Monarch & the Rock

[northernlightIII]

Anyone know the story on this one, apparently a Monach jet missed the Rock in GIB by 200 feet ? Could have been nasty ! :ooh:

[teamilk&sugar]

Rubbish

Get your facts straight....unless of course you are a journo....

[Beakor]

http://www.aaib.dft.gov.uk/publications/bulletins/august_2006/boeing_757_2t7__g_mone.cfm

[oliversarmy]

teamilk&sugar,

not entirely rubbish then.....was 680ft not 200ft.:rolleyes:

[Taildragger67]

So maybe closer to 200 metres, then.

[the_hawk]

Even more, the report speaks of
The lowest altitude of the aircraft when over the land
vs.
The highest point on the land
stating nowhere that the aircraft flew directly over "the highest point on the land". Looking at the full report you'll see it didn't. But (over water) it was even lower than 2100ft, so maybe there's still a story in it?! ;) :rolleyes:

[Localiser Green]

Let's not exaggerate the situation here "missed the Rock in GIB by 200 feet" is highly misleading, as the report states:

"The lowest altitude of the aircraft when over the land was 2,100 ft. The hghest point on the land, just south of the airfield, is 1,420 ft."

Just because the highest point on the land is 1,420ft, does not mean the aircraft was flying over that point at the time. Indeed if you look at the report (Figure 1), it was not.

[northernlightIII]

Milk&S sure jumped there, calmn down they were not my facts I was asking , read the thread,

Does sound like another overblown story.

[oliversarmy]

Surely the story itself is the fact that it turned right to the west of the rock rather than onto the runway heading and away to the East of the rock, at the point of the go around a turn to runway heading would heve resulted in this REALLY being a non event.

OA

[x12]

Well, Monarch do fly to some of the most dangerours places in europe

[alf5071h]

x12 why would you consider Gibraltar to be dangerous – the apes?

Many airports have unique operating hazards; these are identified and appropriate precautions taken.
In this incident, the crew encountered a set of circumstances that resulted in the aircraft not following the required flight path. Unfortunately, the AAIB appears not to have fully explored the circumstances – the human factors.

The focus of the report is on the need to maintain visual contact. In this incident, the first officer appears to have been head down and perhaps the Captain also when selecting FD off. Using the Reason/Dekker approach to organizational errors; then company SOPs could have prohibited the extraneous tasks. The frequency change could be made at a later point, and the need to switch off the FD for a visual approach has to be examined. This is classic threat and error management – avoid the error provoking situations.
Another consideration is the possibility that both crew members suffered a turning illusion. The aircraft was in a low bank angle turn and as the GA was commenced, the crew did not detect the continuing turn (“the commander considered that he was maintaining a constant heading”). This view could be supported in that the GA thrust was applied where the aircraft was apparently tracking north of the centreline (077), but then stabilised tracking south of the centreline (135) before ATC intervention, all headings approximate. Thus the ‘hold track’ GA function would have been expected to fly the aircraft on a more northerly track than that achieved (assuming a 077 hdg or there about, at GA selection).

A positive aspect is that this incident demonstrates the value of selecting EGPWS Terrain display for all approaches. Although this was fortunately not used due to timely ATC intervention, it provided another ‘in depth’ defensive layer which made the next threat visible (“… as the aircraft turned, noted high ground depicted on the left side of his HSI display”).

We should remind ourselves that a better understanding of an incident depends on our ability to assess why the conditions encountered by the crew (initial GA hdg) appeared normal to them at that time.

[teamilk&sugar]

Read and comprehend the report.

Some of you guys really need to get a life.

[GreatCircle]

Alf's post is a super summary.

The AAIB report does not criticise the MON crew, nor does it suggest GIB is inherently dangerous. Nor does the report suggest in any shape or form the operating crew were over the highest point of the land mass during the GA.

It does however make clear recommendations about the use of visual aids available at the field - which I am sure are eminently sensible, and comments on the operational procedure of MON having designated commanders handle aircraft on those sectors.

Nothing to get excited about, really - but an interesting discourse over procedure at one of the world's more interesting fields...

Am I correct in assuming, the UK RAF provide ATC cover at GIB ?

Lastly, you can see why the press would get excited about it...it is easy to manipulate the findings of the AAIB as "Big jet scrapes apes noses as pilot misses runway"....and something I hope all of us here on pprune and in the professional aviation community will go out of our collective ways to discourage and stop...

