PPRuNe Forums - View Single Post - Our Airline (Nauru) seriously close shave during NDB approach
Old 18th Mar 2018, 12:59
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Judd
 
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Much to learn from this incident. The DME was at the airport and if the crew had constantly checked DME versus altitude (320 feet of altitude for every one nm) from 10 miles out it would have been obvious that the stepped down profile as depicted on the chart was going to put the aircraft extremely low over the sea and at night. Commercial pressures would not have helped, either.
The ATSB report stated: "From the time the captain set the thrust toTOGA until the aircraft was stabilised on the missed approach path (at about 0905), the recorded aircraft pitch angle varied from -0.35° to +16°.
That is a significant pitch change, with the aircraft attitude at one stage below the horizon and within seconds of hitting the sea. This suggests the PF was probably chasing flight director indications and over-controlling while doing so.


If there is one thing positive to be learned from this incident, it is this: CASA must seriously consider including a lot more emphasis on manual raw data instrument flying competency during re-currency training and for each IPC. Otherwise, history will inevitably repeat itself.

Last edited by Judd; 18th Mar 2018 at 13:52.
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