Merged: NJS/QANTASlink 717 accident report update [Archive]

neville_nobody

12th July 2008, 13:16

This article doesn't exactly paint NJS in a very favourable light......

Steve Creedy, Aviation writer | July 12, 2008

THE co-pilot of a QantasLink jet that landed so hard in Darwin it creased the aircraft's skin had raised concerns about difficulties with landings before the accident.

An investigation by the operator of the Boeing 717, National Jet Systems, also found there had been an influx of less experienced pilots because of a skills shortage, and problems with training procedures.

The 717 landed heavily on the left main landing gear on February 8.

None of the six crew or 88 passengers was injured but damage to the aircraft included creases to the skin above and behind the wing and damage to the airframe.

An Australian Transport Safety Bureau interim report released yesterday said the co-pilot had been involved in at least two hard landings in the 15 days before the Darwin accident.

It said the pilot had raised concerns about difficulties with landings with a check captain during a previous flight and with another check captain after the Darwin accident.

But he did not report the landing difficulties directly to NJS's training organisation because of worries about procedures and how it would be handled.

Investigators said NJS's pilot training and checking manager had also been acting as head of pilot training for the 717.

They said NJS had found during its investigation that the lack of a separate head of 717 pilot training had been a factor in the flight crew's lack of confidence in the training organisation's ability to manage information.

"This situation has been aggravated by the irregularity of check and training meetings," the NJS investigation found.

"Flight crew have reportedly been reluctant to identify training issues directly with management."

NJS also admitted that a pilot shortage had forced it to employ less experienced pilots.

NJS has since hired a separate 717 training captain and developed new training procedures.

Icarus53

12th July 2008, 23:57

NJS also admitted that a pilot shortage had forced it to employ less experienced pilots

The co-pilot in question had around 7500 hours if I'm not mistaken - I would not classify her as "less experienced". While I strongly believe that hours in a log book do not necessarily add up to experience, I don't think this comment (which was apparently sourced from a QANTAS internal investigation report?) is particularly relevant in this particular case. Even though she was relatively new to the 717, the current employment climate hasn't changed the fact that everyone has low time on type at some point. Another example of media/company pushing a hypothesis with the wrong evidence?

The ATSB report (which I can no longer open for some reason, so bear with me if I am off the mark here) raised a number of questions for me:

1. If the a/c passed over the locator at 3000' (which is the altitude at which the approach commences), how did it end up above the glideslope, requiring it to capture from above?

2. If the aircraft did achieve its stable approach criteria, how did it become such an unstable approach. The best definition of a stable approach I've heard is when the aircraft requires only minor control inputs in order for the aircraft to continue to the correct touchdown point at the correct speed". If this was the case then I can't see how such large RODs resulted without substantial external forces?

Question for the NJS boys and girls - how are things in the training system now? One of the primary outcomes according to the report is that there is now a 717 qualified HoT. Has this improved things? Is the training culture a positive, supportive one?

That's enough for a Sunday morning methinks ...

beaver_rotate

13th July 2008, 00:08

Not that it changes anything at all, but Steve Creedy has just assumed the co-pilot is a 'him' when in fact it was a 'her'.

A minor detail

UnderneathTheRadar

13th July 2008, 00:38

Icaraus53,

My best guesses to your questions are:

1. One of the safety actions from the ATSB report was to remove the incorrect level section shown on the Jepp plate from the localiser - this may indicate that the crew were not expecting/not ready to capture the glideslope when they did.

2. Whilst I agree with your definition of a stable approach, I think the 'stable approach' criteria which SOPs mandate is different - they are simply to ensure you're not hot 'n' high on final with the subsequent problems that may cause. You can meet the required standards (the figures were quoted but I can't remember) at the 'gate' and then still make excursions around (and in this case outside) the allowable tolerances - particularly if you were trending speeds and/or ROD at the gate.

Just my opinions and happy to be corrected.

UTR

F.Nose

13th July 2008, 02:39

2. Whilst I agree with your definition of a stable approach, I think the 'stable approach' criteria which SOPs mandate is different - they are simply to ensure you're not hot 'n' high on final with the subsequent problems that may cause. You can meet the required standards (the figures were quoted but I can't remember) at the 'gate' and then still make excursions around (and in this case outside) the allowable tolerances - particularly if you were trending speeds and/or ROD at the gate.

Dead right and if you ask me, both the ATSB and the NJS investigators are off the mark. In my opinion this accident was a result of poor handling and has nought to do with uncoupled approach, black hole, no center line lights,the 60m rwy, weather or anything else.

