AF358 at YYZ report to come out

[Dushan]

Plane landed too fast, report finds (http://www.nationalpost.com/todays_paper/story.html?id=145219)

This article in National Post may require a subscription, so here is a tidbit...

CanWest News Service
Published: Wednesday, December 05, 2007

An Air France plane that crashed at Toronto's Lester B. Pearson International Airport in 2005 came in too fast and landed almost halfway down the runway, the Transportation Safety Board of Canada said yesterday.
The board will release its final investigation report into the crash in Toronto next Wednesday.
"The aircraft approached Toronto in a severe and rapidly changing thunderstorm with shifting winds and limited visibility.

[punkalouver]

According to my source at Air France, it was mentioned on descent with the Tstorms around that that's why they get the big bucks. On short final they said it was like flying through Niagara Falls.

[dessas]

Dushan,
It will be appreciated by a lot of blokes here if you paste the link when the report comes out. I have heard rumors that Airbus will introduce a major change to SOPs related to use of autothrust.
Thanks:ok:

[Mad (Flt) Scientist]

I'd imagine TSBC will place the report on their website pretty quickly; that would avoid getting a second-hand version via a newspaper.

this (http://www.tsb.gc.ca/en/reports/air/2005/index.asp) is the current list of reports for 2005. You'll see the AF358 accident currently has a preliminary entry (as of Nov 05) about 8 entries down, which is where I'd expect the final report to show up when released.

[Miraz]

On short final they said it was like flying through Niagara Falls.

I was SLF on this flight - I'll concur with this, the last section of the approach was seriously soggy - I couldn't see more than half of the wing in the heaviest of it.

[punkalouver]

I'm not sure what SLF means, but if you were on this flight, perhaps an account of your experience would be quite interesting from what you saw to what was said by flightdeck or cabin crew or any other observations you had.

[BRE]

SLF = self loading freight

[alph2z]

You don't need to wait for that report. Everything's already answered in the AF358 thread; and then some. :}
.

[rigpiggy]

Plane landed too fast, report finds

Air France Crash; S kidded off runway near Highway 401

CanWest News Service Published: Wednesday, December 05, 2007
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An Air France plane that crashed at Toronto's Lester B. Pearson International Airport in 2005 came in too fast and landed almost halfway down the runway, the Transportation Safety Board of Canada said yesterday.

The board will release its final investigation report into the crash in Toronto next Wednesday.

"The aircraft approached Toronto in a severe and rapidly changing thunderstorm with shifting winds and limited visibility.

"It came in too high and too fast and touched down almost halfway down the 9,000-foot runway," the board said in a statement released yesterday.

"A combination of a wet and slippery runway and crosswinds meant the aircraft simply ran out of room."

The plane crashed on Aug. 2, 2005 with 297 passengers and 12 crew members on board. All survived after the plane skidded off the end of the runway and into a ravine near Highway 401.

One official said it was "a miracle" there were no deaths. Nine passengers and two crew members suffered serious injuries.

An interim report, released by the Transportation Safety Board in November, 2005, found no mechanical defects on the Airbus 340.

Information gathered by investigators in the interim report found the plane had almost no chance of stopping amid a sudden gust of wind and a line of fierce squalls that struck it just above a rain-slicked runway in the last few minutes before landing.

As the massive jet came in -- higher and faster than usual, the interim report said -- it was hit by sheets of rain, which significantly reduced the crew's forward visibility.

And, according to the digital flight recorder, at almost exactly the same time, the wind shifted, "causing a tailwind component of approximately five knots."

Meanwhile, the storm had left the runway "contaminated with at least ¼ inch of standing water."

The interim report also found the Air France jet landed about halfway down the runway.

Shortly after the crash, Jean-Cyril Spinetta, the chief executive of Air France, reportedly blamed airport authorities for allowing the plane to land in bad weather.

The interim report indicates air traffic controllers were aware of traction problems on the runway used by Air France Flight 358 and informed the pilot.

At least 107 passengers have joined a class-action suit against Air France, Toronto airport authorities, the control tower staff, Airbus, Goodrich, which built the jet's escape chutes, and the two pilots, seeking damages of more than $150-million.

Close
Reader Discussion

[BeechNut]

Let's see, 150 million divided by 107 passengers (in the suit): $1.4m per passenger.

