Report on 1999 B757 crash at Girona finally published

[IcePack]

Here

http://www.mfom.es/ciaiac/publicaciones/informes/1999/1999_054_A_texto_ENG.pdf


There for the grace etc.

Nasty night and lady luck on a sicky

[2Donkeys]

That would be GIRONA (spain), for the avoidance of any doubt.

I thought this report had been published some considerable time ago....

[simfly]

I'm actually reading over the report again right now, and the impression I'm getting is that the crew could have done some things slightly diferrent, but ultimately the MAIN factors seem to be the runway lights going out at the critical point where the PF is looking for visual cues(the lights came back on by emergency power within the 15second period required, but too late...), and the "sink rate" warning sounding over the last few rad alt callouts.

The crew screwed up big time - and there's little point in playing the "anyone else's fault but the pilot's" card here.
These comments I find too harsh, and I'm wondering if Joyce Tick has actually read the conclusions/findings of the investigation on the flight crew (page 88-would post them but can't seem to copy the text :* ) or if he/she has made their own conclusions! especially as the report suggests that another (of the many) factors may have been the crew/airlines non-requirement to train go-around proceedures below minimums, the PF's apparent "shock" at the runway lights going out at that stage may have been reduced to some extent.

The sad thing is that the report says that if the nose landing gear support structure hadn't have displaced the control/thrust lever control cables in such way , the aircraft may have just come to an eventual stop on it's nose on the runway. The displacement of the thrust cables caused an increase in thrust, which literally powered the aircraft on into the actual events that occured thereafter. All in all, many factors from not only within the cockpit contributed to the incident, including bad luck!!!!! though it still amazes me to this day how there was no loss of life or very serious injury (at the time:sad: ), and I would hope that the crew can carry on their career with greater knowledge of such situations leading up to the event, I'm certainly not worried if I'm ever sat behind them if I was pax on their flight...

[NoMuff2Tuff]

One fatality in this incident, passed on 5 days later after treatment. RIP

[willoman]

Simfly - In general terms I agree with you. Joyce Stick appears to have not fully read the report and as a consequence ends up quoting cliches and shooting from the hip. The main cause of the aircraft departing the runway was the left thrust lever cable run being displaced and running to high power and thus causing the aircraft to yaw right - otherwise it would have been a very heavy landing incident but repairable.
ATC bears a heavy responsibility in their management of the airfield lighting systems and subsequent reaction to the crash response.
Incidentally, both pilots have now retired.
The fatality was a supposedly terminally ill gentleman, the death of whom was not attributable to the accident.

To anyone who may be confused - Joyce Stick has removed his previous unnecessary comments to which several inputs have referred though his remarks have been paraphrased by others.

[Buckshot]

How common is it for an airline to employ FO's with 349 hours total and no ATPL, as was the case in this incident?
Where I come from, you need 3000TT before you can even send in your CV and even then you'd be at the bottom of the pile.
I have read the report in full - please understand that I am not saying the inexperience of the FO contributed to the accident IN ANY WAY - just making an observation.

[M.Mouse]

Page 6 and 7 states that the FO had a TT of 1,494 hours of which 1,145 were on type.

Where do you get 349 hours from?

Paragraph 2.3.2.3 on page 77 makes an interesting observation.

[Buckshot]

M.Mouse, at the time of the accident the FO had a TT of 1,494 with 1,145 of that of the 757, his only type rating according to the report. So, he must have come to BY with a TT of 349 hours.
I am just making the observation, without trying to make a point of it, that this was a very low time FO when he joined the company.

[toon]

but for the grace of god,

a question though, does anyone have to justify the fuel load in brits ? with that weather it seems a bit short (15 mins) extra, and in a 757 10200kgs is a strange fuel load any way ?

[LYKA]

established on the LOC, WXR-RDR turned off! Hmmm!

[M.Mouse]

Buckshot,

I understand now.

In BA cadets were coming out of flying college under the JAR OPS rules and after considerable conversion training they were RHS of aircraft up to the B757s with circa 200 hours.

Very technically competent but the lack of experience was very obvious.

[Groundloop]

I don't know how many of you have seen this photo?


http://www.airliners.net/open.file/327987/L/

They were very lucky the aircraft followed the track that it did. It is terrifying to imagine what would have happened if it had gone into the trees.

[phoenix son]

Toon,

10200KG was presumably the Block Fuel, minus the standard taxi figure for BAL B757's which is 200KG, obviously leaving 10T once off the runway. I agree, even as a non-flyer, that given the projected weather upon arrival that more fuel may have been prudent...20/20 hindsight is a great thing though isn't it?


M.Mouse,

Para 2.3.2.3 seems to contradict itself? It starts off apparently suggesting CRM may have been lacking at the time of the accident, but then states that even if the "monitored approach" working practice had been used, it may not have made any difference anyway?

I agree that a higher-houred pilot should have better experience of every situation, but it is a sweeping generalisation. I flew jumpseat (on a B757, coincidentally) with an FO on his third "live" sector recently, and I honestly cannot remember flying with a more "focussed" and proficient pilot (Particularly flying a last-minute change to a procedural approach at MAH! Certainly made me sit up and pay attention!)

PHX

[simfly]

Regarding the F/O's experience.... Over 1000 hours on type is still a good number. It's well over a year, and one would hope that after that sort of time, he would have been fairly proficient. Agreed there maybe sometimes unusual events which he may not have experienced, but couldn't that happen to anyone at almost any time in their flying career??

[M.Mouse]

Phoenix Son

Not wishing to start an interminable debate about the 'monitered approach' but given the unfortunate set of circumstances that prevailed it is my belief (I have around 15,000 hours experience) that it would have allowed the Captain to reduce his obviously considerable workload.

Similar in some respects to the actions of the Captain involved in British Midland Kegworth crash where the Captain also elected to fly the aeroplane while at the same time managing a very difficult situation.

It is BA policy, in circumstances where a situation develops requiring managarial oversight, that control of the aircraft is handed to the FO. He is competent to fly the aircraft as instructed, or required by a procedure, and it allows the Captain that all important space which is needed to maintain an overview and make decisions accordingly. We also employ the monitored approach as an SOP and in the circumstances of the Girona flight I know which procedure I would have preferred.

It was my first thought that the fuel carried was not overly generous for the forecast weather. 15 minutes extra is not a lot when one considers

TEMPO is used to describe changes which are expected to last for periods of 30 minutes or more but less than one hour in each instance, and which in aggregate are not expected to cover more than half the total period for which the TEMPO is indicated.

There IS huge pressure from management in many companies not to carry excessive amounts of fuel.

Diversions create delays, costs and high workload. No doubt the wish to not divert lead to a strong desire to get in from the second approach. One has to ask the question if the aircraft was carrying another 30 mins of holding fuel would the crew have elected to make the approach when they did?

All personal opinion from the comfort of my study and I don't believe that a pilot alive does not feel for the situation that the crew found themselves in that fateful evening and it is a small mercy that the accident, bad as it was, did not turn into a massive tragedy.

A final comment. I don't doubt the competency of the FO you observed when jump seating and I have rarely flown with an FO who gives me reason to doubt that competency but there is a world of difference between competency and experience. Something not fully appreciated until having that experience! The 1500 hours of the flying that the BY FO had would have covered a huge variety of often demanding flying that the BY network provides.

[Idunno]

Without wishing to get into any dispute, or indeed to be accused of hindsight, I do think 15 minutes extra in TS conditions is a bit tight. Especially when all the alternates (indeed the whole region) seemed to be having the same weather. I guess you could say the skipper was carrying enough to hold and allow a single cell to clear the field...15 minutes might do it...but all the same I personally would like more. Maybe they had weight/range probs? I'm not familiar with the type.

As to the crews competence, I may be reading it wrong but I thought the F/Os input sounded OK. He seemed to make all the required callouts (e.g spotting the 1000fpm descent and calling it). Given his low time I expect there was (even with the best will in the world) quite a steep cockpit gradient.

Incidentally, do Aussie rules require an extra 1hr holding fuel when CBs are forecast? Heard so somewhere.

[fireflybob]

If the destination is tempoing (= change of up to one hour) thunderstorms then perhaps carry an extra one hours holding. If, in addition, the alternate is also tempoing the same then best find another alternate with better weather!

Flying around in such weather without a lot of extra fuel puts crews under enormous pressure and, I believe, this accident is an example of what can happen. The crew and, in particular, the captain have all my sympathies and it was fortuitous that all initially came away more or less unscathed.

I have yet to read the full transcipt of the accident report but I feel that operating close to minimum fuel reserves was a major factor in this accident and in the circumstances the crew were fortunate in carrying out a "controlled" arrival at an airport rather than running out of fuel downwind.

[phoenix son]

M.Mouse,

I agree with your comments re. the difference between competency and experience - Like I said, hindsight is a wonderful thing, I don't envy the situation the crew found themselves in at all. I don't fly, you do, and I think we both feel the same about these guys,

There IS huge pressure from management in many companies not to carry excessive amounts of fuel.

And sometimes, that pressure adds to the situation, which may well be the case here.

PHX

[Danny]

We appear to be descending into the usual PPRuNe scenario of 'expert' analysis by people whose only experience of piloting a B757, never mind any other heavy jet or even any aircraft, is anecdotal, to say the least. Mixing that with an uncanny ability to interpret a brief synopsis of the accident and come up with conclusions that have been thoroughly examined in the report, only goes to show that they are either unable to read the whole thing or are somehow gifted with divine insight that warrants them a permanent job with the AAIB should their services be required. :rolleyes:

Please, can we limit the discussion to facts that we, the people who fly these jets and operate into the airports, can learn from. There is no need for the 'schadenfreude' attitude of some posters (although I see some comments have since been removed) together with the 'green eyed monster' questioning by wannabes who are unable to comprehend that 1,145 hours on type with this operator represent about two years of operational experience into some very demanding airports and weather scenarios. Gaining successful employment on this type of equipment is not that uncommon in this business.

What I find slightly disturbing about the report are the references to fatigue and tiredness which are mentioned briefly but ignored in the conclusions. I know what I feel like on a third consecutive night duty. Add marginal, severe weather for a non-precision approach and I certainly wouldn't have envied this crew and what they had to deal with.

Section 2.3.1 specifically raises the points that whilst the crew did not think tiredness or fatigue were factors in the accident, considering that this was their third consecutive night flight, an analysis of their schedules carried out by DERA concluded that cumulative fatigue did not appear to be an issue but short term fatigue was a 'possibility' even though the recovery periods 'appeared' to be adequate. Even more interesting, I thought, was the reference to the previous two nights duty (Cardiff to Tenerife and Cardiff to Bodrum {and back}) exceeded the NASA and European Scientists 'recommended' 10 hour limit for duties starting or finishing between 0200 and 0600 local time.

In other areas of industry, studies have shown that the accident rate for shift workers increases on consecutive working nights. Also, scientific studies show that the change to being active in daytime rather than night, especially as you grow older, leads to difficulties in adapting to time changes as a result of the shortening of circadian rhythms. In the case of the commander, the report states specifically that "he was within the risk spectrum and on his third consecutive night of duty and it is therefore probable that he had suffered an accumulative loss of sleep."

And that's it from the report with regard to fatigue and tiredness. Does anyone else sense that there is some conflict between DERA concluding that the duties were not fatiguing and the two reports referenced to, one by NASA AMES Research (Principles and guidelines for duty and rest scheduling in commercial aviation) and one by Aviation Space and Environmental Medicine (Age, circadian rhythms and sleep loss in flight crew)? Considering that DERA had a hand in recommending the rostering practices as some sort of 'balance' between managements & beancounters desire to get their pound of flesh from pilots and the pilots desire to work as much as possible during daylight rather than through the night, their conclusion that 'recovery periods' appeared to be 'adequate' seems rather feeble.

[toon]

phoenix, i have over 6000 hrs on 757/767's, not as many as the captain concerned granted, but just goes to show that we can all make mistakes, as soon as i see thunderstorms on the taf i think nothing about putting on 2 tons extra (1750kgs is 30 mins holding at 1500ft) , maybe more if its night ! but hindsight is a wonderfull thing.

[Yeovil]

Danny's observations about tiredness - third consecutive night flight are very apt.
Also readers should be aware that some big operators ( I don't know about Brit's ) but BA certainly put crews under a lot of pressure to take Cirrus ( flight plan fuel) .
The Cirrus may have as little as 6 mins contingency.Routes and diversion fuel figures are often @tight@ or simply unrealistic.
They publish league tables to highlight "offenders"... who are called in front of mgt for a roasting .
Unbelievable, but true.

[M.Mouse]

Also readers should be aware that some big operators ( I don't know about Brit's ) but BA certainly put crews under a lot of pressure to take Cirrus ( flight plan fuel). The Cirrus may have as little as 6 mins contingency.Routes and diversion fuel figures
are often @tight@ or simply unrealistic.

From conversations with colleagues when we see very low contingency figures we all seem to decide on a figure for ourselves.

They publish league tables to highlight "offenders"... who are called in front of mgt for a roasting.

That statement is inaccurate. Fuel tables are no longer published and most of us never read them anyway! The only people I am aware of being called in for a 'roasting' are those routinely carrying way more than everybody else. The 'roasting' is in fact a discussion. I would be happy to have such an interview because I believe I make considered fuel decisions.

Nobody has ever been disciplined, openly or otherwise, to my knowledge, for excess fuel carriage and believe me some of the now retired 'old school' routinely would carry vast quantities of excess fuel! One jumbo Captain in particular would always take 20 tonnes extra if he could physically get it on board!

[Waldo]

Returning to the subject of low houred first officers. I believe that some airlines are now employing first officers on B757 and other complex aircraft with the grand total of 160hrs training. Now that would have made interesting reading in the report!

[Shuttleworth]

M Mouse .

I know the league tables are there .... I saw them yesterday.

Maybe you are long haul? ... but Yeovil has a valid point.
There is pressure from BA SH mgt to carry Cirrus fuel . I could post the documents here , but it would degenerate into a slanging match. Lets stick with the Girona incident ....

[crackerjack]

:( A very sobering report. As someone with an interest, one of the things that interested me most was the skipper's decision to take the approach off the f/o who was pf. Shades of Kegworth indeed.

If a company like Brits - who 'pride' themselves on the quality of their training, don't trust their f/o's to fly non precision approaches in poor weather, what hope is there?

I was impressed by M.Mouse's posting regarding monitored approaches - any more ideas?

