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NTSB says Delta Pilot Error

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NTSB says Delta Pilot Error

Old 22nd Sep 2016, 09:33
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Originally Posted by Basil
I was FO on an aircraft following a very big merger.
We operated the monitored approach system. My captain came from a company where they did not.
C: "D'you mind if I fly my own approach?"
FO: (In warning tone) "Well, YOU'RE the Captain."
FO: (on short finals) "YOU'RE HIGH AND FAST ON A SHORT WET RUNWAY!"

Despite warning, Capt lands and bursts all maingear tyres. I thought we were going off the end.
Funny old thing; I never heard another word about it.

JFDI!
Maybe better and safer CRM should have been applied?
'Do you mind if I do my own approach?' - 'Well captain the RVR/wind/etc is xxx and SOP states that we should rather do a monitored'
'YOU'RE' HIGH AND FAST ON A SHORT WET RUNWAY' - ' Speed is Vref plus twenty, slope 1 dot fly down'...'Go Around'

The burst tires and almost over running the runway are as much your fault for not calling the go aroud
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Old 22nd Sep 2016, 09:39
  #42 (permalink)  
 
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Good vis in howling winds and I fly the aircraft to about 500 ft where the F/O takes over to land

Monitored approaches: I knew of these, but was flying for an airline (B737 family) where they were not in use. F/O was PF single channel ILS. Procedure was for PM to search for lights <500'. At +100 nothing seen, nothing said; at "minimums" PF looked up, sawing nothing and went around. However, as PM, I had been looking out all the time and seen the whole situation. Our 2nd approach was a briefed monitored approach, like our LVO ILS, except a man land by me. It worked a treat.
Many years later, for various reasons, but primarily a safety & success aspect, the monitored approach for precision & NPA's was introduced; but with bad weather parameters. i.e. only when necessary due weather. In that case PF would use AP. It was very relaxed, more so than the previous PF all the way to landing in limiting weather technique. The head-down to head up close to the ground can cause some delay in 'deciding'.
Using a monitored approach for all approaches seems over kill, and especially in the scenario quoted; last minute switch for PF in strong winds. In a couple of runway excursions, in strong x-winds & gusts, one of the contributory factors in the accident report was that PF disconnected the AP too late in the approach; they were not feeling the air during the approach, and how the a/c was behaving came as a surprise too late it be in tune with the environment.
One size fits all may not be the best.
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Old 22nd Sep 2016, 11:16
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Good vis in howling winds and I fly the aircraft to about 500 ft where the F/O takes over to land
I humbly suggest that if the winds were howling that much then the FO probably would not be doing the landing and this would have been discussed beforehand. If the weather is okay then the take-over would normally be around 1000', with plenty of time to get a feel for it. If the weather is at or close to limits then it will be the FO flying the approach for the captain's landing. As you say, plenty of opportunity for captains to cock it up but I suppose it has to be assumed, when designing these procedures, that someone is allegedly more capable and it seems reasonable to assume the captain will reach those lofty expectations.
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Old 22nd Sep 2016, 11:23
  #44 (permalink)  
 
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Poor visibility transition

Re: However do military fighter pilots cope with 200 ft decision heights when flying single seat jets....

DH has an RVR associated with it: typically 200ft may be 550m or 1800ft RVR. Sure, transition from a defined cloudbase isn't much of a problem but most other conditions are, since the RVR values you're given aren't necessarily or even usually the "real" RVR that represents what you can actually see. The illustration below with different touchdown, midpoint and rollout RVRs (700/400/900m) shows why RVR readings don't tell you the actual RVR: definition "the distance over which a pilot of an aircraft on the centreline of the runway can see the runway surface markings delineating the runway or identifying its centre line." Anyone like to give an answer to the question at the bottom of the picture?



At DH you are required to to decide, based on what you can see, whether the aircraft trajectory - position and rate of change of position - is satisfactory to continue. The USAF Instrument Pilots School and other research organisations showed decades ago that (1) you need to assess whatever visual cues you can see for 3 seconds before you can make a judgement of where the aircraft is actually going, and (2) to tell whether its vertical path is correct you need to be able to see the touchdown zone.

So when it really matters, with minimum legal RVR, you have no chance of seeing touchdown zone lights at DH. Even if the atmosphere has a uniform 1800ft RVR, when your wheels are at 200ft, your eyes are going to be at least 4000 ft from the touchdown point so you can only see a few approach lights. 3 seconds earlier, when you really need to start the assessment you'll see even less.