[Localiser Green]

The usual accurate reporting from The Sun on this incident:

http://www.thesun.co.uk/article/0,,2-2006380165,00.html

[mde]

you could put --that big jet disapears up ape's **** on missed approach
RAF subcontracts out ATC at Gib

[Two's in]

It would seem that the AAIB's work is largely redundant in view of that masterful piece of analysis from the Sun. Beats me how anyone here could even think of berating journo's.

[GreatCircle]

Here is the email address of the Sun's moron who wrote the article: -

[email protected]

I am about to email the dear chap/chapess and tell him/her/it my thoughts on his/her/its amazing piece of journalistic analysis.

Best make it words of one syllable or less, so he/she/it understands it.

Anyone else up for sending a note ? :E

[DH121]

It's clear to me that the Sun journolist didn't bother to read the AAIB report. For gods sake - there's a plan view of where the aeroplane went in the report.

[cwatters]

I'm not worried about the quality of the Sun's reporting - I worry far more that some people believe it to be accurate reporting.

[radarman]

Is there any standard procedure for crews to inform ATC of a Go-around immediately the decision is made, or is the advice to 'Aviate, navigate, communicate'? If the MON crew had said they were going around at the time they increased thrust ( passing heading 077) the controller would have been able to give them a safe heading to pass to the north of the Rock. As it was, the first the controller knew of the Go-around decision was approximately ten seconds later, when he asked if the crew were still visual. By this stage the aircraft had turned further right to head directly for the Rock, and the stage was set for potential disaster. Thank goodness Mr Boeing put some good beefy engines on his 757's.
Incidentally, the AAIB report paints a rather benign picture of the terrain situation when it says simply that the lowest altitude of the aircraft over the land was 2,100ft, with the highest point on land being 1420ft. In reality it was a sh*tty night, an aircraft had got itself pointed straight at the Rock two miles ahead, and starting from an altitude of 550 feet it was just a question of faith as to whether the climb gradient was going to be steeper than the slope of the west face of the Rock. It was not a pleasant experience - the talkdown controller said he thought he was talking to a dead man.

[DH121]

it was just a question of faith as to whether the climb gradient was going to be steeper than the slope of the west face of the Rock

The aircraft did not actually overfly any high ground. Read the report.

[radarman]

DH121. I have read the report, cos it's my evidence that's in it! You're quite right though - thanks to Rolls Royce responding to a boot-full of wellie, and a timely turn, the aircraft did not actually fly over any high ground (That's according to the QAR trace, but not according to one of my colleagues who saw it overfly his house some way up the Rock) However, I suggest you study the topography and contours of the Rock. These are not evident from the map in the report. You will then be able to see that a flight path half a mile further east could have resulted in disaster. I repeat, at the time it was a question of faith etc etc. Adrenalin is brown, and it smells like sh*t. :uhoh:
Any replies to my question about when crews notify ATC of a go-round?

[DH121]

Radarman - I don't disagree and I am familiar with The Rock. I just wish some people posting on here would stick to the facts, rather than being sensationalist, like The Sun.

We call "going around" ASAP, subject to cockpit workload. All being well, as soon as gear retraction has been initiated.

[Earthmover]

Radarman you raise a good point about when to inform ATC of a go-around. I've always taught (for many years actually) get the aeroplane going up, configured and in the correct mode before contacting the Tower ... with a new lad/ess in the RHS one can end up doing all this ones-self if ATC come back with any complex instructions or non-standard missed approach procs (I know that's unlikely in our ATC system because you tell us in advance usually, but elsewhere I've had really complex stuff issued during the initial climb off the G/A.)

But you've caused me to think again about this ... especially where terrain is a factor. Hmmm.

[Pilot Pete]

But you've caused me to think again about this ... especially where terrain is a factor. Hmmm.

I don't know why you should 'think again'...it is better to get the aircraft correctly following the standard missed approach, in the correct configuration than to not complete that correctly with one pilot talking on the radio....

The standard missed approach will provide the requisite terrain clearance if flown properly.

What you are talking about is a 'double failure', where you don't fly the standard missed approach, don't configure the aircraft correctly and end up with ATC 'interrupting' this with a timely intervention and change from the standard missed approach, as in the case with G-MONE. If you look at the root cause of the problem it was the incorrect initiation/ following of the missed approach which required the intervention of the controller. If the crew had actioned the missed approach correctly and then flown the procedure accurately there would have been no need for the ATC intervention, hence your idea of 'thinking again' would not be required.