The ATSB report contains three FDR print outs. If you print Appendix C:FDR-Spoilers and Appendix B:FDR-Short Final and lay them down on the table next to each other they are easier to analyse.

At 11:44:45 when the A/C is at 100'(RA) we can see that the throttles are retarded and are at flight idle by 44:46 when A/C is still at 90'. This may not be alarming if it were carrying speed but at 44:46 we can also see that speed is approx Vref+5 (Vapp). We then see a small peak in 'thrust lever advance' and flight idle again at 44:48 when the A/C is at 65' and speed is at Vref. There is then another smaller 'thrust lever' peak and the throttles are closed at 44:49 or 30' where the speed is recorded at approx Vref-5.

At 44:49 the sink rate is -1000'/min and we see '18 degrees Control column nose up command' but the 'pitch' does not change and the ROD is not arrested. Not surprising when speed is at Vref-5 and the throttles closed.

In short, when the A/C was at 100' at Vapp you would expect an N1 of approx 60% to maintain speed and slope to 30'. The FDR however shows that the thrust levers are closed and the two little peaks that we see are, in my opinion, consistent with the Autothrottles pulling against the hand in an attempt to increase power to maintain Vapp. Speed then continued to decay, the sink rate increased, power was held off and despite pulling back on the control column ROD could not be arrested.

ITCZ

13th July 2008, 05:52

if you ask me..... In my opinion....
It appears that
You weren't asked, and..
an opinion based on maybe five minutes of loose interpretation of a couple FDR summaries is of questionable value.

Lord Flashhart

13th July 2008, 09:15

ITCZ,

Well, i am asking your opinion. What do think happened?

F.Nose

13th July 2008, 11:12

ITCZ,

Here's a challenge for you. Instead of posting insulting comments, why don't you have a look at the FDR recordings and tell me what is wrong with my observations.

Mach E Avelli

13th July 2008, 12:35

Question - does NJS still do post-simulator-endorsements (circuits) like they used to do for the 146?
If not, why not? Is the simulator they use really so good that this is no longer required?
Also, how often does their manual say they will have check and training meetings, and how often do they actually have them?

scrubba

13th July 2008, 13:42

Why would you need post simulator endorsement circuit training if you use a Level 'D' simulator?

Do the two pilots that crashed this thing go to these meetings or is there some other process that translates management meetings into pilot performance?

4dogs

13th July 2008, 13:53

Scrubba's comment made me read the ATSB Interim Factual Report in detail. Clearly Steve Creedy and the New Ltd reporters were reading a different report from that which I read - is there another report out there that actually supports what these wonderful Australian journalists are publishing?

As far as the ATSB report is concerned, there seems to be a disconnect between the body of the report and the interim findings - so how much is fact and how much is wishlist/whatever?

Stay Alive,

4dogs

Capn Bloggs

13th July 2008, 14:53

If the a/c passed over the locator at 3000' (which is the altitude at which the approach commences), how did it end up above the glideslope, requiring it to capture from above?
Because the aircraft is so "smart" that it decides what VNAV path to fly all the way to the threshold. Unfortunately, that does to involve, necessarily, attempting to or making a special vertical path allowance to capture the G/S. This results in going ever so close to the GS from above, but sometimes missing it.

On an uncomfortably frequent basis the 717 will miss the GS, so the crew is then presented with a capture from above, with attendant VS and Altitude Selector setting issues. If not captured promptly things can turn to worms very quickly.

It would help of course if the FMS database was programmed so that the HWS altitude of 3000ft was an AT altitude instead of an AT or ABOVE altitude. But then what would a bunch of antipodeans know about flying Boeings?

4 Dogs,
Clearly Steve Creedy and the New Ltd reporters were reading a different report from that which I read
What bit/s did you think News incorrectly reported?

Mach E Avelli

13th July 2008, 21:21

Scrubba, I have often seen pilots come from level D sim conversions and have no idea how to land the real thing. The PSE is a useful confidence builder for any pilot coming to his/her first large aeroplane. Perhaps not so necessary for pilots moving from one transport jet to the next, tho' I have seen widebody pilots make a real mess of the first few landings when coming back to narrowbodies, despite simulator. No doubt some pilots going to their first widebody also make a pig's ear of their first few landings.
One agenda item that is usually on regular check and training meetings is discussion of any difficulties being encountered on the line. From the report, the F/O in this incident had been experiencing problems and had herself brought this to the attention of someone in the organisation. Sure, a meeting won't prevent the occasional botched landing, but in this case there was a trend that apparently was ignored - at great cost.
Re the other comment above on difficulties getting it sorted if it runs high at glideslope intercept point and fails to capture - whatever happened to the notion of hitting the autopilot/flight director disconnects and driving it immediately back to where you want it with good old Mark 1 hand and eye co-ordination? I have never flown the 717, but doubt that Boeing have changed their long standing advice to manually intervene at the first hint of getting behind the automatics.

maui

14th July 2008, 00:23

Jeez Mach!

