Originally Posted by
Seaeagle109
Well, we knew it would be disappointing reading.
OM policy presented in the report doesn't appear to include discussion on conditions required to descend below DA/MDA, however the Jepp review part of the OM notes actions for undertaking an MAP. As the same crew had studiously avoided response to a similar number of EGPWS/GPWS alerts on the prior flight into the same airport, that would appear to be an area of reinforcement training worth some effort by the company. Any discussion on criteria to continue an approach below DA(H)/MDA appears to be missing.
The images show that the VNAV and LNAV was properly displayed all the way to the water landing. FPV was not displayed in any PFD, but is available... The comments of P18 state that the pilot disconnected the AP when it commenced a pitch up for the GA... which doesn't gel with the function of the APFD of the displayed VNAV, and the altitude selected in the first cockpit image, however, what happened at that point is important to understand as to why the plane ended up out of sorts. The CVR transcript, and the DFDR would indicate what altitude was set on the MCP, and when it was set/reset to the MAP height. The change to VNAV mode that happened at the point that the AP was disconnected suggests that the aircraft did capture the MDA, and the images are of the MDA reset to the MAP alt. The importance of that is the fact it ensures that the aircraft would be destabilised by an ALT CAP at MDA, which sets up the wild ride thereafter. The "raw" data remains valid, the crew just end up throwing away a "stable" approach at relatively low level, disconnecting AP, losing FD, and going to manual thrust, which appears to have been reduced promptly.
The volume of recommendations looks great, but seems to have weight rather than relevance to recommendations on how to stop crew disregarding EGPWS/GPWS alerts and warnings, or continuing a descent to impact, well below MDA, without having a piece of concrete in front of them. The comments on the PAPI comes up before the visibility went bad due to the rain shower. Thereafter, having to turn on the windscreen wipers to get the seaweed off so that you can see the barnacles and oysters on the submerged rocks would make it unlikely that a PAPI was being followed.
At "100" is there any expectation that there should be a threshold clearly visible and a runway with all of the pretty markings and lights etc, somewhere near the window? If not needed at "100" when the MDA was some 20 seconds earlier, then at what point would the crew get a bit uncomfortable with the waves under their window.
Little in the recommendations appear to work on the underlying problem, continuing an approach below minima without seeing the runway, lights, PAPI etc.
GPWS is not installed just to increase the ZFW.