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Old 10th Jan 2017, 19:24   #1 (permalink)
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Canada Rouge at Montego Bay

With respect to the crew, who I am sure didn't set off that morning to (almost) wreck an aircraft, this could be another reminder to the pilot community to stay sharp at the pointy end, hopefully endorsed by a supportive training department. Notwithstanding the balls up of an approach, it's the last couple of hundred feet which are really interesting. Touchdown at 108 KIAS, 15,3 deg AoA, 125 ft past the threshold, at 3,12 G with a last second attempt to save it with full thrust. We all know which accident it resembles, in this case they just had enough energy to make it to the runway.

Report: Canada Rouge A319 at Montego Bay on May 10th 2014, hard landing at +3.12G
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Old 10th Jan 2017, 20:03   #2 (permalink)
 
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My guess: PF "forgot" that he already disconnected A/THR.
Fly NPA with managed speed and autothrust ON. Makes life easy.
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Old 10th Jan 2017, 20:13   #3 (permalink)
 
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Most AB pilots will recognise what was going on there. Once the AB starts to "run amok " best disconnect everything & hand fly it.if you can't get it stable go around. But as discussed many times on these forums if you are not happy with your ability. Thrust to toga & go around level off & start again. Mind you some go arounds end up just as bad, but at least you should be a bit further away from the ground.
When I say run amok = self induced.
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Old 10th Jan 2017, 20:35   #4 (permalink)
 
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I was a bit alarmed to read this


- Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach.

Surely this is exactly the sort of thing simulator checks are for. I mean an unstable approach should always be followed by a go around should'nt it otherwise you end up where these guys did or worse. And if its a predictable occurrence then they should get the training on how to handle it. A view from down the back but it really struck me as an odd statement
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Old 10th Jan 2017, 20:45   #5 (permalink)
 
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Toronto Montego Bay is not a short flight. One can surmise the beginning of this swiss cheese was not reviewing the NOTAMS en-route before staring the briefing. For me that is unprofessional. Missing it before flight is one thing; missing it during the flight is not good.
Reading AV's a/c it said they were 9.9 degrees attitude near the ground. I am not an AB pilot, but in B737, at that attitude, the touchdown/runway is out of sight. You can see a lot of sky and not much ground. That in itself is a clue that all is not good with your world at that moment, and continuing might not be the best option.
IMHO all this talk about automation and this & that over complicates the more simple fact that if you can not see the target you are unlikely to hit it. They were very lucky not to plant it short of the tarmac. 125' is not much.

Back to the 2nd slice of cheese; it does seemed to have been rushed. the PM was playing with the flaps like it was a manual gear shift, without PF realising. Not good.

Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach. As a result, the occurrence flight crew did not recognize the multiple deviations in airspeed and thrust or the deficiencies in coordination and communication, and they continued the approach well beyond the stabilization gates.

I find this unrealistic. Every airline I've flown with had stabilised criteria. They were written down and made perfect common sense. If the parameters didn't past the test you were considered unstable. KISS. To design a simulator scenario to demonstrate unstable parameters, so the crew can experience them, is IMHO extremely difficult. They experience the stable criteria every day. If it's different and outside limits then you are unstable. To have to train with professional crews seems unrealistic.
It seems we are going to have to train crews how to do it correctly, and then let them see how it is if they screw up. Given the vast variety of possibilities we shall be flying the sim more than the real a/c.
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Old 10th Jan 2017, 20:58   #6 (permalink)
 
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@ pac britanica
Quote:
I was a bit alarmed to read this

- Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach.

Surely this is exactly the sort of thing simulator checks are for. I mean an unstable approach should always be followed by a go around should'nt it otherwise you end up where these guys did or worse. And if its a predictable occurrence then they should get the training on how to handle it. A view from down the back but it really struck me as an odd statement
TSBC have included a similar comment in a recent report on a dash 8 incident in Toronto.
http://www.bst-tsb.gc.ca/eng/rapport...8/a14o0218.pdf
Quote:
Findings as to risk
1. If operators do not provide adequate simulator training for flight crews to recognize an unstable approach, then there is a risk that flight crews will continue an approach when it is unstable, which may lead to a landing incident.
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Old 10th Jan 2017, 21:24   #7 (permalink)
 
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Rat 5
thnaks for the explanation -as I said I dont have a flight deck view and if it is ahrd to program a sim for these conditions I guess why they do not do it.