[Maxrev]

Hindsight is indeed a wonderful thing. What if they'd taken more fuel, what if the lights hadn't gone out, what if, what if...

The over-riding factor was the fuel state. Their options became limited by poor fuel planning in the first place. The rest was down to some poor airmanship and lady luck running out on them fast with the runway lights failing, and the subsequent damage to the systems after the bounce that caused them to accelerate off into the grass.

Lady luck did appear once again however though in the form of a lovely soft, wet field that prevented a fire.

This could happen to any of us on a bad day. These guys had made a couple of bad calls and it bit them on the ass big time. Next time you drop into a field on a crappy day with marginal fuel think how it might have been....

[NOT ORANGE]

Brittania have been flying around for years with minimum fuel always saying that they save 10 million or so over the space of a year by doing so.I was flying to BCN that night and had plenty of fuel for other options such as PMI,IBZ as I would consider that sensible thing to do.GRN is very close to BCN and not what you would consider a bolt hole on what was a sh...y night.You have to ask was it sensible to have one choice and that was to make an approach under a cb.

[acbus1]

Some observations re the thread as a whole.

Sponsored (in name if not in monetary terms) students graduate from schools such as Oxford and join airlines (using the term loosely in some cases) with a heck of a lot less than the figures given here. All of it on light aircraft and all but tiny fraction on single engine piston tiddlers.

The experience level of some f/o's is a disgrace. Stick em in a small turboprop for a couple of years, I say.



Anyway, was this a case of "pilot error" once again?

Or does anyone in the know want to tell us about pilot fatigue in this case?

Come on, it's an anonymous forum!


And would anyone like to confirm the Gestapo treatment of the Captain, without rest or recovery, immediately after the incident?

My understanding, from colleagues of his, is that under interrogation, he was asked if he was suffering from fatigue and was obliged to reply "No". To reply otherwise would have exposed him to reprimand for "flying when knowing himself to be fatigued" or such like. (The CAA cover themselves nicely with that little phrase, but how strange that it's no defence if you phone crewing and refuse to fly when you're within CAP........outside of BA, anyway).

[Jet A1]

Low houred F/O's - Big deal - BA have done it for years ! You guys obviously think you are infalable. Captains make misjudgements too even with 0000's of hours !

[Big Tudor]

Two very nice people and very experienced pilots. Men who I personally feel proud to call colleagues, albeit in a previous chapter of life. The were called upon to make some very serious decisions in a very high workload situation. They made the decisions they thought were right at the time, not knowing that circumstances would prevail to make it one, if not the, worst night of their lives. I'm sure they would be the first to admit that, with hindsight, they would have done things differently. They didn't, and have not only suffered the consequences of a major aircraft accident and subsequent inquiry, but are also suffering a 'Kangaroo Court' from the supposed professional aviation community. One wonders how many of the good ladies and gentleman on this BB have been in the same situation as these two, the difference being they have been fortunate enough to be able to analyse the situation from the comfort of their local pub over a quiet pint rather than a full accident inquiry. There but for the grace of God go we.

May I respectfully suggest that, rather than questioning the fuel loads and experience levels, we all draw as much experience as possible from this sad episode and draw it to a close. And while we are about it pray to whichever God we each believe in that such a situation will not happen again.

[Terror_is_firmer]

Here, Here. Thankfully no one (except the chap that passed a few days later) was killed in the accident.

[BOAC]

I would vote for Big T's post to be an excellent one on which to close this thread, or at least move on to discussions of the effects of accumulative sleep cycle disturbances.

As Big T says, what I or anyone else WOULD have done is pretty well irrelevant. This is a report on what HAPPENED to a crew and pax.

What IS relevant IMO is Danny's observation on the findings regarding 'fatigue' ('BAD' word) and extreme tiredness ('OK' word).

Anyone else agree?

[Tartan Giant]

I have read the report cover to cover, and I will start by saying it was a miracle there were no deaths or people crippled as a result of this accident. They were all very lucky that night. The muddy field/run-off area and the rain certainly was a fire suppressant – lucky.

I am sympathetic to the flight-deck crew at the sods-law sequence of events that culminated in the sad and dreadful accident. Those aviators left in the wake must learn from this accident.

Whilst 3 night flights might be legal, they play hell with your mental capacity even when the adrenalin is flowing and the “suits” and paperwork speak of more than minimum rest was taken.
On paper it looks good but hand on heart everyone, they are draining, even if you sleep well after the first two night flights.

Danny makes a good and valid point at the previous two night-flights these guys flew; a TCI (10.50 FDP) and that Turkey slog, 11 hrs FDP. Then this third launch into a very dirty night with CB’s where you don’t want them.

I mentioned luck, what was not lucky was the Commander’s choice of Ramp Fuel.
Taking such an small amount of extra fuel was not wise in my opinion, given the destination and ALL the alternates were forecast to suffer from thunderstorms.

There is the first lesson in commercial aviation – to hell with management pressures to take “minimum fuel” when you know the bets are against you.

I read about the fuel league tables – tear them up guys/managers. Penny pinching at the sharp end is completely futile. I think at the back of the Commander’s mind that night was that undeniable nagging doubt, “I have too little fuel to play with” – hence the mind changes about diverting. Taking, “an extra 15 minutes of holding fuel to allow for possible delays” does not cover it.

I have operated into GERONA many the time, and knowing there is no ATIS at least 120 ‘out’ and prior TOD one pilot talked to Gerona and got their “latest”. It would appear the “latest” weather was procured only about 50 miles from the overhead: “When within radio range of Girona at 21.14 hrs the crew requested the latest weather”. Eight minutes later they were O/H the VOR.

Another hellish bit of luck (airmanship) was the crew failing to notice the airbrakes were left “out” for 14 minutes ( 21.18 hrs until 21.32 hrs). It shows you the difficult and demanding task that was on their hands that night, and the lack of spare mental capacity available between them.
What did not help either was the Commander losing his VOR “plate” for R/W 02 (21.24) after he exercised his prerogative and became PF. A CRM question again? On passing, it is not clear to me if he managed to have his own “plate” for the ILS on 20 – perhaps I have missed that somewhere?

A CRM question might be, why did he not hand back control to the F/O who had already briefed for an ILS on 20 and still had his “plates” available? The task sharing throughout the whole unfortunate affair fell very heavily on the Commander.

Taking a small amount extra over and above the “minimum fuel” might look good in an office to some desk-bound manager, but on a rotten wet night, flying into thunder storms (destination and all ALTS) is not a very good idea.

I don’t think the Gerona Air Traffic Controller was very helpful to this crew either. Taking 20 seconds to pass the Barcelona weather is poor service in my experience, and the further lapse (see 21.36:52 exchange).
The female ATCO on duty had only been doing the job for 3 months; and it sounds/reads as if she was acting alone in the tower that night as the report mentions no other ATC Officer and indeed no Supervisor. I say that because I recall the time (years ago) on a night flying into a major Spanish airport that the same voice came up on APPR/TWR/GND and on questioning if he was actually covering all ‘positions’ I was told “Affirmative”. My ASR was never answered! Much like the Electric Power Company never answered the questions about power outages at Gerona that night (that was a damnable disgrace).
It may well be that Gerona had ATC assistant/s available, but they did not have immediately to hand the latest wx’s one might expect on such a foul night. Perhaps that is why the female ATC Officer was on the phone so much, and the crew's request for weather to the North was never fulfilled.

With the greatest respect, it must be said the mental capacity of the Commander must have been reaching saturation point during the GA and then straight into a runway switch for the ILS on the other end, as his calls for Flap Up and then Flap One were only 8 seconds apart (21.38:14 and 22). Perhaps the low fuel state and the “insufficient fuel” FMC message got home. I can really feel for him.

I’m not familiar with the B757 “Landing Check List” but it crosses my mind reading the landing check-list after the OM is a bit late (OM at 21.44:20 – 43) and the intimation the Landing Check List was read at 21.44:56.
When one considers the weather, all the checks should be done and dusted nice and early to concentrate on the execution of a precision approach in crap wx.

I am also surprised that the A/T could not handle the speed sufficiently well in the relatively smoother conditions on the ILS such that the F/O called, “bug minus 10” after the OM and then again, “bug minus 5” and then the Power Levers were advanced – it is unclear from the report if that was by physical intervention by the Commander or the A/T system itself, as the report mentions the A/P and A/T being disconnected 4 seconds after that minus 5 speed call (21.46:58) and some 26 seconds after the Commander called, “Lights in sight” (21.46:32).

The situation got very desperate indeed some 12 seconds later when at 120’ AGL “near full nose down elevator” was applied. The sods law of those lights failing (?) and the loss of spatial awareness by the Commander shows how rapidly it can turn to absolute :mad::mad::mad::mad::mad:.

The Commander stating he, “did not see approach lighting or PAPI lights” calls into question whether these lights were actually turned on for him after the 02 approach !
The F/O did not see the Approach Lights or the PAPI’s either.
The inexperienced ATC Officer acting alone said she was, “absolutely sure” the lights were on.
I would contend, two pilots with 18,194 hours between them would not miss seeing a full set of Approach Lights (CL5B) in a black, miserable, rainy night.

The Commander said, “Lights in sight” at 21.46:32, some 26 seconds before he disconnected the A/P and A/T.
Sorry Gerona ATC, but it’s two against one, and you offer no other evidence those lights were on and serviceable.

There are many lessons to be learned; from the ramp fuel decision, to the low fuel state in severe weather, the minimum ATC support and handling (not to mention the late “rescue” services), CRM, and the body/mental stress of operating three long night flights in succession.
A hellish combination of misfortunes, hopefully never to be repeated.

We are all smart ar**s after the event.
One major item was the fuel carried. I do think the mental capacity would have been opened up if that huge worry was not with the Commander, and would have given him far more time and options up his sleeve. The pressures placed upon him were too many for my liking. I am very sorry it ended the way it did, but very relieved nobody was killed.

On Danny’s question: Does anyone else sense that there is some conflict between DERA concluding that the duties were not fatiguing and the two reports referenced to, one by NASA AMES Research (Principles and guidelines for duty and rest scheduling in commercial aviation) and one by Aviation Space and Environmental Medicine (Age, circadian rhythms and sleep loss in flight crew)?

There is conflict there. Even though 1993 might not be that long ago, things have changed.
http://human-factors.arc.nasa.gov/zteam/fcp/FCP-history-age.circ.html

http://human-factors.arc.nasa.gov/zteam/fcp/pubs/p.and.g.intro.html

TG

[phoenix son]

Waldo,

Sorry if it seems like we are going in circles here, but whilst I wholeheartedly agree that the more experienced a pilot is (or anyone in any job for that matter), the more capable they are likely to be when it comes to dealing with out-of-the ordinary, that doesn't automatically mean that a low-houred F/O makes a bad pilot. Sure, they have lots to learn, but they've also spent the last couple of years getting to that RHS where they are now sitting, not an easy job in anyone's mind.

PHX

[Final 3 Greens]

To add to Danny's examples, the insidious nature of tiredness also impacts the efficient execution of project plans.

If you analyse the error rates of teams working long hours/weekends/overtime against norms for teams working 9-5 hours, the results are quite clear.

It truly is a human factor in aviation.

[DingerX]

Always interesting to read the conclusions reports like this come up with:
A) Sure it's 2-1 that the approach lighting or PAPI lights were not on, but the report uses separate"In sight" and "Contact" calls, along with the ATC's claim that she was dead certain, to conclude that it was "probable" they were on. A more believable conclusion would be that the state of such lights was "undetermined".

B) While the report makes numerous recommendations for changes in practice and regulations, such as suggesting requiring training for initiating a GA below decision height, its only comment on the power failure is that the 11-second interval during which the lights were off -- long enough to make 2 of the 5 contributory factors in the report, and, after the crash, to cause the ATC to lose sight of the crashing aircraft -- is that 11 seconds is well within the 15 seconds mandated by the ICAO. Come to think of it, there were several power failures, including a non-functioning crash alarm, but these failures of primary safety systems appear to be treated as acceptable since they comply with regulations.
I mean sure, you can train crews to deal with losing the runway lighting 7 seconds before touchdown, just as you can train crews to deal with losing an engine on TO; but it's also effective to get manufacturers and maintenance to minimize the possibility of engine failure in the first place. Is it too much to ask that airport operators ensure their primary safety systems function in adverse weather, when ATCs, emergency services and crews are likely to be task-saturated? Or maybe suggest that 15 seconds is more than enough time for an aircraft to crash unseen by those on the ground?

l mean sure, airfields are big places, and locating an accident in severely reduced visibility is difficult, and should (as experience shows) be a part of the training received by emergency crews. But would it be helpful to have a source of power that was working? Would that have reduced significantly the 40 minutes or so between the incident and the arrival of the emergency services at the site?
Okay, sure, I'm nuts, and most places in the world can't afford such an infrastructure, especially if the airfield in question handles primarily seasonal charters. Is there any harm in asking?
(unless, of course, there was pressure on the investigation not to cost the Spanish government any money)

[NoSig Break]

I have heard that the pilots based in CWL were at their wits end and knackered after a hellish summer. I think that the report fails to give adequate weight to the issue of fatigue.

Both the pilots no longer fly. Very sad story indeed.

P.S I have flown into GRO at night in the rain and the whole approach lighting system was turned off, very gash ATC.

[Backtrack]

No Sig Break:

Capt is retired & drawing his pension. FO is still with BAL (probably not far off command). Hope this eases the sorrow.

[NoSig Break]

Backtrack old chap,

It is not quite that simple.

I know for a fact that the FO has hung up his spurs. He feels like a tremendous weight has been removed from his shoulders. I wish him all the very best in his new endeavours.

As for the Skipper, he went on PHI and subsequently retired, never managing to fly the line after the accident.

I hope, in time, they can get over the whole affair.

[Backtrack]

NoSIg Break,

Yes I am old & I am a chap, but please don't patronise me, especially when you don't have all the facts.

"I know for a fact that the FO has hung up his spurs." (your quote).

Can you then explain to me why his name still appears on the seniority list?

As for the capt, what I previously stated still holds true - he is drawing a BAL pilot's pension.

It would be wrong of me - and you - to put any more concerning the current position of these two pilots. However, I stand by my previous post.

[Silver Tongued Cavalier]

An old instructor once told me:

"You can play around with weather, and you can play around with fuel.

But NEVER play around with them together!!!"

[EGGW]

NOsigbreak, listen to Backtrack.

Fact, the Captain DID fly again, subsequently retired on PHI and pension after some medical problems, related to a head injury in the incident. Good luck to him.