Aviate, Navigate, Communicate. If they had initiated the missed approach correctly (Aviated), then followed the standard missed approach accurately (Navigated) and then told ATC what they were doing (Communicated) then this report would not be being discussed here. Or at least that is what I have learnt from reading this report.

PP

[Earthmover]

I said I'd think about it again. Note the 'hmmm' ... I thought it a valid subject to review and analyse to see if my teaching is reasonable. I was pleased Radarman raised the subject. Thanks.

[Blighty Pilot]

What you are talking about is a 'double failure', where you don't fly the standard missed approach, don't configure the aircraft correctly and end up with ATC 'interrupting' this with a timely intervention and change from the standard missed approach, as in the case with G-MONE.
:confused: Who said the aircraft was configured incorrectly???
Who's to say if ATC had not interupted the pilots carrying out thier standard proceedures they would rectified the problem as opposed to having the "aviating" and "navigating" inturupted.
I am also lead to believe that the radar wasn't actually working correctly and the returns were intermittant at the final approach stage of the arrival.
Easy to judge when you don't have all the facts or you take what The Sun prints as fact!!

[chandlers dad]

Here is the email address of the Sun's moron who wrote the article: -

[email protected]

I am about to email the dear chap/chapess and tell him/her/it my thoughts on his/her/its amazing piece of journalistic analysis.

Best make it words of one syllable or less, so he/she/it understands it.

Anyone else up for sending a note ? :E

Please make sure that you send a copy to his editor as well. This way the editor knows what trash the writer is putting out. Maybe it will be vetted a bit better next time.

[Pilot Pete]

Easy to judge when you don't have all the facts or you take what The Sun prints as fact!!

When you read the report:rolleyes: it says that the TOGA button was not pressed until after G/A thrust was applied and that therefore the crew did not follow the correct go around procedure. By then pressing the TOGA button after initiating a turn and a climb the flight directors popped up and gave them current ground track, which was taking them towards the high terrain. I would consider this to be an incorrect configuration of the available systems for the phase of flight.

Who's to say if ATC had not interupted the pilots carrying out thier standard proceedures they would rectified the problem as opposed to having the "aviating" and "navigating" inturupted. And who's to say that they wouldn't have had a CFIT if ATC hadn't interrupted them? Look at the ground track shown in the report. Are you trying to say they were flying the missed approach correctly, or were about to correct their 'off track' flight? This is what the report said When visual contact was lost, the crew were required to carry out the missed approach procedure. The aircraft was now right of the centre-line and turning right, although the commander thought that he was maintaining a constant heading. They were following the flight director which was taking them towards the high terrain and not over the runway following the correct missed approach track. It also states Without CVR and FDR information, it was not possible to determine the exact timings and actions of the crew. Nevertheless, it was apparent that the crew had not maintained continual visual contact with the runway and then did not comply fully with the go-around procedures. Thirty seconds after the aircraft commenced the turn, the engine thrust increased for the ‘Go‑Around’. At this point G-MONE was descending through 650 ft at 134 kt, with a bank angle of 8º to the right and turning through a heading of 077ºM. The aircraft descended a further 100 ft to 550 ft before it entered a climb. It then achieved a climb rate of about 3,000 ft/min whilst turning onto a heading of 140ºM. It remained on this heading for 12 seconds before turning left onto a heading of 134ºM for a further 12 seconds, followed by a turn to the right onto a heading of 180ºM. As G-MONE turned onto the heading of 180ºM, it was overland and climbing through 2,100 ft. Note the amount of time they were on track 140 degrees and then 134 degrees. Total time 24 seconds heading towards high terrain. I don't think they were aware that they were heading towards the high terrain, because if they were they would not have stayed heading towards it for 24 seconds. They believed they were following the missed approach, but because of loss of situation awareness and incorrect initiation of the go around they were not.

My personal opinion is that the controller prevented the last hole in the swiss cheese lining up by telling the crew to turn onto 180 degrees when he saw them heading towards the high terrain and not following the missed approach correctly. So we can all 'judge' for ourselves based on the facts as produced in the AAIB report. If you can draw another conclusion then it would be interesting to hear it so that we can all learn from this incident, because at the moment I stand by my last post as being what I have learnt from it.

PP

[ChristiaanJ]

"They were following the flight director which was taking them towards the high terrain and not over the runway following the correct missed approach track."Don't we have a potential problem here somewhere? Next time ATC may have a bit more of a radar problem, or the GA may be on one engine after a bird strike....