So even if you are right on the glideslope at DH, if your vertical trajectory isn't also 100% right, you won't be able to detect it until you get a lot lower - by which time it may be too late to correct it. Illustrated below.


This is the major cause of poor visibility accidents recognised decades ago and was one of the driving factors behind the development of autoland systems.

Last edited by slast; 22nd Sep 2016 at 12:26.
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Old 22nd Sep 2016, 13:40
  #45 (permalink)  
 
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The PM selects reverse as soon as main wheel touch down.
Real smart when the PF decided to Go Round ala EK521.
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Old 22nd Sep 2016, 15:38
  #46 (permalink)  
 
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Muddling about monitored approaches

Since this thread seems to be drifting anyway.....
There's often muddled thinking about lots of issues regarding "monitored approaches". I use the term Skybrary term "PicMA", partly because just "monitored approach" can be taken to imply that the "traditional" PF/PM flying doesn't include monitoring, which obviously it does.

The case for using PicMA for all routine IFR approaches, not just "when needed", is the same as preparing for an engine failure on every takeoff - you just can't tell in advance when it will be needed. If you've only prepared for a nice sunny day and reality turns sour, s**t happens. Many accident reports prove this, and they ALWAYS blame the crew. UPS 1354 crew for example "expected to be visual at 1000ft aal". But if you're prepared for the worst and it turns out to be a lovely day, nothing's lost.

Similarly there are lots of accidents in "good" conditions where monitoring has broken down - the PM has recognised that the situation is unsatisfactory (e.g. high / fast ) but been unable to convince the PF, who has the higher effective authority, and got caught between the need to help the PF who believes the problem can be resolved, and his/her own judgment that in fact it won't be solved in time. Either could be correct, but the PM's view is fail-safe (safe if wrong), the PF's is fail-dangerous. In a PicMA the PM definitely has the authority to impose the safer option. See post 33 this thread! It's very easy and facile to be smug and say "should have applied better CRM, it wouldn't have happened to me". OK, congratulations, but most of us are a bit more fallible.

The smart way to look at this issue is that you want to standardise on a default operation for the worst risks (which relate to visual transition) and build in flexibility to deal with other real world factors. PicMA operations optimise the IFR approaches which are where public transport risks are highest. So a "best practice" application would start by assuming it's going to be a worst case - rubbish visibility to DH, F/O flying to DH and G/A if needed, Captain takes control when satisfied landing is safe.

The worst case won't actually occur most of the time, so the intelligent way is then to allow your crews (especially Captains) to be professionals and allow the control change at a higher altitude when appropriate. That may well apply with the "strong crosswind but good visibility scenario. For example the following would cover the "good vis but howling gusty crosswind scenario: "At the Captain's discretion, he/she may resume control above DH/MDA provided
a) the aircraft is established on final approach in stable landing configuration,
b) the probability of a go-around due to inadequate visual reference is nil (e.g. touchdown point is visible), and
c) the probability of a go-around due to other factors is low (e.g. runway clear etc).

Another muddled issue is "F/Os won't get experience/ role reversal" etc. There's absolutely no logical reason why using PicMA as your standard everyday procedure should inhibit this in any way. The distribution of T/Os and landings etc. can be identical to that using traditional PM/PF flying. Many traditional operators write the PF duties under the title "Captain" and the PM duties under "First Officer" or "co-pilot", and no-one says that means F/Os can't do takeoffs and landings there. What certainly does happen in PicMA based operation is that if you have Captains who don't give legs away, their F/Os may not get landings but they do get pretty good at shooting approaches because they get to do a lot of them!
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Old 22nd Sep 2016, 15:52
  #47 (permalink)  
 
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So there you are on a CAVOK day drifting down into quiet skies for a downwind visual join CDA to a spool up at 1000' in the slot intercepting finals. Lovely & Rewarding. You've been thinking ahead and planning what to do after VNAV has placed you where you want to be at 10,000 even as low as 5000'. Perhaps you wanted to hand fly from 10,000. In the case where the other chappie is going to takeover and kiss the ground where is the point of handover? Surely it should then be TOD. IT also makes for an interesting brief. The GA could be made by either pilot, but executed by only 1. Who briefs it?
Monitored approaches on dodgy days could be better & appropriate; depends on the dogdiness. Monitored approaches on clear days does seem open to discussion. I can well understand some will that it allows for early correction of hot/high approaches as the other chap is not going to out the a/c where you want it to make your greaser on the white patches; shades of B737 off the end in india, and TSL, & glide medium fall landing in Sweden come to mind where PM (F/O) was not assertive enough to stop the prang & near prang, all occurring in good weather.
I suspect there will remain 2 camps; reason being only the minority will have sampled both options.
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Old 22nd Sep 2016, 16:06
  #48 (permalink)  
 