Fact. F/O is still flying.

I myself was in ALC earlier that same day, the CB's were huge and widespread. B***ard of a day, anywhere in that area.

Please can we stop the what ifs, so what hindsight is wonderful isn't it.

EGGW.

[blue up]

EGGW

Bad news. F/O HAS gone, as of a few days ago. Was due to be starting command course, so company (and everyone else) thought him able and capable enough. Great guy, and more able than me.

Will be missed. (and I'm not even looking at my roster!!)

[EGGW]

Oh well, my info was correct last Wednesday. Thanks all the same. And good luck to him!!


EGGW.

[Pagoda]

Some posters seem to be apportioning some of the blame to the inexperience of the FO. Short of questioning the Cpts decision to do another approach what could the FO have done differently? IMHO he did his job well providing good support to the Cpt. The report mentions this by stating that the crew worked well as a team.

I cannot see why the controller gets criticised by some posters either. It is a small regional airport with limited facilities. She did her best within the resources available to her. Some posters have obviously not read the report. She sounded the alarm 40 seconds after the crash (the alarm did not work so she telephone the emergency services a few seconds later). Perhaps somebody in the ramp thought that the A/c had diverted, ATC and the emergency services didn't. It would be great if they had a fully working Heathrow airport everywhere we go, just for us, just for 20 aircraft a day three months of the year. Life is not like that. We as pilots must take all the factors influencing the flight into account.

It all turned to **** with that full nose down elevator. After that it was never going to be easy. Fatigue must have been a factor at that point

Can we now paste this thread into the one about 'overpaid bus drivers....'

[fireflybob]

The purpose of accident investigation is to find out what happened and why - NOT to apportion blame.

Pilots are human beings and by definition are capable of "error" but to blame any accident on the pilot is far too simplistic. Accidents are a product of the entire "system". Error chains can start anywhere and with this one it might be argued that such a chain started with the (permitted) FTL schemes that exist (this is no criticism of Britannia) or with a fuel policy which promotes "economy" rather than "safety".

I recall on one CRM course I attended the facilitator talked about the "poor judgement chain" - once one poor judgement is made then the probability is that more will follow at an ever increasing rate. I am not criticising the aircraft commander (there but fot the grace of God go I etc) but once the decision had been made to take only an extra 15 minutes holding then the odds were beginning to be stacked in the wrong direction. Poor judgements chains can only be broken by questioning their starting point and acting accordingly.

My experience is that crews are rarely given any training and guidance as to how much extra fuel to take when appropriate. As a training captain some years ago who often operated to GRO and the like I taught crews to look critically at the destination and alternate forecasts especially when either were close to minima and if there was any doubt to load more rather than less. I know that excess fuel carriage can be a contentious issue in some companies but such policies are, I repeat, part of the potential error chain. It is also important that crews understand the ramifications of terms such as TEMPO etc.

This type of accident could have happened to virtually any operator but we have to ask ourselves, as professional pilots, how WE as individual crew members in whatever role can prevent a similar accident in the future.

[Dogma]

Seems Nosig Break was quite correct. Patronised or not.

Real shame about the First Officer, he was an excellent pilot. I too wish him well for the future.

[Cap 56]

Things have happened and only lessons can be drawn from these events.

Basic common sense tells you; if you have no visual cue’s to land from at the latest at DA or MAP, you make a go around!

But visual cues are not the only thing that may fail.

A thorough knowledge of ILS systems reveals that although LOC and G/S may well be centered it does NOT mean the Aircraft is within the limits or centered with the runway center line.

Some Airlines allow the F/O to continue an autopilot coupled approach (on the condition the LOC and G/S are centered) even if the Capt does NOT react at DA or MAP assuming incapacitation.

The logic behind this is that it is far safer to continue on the Autopilot than to carry out a missed approach with the autopilot by the F/O only.

Edited:

The logic behind this is that it is far safer to continue on the Autopilot and land than to carry out a missed approach with the autopilot monitored by the F/O only.

Another issue is that of extra fuel, 15 minutes is nothing!

If you take extra fuel, then you take plenty and not what I call some kind of psychological fuel of 15 min but at least 30 min if not 60 min.

Not so long ago there was a 757 cargo in LIME with TS all around the place and the same scenario nearly developed.

Again the crew took ONLY 15 min extra, all this causes a tremendous amount of stress and leads to errors.

Considering the small amount of extra burn due to the uplift there is no valid reason why this extra burn should not be considered as an insurance premium against tragedy.

It can only be explained as either reckless behaviour and/or bad company policy.

It is not a question of training but of common sense, only!

There are no clear criteria set out but if you check the WX and you see TS at your destination the you go and look how widely spread they are.

If it is confirmed that they are all over the place and not in a confined area only, then you know what your chances are.

Far too often, do we think that aviation is state of the art technology, perfectly regulated and controlled all this creates a blind confidence in the system.

Everybody with some years in the industry knows for a fact that it is far from perfect

[Mr Angry from Purley]

I hope the guy did not leave because of the report being published. If so he probably didn't need the comments here

[Rananim]

The practice of putting a student pilot in the right seat of a commercial jetliner is troubling and its implications need addressing.I dont agree with it and yet I know many airlines get away with it year after year.Aircraft are so reliable these days.Its not just that the poor guy is woefully unprepared for the huge workload and cognitive decision-making in the event of a LHS incapacitation.The real issue is that it creates a steep gradient between left and right seat.All US majors reject this model and for good reason.For CRM to function as IT WAS INTENDED WAY BACK WHEN,the gradient should be shallow enough to ensure that:
i)the "junior" pilot has a database of knowledge and experience which enables him/her to communicate any concerns about the flight.This communication can vary between timely and helpful advice to direct contradiction.
ii)the "senior" pilot,mindful of the experience of his/her colleague,will readily and confidently use and manage the resources of the right seat.
This model represents the perfect CRM model and I dont pretend that it exists in all US majors,but they certainly aspire to it.This model,when manifested in its purest form,will in fact perform miracles,as in the case of the DC-10 crash at Sioux city,where 182 people escaped certain death.
Increasingly,there seems to be a new model; communication of the type given in (i) is now based on the desire to conform to a politically-correct flightdeck(an anathema to pure CRM).Advocacy and assertion is there but now there's no database to back it up.Or alternatively,the communication is not forthcoming at all,because quite rightly,the first officer feels he/she is ill-equipped to advocate or assert anything.
Pilots wanted:college grad,3000 hours,1000 turbine,must have seen a bit of life.

[Cap 56]

Rananim

You have my blessing.

CRM has evolved into some talk show and has become a way to select pilots NOT on what they know “Database” but on the, are they “Nice” criteria like a kind of “Would I like to sit next to this guy for 8 Hrs”

For many years, models have been developed to select pilots and when Competent and Experienced recruiting staff uses it, they can get it right.

I prefer a young F/O with a solid educational background that challenges his Capt with questions over the one that is nice and that keeps quiet.

It keeps me up to speed, the flight is far from boring.

But the essence of the story is often: “How do you as a captain use your F/O as efficiently as possible” or in other words Crew Management. You can invite the F/O to get more involved yourself.

Certainly; when an approach gets difficult you want to use all resources and in my opinion in the case of this Gerona mishap “A MONITORED APPROACH”

[Right Way Up]

"the "junior" pilot has a database of knowledge and experience which enables him/her to communicate any concerns about the flight."
Ranamim - did that include the Southwest that visited the gas station?
Yes we do it slightly different over here in Europe, but that does not mean either of us are getting it wrong. I have never had any problems flying with Cadets, if they are not happy with something they will always speak up.

[simfly]

The practice of putting a student pilot in the right seat of a commercial jetliner is troubling and its implications need addressing

Why oh why are people still going on about this??? It can be observed in the report that the F/O had a few hundred hours total time when he started flying for BY, BUT!!!!!! he had well over 1000 hours at the time of the accident, so why are people reffering to him as a low hour F/O??? He would have had 1-2 years experience! Where in the report does it comment on this??? If people want to discuss the pros and cons of low hour pilots please start another thread (or search for the past ones!) as people who have not read the report will start believing things that were not reported as factors!

[cargo boy]

Typically, those that 'prefer' to argue about their revulsion at having 'young' inexperienced First Officers are the same ones that most Captains, young or old, experienced or inexperienced, can't stand spending long periods with on the flight deck. You only have to listen to Cap56 and you'd think he was an experienced jet CAPTAIN! :rolleyes: There can be little worse for anyone, Captain or First Officer to have to listen to someone pontificating from a position they don't have the credibility to claim to be coming from. A bit like listening to a "Jack of all trades, master of none"!

As has been pointed out already and suitably ignored by those that like the sound of their own voices, the F/O had two years of experience on the B757. Where he started from is irrelevant and yet we have 'pseudo experts' trying to tell us how terrible it is to have to fly with a cadet pilot. If the F/O had been only just released from line training, maybe, just maybe, there may have been a point to be raised but in this instance the F/O performed appropriately and according to the book.

So, would the pontiff (and I think we all know who we are talking about) please go back to lambasting other airlines about how to fly into Johannesburg on a hot night. The lecture on cockpit gradient (an inverse one in this case) would be better applied to a situation where an F/O was driving his Captain to distraction with his self deduced gospel about how he thinks it should all be done.

The Gerona accident was just that, an accident. It wasn't one single causal factor but a number of them, as in just about all accidents. We, as pilots hope to learn from them. Anyone who tries to use the information to pontificate about how it should be done will probably find themselves being knocked off their pedestals. This accident could have happened to any one of us, including the pontificators. Line up enough holes in the Swiss Cheese and, as we have learnt from this one, the brown stuff can and will hit the fan. Third night flight in a row is not where you want to be when you can see through the cheese.

[broadreach]

Throughout this thread I've been wondering what the Captain and the FO thought of the final report and of the 20/20 hindsight comments hereon. I would only hope that the positivve comments of ex-colleagues outweigh, for them and by a long shot, the censure expressed by those who don't know them and weren't there. Particularly with regard to the FO, apparently leaving of his own accord shortly after the report was published, no indication as to whether he's off to another flying job, entering a new career or just contemplating the future. Whatever his course, best wishes.

[acbus1]

It is interesting that the subject of low hour f/0's is being mixed in with the Girona topic.

This leads to the impression that the Girona f/o was in some way lacking. The majority of posters cannot know that.

My original post herein lambasted low hour f/o's straight from training school. OK, so I've flown with f/o's with over 10000 hours who should'nt be allowed in a cockpit, but they are few and far between. The big problem (and I am in a position to speak from experience) is low hour f/o's with little experience, maturity, humility and all of the other ingredients which go to make up a colleague who helps rather than hinders.

For goodness sake, some of the guys I've seen can't land the aeroplane anything but roughly on a calm, CAVOK day. Throw in some wind, heaven forbid a crosswind, and watch out!

The system needs sorting out by the CAA (wishful thinking, then).

Sorry to go off topic (or is it?). :hmm:

[SortieIII]

CRM has evolved into some talk show and has become a way to select pilots NOT on what they know “Database” but on the, are they “Nice” criteria like a kind of “Would I like to sit next to this guy for 8 Hrs”

CAP 56 you must have had a different CRM experience to the one I have had. I was taught that the bottom line of CRM was flight safety.........being nice is nice, but flight safety takes precedence.

[Max Angle]

Very sensible and balanced editorial in Flight International this week, it's well worth reading and I have copied it below, the last sentence is particulary pertintent.


Sometimes an accident warrants examining because it is extraordinary. The Girona report needs study because it is ordinary

If Professor James Reason was looking for the ideal real-life example to demonstrate his famous "Swiss cheeses" model of what enables accidents to happen in a basically safe system, the just-published report on the September 1999 Boeing 757 accident at Girona in Spain has it all.

Now the investigators reveal a web of interacting forces, circumstances and influences, even including what secular insurers still call an act of God. Gamblers would call it a wild card.

It is worth using an event like Girona to examine whether, just sometimes, things like this are bound to happen and we have to accept it, or whether something could - or should - have been done that might have blocked the chain of events. Although this 757, with 245 people on board, careered off the runway at high speed with almost all its controls disabled or malfunctioning, only one person died as a result. Even the low toll in human life could be considered a matter of luck.

This aircraft set off from the UK for Girona, knowing its destination and all its alternates were affected by a band of stormy, frontal weather - but it was the type that might delay a landing until a storm cell passed rather than prevent it. The captain loaded an additional 15min of fuel above standard company diversionary minima to allow for this. On calling Girona it was clear that a storm cell was close to the airfield, but it was dark and its precise location was not communicated. The wind - not strong - had shifted from southerly to northerly, so the captain decided on a runway 02 non-precision approach rather than a precision approach on to 20 with a tailwind. The trouble with 20 is that it has a strong downslope - just above the International Civil Aviation Organisation recommended maximum. And the runway - adequate but not generously long at 2,400m (7,900ft) - was going to be wet, so the captain opted for the risk of a non-precision approach rather than the alternative risk of a tailwind landing on runway 20. He also took over as the pilot flying at that point. But the VOR/DME approach did not go well, the tower/approach controller advised during it that the storm cell was now over the airfield, and the captain carried out a go-around. Meanwhile, the wind was shifting again to southerly, making an ILS to runway 20 plausible for the second attempt. Then the aircraft flight management system advised the crew they were approaching company fuel minima, so the captain was under pressure to make a decision whether to divert or not. It was dark, turbulent and the rain over the airfield was "torrential", but had they diverted to any of the alternates it might have been the same. As they established on the ILS for runway 20, the "must land" mindset would have been a tempting one to adopt. The approach was turbulent and not stable relative to the glideslope, but the runway lights were visible before decision height and, despite a sink-rate warning from the ground proximity warning system on short final, the captain clearly thought the landing could be safe.

Then fate played the wild card. The runway lights went out for 11s just as the captain needed them to judge the final descent and flare. The report says a contributory factor in the very hard, nose-down landing that followed was "the effect of shock or mental incapacitation on the pilot flying at the failure of the runway lights, which may have inhibited him from making a decision to go-around". Most pilots have experienced an unexpected loss of visual contact with runway lights at the last moment - usually due to a patch of fog caused by a local micro-climate effect - but by the time the pilot has registered the loss of contact the lights usually reappear again.

