I/O Error with a Difference

[Belgique]

A RYANAIR flight with 144 passengers and crew on board narrowly avoided a crash-landing at Knock Airport last March after both pilots became distracted with the aircraft’s computer system while attempting to land the plane.
Details of what air accident investigators described as "a serious incident" only emerged yesterday with the publication of an official report into the event.
It revealed that a ground impact warning system was triggered on board the aircraft after it began a rapid descent on an approach to Knock Airport. The report concluded that a collision with the ground was "marginally avoided."
"The captain and flight officer were so engrossed in trying to re-programme the [aircraft’s computer] that they both lost their critical situational awareness for a time," said the official report.
The incident happened when the pilot of the aircraft had to abandon an approach to Knock Airport after breaking through cloud cover and realising that the plane was just 400ft above ground level.
A report by the Department of Transport’s Air Accident Investigation Unit showed that the pilot had intended to descend only to the recommended limit of 1,300ft before circling the airport to land.
Instead, the aircraft had descended dangerously below that limit as Knock Airport is situated on a plateau at 665ft above sea level.
Data provided by radar equipment showed the aircraft was descending at the speed of 2,200 feet per minute — three times the normal speed for approaches to airports.
The incident occurred on board a Ryanair Boeing 737-800 aircraft on a flight between London Gatwick and Knock Airport on March 23 last. There were 138 passengers and six crew.
The AAIU report found that confusion arose among the cockpit crew about which direction to approach the runway at Knock Airport for a landing.
It claimed uncertainty about weather conditions at Knock by both the captain and his assistant officer had impaired their decision-making.
The two pilots were also hampered by the fact that several navigational aids were unavailable at the time due to improvement works being carried out at the airport.
However, the AAIU noted that information about the unavailability of such navigational aids had not been conveyed to the Ryanair flight crew by the airline.
The AAIU also acknowledged that a widely used professional manual containing information on approaches to all airports had not been updated to reflect the ongoing works at Knock.
The cockpit crew were also distracted by the fact they were trying to input information on an extra navigational aid, which had recently come into operation, into the aircraft’s computer at a time when they should have been concentrating on their visual approach.
"The work overload meant that normal routine checks were not carried out and there was no questioning of the developing situation by either pilot," said the AAIU report.
It concluded that the flight crew had contravened Ryanair’s own standard operating procedures by descending below 1,300ft to circle the airport.
Ryanair was also criticised for failing to report the incident until 12 days after it occurred. Such a delay was "unacceptable" and contrary to aviation regulations, said the AAIU.
Last night, a Ryanair spokesperson said the company had assisted and co-operated fully with the AAIU report and had accepted and implemented all of its recommendations.

[Flight Detent]

Would't it be nice to have an extra pair of experienced eyes in the flight deck to offset this and many other potential problems........Oopps, I forgot, they did, but then decided he was no longer 'required'.......pity that!

Cheers FD:ugh:

[blue up]

Never fails to amaze me that in this day and age we still get Volmet broadcasts without info on runway in use at last report. Zooming across the pond recently to a destination on the coast that has a weak ATIS and finding ourselves unable to make a cohesive plan for arrival. 10 hours of boredom with 20 minutes of frantic button-pressing. Surely, in the 21st century we can come up with data links that can fast download weather etc from sat or maybe units co-located with VORs. $100,000,000 aeroplane? C'mon! Automatic ATIS uploading ought to be simple in "The Information Age".



Dear Mr Boeing.

With regards to your new 787. Could you please give us radios that work at longer range. Also, dust filters in the flightdeck aircon ducts, seals between the lav floor and the flightdeck, sunvisors that don't have gaps round the edge, power points for our laptops, cupholders that aren't directly below a piece of structure (I like LARGE cups of coffee) and more clips to hold Jepp charts on the side panels.