You mean use your head and hit the 1946 switch.

Get real. This is an automatic aeroplane. Can't have pilots flying the thing. Anything could happen.:rolleyes:

Maui

Icarus53

14th July 2008, 05:39

whatever happened to the notion of hitting the autopilot/flight director disconnects and driving it immediately back to where you want it with good old Mark 1 hand and eye co-ordination?

Mach,

I agree with you there, but to be fair - the report states that this is effectively what happened. In the first instance, the pilot attempted to recapture the GS using V/S mode on the autopilot, then disconnected the autopilot and captured the GS manually.

BuzzBox

14th July 2008, 08:08

It would help of course if the FMS database was programmed so that the HWS altitude of 3000ft was an AT altitude instead of an AT or ABOVE altitude.

VNAV would still put the aircraft slightly high on G/S at HWS if you followed it all the way down to G/S intercept in hot weather. The aircraft altimeter might be indicating 3,000 ft, but if the temperature is greater than ISA the true altitude would be slightly higher, putting the aircraft above the glideslope at HWS.

Why not take the aircraft out of VNAV earlier and use another mode such as V/S to make sure the aircraft intercepts the glideslope from below?

Just a thought...

Mungo Man

14th July 2008, 21:02

I find it difficult to accept that a pilot with 7,500 hours and 400 on type would have such difficulty landing such that several heavy landings occur in a short space of time. Make me think of that MD-11 that got bent on landing in the States a while back. The pilot had thousands of hours but a poor flying history. Landed with lots of drift, crab and high ROD, gear collapsed. How do such pilots get so far in the industry?

SHAGGS

15th July 2008, 06:15

Sounds like NJS's Check and Training Department need a good clean up.
Regardless of the experience of the co-pilot who was involved, she did pass her concerns on about her difficulty with landings to the appropriate people, and what happened, nothing obviously until NJS ended up with a bent plane. Was the Captain a Checkie, No ! And he shouldn't have to wear the rap if the F/O screws up if the company can't put confident and well trained pilots in the cockpit with him.

This really is a swiss cheese job, all the holes lined up and bingo. Very lucky there weren't any serious injuries of fatalities. I know there is/or was a pilot shortage, and to try and justify part of the blame onto having to employ low time pilots just does cut the mustard. Nothing wrong with employing low timers, but they need more training in most cases than experienced pilots.

17R35L

15th July 2008, 06:38

7000 hours low time?

cunninglinguist

15th July 2008, 09:31

F.Nose, your analysis of the FDR sounds pretty good to me, the only thing wrong is certain NJS drivers have a hard time admitting the outfit they work for is complete crap, human nature I guess.

[QUOTE]7000 hrs low time ?[QUOTE]

7000 hours on what ? piston, T/prop ? yeh, 7000 hrs does not an ace make ( necessarily )

leg man

15th July 2008, 09:37

Total time is no indication of a pilots ability this is just another example. What did the 7000hrs consist off? I bet it wasnt jet operations?

Pilots shortage and high turn over puts pressure on the check captains to check to line copilots that probably require more training or should not be checked at all.

Lefthanded_Rock_Thrower

15th July 2008, 10:30

When did 7,000 TT become "Low TT" ?, in other countries FO's have bare licences in this type.

Perhaps said pilot was simply having a bad day,,,,,have you ever had a bad day ?.

cunninglinguist

15th July 2008, 14:35

Read the report, aforementioned f/o had lots of bad days, self confessed.
7000 TT means jack s**t.
Yes, in other countries F/Os have 250tt on similar or bigger types.................ask the Captains of those A/C how much support they get when the going gets tough, or slightly abnormal.

Kangaroo Court

15th July 2008, 15:00

Yes, I think we can all agree that 7,000 hours at the golf course does not mean we can all play like Tiger. Perhaps this was yet another example of how people believe that throwing money at a problem ie: Pay-For-Training can make the problematic history disappear. This is totally irresponsible and is the reason the Yanks have the Pilot Records Improvement Act, to prevent pilots with poor training records being unleashed on unsuspecting employers who have been smoothed over by some interview prep' course.

captaintunedog777

15th July 2008, 19:14

Some people were just meant to fly. No matter what the training or who's head of the training department. :=

SHAGGS

15th July 2008, 22:39

Doesn't matter how many hours we have, we all have a bad day now and then. The problem is that the F/O concerned knew she had a problem and sought help prior to the accident, and what happened ? She get none.