A pilot is "the system's goalkeeper", and this one got past the 757's crew. So where else did the defences fail? Girona, with its steeply sloping runway, is scarcely perfect, but that was a known part of the risk management calculation. With hindsight, 15min of extra fuel was not enough. A recommendation that go-around manoeuvres below decision height should be a mandatory part of recurrent training seems useful because it would help pilots override a "must land" mindset. Another recommendation - that more precise real-time weather information should be immediately available to controllers - would have helped the captain with decision making. There's plenty else - the report is a gift for nitpickers.

The Girona report should be required reading for airline and airport safety committees, because there is no "silver bullet" solution for this one. It was an ordinary situation that got out of hand, and all operators can face challenges like these at any time.

[Traffic]

Very sobering indeed.

I would be very interested to read Appendix 3 to see how many hundreds of others would have ended up in the same position, albeit in the sim.

Goes to show just how few holes there are in the Swiss cheese to line up these days... courtesy of the beancounters.

'The only time you have too much fuel is when you are on fire' was one of the first rules of flight planning ...back in the days when flight crew had complete control of the safe operation of an a/c.

[411A]

...back in the days when flight crew had complete control of the safe operation of an aircraft."

Hmmm, the license these flight crew held certainly required the full authority for carrying more fuel, yet the Captain chose not to do so.

Quite frankly, having operated into Girona more than a few times (yes, at night, stormy weather etc), it would seem that the operating crew in question stuffed it up rather badly...a lesson for all, to actually pay attention to what the hell they are doing.

A bit more experience in the RHS wouldn't hurt either.

[atse]

it would seem that the operating crew in question stuffed it up rather badly ...
It might seem like that to you. But the Flight Editorial provides a wiser perspective on the events. One needs to have a bit of imagination to see how one can quickly find oneself up to one's ears in unexpected troubles.

Perhaps persuading yourself that it could not happen to you just represents a failure of imagination, rather than an affirmation of the skills you demonstrated in successfully getting yourself in and out of Girona on several occasions?

[411A]

You make a good point, atse, but then again the photo of the concerned aircraft off the side of the runway clearly showing the damage done, really says it all.

Yes, Girona has some of the same problems that many Spanish airports have...poor atc communication, rather nasty weather at times, high ground nearby, sub-standard lighting...but in the end it is the Commanders responsibility to factor all these in, and if the picture is not pretty, then immediate diversion becomes necessary.
If you don't have the fuel for same, due to poor planning in the beginning, or waiting too long to make that diversion decision, then the picture becomes very nasty indeed.

Many pilots (and especially, airlines) can learn valuable lessons from this very unfortunate accident.
Wonder if they will?

[atse]

The point I was making 411A is that the photo of the aircraft is a photo of an outcome, the end of a process. It is singularly inappropriate to judge culpability by the outcome. It may appear reasonable to do so, but it just ain't so. (You quickly end up in a position where the worse the outcome, the more the culpability ...).

Even in your response where you say I make a "good point" you quickly revert to the attribution of crew error with implicit backwards reasoning along the lines of:

- Bad things happened,
- The captain's responsibility is not to have bad things happen,
- Therefore, pilot error

[NoSig Break]

All I can say is Fatigue was a major factor in this accident!

1998 at Britannia was a turning point, a lesson in how not to run an airline.

441a : How many times have you diverted? And I don't mean on Microsoft flight sim!

[BOAC]

Still trying (with ´Big Tudor) manfully to try and drag this away from the vulture mentality into looking at Danny´s fatigue points.

A recommendation that go-around manoeuvres below decision height should be a mandatory part of recurrent training seems useful because it would help pilots override a "must land" mindset.

Good idea in my book, and one of the things I started discouraging some years ago was the dialling-up of the ground frequency (if any) on finals, which could pre-condition the ´land´ mental picture. Leaving the radar frequency in place is better.

Can we now leave THIS crew alone - please, or are we all going to conduct our own ´accident investigation´ here over and over again?:(

[Wig Wag]

411A :-

The report states:

1.17.1.9. Fuel Policy

The Operator's fuel policy objectives are as follows:

a) A sufficient quantity of fuel is carried for the intended flight with a safe margin for contingencies.

b) The range capability of the aircraft is fully exploited.

c) The uneconomic carriage of fuel is minimised.

If you were operating under this fuel policy how might it affect your daily decisions, year in year out, on how much extra fuel to carry?

[Cpt CadetEntry Pilot]

I heard that there were 3 aircraft in the hold that night who were diversions from BCN (The nominated diversion for the Britannia flight).
Does that change your opinion about them commiting?

[fireflybob]

I think we could go round in circles for ever on this one but a couple of comments:-

>a) A sufficient quantity of fuel is carried for the intended flight with a safe margin for contingencies.<

It is surely the aircraft commander who makes the decision to ensure a "safe margin".

>c) The uneconomic carriage of fuel is minimised.<

Emphasis on the word "uneconomic".

>If you were operating under this fuel policy how might it affect your daily decisions, year in year out, on how much extra fuel to carry? <

I hope that as an aicraft commander it would never influence my decision to carry any extra amount of fuel I deem necessary for safe flight. Further there must surely be other instructions in the fuel policy that the aicraft commander has the overriding authority as to how much fuel to depart with?

I cannot understand why various posters are being so defensive about this aspect. Surely it is a fact that more fuel should have been carried on this flight? Why dodge the issue? You only need to eliminate one of the holes in the cheese model to avoid an accident.

[troubles]

Accidents are caused by a chain of events that were able to happen because some defences failed. Mentioning a specific defence (ie. crew experience, CRM, fuel etc..) is not meant to single out a cause, it's just to poit to were defences failet to meet their objective.
By law it's so easy, the commander shall...... So it's all his/her responsibility nowhere however does JAR-OPS say that the company must make shure commanders take their responsibilities. Worse even in many occasions the company consider a pilot who is willing to take a risk (read breake a rule) a better pilot because it helps the company to acieve their goal which is making money.
Detailed discussions into the amound of fuel required is in my opinion bs. we should discuss how to deal with commercial pressure, and how to regain captains authotity because that is were the risk starts.

Troubles

[averytdeaconharry]

I worked for an airline that had a set of, I think it was six, corporate objectives. The first was that "the company should operate to standards of safety that tolerate neither accident or incident". It is obvious commonsense that if there is only one corporate objective in an airline it would have to be about safety.

Once you have established such an objective all sorts of things flow from it if is going to be achieved. The Captain's authority over the preparation for the flight and the management of the flight are just two examples.

I am not going to pass any judgment about the Girona crash because all the issues would appear to be in the accident report. But I would like to see the corporate objectives for the business as a whole. I was told some years ago by a senior director in the Thomson organisation that thre role of Britannia was very clear. It was to be the mass trassport system for Thomson Holidays.

Some years later I was headhunted to run a shipping business. I did not get the job and I was given some feedback on why. It was apparently because I answered one of the questions at the interview in the wrong way. I was aked what I would do on my first morning there. I answered that in addition to meeting the key people who would be reporting to me I would need to study the accident handling procedures so that I would know what I was required to do if there was any incident or accident on my first day there. I was told in the feedback that I should have talked about profit instead.

I wonder just how many airlines would have a similar view.

[Big Tudor]

BOAC

It would appear that your are striving in vain. It seems strange that the fatigue aspect of the incident is being overlooked by the majority of posters, especially since there have been numerous threads on this BB recently about his very subject, some quite voiciferous. We appear to be concentrating on how much fuel the commander chose to carry and how much more we would have uplifted in the circumstances. Did fatigue play a part in the commanders decision on fuel, one wonders? If the commander had uplifted more fuel would the outcome have been any different?
There are plenty of scary comments about flying when fatigued, but what about the implications of planning when fatigued? It is said that familiarity breeds contempt, what happens when familiarity is coupled with fatigue, especially when reading met briefings prior to a flight. What do you think when you read an all too familiar TAF for an airfield of TEMPO VRB20 TSRA OVC500? Do you take in what the TAF is telling you or is it pushed to one side with an confident look and a "Been there in worse" thought?

[Rads]

I don't think anyone has mentioned the one conclusion that was, I believe, the cause of this becoming an accident rather than just a landing incident.

This is the poor construction of the dog box, which caused thrust to be applied leading to the aircraft departing the clearway. The conclusion was that if the dog box construction was more robust the aircraft would have come to rest within the airport perimeter with little further damage to the aircraft. This is not the first time that this has happened to a B757 yet Boeing do not seem to have any thoughts on rectification of this problem.

[Rananim]

The conclusion in 2.2.2.3 that the cockpit gradient didnt play a role in the crash is frankly suspect.By advocating the use of a monitored approach(a procedure designed to combat adverse cockpit gradient) in its recommendations,the report seems to be contradicting itself.
Disappointingly,the report didnt discuss what role the first officer had in the decision to take only 15 minutes extra fuel.Also no broader discussion on the general fuel policy adopted by the company.Did an in-house fuel league table exist whereby pilots compete for brownie points?What effect did the fuel status have on the captain's decision NOT to go-around when it was mandatory to do so.

[Vox]

Rananim No there isn’t a fuel league table in operation at BY. If the crew identifies a reason to load more fuel than CMR, then they are free to do so.

[HOMER SIMPSONS LOVECHILD]

So hands up amongst the real pilots in this thread who hasn't on some occassion thought to themself,"Sh1yte,I wish I'd loaded more gas!!" ??

[Wee Weasley Welshman]

It will be a big day for passenger aviation in Europe when there is a hull loss + widespread death at any well known airline. If the subsequent report blames fatigue - even obliquely - there will be hell to pay. The whole health and safety mafia will feel mandated to get into aviation and fatigue is their easiest and most powerful entry point.

Doctors, lorry drivers, train and tube operators, Air Trafficers; all are required by law to work fewer hours with more rest than the pilots of airliners. The logic and the media impetus from mass funerals will be overwhelming.

Which leaves one frustrated that the authorities do not prempt and prevent the whole sorry scenario. Lets face it - the industry is overdue for another big one in Europe after many close calls.

Cheers

WWW

[Tartan Giant]

I have been following the thread closely, from the outset, and measuring the replies without further comment since my own.

However, I do feel the need to ask readers what they feel about the one insert by WWW - and I add this:


WWW

I don't think the fuel uplift was unreasonable.

You cannot be serious - surely!?

Are you telling readers, that YOU would take only 15 minutes extra fuel had you been the Commander of that flight?

I wonder how many readers with real airline Command experience would support your veiw of that RAMP fuel decision?


The "poor facilities" you mention - are you talking about NAV aids, or those engaged after the sad event.

I'm glad you engaged your imagination on this one; for I hope never to fly with you in the LHS if you opt and contend it reasonable to carry such fuel loads in those conditions.
Seems the lessons about WX and options have been lost on some F/O's.

TG

[simfly]

was the fuel uplift a contribution to the accident?????

[phoenix son]

was the fuel uplift a contribution to the accident?????

The accident investigators seem to think it was a factor...

"REC 31/04 - It is recommended that the Operator should review its Flight Planning and Clearance Procedures in order to take into consideration probable meteorlogical conditions at the destination and alternate airports, including thunderstorms"

PHX

[Wee Weasley Welshman]

The SIDS, STARS, likely routings, winds aloft, estimated weight vs reality, all these things we know not. The Skipper may have thought himself likely to have quite a bit more than 15mins.

Pointless speculation really.

Cheers

WWW

[atse]

Most accidents can be analysed from different perspectives and, depending upon that perspective (or hobby horse, or bias if you will) a version of events - and how those events could have been interrupted - can be easily re-created in retrospect. Those strongly holding to a particular point of view will invariably find suggestive evidence that just seems “obvious” to them.

The problem is that for each notion as to what factor was critical - e.g fuel, weather, fatigue, cockpit gradient, CRM, etc. - a version of events can be constructed which differs as to the crucial aspects. Working out which version is “correct” can rapidly become a fruitless exercise, since very notion of “correct” becomes part of the problem of analysing the events.

It is, just to take one example, clear that Tartan Giant is somewhat horrified by the fuel decision of the commander/crew. In the absence of knowing the outcome, or the commander’s reasons when he made the decision, the amount of fuel has to be considered sufficient (read that again carefully if you think it is nonsense. Otherwise you are forced to make the claim that the flight dispatch decision was itself demonstrably wrong, at the time of dispatch. I don’t think the evidence is there to make any such statement). The fuel carried may look insufficient IN RETROSPECT, given a particular perspective and the way events unfolded.

But how many times have pilots found themselves in situations that looked much worse, or better, than expected on arriving at destination? Consider it this way: if the crew had carried 45 minutes extra fuel, but arrived at the airfield 30 minutes earlier, held because of CB avoidance and then found themselves in an absolutely identical situation, would we now be hearing anything about fuel? I think not. I think the focus would be elsewhere. My point is that it is not the amount of fuel that is at issue here, but the reasonableness of the decisions made AT THE TIME THEY WERE MADE.

Surely the real point, so well outlined in the Flight Editorial, is that this was an ordinary flight that suddenly, and for various unpredictable reasons went awry. The big problem is that this was indeed an ordinary flight and the path to the dreadful outcome is only clear in retrospect. In my opinion we should be talking about why the Flight Editorial is so important, as well as it’s significant for all professional pilots.

If you think about this event in real time, as it unfolded for the crew concerned, I think there is a lot to be learned about how each of us might wish to approach analogous situations in the future. Surely that is the benefit of having a discussion about accidents?

[Yarpy]

this was an ordinary flight that suddenly, and for various unpredictable reasons went awry

I quite agree. It could have been anyone of us up until the time the lights failed on short finals.

This is as close to being a pure accident as you can get. Rightly, blame was not apportioned.

[Bally Heck]

I was a bit perplexed by one part of the report which no-one seems to have picked up on. And which the investigators seem to have passed over.

However, at the time the autothrottle was disconnected a power correction had just been made to 1.51 EPR, a higher than usual approach setting (around 1.2 EPR)

Higher than usual approach setting is a bit of an understatement! It's not a million miles of take-off thrust. In several thousand hours of flying the 757, I have never seen an approach EPR much above 1.3!

The question begging to be answered is why did the autothrottle make this power change? Looking at the graphs, it lseems that the autothrottle was responding to a speed loss from around 152 knots to 127 knots over a period of around 12 seconds! Also considerably slower than the Vref of 141 knots! The ground speed at the same period went from 132 knots to 123 knots!

The report says that windshear and turbulence didn't significantly affect the performance of the aircraft.

It seems to me that that was one very big burst of windshear at a very low altitude (250ish radalt) A loss of 25 knots!!!

That the captain disconnected the autopilot and autothrottle with this high power setting (possibly because he was concerned by these changes?) left him with a very unstable situation.