This reminds me of a well-known book read years ago about a CFIT in the States, due to a sustained turn, which upset the gyro compass system. Can't instantly remember author or title, but maybe someone does? The story stuck in my mind because somebody battled for years to clear the pilot from the "pilot error" verdict.

[Blighty Pilot]

Standard calls:
GO AROUND FLAP 20
POSITIVE CLIMB - GEAR UP
I hear it was at this point that ATC contacted the aircraft as the pilots were mid flow of SOP's - The next call would have been:
HDG SELECT/LNAV
BLAH BLAH BLAH
I agree with you entierly PP we should all learn form peoples experiences but you do seem to be placing a lot of blame on the crew and not considering the poor lighting at GIB, the weather conditions on said night nor the apparantly dodgy radar.

[alf5071h]

I suggest care is required in any analysis of this event. There are several inconsistencies, which is why my earlier post expressed disappointment in the AAIB’s report. However, I note that they are confined by ICAO Annex 13 to ‘the facts’ which might prevent helpful human factors speculation such as ‘we considered … … but here was insufficient information’. Also, there was a lack of technical information – no CVR/FDR, but I doubt that the all-important FD command information would be shown anyway.

Re “the controller prevented the last hole in the swiss cheese”, perhaps some people overlooked EGPWS and particularly that the crew had selected the terrain display for the approach – a valuable safety aid.

Many commentators fall into the trap of allowing hindsight to (inadvertently) lead to blame – “therefore the crew did not follow the correct go around procedure”.
Our safety interests require an understanding of the incident so we might learn from it; to do that we have to consider all of the issues that made sense to the crew at that time and in the unfolding situation that they perceived.

Beware of assuming too much “They were following the flight director …” we don’t know that, the information shows that the GA selection was late, but even so the ground track shows a continuing turn – see my previous post.
Was the crew behavior consistent with “ … loss of situation awareness … “, again we cannot judge as whatever the crew perceived apparently made sense to them at that time – the commander did not appreciate that he was turning.

These are just are some of the factors which could lead to an explanation of human error, but the error is only definable after the fact (by our hindsight), the crew had no prior intent of making an error and we must not judge them on error, only speculate on how we might do better in the future.

Thus, a lesson for us all could be to remember that we can all make mistakes; i.e. attempting to multitask at an inappropriate time during the approach, ‘delaying’ the GA button due to the surprise of a GA, and being susceptible to turning illusions.

ATC played an important part in this incident, but most procedures and GA routings will ensure safety even with engine and comms failure; as stated - Aviate, Navigate, Communicate – but don’t attempt to multitask even these golden rules (www.airbus.com/store/mm_repository/safety_library_items/att00003105/media_object_file_FLT_OPS-SOP-SEQ03.pdf ) at critical times.

For Ppruners background reading see Punishing People or Learning from Failure (www.hufag.nl/archief/huf03_dekker.pdf ) by Sidney Dekker.

[Pilot Pete]

I agree with you entierly PP we should all learn form peoples experiences but you do seem to be placing a lot of blame on the crew and not considering the poor lighting at GIB, the weather conditions on said night nor the apparantly dodgy radar.

I accept that the written word can come across in a manner different to the spoken word. I am not trying to apportion blame, just trying to read what happened.

From the moment that the decision to G/A was correctly taken (loss of visual reference), the crew should be back on instruments. Poor lighting may have caused them to lose visual reference, but didn't contribute to the badly executed go-around. The weather conditions similarly. And the dodgy radar? Well, again I cannot see that it had a bearing on them not following the standard missed approach accurately, other than the possible 'interruption' from ATC to get them to turn away from the high terrain.

