watching this now, for some reason...

[@navajojohn9448]

Generally on most planes if an uncommanded yaw, roll, climb/decent the first thing to do is disconnect autopilot if it is on. It may be causing it. Then move to the next action.

[@user-xu5vl5th9n]

But this was actually "commanded roll". Not sure if the "uncommanded roll" checklist would cover that.

[@flightsimdev]

One is a spring back switch and one isn't he should have known this as soon as he did it.

[@toddfleury7324]

Both are spring back switches but you’d think the difference in size and shape would’ve been obvious…

[@user-xu5vl5th9n]

Similar to the case where the pilot pulled a circuit breaker which gave a slight offset to the rudder. That did not end so well.

[@Lachy-o5q]

Scary to think one accidental dial turn from a distracted pilot can tilt the whole aircraft…watching all these flight channel videos has made me terrified of flying when I never was before lol

[@navajojohn9448]

So much for training. So much for scanning. So much for stick and rudder skills. Thousands of hours of autopilot will do it. Forget the basics like what makes a lane turn? Rudder is the first thing to check and use to correct direction.

[@andrewgkorol]

When I saw the events unfold in real time I didn't think their response time was unreasonable. A few moments to analyse what the aircraft was doing, took manual control when required, once control of the aircraft was regained they began the trouble shooting process, beginning with engine performance and moving systematically. For context I'm stick and rudder advocate who hand-flies instrument approaches. Knowing the aviation pathways in Australia, my guess is the FO had 2000hrs flying remote in all sorts of 'stick and rudder' aircraft

[@JM87Fly]

@@navajojohn9448 Like all airliners, the B737 is flown, by and large, by instructing the autopilot to follow the lateral and vertical navigational path specified in the FMC. The catch with this is programming the FMC is a manual process, and it’s garbage in, garbage out. Also, because the B737 is a dinosaur from before LNAV and VNAV existed, it occasionally does some weird, wacky and wonderful things when following FMC guidance. This means that a lot of the time if the aircraft unexpectedly turns, pitches, speeds up or slows down, it’s something in the FMC, and the first action is to interrogate the computer to see if the programming is legit. Secondly there is automation philosophy. In jets like this, the usual philosophy is to operate the aircraft in the highest available level of automation at all times. If the automation is doing strange things, you usually step down through the levels of automation to achieve a known state, rather than simply switching it all off. This is for a couple of reasons: first, flying jets can be pretty demanding and removing automation causes workload to immediately skyrocket. This limits the ability of the PF/PM to work together to solve the issue. Second, at high altitude jets must be flown with extreme care and caution to avoid stall, overspeed or over stress. In a situation like this involving uncommanded roll, rudder is the *last* thing you want to use as it’s an enormous, powerful flight control which could stall a wing or snap the tail off if not used with extreme caution. Personally, I likely wouldn’t have done anything different to what the PF in this scenario did. They had an unidentified issue which caused the aircraft to veer off track, so perhaps suspecting LNAV, they went to a HDG SEL to regain tracking. It was only AFTER this action was taken that the bank angle became concerning, at which point the crew called ‘upset’ and completed the required memory items. An own goal in terms of the application of rudder trim in the first place, but pretty well-handled after that from where I’m sitting.

[@Shadow7717]

New format is great, but will this sacrifice the time you have to spend on the regular formats you have been doing? Your vids are far better then other similar ATC channels here on KZbin.

[@AirTrafficVisualised]

I've added a pinned comment - I foresee only occasionally making a video of this style, the plan is to predominately stick with the regular ATV format.

[@boyousef544]

So the Capt turn the Trim switch and the 737 yaw immediately and he never look back what did he turn !!!!

[@jamescollier3]

kinda of a design issue also

[@ats-3693]

Yeah that seems a bit lacking, he noticed the trim control switch was incorrectly switched to left trim adjust and centred the switch again, but didn't bother looking at how much incorrect left trim was now applied then correcting it.

[@azzajohnson2123]

@@jamescollier3absolutely a design issue. Having a commonly used turn switch next to a similar one for flight surfaces and the other one to open a door. The door should be a toggle located very much away from the trim settings.

[@jr800w]

@@ats-3693It sounds like he/she held onto the selector and let go after 8 secs but didn’t look at which dial was turned. It never occurred to the PM that the wrong knob may have been turned. Some sort of confirmation bias.

[@AngusSwann]

I was on a flight on the same day Virgin Australia from Melb to bris at 8 am

[@pcorf]

This aircraft was originally registered as VH-YFP then it was reregistered as VH-YQR.

[@markcardwell]

I like it 😊😊😊😊😊

[@BallisticAviation_YT]

9:58 now, i don’t really like to ask for likes and subs, but that like+subscribe notification is very creative! great video as well!

[@johntu7484]

A momentary distraction and accidental activation of the rudder trim switch sent the 737 into a left bank that quickly exceeded what the autopilot could correct. Timely action by the crew prevented a more serious event.

[@azzajohnson2123]

Reminds me of a time when a plane was lost because of the co-pilots watch pressed down on a safety gate for a lever. And the only reason that happened because he wore a big bulky watch on his right hand (being left handed).