So presumeably the SOP is if the following criteria including speed/R o D/ flap settings etc are not met then you are unstable and must go around-it just struck me as odd -perhaps its the phraseology- that after numerous recent accidents/incidents related to unstable approaches that it appeared was not something that was being coverd in training
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Old 10th Jan 2017, 22:49   #8 (permalink)

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(Not) Recognizing unstable approach on THAT profile is a matter of medical, not remedial / insufficient SIM training.
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Old 11th Jan 2017, 06:51   #9 (permalink)
 
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Sum Ting Wong, and Wi Tu Lo revisited
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Old 11th Jan 2017, 07:27   #10 (permalink)
 
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Aviation Investigation Report A14F0065 - Unstable approach and hard landing - Air Canada Rouge LP
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Old 11th Jan 2017, 07:45   #11 (permalink)
 
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RAT5,

I'm not sure how NOTAMs are presented at your company, but in the companies at which I've worked, it's EXTREMELY easy to miss a NOTAM. An out of service ILS will be buried in a mix of taxiway closures and defective windcones. It's about time some human factors analysis goes into the NOTAM presentation.

In a world where we're getting paperwork on tablets, why can't we adjust the formatting of NOTAMs to something like this?
Quote:

-Runway Closures-
RW 22R CLOSED from 22 Dec 2016 to 26 Dec 2016

-Inoperative Navaids-
ILS RW07 I-SIA ots from 22 Dec 2016 to 26 Dec 2016

-Taxiway closures-
taiway B closed btwn B6 and B7 from 22 Dec 2016 to 26 Dec 2016

-Other stuff-
RW 8R windcone unlit
taxiway D non-std markings btwn D2 and D5
...which is far easier to read than this nonsense

Quote:
!DTW 01/440 (KDTW A0750/17) DTW RWY 27L PAPI OUT OF SERVICE 1701110628-1701131800EST

!DTW 01/439 (KDTW A0747/17) DTW RWY 27L FICON 10 PRCT WET OBSERVED AT 1701110551. 1701110551-1701120551


!DTW 01/438 (KDTW A0746/17) DTW RWY 21L FICON 10 PRCT WET OBSERVED AT 1701110551. 1701110551-1701120551


!DTW 01/437 (KDTW A0745/17) DTW RWY 22L FICON 10 PRCT WET OBSERVED AT 1701110550. 1701110550-1701120550


!DTW 01/436 (KDTW A0741/17) DTW RWY 04L/22R CLSD 1701110513-1701111030


!DTW 01/435 (KDTW A0740/17) DTW RWY 03L/21R CLSD 1701110513-1701111030


!DTW 01/433 (KDTW A0736/17) DTW TWY ALL FICON WET OBSERVED AT 1701110138. 1701110138-1701120138


!DTW 01/432 (KDTW A0737/17) DTW TWY W HOLD PAD AT RWY 03R CLSD 1701110137-1701120133


!DTW 01/430 (KDTW A0733/17) DTW RWY 21R FICON 5/5/5 100 PRCT WET OBSERVED AT 1701110128. 1701110128-1701120128


!DTW 01/429 (KDTW A0732/17) DTW RWY 22R FICON 5/5/5 100 PRCT WET OBSERVED AT 1701110128. 1701110128-1701120128
Even if colour coding is a potential problem, there's no reason they can't be grouped by importance (runway closures, inop navaids etc), and upper case letters used to highlight critical information.

Software filters would also help. If 22R is closed, I don't want to be reading notams pertaining to approaches or departures for that runway. Surely such things aren't considered scifi in 2017?

Last edited by Check Airman; 11th Jan 2017 at 08:13.
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Old 11th Jan 2017, 08:25   #12 (permalink)
 
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Quote:
The official report said that even though the PM called "Autothrust", the PF didn't reply, and the landing checklist wasn't done. It's pretty reasonable to assume that the PF thought the AT was on.
The PF knew the A/T was off at the time (he turned it off himself just the previous minute) -- in fact he told the PM it was off, just 10 seconds before the callout:

Quote:
At 1427:42, the PF stated that the aircraft was too high and that he was correcting, then stated that the autothrust was off. The PM did not hear the statement that the autothrust was off.

At 1427:52, the PM initiated the callouts associated with the landing flap selection portion of the final approach and landing check. The PM called out “autothrust,” which is the first callout item. The PF did not immediately respond, but shortly afterward he initiated a dialogue regarding the FAF and the missed-approach altitude, interrupting the checklist.
The PF probably intended to land with A/T off but was habitually conditioned to having A/T on (AC Rouge SOP strongly recommends A/T on from takeoff to landing). The PM probably thought A/T was on and did not monitor the speed.
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Old 11th Jan 2017, 09:30   #13 (permalink)
 
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It's about time some human factors analysis goes into the NOTAM presentation.