Let me see if I got this right. They had a good fright, but they were lucky enough to survive with just a few scrapes. Their baggage got barbecued.
The $1.4m will provide what exactly? Surely nobody had $1.4m worth of luggage roasted?

I dunno about other folks but if I survived an airliner crash where the aircraft literally burned to ashes, with, at best, minor injuries, well, heck that would be a big enough prize for me... hell, screw the luggage, kiss the earth like the Pope, and be thankful!

Beech

[punkalouver]

Let's see, 150 million divided by 107 passengers (in the suit): $88k per passenger.


Doesn't 150 million divided by 107 equal 1.4 million each?

[20driver]

punkalover - Maybe Beechnut is talking net after the lawyers get their cut!

20driver

[BeechNut]

:O:O:O

You're right. Punched up the calculator wrong and wasn't thinking. Good thing this wasn't a fuel calculation...then again we Canadians are good at messing those up.

Original message edited.

And my point is amplified. You want how many million for surviving nearly unscathed???

[BeechNut]

punkalover - Maybe Beechnut is talking net after the lawyers get their cut!

20driver

Good one!

:)

[JEM60]

What the amount you sue for, and what you get are very much two different things!! Start high, but expect a much less [if any] award.

[Big Tudor]

$1.4 million each? :eek: Doesn't seem quite fair when you consider the soldier who had a pace stick thrown at his head is awarded £300. He was in a coma for 6 days, had a blood clot removed from his brain, his left hand is paralysed and he now walks with a limp.
http://news.bbc.co.uk/1/hi/england/staffordshire/7120438.stm
Maybe he should follow the example in this case and sue the manufacturer of the pace stick, Staffordshire county council, Tesco (cos that's where the sergeant major shops), etc. Oh and he could sue Airbus as well, I'm sure any good solicitor could prove that there was one flying overhead when the incident took place!

[Dushan]

Here it is:
RUNWAY OVERRUN AND FIRE
AIR FRANCE
AIRBUS A340-313 F-GLZQ
TORONTO/LESTER B. PEARSON INTERNATIONAL
AIRPORT, ONTARIO
02 AUGUST 2005 (http://www.tsb.gc.ca/en/reports/air/2005/a05h0002/a05h0002.pdf)

[RatherBeFlying]

On the day of the accident, I was following the progress of the thunderstorm line on the NWS Buffalo radar. Upon leaving work at QEW and Hwy 10 (~12 km. due South of the accident runway), I heard the news of the crash as I encountered a rainfall that brought QEW traffic to a halt. It would not surprise me if this was the same cell that made trouble for AFR358.

Whether or not it was, I feel strongly that weather radar returns would constitute an important part of the investigation. While I do see mention that weather radar returns were investigated, I am disappointed that the report omitted to include them in at least the appendices. Sections 2.4.1 Adequacy of Meteorological Data and 2.4.2 Weather Information Provided by Air Traffic Control beg the question that if a qualified person at ATC had access to the meteorological radar whether timely information would have been passed on to ATC and the aircrews.

It would also be of interest to have simulated what the onboard weather radar showed on the aircraft that made approaches and/or have checked with the crews who did approach what their onboard radar displayed.

As noted in the report aircrews are used to making approaches with thunderstorms in the vicinity. Hopefully patterns on onboard radar could be identified so that aircrews could recognise when it's time to hold or divert.

[sevenstrokeroll]

if the wx looks "iffy" at all...wait 15 minutes...if it clears, you did it to give the pax a better ride...if it gets worse, it proves that you were right to wait.

if high and fast go around and be ready for firewall power if you encounter windshear. (it is possible that if they went around, things might have been worse...look at CLT DC9 crash about a dozen years ago)

and , dear Canada, install windshear alert system...heck, your a first class country, get doppler wx radar!

[J.O.]

and , dear Canada, install windshear alert system...heck, your a first class country, get doppler wx radar!

You are 100% correct, SSR. I am very disappointed that the report did not include a recommendation to install a LLWS system at YYZ. We get plenty of days where conditions similar to those on the day of the accident exist. I have to ask, if the AF crew had been on an approach to JFK in that weather, would they have continued their approach if ATC had advised them of LLWS alerts in the vicinity of the runway? I'd certainly hope not, and instead of a smoking hulk in a ravine, AF would have had a load of slightly inconvenienced passengers sitting at the alternate airport instead.