Am I missing something here? That looks very much like low level windshear to me. And the occurence of that windshear seems to have destabilised the approach to such an extent that the subsequent hard landing(s) occurred.

[Tartan Giant]

Bally Heck,

I bow to your superior knowledge on the B757 and your observation about the EPR setting on the approach just prior to the Commander disconnecting the A/T.

My own limited observation on the A/T aspect was this:

I am also surprised that the A/T could not handle the speed sufficiently well in the relatively smoother conditions on the ILS such that the F/O called, “bug minus 10” after the OM and then again, “bug minus 5” and then the Power Levers were advanced – it is unclear from the report if that was by physical intervention by the Commander or the A/T system itself, as the report mentions the A/P and A/T being disconnected 4 seconds after that minus 5 speed call (21.46:58) and some 26 seconds after the Commander called, “Lights in sight” (21.46:32).

Your point about a,
very big burst of windshear
is not lost on me.

I'm still wondering why just after the OM the A/T was not responding very well to speed loss.
The last EPR setting was, as point out, quite a handfull.

Certainly the large power change would not be helpful nor contribute to a stable approach when needed most - but the loss of visual clues at the very same time added to this poor chaps problems; the application of near full down elevator fills in the story.

TG

[Bally Heck]

Quite so Tartan. I have no dispute with most of the findings. I just can't figure out how the report concludes that windshear was not a significant factor. The basis for this appears to be in 1.11.7 with some waffle about customer options for windshear alerts/warnings.

If a 25 knot airspeed loss to Vref minus 15 at 250 feet insn't significant, I don't know what is!

The effect of this large thrust change to 1.51 EPR would be a considerable nose up pitch which would require significant forward pressure on the column to counter. (typical take-off thrust on the 757 might be around 1.59 EPR) With the aircraft trimmed for the approach rather than take-off this sort of power setting must be close to the limit of elevator authority (educated speculation!)

The autothrottle on the 757 whilst well up to normal day to day operations, isn't particularly good at coping with gusts. It can only respond to speed changes after they occur, and is obviously incapable of anticipating them. The greater the speed change, the greater the correction the autothrottle will make.

I wonder how many people could cope with the workload of almost simultaneously having an aircraft lose 25 knots, trying to pitch upwards like a steeplechaser at Beechers Brook and losing all external visual reference?

[411A]

The auto-throttle was not the cause of this accident.
Nor was any possible windshear.
Nor was it the relative inexperience of the First Officer.

And...fatigue is a complete red herring.
Med flights are not all that tiring, as I should know, as I've done a lot of 'em.

The very simple reason is the total lack of understanding by the operating Commander on insisting on taking min plog fuel (plus just a bit more) rather than the amount really necessary to achieve a reasonable expectation of reaching the nominated alternate.

In short, he painted himself right and properly into a corner, from which he had very few options available.

The guy is a clown, and simply does not belong in charge of a jet transport aircraft.

I fully expect the usual huffing and puffing, but the known facts speak for themselves...as does the wreckage off the runway.

[acbus1]

You'd be amazed (terrified?) to hear of the number of "proud" Captains who carry bare minimum fuel all the time in an outfit I'm familiar with, but could'nt possibly name. be my guest, stupidos!

I was once criticised on a line check for taking 45 mins extra holding fuel on a UK internal flight. CB activity was forecast for the entire destination and diversion area.

OK, I realise that on long flights, the MTOW may restrict extra fuel. I'm not 757 familiar. Anyone know if this was likely in the accident case?

[Flightrider]

The flight plan indicates the required fuel load INCLUDING mandatory reserves to cover various eventualities like holding and diversion; and so the captain's decision to take flight plan + 15 minutes fuel is entirely legal and in keeping with both company and regulatory authority requirements in place at the time.

If those requirements are subsequently subject to review, I feel it is unreasonable to castigate the captain of this aircraft for shortcomings in the standard operating procedures that he was trained to follow.

As a secondary point, are we saying that if the Captain had more fuel, he would not have commenced the approach which led to the accident......? If he would have commenced the approach anyway regardless of fuel state, it possibly was a heaven-sent blessing given the subsequent turn of events that he didn't have more fuel on board. As well as fuel powering engines, it can also power nasty fireballs that kill people very quickly. Thankfully for all, this was avoided on this occasion.

Even with the benefit of hindsight, I don't think any of us can categorically say what would or would not have happened.
Continuing to argue on this one is not making any tangible contribution to safety as far as I can see.

[Cap 56]

There are rules about the minimum fuel, these rules are established to avoid that people would even take less.

These rules are fine if operational conditions are the same as the model used to calculate the minimum required, hence no other factors, adversely affecting the flight are present.

Minimum fuel means that you would arrive (after shooting an approach at your destination) at alternate with only 30 min reserve CALCULATED and taking into account that there are no fuel indicator errors and all parameters used to do the math are correct. This is basic knowledge everybody is familiar with.

Minimum legal and SOP are two different things.

Fuel policy can only be integrated into company SOP if you have a policy that is very elaborate like for example the one from KLM. In other words, when all variables that could reasonably be taken into account are present in writing in the SOP.

If you take 15 min extra you are only 15 min away from landing with 30 min in your tanks in case you divert.

Under certain circumstances, 15 min is nothing.


1. Cat I marginal or CAT II/III
2. Non Precision with a VIS that is lower than 6 x MDH
3. Significant WX

Then it is reasonable to assume that you may have to make a second shot. This has nothing to do with skill but only with luck.

15 min will not give you the chance to do that second shot.

Those that know what they are doing; cater for the cases were they may be unlucky.

Those that do not really know what they are doing need all the luck they can get.

[Cap 56]

If you decide to carry the minimum legal fuel is OK, what is not good is not to be prepared to divert when you feel that your options are narrowing and the enviroment (weather) works against you.

And if you divert then better do it with plenty because you will not be the only one.

I do not want to be patronizing, but these things are know by everybody and that’s exactly why most pilots are amazed that the crew cornered themselves.

Whatever happened during these approaches is subsequent to the fact that the crew had put themselves under pressure because of fuel reasons. It must be very annoying to get those low fuel messages during an approach that needs all your attention.

I-FORD

I agree with you that if you are getting short, you man not even want to try a first shot at an approach. But that would mean you did not consider the possibility at dispatch stage otherwise you would have arrived with more anyway.

[Rananim]

In the States,standard extra fuel when thunderstorms are forecast is one hour and that includes a tempo observation.
Thunderstorms do,however,tend to be more spectacular stateside.
This thread is important and it should be allowed to run its course.I wonder how many UK pilots feel:
a)that their company encourage a minimum fuel policy to the extent that if they request extra,and it is subsequently proven to be unwarranted,that they will in some way be sanctioned?
b)that their chief pilot wears a corporate hat too often?A good CP dances to only one tune:"How can I best help my pilots to attain the safest operation possible?"He knows each and every pilot,their weaknesses,their strengths.And above all,trust is implicit.Its a managerial role,yes,but never a corporate one.Let the ops director try and bridge the gap between economics and safety.

[SR71]

Question....

What may one infer regards their companys attitude towards safety when a regular line pilot asks for more sim time, for no other reason than to become a better pilot, to practise responses to scenarios he has not otherwise seen before and is denied the request?

Is there a company out there that would accede to such a request?

The hegemony of political correctness is far-reaching.

Comment....

The simple argument that suggests the yardstick by which one is good at his job has a direct and unique correlation with one's experience is amusing.

For me, its the guys who get the job done whatever the TAF, and inspite of their experience, who determine the distinction between mediocrity and greatness.

I personally have learned from the report and thats all that counts.

:ok:

[Big Tudor]

Rananim,

Does the policy also extend to PROB30 and PROB40. I have often wondered whether there is a certain degree of apathy creeping in towards PROB30. It seems to be interpreted as the Met Man covering his rear end, just in case it happens.

I am not implying that the met report for that night contained any mention of PROB30 or PROB40.

[Max Angle]

Somebody mentioned that there were two aircraft holding who had come from BCN which was the alternate for the BY flight. This must have greatly increased the "must land" mentality as with your alternate out as well your options are fading fast. The selection of BCN as an alternate was highly questionable given the fx. weather for all the airfields along the coast. I was flying in southern Spain that night and had Madrid fuel up my sleeve (ie. a lot of extra) plus enough to hold at our destination for 45 minutes before diverting. In the end we didn't need it but the weather was really bad all along the coastal area that night and knowing I had enough to divert well inland was a nice feeling. I can remember the details pretty clearly because I read about the BY accident the next morning over breakfast and like many here thanked my lucky stars it wasn't me. I took lots of extra that night but it's quite possible the implications of the forecast weather could have got past me and I would have departed with less fuel than we really needed which is maybe what happened to these guys. I am sure that had it dawned on them that their alternate and most of the other airfields in the area could all go down as well then they would have nominated another one.

It's very easy to scan through the weather pack at briefing without building up a picture of whats going on and what the implications of the information are and I must say that this accident plus a situation I got myself into at the start of my time in the left seat have made me much more carefull when looking at the weather, even on seemingly benign days.

[Bally Heck]

Quite amazing looking at some of these replies! Nowhere in section3.2 of the report (Causes) does it mention fuel or the First Officer's experience as being factors.

In my view most crews would have tried for the second approach, given the wind change, regardless of wheather they had 3 tonnes or 10 tonnes of fuel on board!

A few people seem to think that if an aircraft has lots of fuel on board, the approach won't become unstable below decision height and that somehow it will prevent the airfield lights from extinguishing in a thunderstorm. Perhaps this is a feature of Microsoft Flight Simulator?

If the aircraft had been carrying a few extra tonnes there is a greater chance that the tanks would have breached with horrific consequences.

If the aircraft had gone around from the second approach, there was sufficient fuel on board to take it to BCN.

The captain took more than legal minimum fuel, which in itself is normally quite fat, based on a great deal of experience. What he took was enough, although not fat. It did not bring the aircraft down.

Any chance of discussing the facts of the accident and the lessons to be learned from it rather than worrying the fuel policies and minimum hours requirements of various companies to death?

[411A]

Wonder if Bally Heck is one of those who...steam along every flight with absolute minimum fuel, and feeling lucky doing so?

Those who ignore having adequate (for the anticipated weather) gravy will be caught out sooner or later.

Sad but true, as the concerned Commander found out.
Must be the Brit mentality.:ugh:

Harsh you say? Have a count of the number of threads previously here on PPRuNe about just this idea. Arriving with min fuel, and then having the pucker factor so that ATC was bothered by those who think...don't confuse me with the facts, my mind is made up.

[Brenoch]

Bally Heck,

Surely you can't be serious, the report clearly states that they were below min-fuel for diversion. I know that they would probably have made it to BCN but as you say they had sufficient fuel is just about as far from the truth as you can get. I would think that if more fuel was carried they/he (commander) wouldn't have been as commited to commence the second approach when they did.

I have to agree with 411A on this one, bloody silly thing to do flying into known adverse weather with only 15mins extra onboard..

[Dogs_ears_up]

I Hope you will all forgive an intrusion from a non-pilot crew member. Having read the report, it strikes me that the dominant causal effect of the accident was the loss of visual on the landing lights, exacerbated by the uncommanded thrust increase from the shattered dogbox after impact. To an uninitiated person, fuel and F/O experience may have been contributory factors, but were not the dominant ones. As a Layman, I'm having problems understanding why you're apparently discussing the lesser contributory factors, rather than the major ones.

I'm very concerned that I may be commenting on matters that are outside my area of expertise, and do not wish to impinge on Flight Crew knowledge or experience. It;s just that when I read the report, it struck me as being a particularly malevolent combination of circumstances that combined against the crew, and little more. With hindsight, I expect most pilots would have handled things better, or at least differently. But that is with hindsight.

I have to confess that I work for the carrier involved, and the Captain had flown me on many sectors. He is a man I like and trust, to this day. I would be greatful if you could all avoid the predictable flaming on this subject. I am simply seeking an answer to a straightforward question, asked in good faith from a non pilot. Please, therefore, understand what may be a certain naivete about this post.

[Caractacus]

'Dogs_ears_up', you are not asking silly questions. There is a culture amongst pilots of vigorous debate of the professional issues.

Yes, you are correct to say that if the electricity had not caused the lights to fail the Captain might have landed the aircraft safely.

The issue is that, if there had been more fuel on the aircraft, a landing at that time might have been averted.

Here we get into a real pickle. It is the Captains responsibility to carry extra fuel to cover eventualities. However, the airline is allowed to write a fuel policy which suggests that the carriage of extra fuel should be moderated.

This is the rub. In the UK, some airline management cultures put subtle pressure on Captains to carry minimum fuel.. Some do and some don't. It can depend how resilient you are to peer group pressure. It can also depend on whether you have ever been badly frightened.

I fall into the latter category and carry a lot of extra fuel for fog, strong winds and thunderstorms.

However, even if you carry lots of extra fuel you can still get caught out in extremis. The runway can become blocked or the lights can go out at night just as you are landing having used all the extra gas due to circumstances.

Perhaps we should practice fuel emergencies in the SIM. However, that might lead to pilots carrying more fuel all the time and then the bean counters would quietly suggest to the Board that they do something about it . . .

[Loose rivets]

There has been little comment on the actual moment that the lights went out. Is there any clear data, even in the memory of the commander, of the decision to press on vs. go-around?

Intentional pushing on into absolute rain lashed blackness is not very likely, unless there was a compelling reason to do so. Even if he felt that the loss of lighting was containable, he may just have been unlucky enough to have a vicious weather induced increase in v/s .

Is there any evidence to show that the continued landing was intentional?

[Cap 56]

I used to have a book titled “Weather Flying” written by a certain Bruck (I am not 100 % sure of the name but it sounds like that) I got it from the States and the author is an American.

I borrowed it to a F/O who never returned it to me so I do not have the ISBN.

The writer used to be part of some king of weather research program, actually flying into TS and Hurricanes for scientific analysis etc…..

I really recommend it as it changes your perception of the typical WX ATPL courses into a more pragmatic approach.

I anybody has the ISBN I would appreciate if he puts it on the forum.

Thanks

If you read it you will see that Prob 30 or 40 is a lot of crap.

I know it’s a lot of effort but if over a certain period of time you compare the actual WX you get from the Volmet and Atis with the stuff you got at dispatch stage you learn more than in any ATPL course.

Nothing influences flying more than weather. Weather, always the weather it’s our enemy as well as our friend and you better learn about her/his character if the fields or air are the place where you will spend the next 25 years of your career.

