PP, DH121, MM, et al, the discussion continues to raise interesting points and questions.
Re “… the GIB missed approach is also available in the FMC.”
Is the FMC approved for flying the missed approach - LNAV? My logic would suggest that if it is then why isn’t the FMS used for the approach? Thus LNAV / GA not approved?
Is the FMC accurate enough to ensure no map shift (at GIB); as above, if so use it, but if not, then could a map display be a distraction – even a hazard – see the many incidents involving map shift. The report states that crew were verifying map accuracy prior to the approach.
“How did they get the missed approach so wrong?”
Previous posts described the procedure as a climb on North until 1900ft then turn on to East. In the incident the aircraft had passed the visual decision point ‘MDA’ – the assumed MAP for a GA procedure (?), and was already turning onto East. Thus the crew were faced with a GA from a location not on the missed approach track and well below the altitude requirement of the Easterly heading. So what is the procedure for the loss of visual contact on late final? Do operators assume that the aircraft will be visual to maintain runway hdg – a false assumption in this instance? Any conclusion that the ‘missed approach’ procedure was incorrectly flown could be based on a false premise as it appears that there is no procedure applicable from the location that the crew started from, i.e. a gap in the procedures?
“An action error occurred, namely forgetting to press the TOGA switch.”
An essential element of training and procedures is that they minimise the crew exposure to situations where a single (foreseeable) error can hazard the flight. The operational requirements in JAR-OPS / FCL might assume that any crew would be capable of flying a GA without FD – power, pitch, roll, hdg. A related assumption might be that leaving the FD displayed during a visual approach is not distracting – the assumption being that pilots are taught to ‘look-through’ the FD to the attitude display. I suspect that these might be false assumptions, if so who tells the JAA?
I do not like the term ‘loss of situation awareness’; it suggest that some ‘thing’ can be lost or gained. Most, even the best CRM instructors struggle to define the operational content of the situation and the practical circumstances for loss or gain.
In the incident the crew’s situation awareness was sufficiently accurate to fly the approach and for them to determine the need for a GA. Thereafter their awareness either did not match the actual situation or it was insufficient for them to comprehend the need for a change of action (the commander did not perceive that he was turning – his situation was ‘falsely’ wings level).
How would a commander incorporate a GA SOP into situation assessment (before choosing a course of action) where there is no SOP applicable to the perceived geographic situation? Not that there can be an SOP for every possible circumstance, but there should be some guidance for all of those foreseeable situations – a risk assessment task for company management.
Many pilots discount the threat of illusions. Hopefully most will have experienced some form of turning illusion during instrument training – at a safe altitude with an instructor, and learn to counter it. However, experiencing an illusion in operation, in low visibility, and at low altitude could be very disturbing. In addition both pilots could suffer a turning illusion at the same time, and furthermore if there is significant head movement then there could be a risk of a Coriolis (turning) illusion – dizziness / tumbling.
A recent paper on EGPWS warnings (FSF Safety Seminar Athens) reported illusion as a contribution to approach incidents; one example of a black hole illusion during the approach resulted in a ‘heavy’ being at 125ft at 1.5 nm still descending (FAF Aviation Safety World July 2006).
It appears that there are many contributions to this incident which may have been ‘assumed’, and even more in what this discussion has covered. Perhaps this identifies an important issue in human factors safety – beware of assumptions.