[Nebouzzo]

:ok:I am not promoting The Toronto Star, but these guys are far ahead of The National Post regarding this matter..
http://www.thestar.com/article/284891:=

[alph2z]

Air France Flight Animation (A05H0002)

The following is a flight animation that was created with the data collected during the Air France investigation (A05H0002). The animation is available in the rearview and the side view profiles.
Warning: This video is over 40 MB and could take a long time to download.
1. Right click on the link of the video format you wish to download.
2. When prompted, select "Save Target As...".
3. Choose a location on your PC to save the file.
4. Click "Save".


Air Investigation Video for Windows Media

Side View
* Download [WMV format, 16.0 MB]
* Stream [WMV only]
Rear View
* Download [WMV format, 13.5 MB]
* Stream [WMV only]


Air Investigation Video for QuickTime

Side View
* Download [MOV format, 6.6 MB]
Rear View
* Download [MOV format, 11.7 MB]

http://www.tsb.gc.ca/en/media/video_database/air/a05h0002/index.asp
http://www.tsb.gc.ca/en/media/photo_database/air/a05h0002/a05h0002_thumbs.asp
.

[Airbubba]

I keep hoping someday Canada will try another novel invention from the South: grooved runways.

Thanks for posting the accident board video links. As always, they are chilling to watch.

[punkalouver]

it is possible that if they went around, things might have been worse...look at CLT DC9 crash about a dozen years ago)

Keep in mind that this accident included very improper windshear recovery technique.

I keep hoping someday Canada will try another novel invention from the South: grooved runways.


Would definitely improve safety along with a windshear alert system. Of course so would not landing in a thunderstorm.

[sevenstrokeroll]

Yes, the CLT crash was quite improper after the go around started...insufficient thrust, delay going to firewall power...illusions

The question about the Toronto crash simply has to be: if these guys didn't take into account extra speed, possible shifting winds and the like for the approach, could they have done a proper go around...call me doubting.

[alph2z]

2.4.2 Weather Information Provided by Air Traffic Control
........ Information concerning poor braking action was passed
on several occasions. The radar used in the Toronto tower by ATC is not specialized weather
radar and does not provide highly detailed weather information. Therefore, the crew of AFR358
had a better view of radar-derived weather information from their aircraft’s weather radar than
the controllers did from their own display.
There is no indication that more sophisticated weather radar information, had it been available
to ATC and communicated to the crew of AFR358, would have altered their decision to
continue to land. However, without some indication of the speed and direction of intense,
rapidly moving weather phenomena, controllers are limited in their ability to provide
information that might be of assistance to aircrew. Controllers attempt to use the runway most
nearly aligned into the wind. However, because of weather and ILS outages due to lightning
strikes, the landing runway had been changed several times.
At 1856, the ILS localizer for Runway 24R became unserviceable, forcing the use of Runway 23
for some time. Some arriving aircraft, however, were refusing the approach to Runway 23
because of the nearness of the storms north of the approach path. At 1913, the ILS glideslope for
Runway 23 became unserviceable and, with the unserviceability of the glideslope for
Runway 24R, the only remaining runway aligned into wind was Runway 24L. Under normal
circumstances, the preferred approach and landing runway is announced in the ATIS broadcast.
Equipment outages for extended periods are advertised by NOTAMs. There was no indication
from the crew that use of Runway 24L was unacceptable. The final decision on the acceptability
of a particular runway rests with the aircraft captain.
Given the limitations of the information available on board, crews may require assistance in
projecting the weather situation into the future and may look to ATC for additional
information. This was certainly the case in the accident flight because the crew made multiple
requests to ATC during the initial approach phase for information with respect to the
developing weather conditions. Crews may believe that ATC will be able to provide the most
up-to-date information as they have local climatological knowledge, are located at the airport
(in the case of tower controllers), and may be aware of what other aircraft are experiencing.
However, ATC’s ability to provide up-to-date weather information during rapidly changing
conditions observed with thunderstorm activity is quite limited. Further, some crews have an
inaccurate belief that ATC will close airports based on weather conditions.
.

[Dushan]

Still, the board said its report was not about placing blame.

Which is not to say that Toronto Pravda isn't quick to place blame:
Runways at Canadian airports are falling short of international standards, and Ottawa needs to mandate extended safety zones to prevent crashes like the one that sent an Air France jet hurtling into a ravine in stormy weather, a report said today.

[MarkD]

The Star's post-incident reporting was appalling - and did not go unnoticed here (http://www.pprune.org/forums/showthread.php?t=243194&highlight=AF358).