Finally there is a difference between how a pilot thinks and a lawyer, scary people those pilots that think like lawyers.

[Caractacus]

Is there any evidence to show that the continued landing was intentional?

Whilst it goes againts the grain to shine a torch on just one aspect of an accident report the following is of interest:

1.5.4 Knowing the aircraft was very close to the runway the commander stated that his initial response was shock and without visual cues all he was able to do was attempt to maintain the last <<sensed>> pitch attitude and wings level.

In the absence of specific training for this extreme situation who can say how the commander should have reacted?

[Cap 56]

Thanks Mike, but it was most definitely a pilot. I bought it in 1990 while passing trough Chicago with the DC 10-30 so it’s quite old.

It is really good for those that finished their ATPL and asks themselves “now what do I do with this Met stuff in practical terms” this book provides a lot of the answers.

OK, just found it back trough

http://isbn.nu/

Thanks

[Bally Heck]

Those who have read the report properly will know that another factor consumed 400kg of fuel, and had this event not occured, they would have been above minimum diversion fuel at the end of the second approach instead of just below it. Therefore, they took enough fuel from Cardiff to complete two approaches and divert to BCN with adequate fuel.

I can assure anyone reading this thread that Britannia does not conduct witch hunts or publish league tables against crews who carry extra fuel.

Anyone reading the report with the benefit of hindsight will admit that more fuel would have been more comfortable.

Anyone who thinks the fuel state was the main cause of the accident either hasn't read the report, or worse, has a malevolent desire to see the crew pilloried.

Any chance, any chance at all of moving on from the fuel state and opening up the discussion to other factors?

[Big Tudor]

any chance at all of moving on from the fuel state and opening up the discussion to other factors?
I think BOAC asked that question about 5 pages ago Bally Heck. Didn't seem to have much impact though. In fact Danny raised the fatigue question on page 2!

[BOAC]

Welcome to the Danny/Big T/Boac club, BH. I'm afraid posters here are more interested in proving how clever they would have been (really useful, that:( ) than in addressing relevant issues.

[fireflybob]

BOAC you are entitled to your view which I respect but are you saying that the amount of excess fuel carried when both destination and alternate is forecasting severe weather is not a "relevant issue"?

[Bally Heck]

An issue which unfortunately has been done to death. Maybe if people reviewed previous posts in this thread, they would find that practically any input they have on the fuel situation has been said before on 10 previous occasions.

It is becoming tedious in the extreme reading the same comments over and over (and over) again! It reminds me of why I seldom PPRuNe these days.

A myriad of other issues to discuss without repetition:
Fatigue.
Windshear.
Doghouse design
Shock and temporary incapacitation
Weather
Weather Radar
Cabin safety
Airport safety
ATC
Search and Rescue
CRM
Training
Autopilot and autothrottle performance.
etc.etc.etc

Wouldn't it be great if people bothered to read the accident report and previous posts before becoming instant experts (and greater experts than the AAIB and their Spanish oppos) on god the universe and everything including fuel!:{


Edited to say that I am almost certain that somewhere in the next few posts we will be back on the fuel issue with a rewrite of a previous post.

Go on...make my day punks.

[BOAC]

firefly - I understand your position on this. No, it is not irrelevant. BH, however, puts it far more eloquently than I can!

The fuel WAS loaded, Yes it DID run short, YES, I probably WOULD have loaded more - but is that moving us on?

[Cap 56]

Any chance, any chance at all of moving on from the fuel state and opening up the discussion to other factors?

What other mayor factors are there then adverse weather and its consequances?

If the wx would have been fine this would not have happened.

Is there any other way to deal with adverse wx than to avoid it or when you get into it anyway, get out of it.

To do this you need fuel.

I agree we could open a book on human factors and discuss every item in a way it would find its place in the report. In doing so we would fail to address the core issue and that is that he crew did not have time (fuel wise) to take any other decision then the one they took.

So the main issue really is that it s not that easy to asses at dispatch stage what the implications of some TAF or METAR can be.

But almost never have I seen a degree of intrest in the subject as is often the case with other aviation related issues.

Why would we have to be impressed by a report?

[thegypsy]

Most experienced Pilots would agree that not enough fuel was loaded in the first instance and had an extra few tons been on board would the accident have still happened?? Perhaps or Perhaps not.Nobody knows the answer to that.

Having spent 15+ years flogging up and down 3 nights in a row to places like Gerona,Iraklion,Kerkira,Kos etc etc if there was ever a likely weather problem I alwaysd loaded extra fuel to take into account the fact that on arrival I was knackered and therefore worrying about fuel was one less problem to contend with. I went overseas to get away from this dreadful lifestyle and worked for an International Schedule Airline and have never had to do two night flights on the trot ever again thank God.

The fact that he had enough fuel to divert to BCN and hold for 30 minutes would not have been a great comfort in the circumstances as nobody wants to test the fuel guages to that extent especially if he had heard that BCN traffic was diverting to GRN which some people have suggested was the case.

Fatigue most definitely played a part in this accident , whether there was windshear ,autothrottle problems then these should have been picked up under normal circumstances but these were not exactly normal circumstances by all accounts.

WE can all train for these for these events in the Sim but on the day do any of us really know how we would actually perform in the circumstances?? I would like to think I would have performed a G/A happy in the knowledge I had plenty of fuel but who knows ??

[411A]

Oh come now.

Report for duty, depart from the UK, fly for 3 hours...and arrive knackered?
If this is the kind of pilot Brittania has, suspect they had better double crew for 'safety'.

Aw, poor babies.:{ :{ :{

Professional pilots...NOT.

[kansasw]

Well hi 411A, here is what thegypsy said:

....if there was ever a likely weather problem I alwaysd [sic] loaded extra fuel to take into account the fact that on arrival I was knackered and therefore worrying about fuel was one less problem...........

To which you answered:

Oh come now.

Report for duty, depart from the UK, fly for 3 hours...and arrive knackered?
If this is the kind of pilot Brittania has, suspect they had better double crew for 'safety'.

Aw, poor babies.

Professional pilots...NOT.

Now I didn't see where thegypsy gave his whole schedule or enough information to enable you to know it. IE it appears to me you are answering his post as you choose to interpret or perhaps distort it and perhaps not as he intended it. I don't know why you would do this but perhaps a clue could be found in your last two lines.

What interest do you have in insulting a fellow professional pilot on such a flimsy basis?

Now let me identify myself: simple SLF, fly now and then, technically inclined, like this board and visit frequently, post occasionally. Surely there is a lot here that is above and beyond me, and of course all pilots should be tough guys unbothered by a tad of fatigue, and of course it's your type I want in the cockpit ahead of me hahaha.

So what I am addressing here is none of the technical or investigational issues of the accident in question, which I find quite fascinating, but rather your arrogant attitude which I do not understand. If you care to respond it will be nice if you do so without slashing myself or others. Thanks for listening, Kansas.

[Brenoch]

Would that other factor be flying with the speedbrakes extended for 18 or so minutes???

[411A]

kansasw,

Sorry old bean, but if a regular line pilot can only fly for 2-3 hours (normal time to the Med) and arrive 'knackered' after this short duty period, they need to find another job.

And yes, I should know, as I flew three straight years of nighttime Med turnaround flights.

Knackered...my foot.:yuk:

[broadreach]

This thread is coming around to questions I asked myself after reading the report. I wondered what anyone's gut reaction would be in the instant the runway lights went out, whatever remaining luminescence outside is no use for reference and probably best avoided too, it's a downhill runway and the FO says you're 50ft high.

Would full down elevator and subsequent flare have worked had the aircraft been ten feet higher when the split-second decision for full down was taken? Would a stronger nose gear structure have withstood a fraction less impact load? The questions just go on and on. Lining up the holes in the Swiss Cheese can be achieved from more than one side of the slab, particularly in hindsight.

What seems terribly poignant about it all is that the two men involved are undoubtedly respected as good pilots, that somehow they got caught out by the alignment of holes, that from the moment the aircraft touched down everything else was down to luck. Just look at the trajectory the aircraft took as it left the runway! And that, for sure, they're aware of what's being said on here.

[kansasw]

Fair enough 411A, but strangely you have not addressed my one specific question (that's the sentence that ends with a question mark, it looks like this ? ) nor any of the several implied questions that you could have addressed. You may be a great pilot even great enough to make comments about other pilots like you have based on nothing more than internet information, but you give me cause to doubt your comprehension skills. I am not trying to slash you as I have asked you not to slash myself or others; I am just asking you to address the issues I raise and I do not see that you have done so.

[411A]

kansasw,
Presume you refer to your question about ...'insulting a professional pilot on such a flimsy basis'.

I'll keep it short for others who might have a similar question.

NO (as in zero) pilot should be 'knackered' after such a short flight...period. If they are, clearly the profession is not for them, and they should consider another way of making a living.

As I said previously, fatigue on this flight is a complete red herring.
Seems a few will use any excuse for their actions.:ugh:

[Loose rivets]

To revert to that moment of the lights going out. I seriously doubt that there was a tiredness factor at that moment. There have been moments going into that same ****** field a generation ago, that had me running on a raised adrenalin / blood ratio; if I had been tired after five nights in a row and a double Gerona to round it off, this situation would have had me fully awake long before that critical moment.

I can truly understand that moment of shock, but sometimes the only way out of a situation like this is to take the a/c by the b***s...the problem is, that it's something that modern pilots get little chance to practice. I'm not alone in thinking this, as later editions of ‘Handling the big jets' end with an almost impassioned comment from the revered writer on this issue. No, you can't take hundreds of million dollars worth of aircraft and throw it around like a DC3, this level of handling comes from years of picking up experience in small, often frightening lumps, so perhaps the decision to change the PF is not all that far off. But this is thread slippage, and really, it's that last dive at the probable position of the runway that is the issue. If it was intentional, was it appropriate given all the circumstances? And is it reasonable to suppose that a pilot, not even trained in a wave-off, could execute a blind landing in those conditions?

There are going to be times when there is going to be an emergency causing a commitment to land into horrendous conditions; fire, and God help us, hijack come to mind. But the chances of the lights going out at the most critical moment must be statistically off the scale. This captain may have cornered himself into a difficult landing, but was very, very unlucky for it to become an impossible one.

[kansasw]

411A: "Presume you refer to your question about ...'insulting a professional pilot on such a flimsy basis'."

Yes, that was the sentence ending with a question mark.

411A: "I'll keep it short for others who might have a similar question.

"NO (as in zero) pilot should be 'knackered' after such a short flight...period. If they are, clearly the profession is not for them, and they should consider another way of making a living.

As I said previously, fatigue on this flight is a complete red herring."

Let me be clear that I am not addressing accident causes here and claim no competence to do so. Let me be clear that I hold no brief for nor against the pilot or crew of the aircraft. I have read the report and the thread with interest and with the competence of a concerned and literate observer.

My concern is what appears to me to be your condemnation of the pilot on insufficient evidence. I do not know the guy's schedule. You appear to base your comments on assumptions about his schedule.

Do you have any knowledge there?

That thingy with the squiggle is known as a question mark. It looks like this ? .

I actually don't think you addressed the intent of my previous question. I don't have a lot of hope that you will this one either, but what the heck, let's see what happens.


411A: "Seems a few will use any excuse for their actions."

Eh? I missed something there. Who is using what excuse for what action?

Nother question mark ? that thingy.

Sorry I am being a little snooty here, truly I have no axe to grind except good communication. If you can speak directly and plainly to my issues I will respond and be happy to have a good dialogue on the point. You are welcome to be as evasive or obscure as you like if that is your wont. I will answer to plainness and directness; otherwise over and out. Kansas

[atse]

411A you are not short of a few opinions. It might help if you reflected a bit on what is being said, especially after others provide you with hints as to how you might view things a bit differently and, hence, maybe even learn something new. For instance, immediately after your post containing the words,
Report for duty, depart from the UK, fly for 3 hours...and arrive knackered? Kansasw replied attempting to point out what was probably a major misunderstanding on your part - do you really believe that the implication was that a three hour flight is itself fatiguing? – and asking you a question as to why you take the line you do. But you just keep on going, whether it be fuel or fatigue, or whatever, asserting (rather than explaining) a rather narrow point of view and occasionally implying that those who do not agree are just mind-bogglingly silly. In an earlier post you even referred to the commander of the flight in question as being a “clown”, which is infinitely more telling of you than of him. For what it is worth, I found that gratuitously offensive.

May I commend to you the post by Dogs_ears_up on September 17th. He is not a pilot. Yet he wrote a balanced, sensible and entirely comprehensible piece in a very tactful manner. Yet more to the point, he seems to have no problem in taking the salient features from the accident report, understanding the contextual factors and having an appreciation of the human dimension (often lacking in these discussions). I think his take on – and grasp of - what took place is excellent. He also makes clear his absence of piloting qualification (in contrast to those contributors who seem to feel that to have a licence or to have flown into the same airport gives their opinions greater weight).

You are now doing with fatigue what you did earlier with fuel. Which is to miss what is actually being said. How come the non-pilot got it, but you don’t?

[autoflight]

15 mins of extra gas is an illusion. With TS all over the place, 30 - 60 mins extra should be the choice for a captain with over 16000 hours. Then the pressure would be off.

[thegypsy]

411A Fatigue is cumulative and comes about over a long period of night flights ,early starts etc etc and all I said was I took this into account when loading fuel to any destination where the forecast gave a possibilty that on arrival a hold or diversion was likely. I thus avoided the " must land at any price" which is a very unpleasant situation to find oneself in.

I always found it difficult to get good rest between night flights whether in a Hotel or at Home but 411A we all know you are super human. This does not in any way excuse this accident or make it acceptable in any sense for that reason alone.

Over the years when taking over an aircraft I have shuddered at times to see how little fuel some people arrive with.

[Cap 56]

There is no difference between losing visual reference due to fog patches or the light system suddenly going U/S as such there is no reason to blame the Spanish authorities.

And to be honest, reading this tread, I am indeed worried about the standards of he British pilot certification process.

Even if you are at 60 % of your abilities you should still be able to perform.

However this implies that certification standards must be above what is normaly required.

[411A]

atse,

Seems to me that I understand what went on at Girona somewhat better than others...at least from some of the comments here.

A few say 'fatigue' was an issue.
If it was, the pilot should not have made the flight in the first place.
Either you're fit or you are not...not all that much in between.
If you can't take the heat, stay out of the kitchen.

