A new report on a Canadian Boeing 737 accident. A must read for first officers

[Sarcs]

P377:

One can only wish that the Australian Government, at the behest of the good Senators, would read that report and then ram it down the throat of that fool Dolan and show him how things should be done

Couldn't agree more Para, although at this point in time it would seem to be a wane hope..

Indeed there is much to be learnt from such a succinct report and it would seem that the Canucks not only talk the talk but also walk the walk ... Reference Safety Action Required 4.2 of the report:

4.2.1. Unstable approaches

In this accident, the aircraft arrived high and fast on final approach, was not configured for landing on a timely basis, had not intercepted the localizer and was diverging to the right. This approach was not considered stabilized in accordance with the company's stabilized approach criteria, and the situation required a go-around. Instead, the approach was continued. When the crew initiated a go-around, it was too late to avoid the impact with terrain. Unstable approaches continue to be a high risk to safe flight operations in Canada and worldwide.

Flight Safety Foundation research concluded Footnote 172 that 3.5% to % of approaches are unstable. Of these, 97% are continued to a landing, with only 3% resulting in a go-around. To put these figures in context, there were, in 2012, 24.4 million flights worldwide in a fleet of civilian, commercial, western-built jet airplanes heavier than 60 000 pounds. This means that between 854 000 and 976 000 of those flights terminated with an unstable approach, and approximately 828 000 to 945 000 continued to a landing. The potential negative consequences of continuing an unstable approach to a landing include controlled flight into terrain (CFIT), runway overruns, landing short of the runway, and tail-strike accidents.
Occurrences in which an unstable approach was a contributing factor demonstrate that the severity can range from no injuries or damage to multiple fatalities and aircraft destruction. In Resolute Bay, the continuation of an unstable approach led to a CFIT accident and the loss of 12 lives. Without improvements in stable approach policy compliance, most unstable approaches will continue to a landing, increasing the risk of CFIT and approach and landing accidents.

In this investigation, the Board examined in detail the defences available to air carriers to mitigate the risks associated with unstable approaches and their consequences. These mainly administrative defences include:

• A company stabilized-approach policy, including no-fault go-around policy;
• Operationalized stable approach criteria and standard operating procedures (SOPs), including crew phraseology;
• Effective crew resource management (CRM), including empowering of first officers to take control in an unsafe situation;
• Use of flight data monitoring (FDM) programs to monitor SOP compliance with stabilized approach criteria;
• Use of line-oriented safety audits (LOSA) or other means, such as proficiency and line checks, to assess CRM practices and identify crew adaptations of SOPs;
• Non-punitive reporting systems (to report occurrences or unsafe practices);
• Use of terrain awareness and warning systems (TAWS).

While First Air had some of these defences in place, including a stabilized approach policy and criteria, a no-fault go-around policy, safety management system (SMS) hazard and occurrence reporting, the two-communication rule and an older-generation ground proximity warning system (GPWS), these defences were not robust enough to prevent the continuation of the unstable approach or collision with terrain. Other TSB investigations have shown that non-adherence to company SOPs related to stabilized approaches is not unique to First Air.

In addition, the use of newer-generation TAWS with forward-looking terrain avoidance features will enhance a flight crew's situational awareness and provide increased time for crew reaction. However, if the risk in the system is to be reduced significantly, the industry must take other steps and not rely on purely technological solutions.
The first step is for operators to have practical and explicit policies, criteria, and SOPs for stabilized approach that are enshrined in the company operating culture.

The second step is for companies to have contemporary initial and recurrent CRM training programs delivered by qualified trainers and to monitor and reinforce effective CRM skills in day-to-day flight operations. Effective CRM is a defence against risks present in all phases of flight, including unstable approaches.

The third step involves monitoring of SOP compliance through programs such as flight data monitoring (FDM) and line-oriented safety audits (LOSA). In Canada, TC requires large commercial carriers to have SMS, cockpit voice recorders (CVRs), and flight data recorders (FDRs). However, these carriers are not required to have an FDM program. Even so, many of these operators routinely download their flight data to conduct FDM of normal operations. Air carriers with flight data monitoring programs have used flight data to identify problems such as unstabilized approaches and rushed approaches, exceedance of flap limit speeds, excessive bank angles after take-off, engine over-temperature events, exceedance of recommended speed thresholds, GPWS/TAWS warnings, onset of stall conditions, excessive rates of rotation, glide path excursions, and vertical acceleration.

FDM has been implemented in many countries, and it is widely recognized as a cost-effective tool for improving safety. In the United States and Europe—thanks to ICAO—many carriers have had the program for years. Some helicopter operators have it already, and the Federal Aviation Administration (FAA) has recommended it.