Oh and here too (http://www.pprune.org/forums/showthread.php?p=2126796).

[RatherBeFlying]

The radar used in the Toronto tower by ATC is not specialized weather radar and does not provide highly detailed weather information. Therefore, the crew of AFR358 had a better view of radar-derived weather information from their aircraft’s weather radar than
the controllers did from their own display.
There is no indication that more sophisticated weather radar information, had it been available to ATC and communicated to the crew of AFR358, would have altered their decision to continue to land. However, without some indication of the speed and direction of intense, rapidly moving weather phenomena, controllers are limited in their ability to provide information that might be of assistance to aircrew...
Given the limitations of the information available on board, crews may require assistance in projecting the weather situation into the future and may look to ATC for additional information. This was certainly the case in the accident flight because the crew made multiple requests to ATC during the initial approach phase for information with respect to the developing weather conditions. Crews may believe that ATC will be able to provide the most up-to-date information as they have local climatological knowledge, are located at the airport (in the case of tower controllers), and may be aware of what other aircraft are experiencing. However, ATC’s ability to provide up-to-date weather information during rapidly changing conditions observed with thunderstorm activity is quite limited.Meanwhile at my office I had been entertaining myself with the NWS Buffalo radar images until just before the crash. These images made it perfectly clear that severe thunderstorms were developing and moving rapidly around the airport.

I definitely support the crew's reluctance to accept a goaround into the red return that their onboard radar showed on their missed approach path. Hindsight tells us that the downburst behind them shut the door on the trap.

So how does the crew get the information on thunderstorm activity they need? XMWX does offer this information from US and Canadian radars to onboard receivers. Sample below:

http://www.xmradio.com/images/existing/weather/dt_highresdopplerrad.jpg

[J.O.]

I definitely support the crew's reluctance to accept a goaround into the red return that their onboard radar showed on their missed approach path. Hindsight tells us that the downburst behind them shut the door on the trap.

Okay, maybe I'm picking the fly poop out of the pepper shaker. But, if your missed approach path is covered by weather that you don't want to fly through, shouldn't you abandon the approach altogether? You can fly a perfectly stabilised approach and still need to go around because of elements beyond your control. If you wouldn't fly through such weather between the FAF and the runway threshold, why set yourself up to have to do so during the go around when somebody taxis onto the runway in front of you?

Food for thought.

Jeff

[expat400]

RBF.
So instead of making a go around you should rather crash and burn? A very strange way of thinking I'd say...
J.O is right, if you can't make a go around then you don't do the approach.
Or, (in case you didn't notice until you're already at the outer marker) you change the go around.
I have several times on final informed ATC that "in case of a go around we will start an immediate left/right turn due to weather". Some times they ask me to change direction of turn but in every case it has been acknowledged as a good idea.
Missed approach procedures are not set in stone. You are the commander!

[Miraz]

This are the sections that drew my attention:-

From the Air France MANEX performance information, the predicted landing distance needed for the landing in Toronto on a contaminated runway with zero wind and no thrust reverser was 8780 feet. For Runway 24L, the extra margin was only 220 feet. This very small landing distance margin was eaten up by the long flare during the landing. With a tailwind, there was negative margin, which would mean an overrun

Derived from MANEX Chart TU 04.02.50. 13 A340-313
Full Flaps Landing Distance for Toronto (CYYZ)
Pressure Altitude 500 Feet asl, Manual Braking Wind No Reversers Using Four Reversers
0 2670 m (8780 feet) 2403 m (7883 feet)
5-knot tailwind 3071 m (10 075 feet) 2764 m (9068 feet)
10-knot tailwind 3471 m (11 388 feet) 3124 m (10 249 feet)
The Airbus flight crew training manual (FCTM) states that passing over the runway threshold at 100 feet altitude rather than 50 feet will increase the total landing distance by approximately 950 feet (300 m).


Layman's view :- This would seem to indicate that once Runway 23 (3389m) was out of commission that an approach to 24L (2743m) probably should not have been attempted if the crew had taken into account the surface state of the runway reported by other aircraft.

Even if the approach had been perfect the tailwind would have still resulted in an overrun.

[Mad (Flt) Scientist]

Do those distances include the JAR-OPS 15% margin on contaminated?

[alcorfr]

Expat400,

A very french way of thinking I'd say...I'm french, thank you very much for such an insightful and accurate comment.