Fuel state has been covered before. Certainly not enough for the intended flight, concerning the weather anticipated.

I simply cannot understand the 'press on regardless' ideas that some pilots have. A Commander with the experience level that the ill-fated flight had should have absolutely known better.
Then, to top it off, he grabs the controls from the First Officer, and tries for the dirty dive, which is very bad news in any jet transport aircraft.
It would appear that his handling skills were poor as well. Too much 'automatics' at work perhaps? You be the judge.

As I said before, a lesson for all of how not to fly an aircraft.

[Big Tudor]

Whether it is a lesson in how not to fly an aircraft or not, is it really an exercise in character assassination for the Captain and F/O concerned?
Is it really that far fetched to believe that the skipper could have been fatigued on a short sector? It is considered good practice when driving to take a break after 2 hours. If 2 hours is considered a limit for driving a vehicle then surely it is equal if not worse when flying. Also, what was cumulative fatigue effects of the roster leading up to the incident. Consecutive night flights with interrupted or low quality rest in between? I'm sure I can't be the only one here who has embarked on a journey feeling fully alert and capable of remaining alert, only to arrive at my destination with little recollection of how I arrived there!

411A I'm sure there are many people here who could benfit from your experience. Perhaps if it wasn't delivered in such an agreesive tone more would listen!

[Cap 56]

I stand by 411A on this one.

If you do not say it clearly then you are missing the point.

Has nothing to do with aggression, but with the fact that the reader is to sensitive and/or not capable of accepting a simple truth.

I have seen it on the tread on BA approach techniques were their SOP forces them to consider ever approach as a CAT III using all automatics.

I have seen it with British contractors all over the place.

UK airlines do not encourage their pilots to fly the real stick and rudder and they pay a price for that. The same has happened at KLM.

There is a good reason why JAR has introduced the skill test, unfortunately they did not require to do it without the Autopilot.

[shlittlenellie]

411A - almost every post you've ever written seems intent on generating ire through unbalanced and ill-founded pronouncements. From what you say it is transparently obvious that you are not and have never been a professional pilot in any capacity beyond Microsoft's Flight Sim. Why not take the time to read the report or get someone to read it to you and let them explain the technical aspects. The Captain did not grab the controls from the F/O and execute a dirty dive. As for the undoubted fatigue issues - again you demonstrate a total lack of empathy (and therefore past experience) of the job. The crew were towards the end of a busy summer season operating from an undermanned base where they would have been working 800-900 hours in the year with poor rostering and switching between earlies and deep nights with little variation other than to increase circadian disorder. They were on the third of a deep-night series having had long sectors on the previous two nights with an accumulated sleep debt from a busy season. Until you've flown it, you cannot appreciate it - I have and I do.

The accident report has a bias and does not present an objective assessment of a horrible night and a remarkable number of variables and factors; of which not all are addressed. We would all fly it differently now that we have the benefit of exacting hindsight. I am sure that even in your warm understair cupboard, playing your flight simulator, you have made errors, albeit slight that begin to accumulate. No one is perfect, all of us make mistakes, however the dreadful fact is that an aircraft crashed and we can all (you excepted), as professionals keen on continuous improvement, learn from this.

[delwy]

Cap56, I just love the ?intentional? irony ...If you do not say it clearly then you are missing the pointNow, what exactly does that sentence mean? (And, if I may say so, your entire post is not entirely clear, beyond your wish to bash entire groups of pilots).

[Terraplaneblues]

Can anyone see a good reason why the design of modern commercial jets allows the combined use of speedbrake and higher than idle forward thrust?
The Cali? 757 and this one were both misconfigured at some stage in their flight.

[Backtrack]

At nearly 2 posts per day, 411A seems to have a lot of time on his hands.

Forgive me for being sceptical, but I doubt your professional competency to post anything that should be taken seriously.

[Arkroyal]

I'd guess 411a was just a perfect pilot once upon a time when airlines were run by gentlemen who treated pilots like human beings instead of machines.

I'd sure hate to be in a flight deck with him.

Can anyone see a good reason why the design of modern commercial jets allows the combined use of speedbrake and higher than idle forward thrust? They don't.

Boeings however do.

[Brenoch]

Arkroyal:

Umn... This was a boeing flying around with the speedbrake extrended until they get a master caution for extending the flaps beyond 20 with the named brakes extended..

shlittlenellie:

My ol friend and chap:

We're from the same "neck of the woods", not geographically but airline wise, I do know there is a certain pressure for crews to carry "more or less" what the flightplan says.. (prefarbly less if you listen to the directors in hannover)
I realise that the evening was far from perfect but it was made horribly clear to the crew what they were facing once they get down there..

It seems an extrodinarlily poor decision to carry only 15 mins of extra fuel when destination and all (I say ALL) diversions carry the same sort of weather..

I will refrain from getting into the discussion of applying full nose down elevator when loss of visual contact..

[411A]

shlittlenellie,

Put on your specs and read.
Mentioned before that I personally have done 3 straight years of Med flights from the UK (nearly all from MAN)...mostly late night/very early morning departures.
It's not that difficult surely...even for you, and if it is you need to find another job.

Many pilots from UK airlines drag out the 'fatigue' issue at the slightest excuse.
To them I can only say...when you applied to the airline, you asked for work, did you not?

These types, that cry 'fatigue' at the drop of a hat, don't really deserve the job, ie: move over and let someone else take your place if you are so dis-satisfied.

In short, grow up. :(
You are a big boy now. Act like one.

Oh yes, one last thought. Hand fly a bit more, to keep proficient.
Just might save your backside one night.

[GGV]

411A, are you in the slightest conscious of how this kind of diatribe comes across? Opinionated, offensive, aggressive and negative are the words that come to my mind. If you actually have a real message, it is lost in the distastefulness and arrogance of how you say it. But looking at your posts, it is not clear to me that you have any message, beyond demonstrating a highly questionable ability to read and understand.

[shlittlenellie]

411A (again),
Three years operating to the Med - phwoarr and from MAN too - my hero. Can I just say that I really would appreciate a signed poster of your good self, preferably reeking of your favourite aftershave and dripping with the testosterone that you clearly have in over-abundant supply. If there were more people like you on the flightdeck of modern airliners - well, we'd most definitely be in a far safer, completely objective decision making and less macho, he-man, you tug my beard and I'll bite your testicles sort of world.

One last thought before I leave this debate in your far more capable hands (in that big dream of yours, did you finally lose your licence after the twentieth crash?)... you have over-stated your Med flying experience and I look at three years and consider that it was a comparable length to the Med experience of the F/O that you so roundly criticised for having a lack of experience of such operations. So long and be careful with that simulator: at least it's single pilot operation and I suspect that's where your main skills lie.

[Right Way Up]

411a says "The guy is a clown, and simply does not belong in charge of a jet transport aircraft."

Come on mods, is this really deemed allowable, especially considering other very mild threads are censored!

I think the old saying is that opinions are like @rseholes, everyone has one. Unfortunately I'm not quite sure which part of that saying reflects 411a. Answers on a postcard!
:D

[thegypsy]

411A says hand fly more and be proficient. As he claims to have done 3 summers flying from MAN in the IT market he should well know that one thing UK Charter Pilots do lots of is hand flying as most of the airfields we go are procedural without radar and without ILS .

Autopilot not much use is such places as Iraklion,Kos Rhodes.Lanzarote ,Furteventura,Mikonos, Samos.Santorini,Funchal,Gibraltar to name just a few.

Since I left the UK Charter market to fly for an international long haul airline I have never done a real circuit and every approach has been radar vectored to an ILS with just a few exceptions such as Perth R/W 03, the Essendon arrival to R/W 34 MEL and DPS R/W 09 and the old HKG ILS to Visual.

[sky9]

411A. I really am at a loss. As I understand it you have an company in the USA. You previously worked in the Far East; Singapore if I remember, and you also flew for an IT operation out of Manchester. It really is about time you gave us a full resume of your experience so that we can weigh up how much credence we put on your views.

So that you know I am not a Walter Mitty pilot. I have recently retired after 35 years and 21,000 hrs in the industry and worked in the Middle East and for a UK Charter company.

As a matter of record, I flew with a F/O the night after the Gerona accident. On that night he was flying to Palma and told me that the whole of the east coast of Spain was one large area of thunderstorm activity and the closest airport that was open that night was Palma. We can all have views about whether the crew should have carried more fuel and whether fatigue was a factor. However in the final analysis I cannot say that I would have got it right that night, I am surprised that you can be so sure of how you could do. Finally as a matter of record, the Captain didn’t grab control from the F/O, he took control from the F/O at TOD because of the weather at Gerona; or have I missed something?

[411A]

37 years, of which 30 years is heavy 3/4 engine Command, and 23,000+ hours, just for the record, with ops in Europe, Middle East, Africa, Asia, Australia, and trans Atlantic/Pacific.
You can add to this list exec flying as well as Senior Training Captain (10 years) and fleet management positions.
Oh yes, all the jet transport flying was in two types only, the B707 and Lockheed TriStar.
Not exactly a newby...as clearly you aren't either.

Yes, you are certainly correct in your statement about whether you (or indeed anyone else) could have 'got it right' considering the circumstances on the particular evening in question
but would it not have been a better idea for the Captain to have the First Officer continue with the flying, so he could keep a closer eye on the situation?
I have personally line trained at least 50 First Officers, and have found that nearly all can fly a very accurate ILS or non-precision approach. If they lack any particular skill, it is handling the windshear/strong crosswind types of situations simply because they have not the experience and exposure that the Commander has had.

OK, so this Commander decided to launch off to a destination with very little extra fuel (considering the weather in the general area) for reasons unknown, and decided at TOD to become a one man show.
Doesn't look very reasonable or professional to me.

How about you?

And for those that think that I am being overly critical, just look at the end result of the flight in question.

If this Commander had a bit more concern, extra fuel would have been uplifted, so that more options would have been available, but as it was, he did not, so ended up off the runway.

He, his crew and passengers were very lucky it was not far worse.
This clearly, in my opinion, was an accident that could have been prevented if a more reasonable decision process had been applied.

[Cap 56]

Dewly

If you do not say it clearly then you are missing the point

The previous post of 411A exactly proves my point.

And having an opinion about certain things is Not always hindsight.

411A could keep his mouth shut but he doesn’t simply because he is a concerned natural be it a bit blunt.

But I prefer by far those who have a clear opinion than those that smile and put a knife in your back.

As I am almost sure 411A would defend any pilot against the management if in his opinion the guy was professionally correct.

And that is NOT the BRITISH way of doing things but it is very American.

To quote my chief pilot.

As a captain you are responsible for bringing the acft from A to B.

To do so you have an F/O and AFDS at your service, USE THEM AS EFFICIENTLY AS POSSIBLE and do not overload yourself by not delegating what can be delegated.

Certainly if you feel you are tired, try to be frech when needed and that means once below 300 ft.

13000 + , military and 3 Flag carriers

And yes, I landed last week with 5 tons fuel in the UK on a 737.

No questions were asked.

[SR71]

Out of interest, Appendix B of the report illustrates some radar images for the time period 2133 to 2153 on the night in question.

Correct me if I am wrong, but BCN looks wide open during that time period....

Are those radar images rainfall images?

I haven't actually seen the METARs and TAFs for the day in question as they aren't in the report. Has anyone?

If so maybe they could post them?

:ok:

[Rananim]

Any crew can screw up.The last hundred years has surely taught us that much.More interesting than the actual error chain that night are the set of conditions that made that error chain possible,if not inevitable.
Something led that commander to load only 15 minutes of extra fuel when thunderstorms were forecast.Company pressure has already been rejected,so what was it?A genuine oversight?A belief that European weather is generally benign(which it is)?Was the co-pilot happy with the 15 minutes?Would he have dared speak up if he wasn't,considering his relatively junior status?The report's matter-of-fact statement that the crew "discussed" fuel requirements is frankly bizarre.Dispatch is not involved in the fuel decision in Europe as I understand it.It is fair to say that crews generally dislike sticking out like a sore thumb.Would dispatch involvement("Bad weather forecast in Gerona,we suggest an extra 45 mins,subject to your approval?")not give an automatic company seal of approval?
The fuel,or lack of it,dictated the mindset on that second approach,something which Bally Heck fails to recognize.The psychological benefit of carrying enough gas settles the mind,ensuring that judgement is never clouded by diminishing options.
Steep cockpit gradients do exist and can work.But there is a heavy burden on the Captain.Checks and balances from the right seat might be non-existent or inappropiate("1000 down" instead of "GO AROUND").Failure of the lights was unfortunate but must not be used as an excuse.Go-arounds can and often do involve main-gear touchdown.
Blaming dogbox design is a misnomer.If you dont crash the thing,the dogbox is just fine.
Fatigue might have played a role but there is less evidence for this.Loss of motor skills,induced by heavy reliance on automation day in day out,was not addressed either.The Captain was reported to be in a state of mental shock.Thats unfortunate because it takes but a second to check a -4.5 pitch attitude.Reliance on automatic height call-outs for flare is also an indication of automation over-reliance.This was addressed by the report but not in the correct context,I believe."I didnt flare because there were no call-outs"

[Bally Heck]

An airspeed loss of 25 knots at around 250 ft RA caused a power change to 1.51 EPR. Nearly take off thrust! This caused a substantial pitch up to nearly 6 degrees. The autopilot was disengaged at about this point. Substantial forward elevator would be required to stop the nose up pitch particularly with the aircraft trimmed for the approach.

At this point it would be fair to say that the approach was unstable and a go-around should have been executed. Why it wasn't I can only guess, but possibly due to the combination of an unruly aircraft and loss of external visual cues, the captain was temporarily maxed out.

The rest is history.

If 411a doesn't suffer from fatigue on consecutive night flights, perhaps he is a vampire? Responding to his diatribe merely encourages him. I tend not to read his posts as they seldom add any value to the discussion. Their purpose seems to be deliberately vexatious and if you ignore him he goes away.

[411A]

Oh, I ain't going away, Bally Heck.

This accident is so egregious in its cause and effect, that if other crew can not actually learn from the mistakes that were made by the Commander, then European aviation is in a much worse state than I thought.
These companies cry out for proper licensed dispatchers to advise crews of problems, and recommend solutions.
The US FAA long ago required this, but European operators seem not to learn from the accidents that occur.

That they don't does NOT say much for their operating procedures.
Ha! JAA compliant....phooey. :uhoh:
If Captains can't (by themselves) uplift enough fuel on their own accord, they don't BELONG in the airline business.
What the hell is wrong with the 'thinking?' process in the UK with these few (or maybe more) Commanders?