We are all trained to Aviate, Navigate, Communicate from a very early stage in our training and this incident re-enforces that for me.Re “the controller prevented the last hole in the swiss cheese”, perhaps some people overlooked EGPWS and particularly that the crew had selected the terrain display for the approach – a valuable safety aid. The report mentions that the F/O pointed out the terrain on their left once they were heading 180 degrees, not mention of any comment before then, like they were heading towards it.Many commentators fall into the trap of allowing hindsight to (inadvertently) lead to blame – “therefore the crew did not follow the correct go around procedure”. It's not blame, it's stated fact. The PF didn't press the TOGA switch until after applying manual TOGA power and then didn't follow the standard missed approach.Beware of assuming too much “They were following the flight director …” we don’t know that Conceded, we don't know that. Was the crew behavior consistent with “ … loss of situation awareness … “, again we cannot judge as whatever the crew perceived apparently made sense to them at that time – the commander did not appreciate that he was turning.
If the PF perceived he was not turning, but he actually was, towards high terrain, I would call that loss of situational awareness. Am I missing something here? I ask honestly, not sarcastically.the crew had no prior intent of making an error and we must not judge them on error, only speculate on how we might do better in the future. Completely agree, like IU said at the start, my wording was not meant to be BLAME, merely statement of fact and a personal interpretation of the events in an attempt to learn from this, which as stated, I have.Thus, a lesson for us all could be to remember that we can all make mistakes You bet and I certainly have. attempting to multitask at an inappropriate time during the approach Another good learning point, but I wouldn't say you were blaming them!;) See, it's hard to try to point out these things without sounding like you are attaching blame after the event!

PP

[gbh]

Anyone know what is the published missed approach procedure for GIB?

[DH121]

Of course, the published missed approach assumes the aircraft is on a northerly heading. Having gone visual, this aircraft was heading east. I'm not surprised that they attampted to maintain runway heading, in this case. I'm also not surprised that the turn was inadvetantly maintained, in their half visual, half instrument situation. I think this incident was waiting to happen and I expect it'll happen again.

I think it's wrong to try to blame the controller - he appears to have done an excellent job. Having said that, I've sometimes thought that you get too much talking from GIB ATC. You're the only aeroplane for 50 miles, but they still cause a workload for you. I'm talking more about RAF controllers than the current NATS ones, I think.

[DH121]

Anyone know what is the published missed approach procedure for GIB?

It's in the AAIB report. See above for a link.

[Two's in]

Surely the most obvious "situational awareness" issue here is that they were approaching to a runway equipped with less than optimal navigational aids, and one that also has a very significant piece of rock co-located a few hundred feet south of the runway edge. The company SOP's required previous experience of the field, indicative of the perceived skill levels required to safely operate here, so the assumption is that the situational awareness level and the 'what if' scenarios would have been at the forefront of your mind before starting the approach. Not criticism, just an observation. The further events progress before breaking the chain, the harder it is to affect the course of action.

[Pilot Pete]

The published missed approach from the AAIB report is as follows:‘Continue in radar pattern as directed climbing to 3,900’ (3885’). When over the upwind end of the runway, or passing 1,900’ (1,885’) in IMC, climb on runway heading.’ Of course, the published missed approach assumes the aircraft is on a northerly heading. Don't know where you get this from, it doesn't say that anywhere. It depends when you go around as to where you will be heading, this is why airports like this require a more indepth brief. You must brief the contingency for a go-around after becoming visual and possibly in a turn to final as well as before then and once on final approach. I've not flown there or got the chart to hand, but it would appear that after going visual and turning towards final approach, if you go around you need to head towards the final approach track, then the runway, then fly on the runway track. I'm not surprised that they attampted to maintain runway heading, in this case. Correct, they should have been. I'm also not surprised that the turn was inadvetantly maintained, in their half visual, half instrument situation. Well, I would say that once they lost visual contact and decided to go around they were full instrument, not half and half. Remember, if you have the map display selected on the EHSI (and the report states) The aircraft was being flown on autopilot with the autothrottles engaged and each pilot had ‘Map’ displayed on his horizontal situation indicator (HSI). then you should have the runway and extended centreline (at least) if you have selected the landing runway from the DEP/ARR page in the FMC. This can assist visually to get onto the correct track.

Two's in makes a very astute comment in my opinion.

PP

[Monarch Man]

First a personal opinion from someone that knows both the flightcrew involved, they screwed the pooch:= (not intended to point the finger, as there but for the grace of god..potentially theres goes I!)

Now some observations.

Yes SA was lost, why? I would suggest that this is difficult to assess, as is at what point SA was lost. In any case there is simply no excuse for what took place..only consequences.
The mechanics of the approach are demanding, even on a good day, it is however well within the capabilities of an average pilot.
The missed approach (an often practiced sim exercise) is something that is rarely carried out in anger (in relative terms).

then you should have the runway and extended centreline (at least) if you have selected the landing runway from the DEP/ARR page in the FMC. This can assist visually to get onto the correct track.

This is the key IMHO, not only for SA, but also for the PNF who should have noted any track divergence, and by the fact that the published missed approach also appears on the EHSI as part of the GIB approach function.