I would like to say that, as convinced as i am concerning precise touchdown or mandatory go-around when conditions deteriorate, i will remain very MODEST because i know this crew and many others felt exactly the same just before it happened.

[expat400]

Alcorfr.

My sincere apologies. I intended to be "funny". However, looking at it in this context I failed.

I have no issues with french people or french pilots, only with the statement that it should be better to land long and fast on a critical runway than make a go around.

I will edit my post.
:O:O

[alph2z]

This is a continuation of Miraz's idea..... you mention a 220 ft margin but you ignore reverse thrust which improves this numbers by 900 ft.

I know that NOW (recently), since the Chicago incident, the rules are changing about the use of Reversers in the calculations.

I find the report, but e.g. especially certain details about runway braking distance very frustrating !!! And I have hours to read the charts and report and yet the pilots have much less !!??

From the report:

The calculated landing distance for a runway that is covered with less than 3 mm of water (wet runway), using the airport elevation for CYYZ, using autobrakes “low,” and assuming no wind, full flaps, and without the use of thrust reversers, is 2196 m (7203 feet).........

and yet


......The calculated landing distance5 for Runway 24L at CYYZ for the conditions at the time of landing, assuming ¼-inch (approximately 6 to 7 mm) of water on the runway (contaminated), using manual braking, is summarized in the table below........

shouldn't they be using more black-and-white numbers !!?? Is it 3mm or 6-7 mm ??

They have a chart in a commercial A340 that is not for official use !!??


Appendix H TU 04.01.64.14 313

"Pour Information Seulement (non certifie)"

Can someone show me how to calculate the exact minimum landing distance.

I would have thought that it would be black and white and quick to calculate landing distance.

Poor pilots who have to use these non-100% clear tables and weather reports.
.

[Mad (Flt) Scientist]

It isn't black and white about the water depth because no-one goes out and measures the exact depth of standing water along the entire length of a runway. It's a judgement call.

The contaminated distances are not "official" or approved because there is no certification requirement to provide them. If there was, we'd be adding the 67% padding to the distances and effectively banning operations on contaminated surfaces. Again, there's an element of airmanship expected.

And there's no way to calculate the "exact" minimum landing distance because there's no way to fly the "exact" landing required to obtain it. All performance data presented to pilots has an element of "fudge" in it. Anyone calculating a required distance one foot under what they have and feeling good about the result is fooling themselves.

[RatherBeFlying]

In hindsight, the risk presented by the rapidly deteriorating weather conditions was greater than most pilots would deem acceptable. However, when the AFR358 pilots assessed the available weather information and the traffic flow into the airport, they did not expect that such a severe deterioration in the weather was imminent...

the crew made multiple requests to ATC during the initial approach phase for information with respect to the developing weather conditions...

Until the decision height of 200 feet, the aircraft was stabilized, although an airspeed increase and a deviation above the glideslope were beginning to occur around this height. From then on, the deviations were below the threshold at which the PNF was required to make a call regarding the deviations.

The point at which the situation changed from normal and manageable to abnormal and critical was near the runway threshold when the aircraft entered the perimeter of the cell activity. At this time, a number of circumstances combined, leading directly to the accident...

As they crossed the runway threshold, with the heavy rain, low visibility, lightning, and shifting winds, the flight crew members became overwhelmed by the severe weather conditions and became task saturated, making a normal landing difficult. The pilots, who were by this time both focusing primarily outside the aircraft, were not aware that a wind shift was also occurring. While they were in the flare and the initial float, the pilots did not appreciate how much of the runway was being used up. The tailwind component contributed to the aircraft going above the glideslope and to the overall landing distance required.

The heavy rain obscured vision through the windshield and severely reduced the forward visibility. Both pilots were relying heavily on the side windows to try to determine the position of the aircraft, laterally and vertically. This caused the additional problem in that both of them were now fully concentrating on trying to determine the position of the aircraft. This might partially account for the slow reaction time of the PF to reduce power to idle. In such circumstances, it can be difficult to keep a trajectory toward, or even distinguish, the normal aiming point on the runway...

Air France Airbus A340 crews have the option of conducting a go-around during an approach when it becomes evident that it is unsafe to land. In theory, the decision to go around can be made as late as when the aircraft is on the ground, as long as reversers are not yet selected. Under normal conditions, this is not a problem.