[Cornish Jack]

FD
Interesting thought, but consider, amongst others, the 74 Classic into KL - the 'third pair of eyes' contribution to the event was "Oh S..T", one second before they all died in yet another CFIT.
If you want a REAL accident precluder, introduce an Aircraft Commander, on the flight deck,not physically involved in flying the aircraft and having ultimate authority in respect of aircraft manoeuvring. There's no way someone in that position is going to allow his crew to put him in jeopardy!!
It isn't going to happen (and not just due to financial constraints) but, otherwise, it's down to concentration on the essentials -aviate, navigate, communicate..... plus ca change.

[Doctor Cruces]

I thought that crews briefed before flying, including NOTAMS etc for relevant airports.

Getting to an airport and being surprised that most of the nav aids are not functioning because of planned upgrades seems a little basic to me, unless of course Ryanair's idea of low cost includes not paying for pre flight briefings too!

Doc C

[Two's in]

Once again, there are numerous points of failure along the way that led to this incident, but if you take the (hypothetical) point of view of a lawyer representing the plaintiffs in any case such as this, the aircraft Captain always retains the ultimate responsibility for ensuring he is aware of the pertinent details regarding the conduct of an IFR flight before undertaking such a flight. Yes, that places a major dependency on Flt Ops, but it doesn't remove the responsibility from the Captain. I have yet to see an ANO or FAR directive that relates to the execution of IFR flights by LCC's or Airlines with short turn around times, excluding them from receiving a comprehensive and current IFR pre-flight briefing.

[ARINC]

unless of course Ryanair's idea of low cost includes not paying for pre flight briefings too!
Well yes, believe or not we do have pre flight briefings but just try to do them in 45 min. for a 4 sector day including:
* gadering all the info. (aircraft reg, pax numbers, stand, etc.)
* printing your own plogs
* printing your own met & notams
* ordering your fuel
* brief cabin crew
* collect jepp. fotocopies of all the destinations, alternates and of course checking that each single plate is up to date.
* Fill our container with water for the day (I am embarrassed to even tell that one)
* long walk to the aircraft
* and nowadays we do fuel supervision as well.
Throw on top of that printers that don't work, zero wind plogs, missing jepp. plates and a total chaotic crew control with only one person to control 45 flights during the first morning wave and you will see the recipe for a disaster happening very quick.
Of course you always have the option to show up well before and break the IAA approved 10 hour minimum rest that we get.
Remind me not to fly Ryan Air.... Oh silly me I already don't
How on earth can anyone reading this have any confidence whatsoever in this airlines safety. Am I alone in being truely amazed and not a little shocked. I'm sure the crews are all hard working pros, but frankly, I would expect a bus company to have more safety awareness than this. I pray it doesn't take an accident for someone (CAA EASA or even a Parliamentary select committe, (they can do it for Farepak !) to take a long hard look at this company.

[J.O.]

And short cutting any of the required elements in the name of making that on time departure leaves the commander with his / her gluteous maximus very exposed. Seems to me a few more delays in the name of doing the job right would aid the higher ups in getting the message. But then, that would require a learning safety culture.

[Liffy 1M]

Here's a link to the full report:

http://www.aaiu.ie/upload/general/8545-0.pdf

[John Farley]

It revealed that a ground impact warning system was triggered

Which is just what is supposed to happen because we all know people can make mistakes. So we need automatics to watch our six. We need crew to deal with all the operational issues that are the airline business, but I always found autos could steer the aeroplane better than me. And I don't see any problem in admitting that.

[Duckbill Platypus]

What I don't understand is why are some of you having a go at the "airlines" safety? It is up to the captain to make sure he or she has briefed fully for the flight they are about to make. If there isn't enough time to do so because of the IAA approving a 45 minute report and the company don't supply enough material for the brief then the captain should have the courage of his or her convictions to refuse to operate until they are fully briefed.

Whilst the company may have a reputation for bullying management it still requires their pilots to stand together against any such tactics and unfortunately, it appears that they are unable to form a cohesive grouping to do so. That is probably down to their management culture of bullying tactics, as described recently by a high court judge, but until they manage to get their act together the company will always win. They may have delayed reporting this incident but they still reported it!

Looking at the report, I don't kow how you can blame the company for the crew not briefing before the flight and for still doing around 250kts at less than a mile from the runway, even if they were going to do a circling approach. This crew were extremely lucky and if it weren't for the EGPWS the the result could have been tragic.