This chain of errors IMHO have their beginings in the many uneventful GIB approaches completed by both pilots in the past few years.

[Itswindyout]

That sums it up for me....

I actually carried out my first for real missed approach in anger this month, (at LTN in VFR).

Not bad for 30 years of flying.

Windy

[DH121]

Pilot Pete,

The SRA to RW09 is carried out on a northerly track. The 90 degree turn towards the runway and the rock is only made after going visual.

Interestingly, there is no MDA, just a minimum cloud base of 1000'. A missed approach would normally commence at 1000' above the field, on a northerly heading, turning east after 1900'.

[Pilot Pete]

DH121

Thanks for that, my point being though that on approaches like this (I go to Samos regularly) you need a bit more thought and briefing because you aren't necessarily going to go around from the point you describe heading north!

Monarch Man's comments are as frank as mine, with some additional comments such as the fact that the GIB missed approach is also available in the FMC. I refrained from suggesting that as it wasn't mentioned in the AAIB report and I have not been to GIB, but if we want to learn something from this it is important to ask WHY did this situation develop, HOW did they get the missed approach so wrong and WHY did the crew stop operating effectively?

As there is no complete answer in the AAIB report one can only speculate.

1. Why did the situation develop? Possibly due to several previous benign arrivals into GIB as Monarch Man suggests. But the fact that you have to get specially checked out to go there and (presumably) an extensive airfield brief is enough to remind you each time you go there that it is somewhere to give extra consideration and respect to. The report says that there was a lack of a comprehensive brief prior to the approach. This could indeed lead to perhaps the plan not being fully complete in the mind of at least one of the flight crew. Having been somewhere lots of times before can lead to the temptation to underbrief.

2. How did they get the missed approach so wrong? I think they lost visual and elected to go around. The workload was high and an action error occurred, namely forgetting to press the TOGA switch. The unexpected had happened, they were late in the approach and the brain would have been thinking about rolling out onto final, searching and looking for the visual reference and the all of a sudden this was lost. Once the missed approach was actioned incorrectly I think this is what caused the loss of SA; thrust was manually increased and the nose was rising to the go around pitch attitude. The PNF was on the radio and then noticed no annunciation of G/A on the FMA. He called this to the PF which was not something that he would be ready for or expecting to hear. He pressed the TOGA switch and the flight directors popped back up. This distraction drew attention away from the MAP display which would have been showing that they were not lined up with the runway, not positioning towards the runway extended centreline or following the LNAV missed approach (if displayed on the map). A brief moment of confusion (we've all been there) and the prioritisation breaks down. After the G/A had been initiated, the G/A attitude selected, the flaps set for the G/A and the gear retracted the next priority would be to get onto the required track. This didn't occur and SA was lost with them heading towards the high ground.

3. Why did the crew stop operating effectively? Workload management I would suggest. Thorough brief perhaps missing and then the unexpected happened. The workload then goes up even more and the overload was not recognised (forgetting how to initiate the missed approach using the TOGA button), this leads to loss of SA in at least the PF, but by the sounds of the report the PNF too as nothing was said about the tracking. Then a radio call to say going around which was not the priority, followed by the PNF pointing out that G/A was not annumnciated. This was correct, but could possibly have become a distraction for the PF, taking his mind away from the tracking (MAP display) and onto the EADI. Pressing the TOGA switch then caused the flight directors to pop up and to show current ground track, which was not following the missed approach procedure. The flight directors are very powerful stimuli and it can be difficult to ignore them. I think this compounded the loss of SA. The PF was still turning when he thought he was in wings level flight, so he would have been diverging from the flight director commanded heading too. And during this high workload the PNF didn't mention anything about the lack of correct missed approach tracking. I suspect his SA was lost too in the confusion that was happening VERY quickly. Then the controller recognised the problem and told them to keep their turn going onto 180 degrees as the best way of avoiding terrain. Once the heading was selected to 180 degrees and HDG SEL taken the PNF obviously regained his SA and prompted the PF that the high terrain was on their left from his terrain display.

My airline have a CRM Skills List, which was developed using one of the industry's leading lights on CRM together with our training department. The whole thing centres around WORKLOAD, with sub headings in that area of 'recognises high workload', 'takes or makes time', 'deals with overload and prioritises' and 'avoids distraction and distracting'. We use the list to debrief sim performances and line checks etc. It is a VERY USEFUL tool and I have worked through it with this scenario and it is very helpful.