[@Skeke]

Did they get their afternoon tea though?

[@AirTrafficVisualised]

This is a significant oversight of the investigation report - no update on the status of snacks.

[@brendanbroadhead5699]

While I really like this format and the video itself is done to the highest quality. This video is more educational which I presume was the intent. However as a matter of preference, I prefer the old format with an in depth breakdown afterwards. Nonetheless a great video!

[@AirTrafficVisualised]

Thank you for the feedback, I plan to generally stick to the traditional ATV format so don't go anywhere, there's more of that on the way!

[@brendanbroadhead5699]

@ you’re the best on this platform mate. Much love from a fellow Aussie aviator!

[@fajarikhsan9749]

I thought that switch had been replaced after the incident in japan.

[@aeomaster32]

I flew one of the first B737 300s, and one day had a cabin attendant come up when we were on the ground. She sat on the jump seat and put her foot up on the pedestal. I told her to remove her foot, and when she did, I noticed that the single unprotected switch had moved the rudder trim several degrees. A little later a government airline check inspector was sitting in the cockpit and I said to him that without a guard, the unprotected rudder switch would cause an accident. He said "It already has." They later put on a guard, then changed it to the system shown in this video. Seems it still not fool proof.

[@AirTrafficVisualised]

The ATSB report details Boeing's response to the "Tokyo occurrence," which was: • ensuring flight crew awareness of this specific potential for error and the need for visual identification prior to operating a control; and • ensuring that no aircraft in their fleet had the rudder trim control in the same location as the flight deck door switch on another aircraft of the same type.

[@xr6lad]

People can’t understand the term ‘4pm’ instead of using an international clock very few ‘average Joe’s’ ever use?

[@mizzyroro]

A pity they didn't look at the slip indicator and stepped on it with right rudder to bring it back into coordinated flight. The rudder is the most powerful control surface to counter roll. Even I know that.

[@malkobitches]

Basic stick and rudder…the brick is to the right. ‘Oh let’s input a shit tin of aileron and check the engines”.

[@JM87Fly]

@@mizzyroro you almost never use the rudder in the B737 - especially not at high altitude cruising flight. To do so could actually be extremely dangerous. The aircraft is flown feet on the floor 95% of the time, which is by design. The yaw damper takes care of yaw anytime you aren’t operating the pedals.

[@jr800w]

PM is Captain?

[@AirTrafficVisualised]

Yes, in the multicrew environment it is common for pilots to swap roles (usually leg-for-leg) so that the first officer can gain experience as the pilot flying.

[@navajojohn9448]

How many thousands of times has he reached for and used that door lock? It is even a different size than the rudder trim.

[@gort8203]

And smooth as opposed to knurled. No excuse pilot error, but Boeing gets the blame.

[@feynthefallen]

And how many times has he reached for the rudder trim? The crux is, both feel equally familiar, and the brain on autopilot isn't sophisticated enough to discern round from chunky, only familiar from strange.

[@gort8203]

@@feynthefallen They don't feel equal, they feel quite different.

[@feynthefallen]

@ **sigh** Yes. Consciously. Are you even reading what I'm writing here? If you were closing your eyes and feeling for them, they would be quite distinct. But neither of them would feel more or less familiar than the other, because you would have touched either of them a thousand times. The captain is not feeling for them though. He's opening the cockpit door. He's done that so many times that it has become programmed into his secondary motor cortex. "Move your hand to that position, grab knob and turn left". So as long as he concentrates on the action, he can steer it and feel that the knob is the right one. If he's distracted however, his brain can still complete the action, but without his conscious attention, the hand cannot discern anything more than "familiar" or "strange", so as long as it feels a familiar knob, it will slip the consciousness a little note saying "success".

[@ats-3693]

Flying with crossed controls...

[@navajojohn9448]

Most accidents are pilot errors.

[@iamNOTyourDADDY]

スイッチ操作したら音声ガイド出すべき

[@asquithea]

On today's episode of "bullshit that wouldn't happen on an Airbus..." Nice video tho.

[@aeomaster32]

Air France 447

[@jfyfe67]

I couldn't think of a more appropriate response!​@aeomaster32

[@animegamingdude]

except it can happen on an airbus too

[@ntal5859]

Piolts should be removed from flight status.

[@MooneyOvation2]

Good work on these safety reports. Having said that I’m so over the politically correct bullshit where you refuse to identify the gender of the crew concerned by using a grammatically incorrect plural construct.

[@melbomartin]

Imagine being so fragile that you get upset over something like this. Pathetic.

[@animegamingdude]

using they and them as pronouns to refer to a singular person is not grammatically incorrect you are just too obsessed with woke to understand that

[@jonathanparle8429]

Absolutely abysmal piloting.

[@jspafford]

How about not hire stupid pilots.

[@jakint0sh]

Erm… 13.5k hours on type? Everyone makes mistakes, and besides, do you see how quickly they corrected the situation?

[@Airpaycheck]

That would mean not hiring humans. The best thing is proper training. Don't move a switch until youve looked at what's in your fingers and verify what you are doing.

[@joeds3775]

Spafford staffing dumb comments like Boris the spaffer

[@raybeer5213]

Did they get their afternoon tea though?