When the aircraft was near the threshold, there were ominous thunderstorms with lightning strikes on the missed approach path. At this point, the crew members became committed to landing and believed that their option to go around no longer existed...

It was not until very short final that there were clear indications available to the crew that the flight had progressed to a point where landing was not advisable - the aircraft had departed the glideslope and entered an area of intense precipitation and reduced visibility. The crew had two courses of action with potentially undesirable outcomes: proceed with an approach that was becoming increasingly difficult, or conduct a missed approach into potentially dangerous conditions. At that moment, although Air France procedures called for a go-around anytime the ideal trajectory is not maintained up to thrust reverser deployment, the captain, doubting that a go-around could be conducted safely, committed to continue with the landing.Survival odds going off the end at 80 some kt. are much better than in a failed go-around.Aircraft landed on Runway 24L approximately 9, 6, 4, and 2 minutes before the landing of AFR358 and there was at least one additional aircraft on approach behind the occurrence flight. It is noteworthy that all these crews had also elected to conduct their approaches in conditions similar to those encountered by AFR358.Now how should we characterise the five other crews that accepted the same approach who obviously had better luck? Are they all professionals doing their best with the available information or did they fall equally short? How many other crews would have accepted the approach in those conditions?

[alph2z]

Based on TSB data, I calculate the main landing gear (and plane) left the "flat" grass at 60 mph, WOW. :eek:

Can you imagine driving off into the abyss of a deep ditch at that speed.....and surviving. :eek:

Now, that's good fuselage designing ..... :D :ok:

To come to a full stop they would have needed an extra 1460 feet of concrete beyond the threshold lights.

So even if the 300 m (984 ft) long RESA (ICAO) or RSA (FAA) had been there it would have been (477 ft) too short and they would still have 47 knots to dissipate beyond the RESA.
.

[alph2z]

WTF !!!??????? Is AF still living in the era of the Wright brothers. :ugh:

I always assumed it was a legal requirement to calculate proper landing distance for the specific runway used, wet/dry conditions, etc.... before each landing; assuming auto and manual braking, and no reverse.

Some management heads should roll.

Can anyone explain to me how this can happen after 100 years of flying !!??
I think I'll do the calculation myself and supply it to the pilots on my next flight as a passenger. :sad:

They're flying A340's as if they were flying C152's !!??

4.2.3 Landing Distance Considerations
The crew was not aware of the landing distance required to land safely on a contaminated
runway. This was due in part to some ambiguities in the landing distance information provided
to the crew and an absence of direction by Air France regarding the need for crews to determine
landing distances required.
When the aircraft was on departure from Paris, the Air France Octave system provided the crew
with a maximum permissible landing weight value for the aircraft’s arrival at Toronto. This
weight was 190 000 kg, which was the maximum allowable weight based on structural
considerations. It appears that this was the only landing performance calculation carried out
during the operation of AFR358.
In the latter portions of the approach, the crew actions indicate a concern regarding landing
distance when faced with landing on Runway 24L. From the investigation, it is clear that the
pilots were aware of the landing distance available for Runway 24L. There is no indication that
they had calculated the landing distances required for the arrival, nor are there any direct and
specific Air France procedures that would require such calculations by the crew.
A review of the landing performance charts available to the crew revealed some potential
problems. For example, the application of some of the corrections such as the use of thrust
reversers and other variables were not necessarily intuitive and were sometimes applied
incorrectly.
This accident clearly shows the need for pilots to know the landing distance required by their
aircraft for the conditions to be encountered at the expected time of landing, and to compare
this figure to the length of the runway assigned for the landing. It is essential that both figures
be known to enable crews to calculate the margin of error available so that they are better
prepared to make the correct decision when they encounter deteriorating conditions. In this
occurrence, the crew members realized at some time during the landing sequence that the
landing was going to be long. Had they known that the margin for error was slim, or indeed
non-existent, the crew would likely have executed a go-around.
.

[PJ2]

Take a look at how close they came to a far more serious accident.

The GTAA needs to fill in the two ravines at the threshold of 05 and the 06's. The approach lighting towers may be "frangible" but what they're mounted on certainly is not. A dozen knots more groundspeed off the end of 24L and the outcome would have been substantially different.


http://img135.imageshack.us/img135/2038/2cagy28jnyr7.th.jpg (http://img135.imageshack.us/my.php?image=2cagy28jnyr7.jpg)


http://img135.imageshack.us/img135/2245/af35820vd3.th.jpg (http://img135.imageshack.us/my.php?image=af35820vd3.jpg)

[PBL]

The GTAA needs to fill in the two ravines at the threshold of 05 and the 06's.