Then we have the Hapag Lloyd A310 accident at VIE, FUEL quantity...AGAIN.
Steaming along, the Commander seemly oblivious to the fuel remaining, in spite of the First Officers concerns.

Hey there, big time Captains...maybe you should start to listen to the guys on the RH side, as they seem to be more concerned than YOU are.

Good grief!

PS: Just to add---

Of the many substitute flights I performed from the UK, MONARCH stands out head and shoulders above the rest, in their preflight briefing ability.
Professional guys, who would always recommend extra fuel if the conditions required same...and many times it did.
Other companies could actually learn from these excellent folks.
An old line company doing it right.:ok:

[Brenoch]

First positive note about Monarch on this forum since I can't remember..

Warms my heart mate...

[Loose rivets]

But what about the last few moments? I pose the question again. So much energy has gone into hacking at each other, so much into the tight fuel...we know he found himself up that dark corridor, but why could he not contain those last few seconds? A reference pitch, a survivable rate, the aircraft is a fabulous bit of kit, is it acceptable to wait for a cue for the ground to arrive?

[Cap 56]

It's very simple, they didn't know where the hell they were.

[SR71]

A/my simplistic analysis perhaps...

If you remove one causal event in the sequence of events that led to this accident, a different outcome would almost certainly have been guaranteed.

Fuel is a red-herring for me. I agree it would probably have been prudent to take a little more. There is nothing to suggest that even if G-BYAG had had block+10T onboard the same sequence of events would not have transpired.

The aircraft had fuel for LEBL. It would therefore appear reasonable to assume LFMP and LERS, albeit he'd be on vapour by the time he got there. In all cases, except perhaps LEBL, he'd have been <E @ ETA.

However, he could have committed himself to LEGE.

The outcome in the event of exercising any of these options is pure speculation.

The difference in attitude towards fuel policy between various posters reflects the difference in experience. Just a thought.

If you regularly operate full 735's on 1000NM sectors to/from hot performance restrictive fields, you will know that you are regularly up against RTOW limits. This precludes the carriage of alot extra.

You are then constantly weighing up how many bags to offload versus how much fuel to carry. The most I have been involved in offloading is 900KG out of LSGG purely to allow an equivalent extra uplift of fuel.

The point being that it must be the case that operational constraints allow some pilots less room for manoeuvre than others, whereupon the pressure they are under is greater than others.

IMHO though, the fuel state may have been contributory but not causal.

Neither is the fatigue issue causal. At best contributory. CAP371/FTL limitations ensure corporate culpability on this matter would probably be hard to prove. Even QinetiQ/NASA research brought to bear on the recent debate about FTL limitations has struggled to achieve credibility with the Commission. For all the wrong reasons perhaps...

It would appear that if fatigue is ever an issue, it is up to the individual concerned, bearing in mind the responsible nature of his job, to offload himself. If he doesn't, struggles through the duty, and has a CFIT inicident, then arguably he has only himself to blame with all the associated drastic consequences.

If the skipper himself says he wasn't fatigued, (Pg 7 of the report explicitly states this to be the case of both individuals concerned), lets consider that to be the case.

However, what seems to me to be causal in the event is the failure to GA when visual contact was lost. There was still 6 secs before touchdown to initiate a GA.

And this is an incident that reaffirms the sense in executing a GA in conditions where the visual reference is lost and reminds me not to be afraid to use TOGA. In fact, funnily enough, having reflected on this very matter last week, I almost did exactly that recently into EGFF in torrential rain.

But I'll have to keep remembering not to confuse TOGA with the A/T disconnect.

;)

[RatherBeFlying]

I don't know what's available in Europe, but here in North America, anybody with an internet connection, including dispatchers, can see radar for the entire United States plus the Southern part of Canada.

A dispatcher here who sees a flight with thin reserves headed into an area where CBs are blooming at destination and alternates within range will likely be diverting that flight to an airport in good weather where additional fuel can be taken on.

There is work under way to upload radar to the cockpit so that the crew can take advantage of national radar data: NASA Report (http://techreports.larc.nasa.gov/ltrs/PDF/2003/cr/NASA-2003-cr212406.pdf)

[Bally Heck]

Well done guys.

We are on a roll of thoughtfull comment instead off thoughtless blaming.

I wonder about the search and rescue thing quite a bit. It's hard to beleive that the airfield rescue services couldn't find the wreck! But I've been there and seen the wreckage after the event. Saw the aircraft sitting in a field, pretty well out of sight. Can't really blame the guys for not finding it more quickly. It seems they tried quite hard. Is this a result of airfield geography?

If there had been a fire, it would have been obvious. Thankfully there wasn't.

How many more airfields could host this type of incident without being able to respond?

How can we make this better?

[broadreach]

Bally Heck,

Don't know if you've seen the aerial photo of where the aircraft finally stopped (it was posted here on one of the earlier pages). After losing contact with the aircraft ATC could only suppose it had crashed, but where, if they couldn't see anything from the tower themselves (sorry, she)? It could have been miles away, and who was to suppose it had threaded that needle between the wall of trees into the adjacent field? Imagine if that one passenger hadn't sprinted through the mud, over culvert, etc and alerted the fire brigade - how long might it all have taken?

I'm sure you could think of more than a few dozen airports around the world where, under similar circumstances, the accident site wouldn't be found for quite some time. Memory's a bit blurry but it tells me evenn the Staines Trident accident site took some time to locate.

How to make things better? Well one thing that occurs to me is that when ships go down in oceans, their EPIRBs go off and say "I'm here, Help". When aircraft go down, they just disaappear from radar screens at x altitude. I wonder why, with the the technology available right now, an aircraft can't transmit it's position continuously, linked into the radar image. It may disappear from radar but "there it is, in the field just across the runway".

[Loose rivets]

Just a sad moment of reflection on the Staines. A road traffic cop told me that the real problem that they had getting to the Trident, was the mass of people that had stopped to look.

Back to the present. It sounds as though that lone soul running over rough terrain was a bit of a hero.

[Daysleeper]

their EPIRBs go off
Often resulting in coastguard aircraft chasing yachts up the M25 or trundling round scrap yards.

Many aircraft have automatic ELTs based on a deccellaration switch, a nice heavy landing sets them off. However as airports and fire vehicles can not track on them you would need a chopper or fixed wing. And the accuracy is not that great.

However there are enhanced vision systems for fire trucks. obviously they are expensive and it comes down to cost versus lives saved.
In this case 200+ lives would nicely pay for one or two.

Its derived from tank night driving systems, consisting of FLIR and Low light cameras and a DGPS map position.

However on the night in question the amount of rain (44L/M2 in 30 mins) may have neutralised even this kit.

http://www.galaxyscientific.com/areas/navigati/air3.htm
http://www.massport.com/logan/about_publi_massp.html

[411A]

Does anyone really believe that any airport authority in Spain or Portugal (and indeed we can include most any airport on the Med) has any intension whatsoever in providing emergency services beyond what the absolute minimum requirements are?
We can extend this to ATC as well.

These folks want your tourist Dollar, Euro etc.

What, upgrade emergency and ATC facilities? Whatever for?

[Backtrack]

And yes, I landed last week with 5 tons fuel in the UK on a 737.

Well, congratulations on a safe outcome, CAP 56 , but what exactly is your point?????

You can still crash with this amount of gas.

Too many posters have a fixation that the ramp fuel decision was the one & only cause of this accident. With the benefit of hindsight, we can all see that more fuel would have been advantageous, but no-one - NO-ONE - can categorically state that in this circumstance, the fateful approach would not have be made at exactly the same time, with exactly the some conditions. The only difference would be that AG crashed with more fuel on board.

Re-read the report; it is 100 or so pages long, produced by experts from Spain, the UK & the US. Experts who are professional tin kickers and do this for a living.

At the end, there are 10 recommendations:

1 refering to the operator's fuel policy,
1 refering to go around training,
1 refering to met svcs,
3 refering to airfield & facilities &
4 refering to airframe construction/certification.



Blaming dogbox design is a misnomer.If you dont crash the thing,the dogbox is just fine.

Yeah right, Rananim . And if my auntie had b@ll@cks, she'd be my uncle. Take another look at sections 2.6 & 3.2, & do my eyes deceive me, or do the photos of the flight deck show the reverse thrust levers fully up?

I've learned something from this accident:

This, from I-FORD epitomises for me the whole crux. Let's never stop learning as the best of us is only 99% perfect.

There, but for the grace of God, go I.

[JW411]

I-FORD

"(2) ....like letting the copilot fly the plane until OM or FAF...."

I liked your posting but I would suggest that the above be modified to

"....like letting the copilot fly the plane until minimums...".

Let's face it, they usually do it better than we do!

[broadreach]

Daysleeper,

Agree, there are a fair number of false alarms; nothing on a ship is idiot-proof. On the other hand a few lives have been saved. The technology is fairly straghtforward though and I can't imagine it hasn't been considered; making blending it into proprietary radar technology obligatory may be something else.

Re the links you posted, the view through the firetruck's windscreen at 400' was great! Sounds a bit expensive.

411A, re your last comment: pretty much the same in Wichita as in Girona; a national or supra-national authority says it has to happen and, eventually, it does or it's blacklisted and rendered inoperative by the relevant authority - which might even be Homeland Security. Whether Girona or Aeropuertos Espanoles (if that's the national authority name) want to spend the money is immaterial; if they want your tourist dollar or euro that's the way it has to be.

Rivets, you're right. Arrived on a BEA Trident same time, picked up a rental car and got stuck in traffic, resented being labelled ghoul by H Wilson.

[Aranmore]

Now that this topic has gone quite and the dust settled, lets look (with the benefit of hindsight), at what we have learned.
From the alarm clock going that day (for both crew members), what would you have done differently?
List your points in the order of importance ... one airline has already set this as a project for their winter refresher course!

[B757RATED]

1. Loaded lots of extra fuel so I had more thinking time.

2. Let the FO fly the approach so I could monitor the big picture.

[3Greens]

At least Boeing allow you to make that decision. Once needed to use full speedbrake with cruise power enroute fron
DAR to EBB, in a 767, approx 1hour flt time, it's a great way of increasing the fuel burn to get below max landing weight. Guess in the bus you'd have been hanging around for hours in the hold..

p.s. sos about the thread creep.

[Max Angle]

Airbus do as well, speedbrakes are inhibited above max. continuous thrust not cruise power.

[Scimitar]

As a Training Captain with the airline concerned I have been following this thread with considerable interest and feel that there is just one point I can add to this fascinating discussion.
It has been my pleasure to know, fly with, and sim check both these pilots in the past and I certainly considered them to have been above average. The F/O had lowish hours and lacked experience (but then don't we all at some stage) but was enthusiastic. keen to learn, well prepared and, in short, just the sort of F/O most of us would choose to fly with given the choice.
The Captain I have been professionally acquainted with for over thirty years (from the days when he was an RAF VC10 Captain) and is one of the most highly regarded pilots I have come across in over 40 years in aviation. What frightens me most is that if it can happen this way to these two blokes, what real hope is there for the rest of us when the chips are down.
I now wait with baited breath for 411A to explain to me what a lousy trainer I have been all these years!

[Somedaymaybe]

Hi All,

For those that are interested there is a documentry on the Britannia GRO crash on ITV Wales MON 11th OCT at 11:00am

Lets see how it is percieved from the medias eye!

Regards

SDM

[Jal]

It's on at 11pm SDM :D

[fireflybob]

Scimitar. having done the training captain but for circa ten years, I understand how you feel.

However, my take on this is that, in terms of promotion to command, we know that even your best prospect might make a mistake since he/she is only human and the system will never be perfect. But if they do screw up, at least you can put hand on heart and say you did everything possible to ensure it would not happen.

Unlike the case where one might be tempted to let a "marginal" candidate through in which case you would never forgive yourself if anything went wrong.

In psychological terms there is a difference, of course, between one's "espoused theory" - what you SAY you would do in a specific situation and one's "theory in use" - what you ACTUALLY do when faced with the same situation. As human beings we get round this paradox by "rationalising" - "Ah well, I did it that way because....etc".

That is precisely what is happening on this thread, I venture to suggest. We are all SAYING well if it had been me I would have done so and so but you don't know what you might have ACTUALLY done until you are there!

In training we attempt to circumnavigate (no pun intended) this by actually placing pilots in the sim to see what they ACTUALLY do and then we can discuss and debrief etc and run the scenario again with, perhaps, a different outcome.

Problem is that in the "real" world we often only get one shot at it and hindsight is a great thing. All we can do when "it" happens is to try and learn from "it" to prevent future occurences. It is perhaps ironic that this accident happened to one of the most professional and safety conscious airlines in the world but as my son keeps telling me, sometime "s**t happens"!

[Martin]

Dear Scimitar we have obviously flown together and I absolutelyl agree. Good guys. Dark night, turbulence , rain, vibration, even with loads of skill, bad luck. It could happen to happen to any one of us. Just keep crossing those fingers. And if you haven't been there do please stop writing about a place you can not possibly comprehend. Those that have understand.

[Aranmore]

My Thoughts …

Boeing must improve cockpit floor design.
Boeing should build a warning into their aircraft to alert crew if the thrust is increasing whilst the speedbrake is extended.
Companies must stop applying so much pressure to captains about fuel carried … at that time letters and phone calls from management were a regular feature of life in many companies.
Company fuel policy must include sensible allowances when CBs are forecast at destination and alternates.
The flight crew should have carried a minimum of one hours extra holding fuel (about 3.3 t on the 757).
Given the actual weather at arrival in GRN the descent should not have continued below FL100 until conditions improved.
The FO should have flown the approach. This would have given the captain far greater capacity to monitor the big picture. If the VOR/DME approach had been flown accurately the aircraft might well have landed safely first time.
On the ILS approach the weather radar should have remained on and the autopilot should have been used as late as possible. The aircraft could even have autolanded!!!!
On a manual approach, once you lose visual contact near the ground, you go around … end of story.
The crew could then have diverted to Barcelona.
Everyone should stop criticising the Spanish authorities … their facilities met ICAO standards on the night. Would a UK airport have done any better given the massive CB that was sitting over the field … I personally have experienced lighting failures twice in the UK (fortunately not at the very late stage that occurred in this instance).
Finally, the excellent Flight editorial on the Gerona accident should be made compulsory reading for all aviators.
There, but for the grace of God go any of us.