Now I may be wildly wrong with my speculation about how it happened, but that's how I read the report and those are the lessons I have taken from it.

PP

[Monarch Man]

Just as a follow up to my previous post....

As far as I can gauge, there are a fair spread of opinions around the bases as to why/how this could have occured.
In my experience MON is an organisation with a weath of expertise, tech know how, and most importantly training ethos.
The lessons taken from this incident will be replayed, analyzed, disected, and poured through by our training departments for the next 10 years, with an emphasis on the error chain and CRM aspects of it.

I would also like to add at this point that MON as a general rule respects the fact that crews are human, and that we make mistakes, the company tends to train rather than apply punitive measures.

Like P Pete's employer, MON have an extensive and IMHO innovative CRM programme (although depending apon who you talk too, the opinions can vary a bit), we operate into and out of some fairly challenging places (GIB, Skiathos, Samos, INN, and a few more besides) with specific and well understood/reviewed procedures.

As I've said before, my personal opinion of the error chain is that this began in the weeks and months previous. I for one can hold my hand up to switching freq's close to the ground.

[alf5071h]

PP, DH121, MM, et al, the discussion continues to raise interesting points and questions.

Re “… the GIB missed approach is also available in the FMC.”
Is the FMC approved for flying the missed approach - LNAV? My logic would suggest that if it is then why isn’t the FMS used for the approach? Thus LNAV / GA not approved?
Is the FMC accurate enough to ensure no map shift (at GIB); as above, if so use it, but if not, then could a map display be a distraction – even a hazard – see the many incidents involving map shift. The report states that crew were verifying map accuracy prior to the approach.

“How did they get the missed approach so wrong?”
Previous posts described the procedure as a climb on North until 1900ft then turn on to East. In the incident the aircraft had passed the visual decision point ‘MDA’ – the assumed MAP for a GA procedure (?), and was already turning onto East. Thus the crew were faced with a GA from a location not on the missed approach track and well below the altitude requirement of the Easterly heading. So what is the procedure for the loss of visual contact on late final? Do operators assume that the aircraft will be visual to maintain runway hdg – a false assumption in this instance? Any conclusion that the ‘missed approach’ procedure was incorrectly flown could be based on a false premise as it appears that there is no procedure applicable from the location that the crew started from, i.e. a gap in the procedures?

“An action error occurred, namely forgetting to press the TOGA switch.”
An essential element of training and procedures is that they minimise the crew exposure to situations where a single (foreseeable) error can hazard the flight. The operational requirements in JAR-OPS / FCL might assume that any crew would be capable of flying a GA without FD – power, pitch, roll, hdg. A related assumption might be that leaving the FD displayed during a visual approach is not distracting – the assumption being that pilots are taught to ‘look-through’ the FD to the attitude display. I suspect that these might be false assumptions, if so who tells the JAA?

I do not like the term ‘loss of situation awareness’; it suggest that some ‘thing’ can be lost or gained. Most, even the best CRM instructors struggle to define the operational content of the situation and the practical circumstances for loss or gain.
In the incident the crew’s situation awareness was sufficiently accurate to fly the approach and for them to determine the need for a GA. Thereafter their awareness either did not match the actual situation or it was insufficient for them to comprehend the need for a change of action (the commander did not perceive that he was turning – his situation was ‘falsely’ wings level).
How would a commander incorporate a GA SOP into situation assessment (before choosing a course of action) where there is no SOP applicable to the perceived geographic situation? Not that there can be an SOP for every possible circumstance, but there should be some guidance for all of those foreseeable situations – a risk assessment task for company management.

Many pilots discount the threat of illusions. Hopefully most will have experienced some form of turning illusion during instrument training – at a safe altitude with an instructor, and learn to counter it. However, experiencing an illusion in operation, in low visibility, and at low altitude could be very disturbing. In addition both pilots could suffer a turning illusion at the same time, and furthermore if there is significant head movement then there could be a risk of a Coriolis (turning) illusion – dizziness / tumbling.
A recent paper on EGPWS warnings (FSF Safety Seminar Athens) reported illusion as a contribution to approach incidents; one example of a black hole illusion during the approach resulted in a ‘heavy’ being at 125ft at 1.5 nm still descending (FAF Aviation Safety World July 2006).

It appears that there are many contributions to this incident which may have been ‘assumed’, and even more in what this discussion has covered. Perhaps this identifies an important issue in human factors safety – beware of assumptions.