Spot on. Absolutely, and better filtering. there is far too much spurious stuff that masks the important bits. It's interesting that so much HF research is done on the actual operation of the a/c and all its systems. Here is an item (NOTAMS) that might seem trivial yet often proves to be the start of events.

Is this not a very suitable issue for the national union technical committee to make up with the relevant authority? Knowing what approaches are available is a critical as knowing the weather because they go in combination.

This has become more important in recent times. When I worked with flight dispatchers who gave preflight briefings this type of item was highlighted. Later, a dispatcher may not brief but would still 'marker highlight' important items in the NOTAMS. Now, in more & more cost cutting, everything is crew self brief in a reduced pre-flight planning report time. You have to print your own nav plans, check the a/c HIL's, print & check the weather, check...check....and still make the slot, but don't rush. Oh Please!
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Old 11th Jan 2017, 10:10   #14 (permalink)

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RAT5, I have to agree with you. I stopped flying way back in '04, and even then there was too much information covering the really important bits. I can only imagine that it's got worse. Add to that the time constraints where there is only about five minutes to check everything before having to head off to security etc.
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Old 11th Jan 2017, 12:26   #15 (permalink)
 
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It really is needle in a haystack stuff with twenty odd pages of trivia like crane positions for example which personally are for me not terribly high priority. Then you have coded validity times, e.g. the ILS is out of service from 30 Aug to 10 Dec but coded in numbers, while there are pages of the Greeks or the Turks saying they do not recognise things each other are doing. Surely some form of prioritisation listing ops critical data together with opening hours of alternates could be contemplated? It does not however excuse this truly alarming performance by two experienced pilots.
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Old 11th Jan 2017, 13:59   #16 (permalink)
 
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You should see the Indian airports, with four or five pages of arse covering irrelevance. They should be told to sort it out or be isolated, nothing in, nothing out.
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Old 11th Jan 2017, 14:29   #17 (permalink)
 
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I would imagine that a lot of the problem is in the arse covering - anyone who replaces the current NOTAM presentation with a new format will be immediately put up against the wall if the algorithm used misses something that is, after an incident, deemed important.

And even if the algorithm is perfect, if someone presenting the data to it (I don't know how these are generated) is imperfect then you will get imperfect results. Garbage in, Garbage out.

So from a purely technical point of view, I can see huge benefit in having something that parses or sorts the messages , but from a liability point of view I can see why no-one would want to do it...

-edit- I am an IT guy, this kind of stuff interests me, dealing with interactions between humans and machines . Where do the NOTAMS come from - are they public info that anyone can grab , any time? Is there a better thread for this discussion

Last edited by Snyggapa; 11th Jan 2017 at 14:56.
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Old 11th Jan 2017, 15:03   #18 (permalink)
 
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There appears to be a drift away from the subject in hand here.

Let's put it bluntly, that this crew messed up big time and were lucky to walk away from it unscathed; forget there not being an ILS and all the NOTAMS. What were they doing allowing themselves to get into such a dangerous and unstable position. The Capt seems pretty experienced on type, and the FO was not so much so on type, but had a significant number of hours. When one of them saw that they were digging a hole for themselves, they should have gone-around and not persevered putting the lives of those who trust in them at risk.

This crew should be ashamed of themselves.
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Old 11th Jan 2017, 16:25   #19 (permalink)
 
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And so back to a regular question -
Why are airline pilots so reluctant to go around ?

Lack of practice ?
Fear of being asked why ?
Commercial pressures ?

Coming from an african bush background every approach was a potential go around, mainly due to errant wildlife and it happened on a regular basis, a few times a month so we were always ready.
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Old 11th Jan 2017, 16:46   #20 (permalink)
 
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Most modern aircraft CAN be a handful on a go-around. Can't find it at mom but in the early days of the A320 at LTN one went around & if I remember got to 13000 ft before the crew got it under control. (G/A alt = 3000ft). I had one almost get to the stall (into VLS) on an automatic go-around. (I disconnected & flew it before anything serious happened). This is not a AB Boeing thing as Boeing have had their fair share.
So I believe a lot of pilots subconsciously resist go arounds. The crew in question had already "lost it" so going around probably didn't enter their conscious thought.
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