PPRuNe Forums - View Single Post - Air Crash Investigation TV next week. Boeing 737 NDB approach goes wrong.
Old 2nd Dec 2007, 04:39
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Pollution IV
 
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Dubrovnik was a classic example of a systemic failure and the Group commander was subsequently relieved of his command for gross negligence. The Air crash Investigators episode is rather a poor precis of the event unfortunately.

The whole lack of support to the 'front-enders' in this industry is a sad indictment of the times in both civil and military aviation. The higher-ups seem very happy to push crews to the limits in order to get the job done, even when commercial pressures are not a factor (self glorification perhaps?). I have studied this accident extensively for CRM trng purposes and the thing to take from it is that despite the pressures felt by the crew, there is one protecting shield that will prevent you becoming a statistic - strictly adhere to the rules of aviation. The crew made the following breaches in flight discipline in the conduct of the twin locator:

1. Commenced the appch way too fast (approx 80 kts above design criteria) in less than optimal config;

2. Continued the appch outside of tracking tolerances (possibly on INS);

3. Incorrect Navaid tuning during the appch. The wreckage reveiled the acft ADF was tuned to the first NDB/locator, thus the crew had no way of legally determining the MAP, which was o/h the second locator.

If the crew had properly responded to any of these criteria in the correct way (ie conducted a MAP immediately), the result could have been very different.

In fairness, there were many contributing factors to the error chain, such as badly interrupted min rest before the task, lack of a proper pre-flt briefing which included lengthy 'SPINS' (special instructions for mil ops), endorsed use of inaccurate/incorrect IAPs by the Group Command, and task focus pressure to get the high level Official to his meeting (or perhaps not get into trouble for failing to do so?). All these issues added to the difficulty of a flt conducted by a very fatigued crew.

The lesson is that aviation rules/SOPs were written in blood and you ignore them at your peril. It is hoped that all crews don't mean to breach the rules of any IAP, however, mistakes will certainly happen if you allow them to. The crew were warned by another mil Capt, who only just managed to get in previously, that the cloud base was at mins. The conduct of an unfamiliar appch with less than optimal Navaid set-up, in very poor wx, with proximity to significant terrain, would require thorough and careful consideration and execution. It would seem that this crew rushed themselves unnecessarily and opened the door to this fatal chain of events. A sobering lesson for all of us at the sharp end.
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