The IAA, CAA and EASA have all got to share in the responsibility of this incident. The captain will be ultimately responsible but the chain of events started way back when the various regulatory bodies approved the AOC of Ryanair. To allow their restrictive, 45 minute duty reporting times when, as most of us know, especially those of us lucky enough to work for proper airlines, you know the ones, where safety really does come before profit, we either have a more realistic duty report time AND traffic personnel who put together a proper briefing pack and it is waiting there for us.

The regulatory body that allows a company to have a 45 minute report for a medium jet operation with up to six sector days has got to take the blame for that one. In a legacy airline operating heavy jet long haul routes, ie. single sector day, we have 90 minute report. It doesn't matter how short the sectors are, they still need the same amount of time to brief. 45 minutes is a joke, and a sad one when you find out that the crew have to prepare all their own paperwork, do the brief and then make it through the idiotic security system to the aircraft in that time. I'll bet that not one operations inspector has arrived at the report time and gone through the routine, on a regular basis and managed to do it in the time allocated.

So, crew report earlier than required, on their own time and still rush through it all, inadequately briefed. The IAA, Ryanair AND the pilots are all responsible. The only trouble is that the first people at the scene of an accident are the crew themselves!

[Ignition Override]

How many crews have long forgotten the lessons from the B-757 tragedy in Cali, Columbia about 12 years ago, and others, or close calls in B-737s, A-320s etc? Four shiny, brand-new stripes are no protection. Neither are four old, faded stripes and an encyclopedic knowledge of theory and procedures, required by some foreign agencies.

Automation should never be trusted to keep you and your passengers alive, or even comfortable, whether with or without awareness of speedbrake extension in almost every descent, EGPWS, altitude warnings etc. Read up on what the Factory Test Pilot tried with the brand-new widebody aircraft at the factory airport. It is not difficult to find. Some automated aircraft are described by many experienced pilots as "having quirks", no matter how basic or advanced the automation. The more modes available, the higher probability that a new situation in mountains/IMC can set a trap? The CIVET into LAX at 230 knots with 3 runway changes can be bad enough.

As an observing brand-new Instructor Pilot commented about seven years ago during our Initial Training, when we discussed the need not to hurry anything: "Speed Kills". A mission-oriented mindset can quickly override the focus on safety.

'Tex', I hope you have a nice retirement.

[WHBM]

Who has regulatory oversight of Ryanair flights based in/departing UK airports. Is it a case of :

UK CAA : "Well they're an Irish airline so nothing to do with us".

IAA : "Well that's not a flight departing from an Irish airport so nothing to do with us".

[unablereqnavperf]

Im afriad there is no excuse for an Irish airline operating to an Irish airport not knowing that there is major improvment work on the the go there!

Just another of the many reasons why my family and I will never fly on this airline!

With apologies to the good operators still with this airline,sadly your numbers are fast being diluted!

[CamelhAir]