Sounds as though NJS management have a bit of a culture problem. Hopefully we all can learn from this accident and move on in a positive direction.

What happened to the Captain, is he back on line ? And is the aircraft back in service ?

ShockWave

16th July 2008, 19:38

Any one who is not confident to be able to perform their duties should not report for duty. Whether it is due to sickness or any other reason? If you belive you don't have the necessary skills to perform your job, but still turn up to work and take passengers for a ride, you are irresponsible and deserve to be prsecuted. It is that simple. The company also has the responsibillity to ensure you are trained to the required standards.and will be held responsible if found to be negligent in this.
However, as alway we pilots must take the final decision as to whether we are prepared to accept the responsibillity for our actions. If I don't think I can land my aircraft in any conditions I am likely to experience I am not going to be stupid enough to take it into the air. You should never assume that there will be someone else available to save you.

What input did the Captain have during the approach and landing? Did he/she attempt to take control at any time? The Captain is responsible for the safety of the aircraft so why allow this situation to develop so far and then fail to prevent the aircraft being flown onto the runway at 900fpm. It must have been fairly obvious things were less than satisfactory. It makes no difference that he/she was not a training Captain, it was his/her aircraft and he/she allowed their co-pilot to screw up. Not a good day.

Capn Bloggs

17th July 2008, 02:41

Shockwave,

I agree, to a point. That classic line from Topgun, "your ego is writing cheques your body can't cash" comes to mind. Whether due to ego or lack of talent/training, a person's perception of their performance may be higher or lower than their actual (or required) performance. IMO it is the responsibility of the training and checking organisation to make sure a pilot is at the required standard for the operation. I think your inference that the FO, because she asked for more training, should not be in the cockpit is a little harsh. If fact, she should be complimented on identifying a problem and asking for help. That does not necessarily imply that she thinks she's so bad that she shouldn't be in the cockpit and should take herself off line.

Regarding the Captain's performance, once again, I think you're being a bit too black and white. While the approach was pretty wobbly, which would indicate that a dodgy landing may ensue, not a lot matters until the gravy-stroke at 30 feet. Unless one becomes paranoid and takes over at the slightest hint of a problem, it is difficult to micro-manage the flare when one is not the PF. The captain relies, to a large extent, on the skill and ability of the FO to not "crash" the aeroplane. As I captain, I should not have to continuously worry about what the FO's landing will be like or whether I should take over. If that is the case, then the T and C system has failed to do it's job.

SHAGGS

17th July 2008, 03:22

Capn Bloggs,
I totally agree 100% with you comments, you have taken the words right out of my mouth !

Shockwave,
I can understand where you are coming, I feel that the T & C department should have addressed the issue before the accident.

Ruck Bogers

17th July 2008, 03:46

It all Risk Management gone wrong

From the CEO PN all the way down through the C + T department.

The failure of PN "No Horizons", junior FO's on "B" scale wages, nil morale within the company and a high performance jet = a smackdown landing.

NJS would rather employ nil to very low jet time FO's on B scale wages than to employ experienced jet hours Pilots from inhouse. This is evidenced by the number of experienced FO's walking out the door.

Its all about the $$$$.

Responsibility for this rest squarely with the "we-can-do-no-wrong" CEO PN.

Welcome to National Joke's regional jet operations. :mad:

five dogs

17th July 2008, 06:24

Buck,
I think you are still in space.

For starters, there are not many "experienced" 717 F/O's walking out the door. A few inexperinced ones have.
Although you cannot name them on here, you can give us a hint of where they have left from and gone to.

If this person was trained to a satisfactory standard on day one, and then if her problem was addressed when she bought it to the attention of the C&T dept, this probably wouldn't have happened.

Agent86

17th July 2008, 06:50

I think you will find the first port of call for the FO to sort out the "problems" was to talk to line captains ...and we all know what happens then:confused:
The request for help was after the event and was given.

five dogs

17th July 2008, 07:03

As a check and trainer you should know better than tell porkies on here 86.
The F/O advised a check capt, in fact a check capt saw for himself firsthand PRIOR to the event. A brief brief was given, you may call that help, that may also be part of the problem. :eek:

Lets all balme the line capts cause the 217 org could do no wrong, could it. :yuk:

Who trained this person? Maybe thats were the problem started? :oh: