Re “Captain was fired after this incident”.
If this is true then the action does little to further the cause of aviation safety.
The incident is an example of a threat (TEM terminology) which was not, or could not be detected. This is typical of the hazards associated with visual misidentification / illusion, and similar to several of the incidents described "here".
In these instances, both crew members can simultaneously suffer a failure in situation awareness, which does not enable or contribute to good cross monitoring.
Whilst the VOR could have been monitored more closely - SOPs were not followed, the report fails to identify why such a ‘failure’ (crew procedural violation) occurred. Similarly there is harsh wording about the crew’s failure to “comply” with the approach procedure – the crew did not check that the aircraft was following the procedure, … but why? Something we all might do when ‘visual’?
The report concludes the ‘probable cause’ as a crew decision failure with contributory factors; one of which was poor CRM. The report earlier defines CRM and crew responsibilities, and discusses error, but perhaps fails to support the conclusion of poor CRM, which IMHO together with the probable cause leaves the blame option open.
Was this aircraft fitted with EGPWS?
If so, at what altitude during this approach should an amber alert ‘Caution Terrain’ be given, together with the amber ND/radar display?
Was the EGPWS obstacle mode enabled?
Did the company SOP specify displaying the EGPWS map during the approach?
-Well you have to be bloody stupid to fly a visual approach to unfamiliar runway at night! And think, hey I see the runway...
Probable Cause:
The decision of the Flight Crew, to continue an approach using visual cues alone, having misidentified the lights of a building with the approach lights of the landing runway.
Contributory Factors:
1. The fixed red obstacle lighting on the roof of the building, together with the white internal lighting, resembled the approach lights of the landing runway when viewed from the approach path.
2. The failure of the Flight Crew to follow Company Standard Operating Procedures.
-The Flight Crew did not comply with the non-precision instrument approach procedure, and elected to continue with a visual approach from approximately 2,200 feet contrary to Company SOP.
3.Poor CRM of the Flight Crew
-The Investigation identified poor communication and teamwork, and a major degradation of situational awareness, which was not resolved by the Flight Crew.
4. Communication with Maintenance Crews on RWY 10-28 distracted the AMC at a crucial time during the approach, while the AMC was the sole occupant of the Tower
-The final intervention by ATC, although somewhat late, was the primary factor in providing a safe outcome to this Serious Incident.
JJ83, so in addition to reiterating the investigation’s conclusions (and similarly failing to provide any explanation / solution), you accuse the crew of being ‘stupid’.
The purpose of investigating such incidents is “…. the prevention of accidents and incidents” (ICAO Annex 13).
The report identifies preventative measures in the recommendations. Changing the Tower lighting addresses the obvious hazard; yet in acknowledging this, it might be construed that the crew’s decision based on what they saw was correct.
However, the apparent failure to following the VOR procedure or the operational SOP appears to be grouped in the recommendation to review CRM training. No evidence was presented relating to poor training; indeed the crew’s training was assessed as being satisfactory and met all regulatory requirements. If the investigation considered that the standard of CRM was insufficient, either a higher regulatory standard might be justified, or an explanation of why the crew did not exhibit their assessed standard on the day of the incident should have been given.
Lest I should be accused of being overcritical of the investigation, the Irish AAIU should be congratulated on addressing the difficult area of human factors, which is often avoided in such investigations.
IMHO a more considered view of the crew’s performance might come from a speculative review of the crew’s behavior including the possibility (probability) that the errors identified in hindsight (misidentification, violating SOPs) were to be expected in the situation and were within the limits of human performance.
Using James Reason’s view of accidents – latent factors and an unsafe act, the latent factor of the lighting was identified together with the act - human nature – believing what is seen; but for the procedural factors, only the unsafe act was mentioned.
The Irish AAIU have released their report on a serious incident that happened at Dublin in August 2007 involving a Flightline MD-83 from Lisbon. Among the contributing factors was poor CRM of the flightcrew, who did not follow company SOPs.
Serious Incident: McDonnell Douglas MD-83, G-FLTM, Santry Cross near Dublin Airport, 16 August 2007: Report No 2009-010
21 April 2009
SYNOPSIS
The aircraft departed Lisbon with the Co-pilot as Pilot Flying (PF). The flight progressed without incident until commencing its approach to Dublin Airport. The approach was made at night; the weather and visibility were good. Due to scheduled maintenance on the main runway (RWY 10-28), RWY 34 was in use for landing. The flight was cleared by Air Traffic Control (ATC) to carry out a non-precision approach to RWY 34. During the approach, at approximately 5 nautical miles (nm) from touchdown, the aircraft began to deviate left of the approach course. This deviation was due to the Flight Crew mis-identifying the lights of a hotel at Santry Cross as those of the runway approach lighting system on RWY 34. The aircraft continued to descend below the Minimum Descent Altitude (MDA) without proper visual identification of the runway in use, and continued to descend to an altitude of 580 ft above mean sea level (AMSL) before executing a go-around.
At the point the go-around commenced, the aircraft was approximately 1,700 ft from the building and 200 ft above it. On the instructions of ATC the aircraft turned right and climbed to a safe altitude. The aircraft subsequently landed without further incident. There were no injuries.
This sounds like a knock knock joke. Why is a hotel lit up in the vicinity of an airport in such a way that it may be mistaken for a runway? Is there no local authority planning for the arrangement of lighting of buildings near airports. OK vmc conditions were in operation at the time of the incident but had the visibility been marginal it could have happened to any crew.
I hope this long delayed report has caused some head scratching at the local authority if they ever get to read it.
Checkboard
They went around from 580' AMSL. Dublin airport, as I recall, is 325 AMSL, and the hotel well may have been above the level of the airport. Hence the 200' clearance. Personally, I used to try and miss sticky uppy pieces of the land scape by something more than 200' vertical seperation.
One question asked (as yet unanswered), was if the aircraft was fitted with EGPWS. Presuming that it was then at what altitude would an alert be given?
I think that the incident provides a salutary lesson, particularly with the similarities of those incidents described in TAWS Saves.
dontdoit, to avoid being labeled in the same manner as you address the incident crew, I suggest that you read the report in detail and the link to similar incidents above.
Then reflect on the behaviors reported, consider the incident crew’s perspective, and the human issues which you or anyone else might encounter in similar circumstances.
dontdoit, Who are you flying for now, so I can go and fly with someone else?
Ever hear of the saying "There but for the grace of God go I"? Or you one of those chaps whose only mistake was the time you thought you made a mistake?
At a final approach speed of 130kts, they were less than 8 seconds from the hotel......I'm sure guests in the top floor got a fright as the go-around was initiated!
As the report states, if the crew had bothered to read the NOTAM beforehand then this in all probability wouldn't have happened. They were lucky this time..
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