[Zeffy]

Please forgive the slight digression (another man's hijacking?), but doesn't this incident brightly illuminate the hazards of "IFR drop-offs at a point in space" approach procedures? -- i.e., those with circling-only minima and very high HAA's/HAT's, those with lengthy visual segments, etc.

Irrespective of the cause (crew error, scud, precip, etc.) -- initiating a missed approach from a point beyond the MAP and/or below MDA/DA is fraught with risks.

RNP_RNAV procedures have the potential to greatly reduce risk at locations like LXGB. For example, note that two procedures at another challenging airport not only provide continuous vertical guidance and vastly improved operating minima, they also offer positive course guidance throughout the missed approach segment.
http://www.aip.net.nz/pdf/NZQN_45.3_45.4.pdf

Obviously, RF (Radius to Fix) legs provide the procedure designer enormous flexibility.

Procedures like the NZQN RNAV imply the need for GPS-updating of the FMS in addition to FD logic that sustains LNAV-coupling in the event of a GA selection. Dropping to TRK, HDG or ROLL HOLD won't do a satisfactory job of keeping the airplane in the middle of the fairway, especially when the DA point occurs in a turn.

[Cuillin]

One other thing worth pointing out is that if the Spanish allowed flights inbound/outbound from GIB to use their airspace that is in close proximity (ie around Algeciras/La Linea) then this incident probably wouldn't have occurred. It is only recently that they started allowing diversions to Spanish airports.

Similar airspace politics contributed to the Crossair RJ crash at Zurich a few years ago.

Politics compromising flight safety.

[Zeffy]

Politics compromising flight safety.

Agree that it's an unfortunate part of real-world aviation, with abundant examples.

Having acknowledged that ugly little facet, the characteristics of RNP RNAV procedures would frequently permit accommodation of the political/environmental/ATC requirements without having to resort to risky NPA's with long visual segments, landings with tailwinds, landings with difficult x-wind components, etc.

[Midland63]

Is this the same MON 757 Gibraltar event I recall a thread on here a wee while back when a contributor claimed he was a pilot sitting in the back of the plane? Other contributors doubted his credentials. I recall reading about the lights of various Spanish towns visible at various points in the flight - or was that another MON/GIB event (or "non-event")?

Rgds, Neil

[flown-it]

RNP RNAV Procedures are great and GNS approaches are coming. However we have to work with what we have..and therein lies the problem. Round dials and NDB approaches concentrated the mind wonderfully. We now have glass everything and we let the magic fly us. :ugh: Back to basics chaps. Every go-round is annunciated.."Go-round TOGA". Said every time ,done every time. PRESS the BUTTON. Now at least we have our FD pointing where it should. BUT. And this is a hugh BUT... its dumb. Pitch up and wings level is all it knows. We have to follow a routine. Again every time and the same way every time. Flaps, positive rate, gear, Missed approach altitude. NOW make your FD smart. Give it a roll and pitch mode mode. Heading and V/S (or FLCH). Now at the very least you are climbing to a safe altitude and you have control of your heading. Now turn the d#mn thing yourself or if you can't live without FMS, verify the missed approach has sequenced and arm LNAV. Works every time and more to the point, since you've done it a thousand times in the sim it's a non event. And before you start firing I've done my share of missed approaches for real and they really aren't a big deal.

[Dangerman]

Is this the same MON 757 Gibraltar event I recall a thread on here a wee while back when a contributor claimed he was a pilot sitting in the back of the plane? Other contributors doubted his credentials. I recall reading about the lights of various Spanish towns visible at various points in the flight - or was that another MON/GIB event (or "non-event")?

Rgds, Neil

http://www.pprune.org/forums/showthread.php?t=218616

[MANTHRUST]

If only we were all as good as flown-it. sounds like he never makes mistakes!
Seems to have spent a lot of time in the sim though?
Now lets try that one again shall we ace!

[alf5071h]

No one has followed up on the issue that the location of the point at which the approach was discontinued was not on the missed approach path. Furthermore, there does not appear to be any approved procedure for loss of visual reference after commencing the turn and continuing the descent below the ‘visual commit point’.
Perhaps we should consider the crews mental workload / puzzlement in this situation; is the GA wings level straight ahead, or is a turn back onto North allowable/safe. In either event, there might be considerations of obstacle clearance (or over flying national boundaries).
This might represent the classic case of a situation where there is no SOP – the crew has to solve the problem of what to do there and then; unfortunately being ‘there’ is not conducive to continued safety and ‘then’ requires immediate action.