Worldwide, FDM has proven to benefit safety by giving operators the tools to look carefully at individual flights and, ultimately, at the operation of their fleets over time. This review of objective data, especially as an integral and non-punitive component of a company safety management system, has proven beneficial in proactive identification and correction of safety deficiencies and in prevention of accidents.

Current defences against continuing unstable approaches have proven less than adequate. In Canada, while many CAR 705 operators have voluntarily implemented FDM programs, there is no requirement to do so. First Air was not conducting FDM at the time of this accident. Furthermore, FDM programs must specifically look at why unstable approaches are occurring, how crews handle them, whether or not crews comply with company stabilized-approach criteria and procedures, and why crews continue an unstable approach to a landing. Unless further action is taken to reduce the incidence of unstable approaches that continue to a landing, the risk of approach and landing accidents will persist.

Therefore, the Board recommends (A14-01) that:

Transport Canada require CARs Subpart 705 operators to monitor and reduce the incidence of unstable approaches that continue to a landing. A14-01

The TSBC through their employee interactive blog (vs the Beaker blog) put out the following blog piece:

One unstable approach too many
March 28th, 2014 Posted by: Brian MacDonald

According to international air industry figures, 3.5 to 4 percent of all aircraft approaches to landing are unstable; and of those, 97 percent actually continue to a landing. Most of the time, everything works out just fine. But sometimes there are consequences: a runway overrun, a tail strike, or in the case of Resolute Bay, Nunavut, on August 20, 2011, a fatal crash. It’s time to put a spotlight on this issue to see what needs to be done to address this ongoing problem.


Any pilot will tell you that landing is one of the most critical phases of flight, in part because the aircraft is maneuvering at a much slower speed, and much closer to the ground. A stabilized approach helps to ensure that the plane is ready for landing and that the pilots are prepared for the demanding task of landing an aircraft. Many air transport operators incorporate stabilized approach policies and procedures within their operations. This is intended to be an administrative defense against several negative outcomes, such as runway overruns and controlled flight into terrain (CFIT). A stable approach involves controlling, and stabilizing, several key criteria before the aircraft reaches a predefined point – usually several miles back from the airport, at 1000 feet above the ground. These criteria include:
A. Course – The aircraft is on the prescribed track to land. This avoids any excessive bank angles during the final moments before landing;
B. Speed – Should be within a few nautical miles per hour of appropriate speed for approach conditions of weight and weather. This provides the slowest speed for landing, but with built in safety margins;
C. Rate of descent - Should be set to maintain the glide path. This avoids excessive changes and allows an optimum closure rate to the runway surface,
D. Power setting – Should be set to maintain optimum airspeed and rate of descent previously mentioned. This prevents excessive changes to airspeed and rate of descent and ensures the engines are in a power range that allows for rapid acceleration should a go-around be required; and
E. Aircraft configuration – The landing gear should be down and final flap selection completed. This avoids configuration changes in the final moments of the approach which could in turn adversely affect speed, rate of descent and power setting


An approach is considered stabilized if all criteria in company procedures are met before or when reaching the predefined minimum stabilization height. An approach that does not meet the criteria at this point, or becomes unstable below this point, requires an immediate go-around— which means climbing to a safe altitude to determine the next course of action. On that fateful day in August 2011, the First Air pilots initiated a go-around, but it was too late.


Flight crews are required to stabilize approaches to runways for a number of reasons. Landings will be more consistent and predictable. Flight crews also have more time—and more attention—to monitor key elements such as communications and systems operation, thereby boosting their situational awareness. And at the heart of all of this is safety. Establishing and stabilizing the key variables in advance means fewer last-minute adjustments, which helps minimize workload during this critical phase. So when flight crews reach the pre-determined point where they must decide whether to proceed with the landing or carry out a go-around, they have more space—and time—to do so.


But this didn’t happen on August 20, 2011. The investigation into this accident highlights that there are too many unstable approaches that continue to a landing—some resulting in tragedy. Because current defences have proven less than adequate, and unless further action is taken, the risk of landing accidents will persist. That is why the Board issued a recommendation that:


Transport Canada require airline operators to monitor and reduce the incidence of unstable approaches that continue to a landing.


If air operators take a hard look at addressing unstabilized approaches, this will hopefully mean safer landings for everyone. - See more at: One unstable approach too many - The TSB Recorder - The TSB Recorder

And perhaps to highlight the issue of unstabilised approaches the TSBC have released another report of interest and as noted here aviationsafety.net (FSF): Embraer 145 runway excursion caused by unstabilized approach and improper braking technique during heavy rain


Happy Sundy learning...