Ryanair holds an Irish AOC and is therefore, regardless of origin/destination of the flight, regulated by the IAA.
Therein lies the problem. The IAA has neither the ability, nor the interest, in overseeing ryanair. They are utterly toothless and beholden to mol’s threats to relocated to eastern Europe.
The problem highlighted by this incident, of the inadequate preparation, is typical. This is a known problem and has contributed to previous incidents. It is absolutely impossible, in Dublin, as anywhere else, to get a days operation fully briefed inside 45 mins, while allowing for a long drive to the aeroplane, the security queues etc. Why is nothing said about the lack of back-up, the operational deficiencies, the broken printers etc etc? Is this what the IAA considers to be an environment conducive to safely planning a days operation? We know what FR management think, but they don't care.
The report is a farce also. The raison d’etre of an incident report is to present the facts AND ask why they occurred. The major contributory factor of inadequate preparation is highlighted, but at no time is the question asked as to why. Why is this? Is there an agenda from the responsible agencies to cosset ryanair in case their business is lost? That’s a rhetorical question as the answer is as obvious as night follows day.
So once again, through wilful company neglect and total regulatory failure, the problem drops into the laps of a good crew, who are left to carry the can for a total lack of support from anyone else.
Have the IAA not yet learned? Ryanair themselves will do NOTHING safety related that costs any money at all unless forced to. Safety is not a priority at this company. Do they not realise that when the “big one,” as inevitable as it is unthinkable, happens they too will be in the dock, charged with gross and wilful neglect in their responsibilities?
Why has nothing been said, apart from a half-hearted demand not to do it again, about the extreme delay in reporting the incident to the authorities? This has happened so often before (CIA, Skasta etc). Again, no questions as to why? Doesn't anyone in the IAA/AAIU care about a systematic failure to own up to serious incidents? Shouldn't someone be asking a little more about a safety culture, or lack thereof, that permits these "oversights"?
The aviation industry is as safe as it is through decades of application to increasing safety, to putting in place safety layers, checks and balances. Ryanair and the IAA are systematically, in the name of cost cutting and money making respectively, removing these layers.
As for the pilots, damned if you, damned if you don’t. Turn up on-time, preparation is rushed. Act professionally and turn up early, and what thanks from the company? Another pay cut? More abuse? Maybe a little bullying? Or maybe just some plain old-fashioned firing.
And yet pilots are the one functioning layer of safety at ryanair. That’s what it’s been cut back to. So we are now in a situation where the only thing preventing the smoking holes is being, yet again, systematically undermined. Having removed every other layer of safety, ryanair now see fit to attempt to reduce the stature of the last layer to that of underpaid bus driver. And if that doesn’t work, bullying and vindictiveness are a nice substitute.
There is no safety culture in ryanair management. Nor the IAA. Period. “But it can’t be like that” I hear you say. But it can. And it can be, precisely because you don’t believe it can be.
Be afraid, be very afraid.

[WHBM]

Sorry to keep going on about CAA/IAA and who does the oversight, but ......

If I recall correctly when a Far Eastern long haul airline was suspected of arriving at Heathrow with inadequate fuel reserves I believe it was the CAA who moved on that one, including requiring fuel quantity checks on each arriving flight, then after a while on a sample.

Now if the CAA could move on a safety issue then on a foreign airline operating into the UK, why cannot they make checks with the situation being discussed here.

[RogerIrrelevant69]

WHBM,

Knock Airport is in the Republic of Ireland. CAA has no jurisdiction there!

[WHBM]

I think I understand that :) But they do have jurisdiction at Gatwick which is where the dispatch issues we are discussing presumably arose in terms of flight documentation.

[Dave Gittins]

Am, I missing something (I stress my credentials as a mere Cherokee driver). The report states (2.2 page 7) that the PF had done a line check into Knock the previous day. One would have expected that would have made him fully aware of the "work in progress", and conversent with the constraints on the nav aids etc. Or is it possible that the line check .. and whoever conducted it ... had an equal paucity of up to date documentation ?
This doesn't get another mention but I consider it to be one of the more disturbing aspects of the whole incident. Apart from hurtling around like a couple of undisciplined fighter pilots (and I was only just reading the thread about keeping below 250 kts below 10,000 ft.)
DGG

[CamelhAir]

WHBM,
The crew started in Dublin, Gatwick was a turnaround. The flight sequence was DUB-LGW-NOC. All docs would have been obtained in Dublin.
Unfortunately, as far as the CAA is concerned, it was an Irish aeroplane operating in Irish airspace when the incident occured. Had it occured on the approach to a UK airport, then they could intervene.
One expects that the CAA might ask tougher questions than the IAA, so more's the pity they have no jurisdiction in this matter.

[NigelOnDraft]

The report states (2.2 page 7) that the PF had done a line check into Knock the previous day. One would have expected that would have made him fully aware of the "work in progress", and conversent with the constraints on the nav aids etc. Or is it possible that the line check .. and whoever conducted it ... had an equal paucity of up to date documentation ?
It almost certainly did have the same lack of documentation. But if they were on 27 the day before, none of the "issues" would have arisen, or the weather was better etc.
(and I was only just reading the thread about keeping below 250 kts below 10,000 ft.)Report seems quite clear they always were below 250K IAS < 10K'. See p4 - NB "strong tailwind" ;)

[jumbojet]

blah blah blah! If the crew had confirmed "ALT HLD" on the FMA, the a/c would of not decended below 1300ft. "ALT AQR" is not good enough; Its what their for.