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In the case where the other chappie is going to takeover and kiss the ground where is the point of handover?
If the weather is okay then the take-over would normally be around 1000', with plenty of time to get a feel for it.
I suspect there will remain 2 camps; reason being only the minority will have sampled both options.
I'm now doing a job where, as PF, I fly the whole thing and I handle the TRs. I still much prefer the system alluded to above i.e. 'monitored approach' on every sector and PM wiggles the TRs.
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Old 22nd Sep 2016, 16:14
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Well the thread seems to have well and truly drifted SO, as someone who moved to Big A some years ago from an airline that operated "conventionally" I agree with Exeng, monitored approach for all ops is bonkers as is PM doing the reverse.
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Old 23rd Sep 2016, 13:40
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... And IMHO if you fly an aircraft with a HUD, or HUD/EVS this should negate the use of monitored approaches.

But now we are so far off thread...
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Old 23rd Sep 2016, 18:07
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Although the thread title cites 'Pilot Error', the NTSB did not state that, neither as a conclusion or probable cause.
However, their discussion did identify several decisions that, with hindsight were less than optimal. Several contributing factors were considered, but most aspects focused on the evolving event and reactive safety solutions.

Is it standard for US operators to use calculated landing distances up to the limiting value. And then being dependent on the accuracy of the reported runway condition, touchdown position and speed, and the availability of reverse. Also would this consider if the landing data provided sufficient margins, crew additives, or even if it considerd the lower EPR thrust reverse.
Many (non US) operators are believed to consider the next lower runway condition and the use of manual brake which provides 'a bit more' than autobrake; this may alleviate some of the PIREP bias and a changed, or inadequately reported runway condition.
The crew having identified an unexpected runway state and knowing that performance was inadequate, continued the landing. The lack of GA puts this accident in the HF area.

Yet the NTSB recommendations consider more/enhanced piloting actions on the runway as a defence, checking, and calls (automated). But in this accident the errant high EPR was identified, called, and corrected, yet control was still lost. Will new procedures change this?

Ref requiring on-board equipment to determine real time braking action may be of limited value. The 'first aircraft' to land may still be at risk of an overrun. Furthermore if every aircraft retarding device was already in use, then what more could the crew could do in the event of an alert. Any device could only generate a reactive safety warning, still relying on pilots' predictive abilities.

Has the NTSB missed the point, or have I overlooked something.
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Old 24th Sep 2016, 07:12
  #52 (permalink)  
 
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TALPA tables were specifically created in the US to get over the subjective nature of runway assessments and to prevent these accidents, but they continue at a similar rate, the pilots taking verbally reported braking actions in violation of the explicit instructions that TALPA braking actions may only be downgraded, not upgraded, by ATC or pilot reports. The guys are simply not bothering to do the calculations. It is complacency, nothing else.
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Old 28th Sep 2016, 13:07
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Originally Posted by LittleMo
Maybe better and safer CRM should have been applied?
'Do you mind if I do my own approach?' - 'Well captain the RVR/wind/etc is xxx and SOP states that we should rather do a monitored'
'YOU'RE' HIGH AND FAST ON A SHORT WET RUNWAY' - ' Speed is Vref plus twenty, slope 1 dot fly down'...'Go Around'

The burst tires and almost over running the runway are as much your fault for not calling the go aroud
Ah, yes, all very well to say sitting quietly on the ground; rather different in the situation.
Suppose ol' skip doesn't go-around: should I fight him for control? Up until then, I hadn't realised that the tvat couldn't fly.

