PPRuNe Forums - View Single Post - A new report on a Canadian Boeing 737 accident. A must read for first officers
Old 26th Mar 2014, 12:43
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Centaurus
 
Join Date: Jun 2000
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A new report on a Canadian Boeing 737 accident. A must read for first officers

I have read many accident reports in my career. This new report which can be seen on Rumours and News forum on a Canadian Boeing 737 crash while attempting an ILS, is surely the most comprehensive I have ever read. It is lengthy but quite enthralling story of how an unstable approach started from top of descent and ended still unstable as the aircraft hit terrain during a go-around, with the first officer constantly warning the captain of impending danger and being ignored. Basically the aircraft was full scale off localiser and below glide slope in the last minute of the ILS in low cloud.

Transportation Safety Board of Canada - Aviation Investigation Report A11H0002

I have included here a pertinent section of the accident report and which prompted me to place it on Pprune. It applies to all Australian operators that have multi-crew aircraft. And more so, where the first officer is inexperienced and lacking previous real world flying. Interpret that as you wish...

Quote: "How far should the first officer allow the aircraft to deviate before taking over control from the captain?

There is a history of incidents and accidents in which the FO was the PNF and warned of a deteriorating situation, but did not take control when the captain continued an unsafe course of action (section 1.17.8.5). In all of these occurrences, the company had some form of two-communication rule, but the defence failed because the FO did not intervene and take control of the aircraft. Some likely reasons for this failure are difficulty in identifying subtle incapacitation, ambiguity in the wording of the procedure, or inhibitions on the part of FOs to take the drastic measure of taking control from a captain.

At the time of the First Air accident, there was no training or guidance within the company on how an FO would escalate a concern to the point that a go-around or change of control could be commanded. In the absence of policies and procedures, such as PACE (probing, alerting, challenging, and emergency warning), enabling the FO to escalate his concern as well as providing the authority to take control of the aircraft from the captain, the FO was limited to an advisory role. The FO was clearly aware of the increasing risk. The approach had continued beyond 2 points at which a go-around was required: first, when there is full localizer deflection, and second, in an unstable approach below 1000 feet. At both of these points, the FO attempted to communicate the need to go around to the captain. While not as definitively and clearly expressed as they could have been, these attempts are indicators that the FO was continuing his efforts to change the captain’s course of action.

The FO had previously flown as captain on another aircraft type with the company. However, he was new to the B737, and although obviously uncomfortable with the navigational situation, deferred to the captain.

There was no policy specifically authorizing an FO to escalate his role from advisory to taking control, and this FO likely felt inhibited from doing so. The FO made many attempts to communicate his concerns and suggest a go-around, but did not take control of the aircraft from the captain.

This accident and the other 3 occurrences cited (section 1.17.8.5) are indicators that failure of FOs to take control in deteriorating situations will occasionally result in catastrophic consequences in the global fleet of transport aircraft. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some FOs may feel inhibited from doing so." Unquote.

While the depth of the report may bore some less than enthusiastic airline pilots the discussion by the investigators on exactly how does a co-pilot take over physical control from the captain intent on pressing on regardless of risk, is worth close study. This subject is rarely covered in airline SOP.
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