[fmgc]

Even so I doubt that the CAA would do anything.

[RogerIrrelevant69]

WHBM

As CamelhAir correctly points out it was a "Irish aeroplane operating in Irish airspace" so therefore no role for the CAA. Blindingly obvious to me and wasn't going to bother replying to the red herring about this thread being about "dispatch issues"?? rather than it being about all the factors that lead up to this serious incident.

Ho hum...

[bloggs2]

There is a lot of waffling about external factors here, indeed some have merit (we deal with similar at other airlines ie briefing times).

However, what i don't get is if you arrive somewhere and end up with an arrival/approach that is completely unexpected and are now under some pressure, where is the basic airmanship, go into the hold at a safe height, sort your crap out and do the approach. No excuse to both be head down barrelling along at the ground regardless of how little time you had in the briefing room at the start of the day.

These guys/gals would have got quite a shock thinking about it afterwards. They and the people behind them would have augered in without the benefit of an important safety system (EGPWS) developed after countless others had died as the result of similar incidents.

[shortfinals]

These may not be directly connected with the incident, but there's some food for thought here courtesy of IALPA via Flight International:


http://www.flightglobal.com/Articles/2006/12/05/Navigation/185/210959/Union+recognition+'is+good+for+safety'.html


http://www.flightglobal.com/Articles/2006/12/05/Navigation/201/210911/Prize+assets.html

[cwatters]

Finally made the Times today...
http://travel.timesonline.co.uk/article/0,,10295-2487057,00.html

The paper edition has the now compulsory graphic showing how high 400ft is compared to Canary barf.

[Dave Gittins]

NoD (Post #21) I grant you that would have been (and presumeably was) the position on the previous day if operations were on rwy 27. But that should not excuse the lack of preparedness .. and I am surprised that the investigation did not review whether the lack of appropraite documentation on a line check was part of a more general problem.

As I said yesterday, I find that one of the most disturbing parts of the whole affair.

Insofar as whether 250 + knts was reached, perhaps - perhaps not ... radar lost them at 1100 ft ( = 435 ft AGL) at 265 kts and accelerating with a surface wind of 15 kts (and a reported tail wind of 25 kts). Still seems a tad quick to me.

[jumbojet]

pherhaps somebody could print the letter the crews received from MOL about what would happen if another rushed apprach was done. Quiet aggressive. I dnt have a copy; RGDS

[alf5071h]

The threats and errors identified in this incident keep on reoccurring. In part, they are fundamental elements of operating in our industry, thus continuous vigilance is required by operators and crews. There are many similarities with the incidents reported in ‘Near CFIT incidents. (http://uk.geocities.com/[email protected]/alf5071h.htm) Perhaps this operator, if not all of us should heed the conclusions and recommendations in the paper with reference to the contributing factors in this incident.
We all have responsibility for threat and error management. It is disturbing that this aircraft penetrated several safety defences, to encounter the last one – the EGPWS. However, the positive conclusion was assured by the crew following procedures (SOPs) by discontinuing the approach.

[MarkD]

can anyone point me to any thread where EI or REs ops have been queried with reference to the ability of IAA to supervise?

[CamelhAir]

can anyone point me to any thread where EI or REs ops have been queried with reference to the ability of IAA to supervise?

Can't think of one off-hand. There are big differences between these 2 and ryanair. ryanair is far-flung and widespread, for example, making the task of a small regulator that much harder. Particularly one that is uninterested.
EI would need rather less supervision than ryanair I imagine, as they have a safety culture, whereas ryanair don't. Read the Flight Internation articles (links above) about the benefit to safety of a union.
Also, EI and RE don't regularly threaten to re-register in eastern Europe. It doesn't take a genius to work out exactly what message, when ryanair threaten to do this, is sent to the regulator.