I may say that was a period during which I preferred to fly with check/training captains because I knew they would follow SOPs.
Our company was bending over backwards to accommodate some difficult and barely competent people.*

* If any of you read this, you know who you are and some of you were a dangerous PITA.
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Old 28th Sep 2016, 13:39
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TALPA tables were specifically created in the US to get over the subjective nature of runway assessments and to prevent these accidents, but they continue at a similar rate, the pilots taking verbally reported braking actions in violation of the explicit instructions that TALPA braking actions may only be downgraded, not upgraded, by ATC or pilot reports. The guys are simply not bothering to do the calculations. It is complacency, nothing else.
To be fair, TALPA doesn't start in the US till 10/1/16, a few days from now. In the aftermath of the SWA overrun at MDW, a safety alert for operators (SAFO) has asked operators to calculate landing distance when they differ from planned. While a voluntary program, my company and many others have made it mandatory to complete a SAFO assessment.
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Old 28th Sep 2016, 14:05
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The so-called "British Airways Flight Operations Department Notice" is a fabrication from the mid 1970s created by a BOAC pilot, who circulated it in a slightly different format as part of an unsuccessful campaign against the merger of BOAC, BEA and several other smaller carriers into British Airways. I have all the original files from that period.
The 'spoof' BA handling SOP can hardly be described as a complete fabrication. Having been forced to adopt this SOP many years ago, it quite accurately describes the monitored approach procedure, albeit in a deliberately convoluted tongue-twisting fashion. And yes, the wording was indeed based upon a typical Ronnie Barker sketch.
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Old 28th Sep 2016, 15:58
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Having been forced to adopt this SOP many years ago, it quite accurately describes the monitored approach procedure
Sorry, silverstrata, I have to disagree there. The spoof made a functional system look like madness.
Correctly used in appropriate circumstances, it worked very well. We used it flying an aircraft without autoland into airfields, some of which only had a VOR or NDB approach and, even on a man-land ILS, it was very useful.
Was it useful for an autoland? Probably less so.
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Old 29th Sep 2016, 00:33
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Well I look at it this way: The important thing about SOPs is that everyone is doing the same thing, and unless an SOP is clearly ill-designed or unsafe (and one would hope the regulator would have something to say about that) then they usually work well – whatever they are - because they are familiar, ingrained in the airline’s culture and understood by all. As far as I can see, more accidents are caused by a failure to follow the SOPs – again, whatever they are - than by the SOPs themselves.

Some years ago, I was sent for line training on a new type with another operator which used BA SOPs. We were asked to stay on for a month or two after we’d checked out (our aircraft had yet to be delivered) so I got a good exposure. It was just fine thank you very much, and yes, PM selected reverse. Yeah, it was a bit odd at first but I soon became accustomed to it. And although SOPs are not designed for pilots' enjoyment, I did rather like the fact that you got to handle the aircraft on every sector. When I returned to my own airline we adopted our own company SOPs, and that was fine too. As long as everyone is doing the same, whatever the particular protocols and philosophy are, then you know what to expect.
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Old 29th Sep 2016, 04:53
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Originally Posted by Basil
Ah, yes, all very well to say sitting quietly on the ground; rather different in the situation.
Suppose ol' skip doesn't go-around: should I fight him for control? Up until then, I hadn't realised that the tvat couldn't fly.

I may say that was a period during which I preferred to fly with check/training captains because I knew they would follow SOPs.
Our company was bending over backwards to accommodate some difficult and barely competent people.*

* If any of you read this, you know who you are and some of you were a dangerous PITA.
Perhaps it is easier to say sitting on the ground but the fact remains, CRM is about your actions to manage this situation. I feel for you, it couldn't have been nice flying for a company with that kind of culture.

However, If he didn't go around on your call, maybe transmitting on TWR frequency "xxx is going around" would get some response, but if still none then, "xxx please note for the record that the captain refused to go around from this unstable approach should anything happen"

I've actually heard that radio call in real life and guess what, the guy went around. Sure you'll have a bun fight on your hands when you land but rather sort it then that land and blow tires and endanger pax.
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Old 29th Sep 2016, 08:29
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The advantage/disadvantage of thrust reverser handling by PF/PM IMHO depends on the technology employed as well.

On earlier jets there probably was some danger of overboosting the engine or exceeding some parameters, making it wise for the PM to look at the engine gauges while the PF stayed outside.

On more modern engines having devices (FADEC, EEC, etc.) limiting this danger to almost nil, the PF might be better off handling the reversers himself, thus having a little less delay when deselecting them for control problems, whatever.

As for monitored approaches, they work great although I don't see a necessity to use them in fair weather.
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Old 29th Sep 2016, 09:10
  #60 (permalink)  
 
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Change of thread

The "monitored approach" aspects of this thread have little to do with the original topic. If people want to continue it I'd be happy to copy the relevant comments to a new one in the "Tech Log" forum which would be more appropriate than "Rumours and News" and leave this one for the actual subject of the NTSB report in question. But only if there are a few indications of agreement that it would meet with approval.
Steve
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