It opens your eyes to take a look at recent runway overrun accidents and see how many deaths and how much damage could be avoided if runways at major airports had standard overrun areas.

So why don't they, even in relatively wealthy areas?

I think the answer is a combination of history, economics and blind hope.

History. Major airports have typically been in their present locations for decades, even as TO/landing distances for commercial aircraft have risen and the city has expanded out to meet the airport. Relocating an airport is prohibitively expensive. After Denver, no one wants to do it.

Economics. Land around the airport is increasingly expensive to purchase as time goes on; the people who pay for overrun areas are not the same people who benefit from their being there; the overrun area on a specific runway usually only earns its living infrequently (last one into the ravine was almost 30 years ago), so cost per life saved for the local administration is relatively high compared with, say, improving local roads.

Blind hope. They won't do *that* again here, will they? (Indeed, "they" usually don't. While overrun accidents occur regularly, overrun accidents at a specific airport and runway rarely repeat. And when they do, at least in relatively wealthy countries something is done: KLGA and KJFK).

PBL

[PJ2]

The button of Vancouver's 08R, (departure on 26L), has far worse hazards:
http://img20.imageshack.us/img20/2894/yvr08r1ip8.th.jpg (http://img20.imageshack.us/my.php?image=yvr08r1ip8.jpg)






http://img20.imageshack.us/img20/2531/yvr08r2fl1.th.jpg (http://img20.imageshack.us/my.php?image=yvr08r2fl1.jpg)





http://img20.imageshack.us/img20/6759/yvr08r3cr3.th.jpg (http://img20.imageshack.us/my.php?image=yvr08r3cr3.jpg)




The "overrun" area is the white concrete section (relatively new). There is a road at the end of the runway which leads into a tunnel. The road descends down into the tunnel on either side of the runway. The jpg below shows the relationships. The overrun area directly ahead has the approach lights for 08R but only after one goes through fencing and into the bog (or possible ocean, if the tide higher in winter).

The runway is the longer of the two parallels but the north runway is never used for departure due to noise complaints from residents across the water along Marine Drive.

On any overrun, one either goes very wide and risks the ditch, fence and bog, (unlikely due to inertia), or goes right down the centerline where there is not enough room to avoid the wings (of a 340) striking the approach lighting if one goes wide enough to clear the fuselage. The drop into the roadway which leads into the tunnel is, at it's deepest, more than the distance from the bottom of a 340 fuselage to the cockpit level.

Overrun areas of the other runways are less of a concern although an substantial overrun on departing 08R would cross a roadway which carries a lot of traffic.

[MarkD]

Re: covering the ravine - I seem to recall a Jeremy Clarkson article which suggested replacing safety belts and airbags in cars with a big spike in the centre of the steering wheel, thus acting as a deterrent to bad driving.

More seriously, I feel it would be better to use EMAS rather than adding more concrete to a fairly depressing area, containing as it does several major highways plus Pearson. Maybe the Government of Canada could release some of the security charges and airport rents they are grabbing from Pearson and invest in safety rather than demand it be self-financed.

[alf5071h]

RBF re #38 “Survival odds going off the end at 80 some kt. are much better than in a failed go-around.”
Your statement is very much open to debate; there is no evidence that a go around would have failed. Furthermore, if taken at face value and used in other situations the statement could be hazardous. Compare the result of the YYZ overrun with the accident at Congonhas and then argue against a GA.

There are many ways of representing the YYZ situation; I choose TEM / decision-making.
A critical point was the decision to make the approach. The threats at this time were either ill-defined (information not available) or known but not adequately considered (risk assessment). Contributions to the latter activity would involve human behaviour and industry norms. Thus in hindsight the decision to make the approach in the prevailing conditions was an error, a weakness in judgement, also made by several crews preceding the accident.

The report observed that it is industry standard to make such approaches, i.e. we bear the risk as a normal operation whereas perhaps we should not – industry complacency. Perhaps this is because we don’t understand (or wish to acknowledge) how close to the edge of the safety boundary we operate (yet statistically still remain a very safe industry). For example the 1.96 wet runway landing distance factor may have to be 2.2-2.4 to maintain a level of safety consistent with a dry operation (TC report on landing on wet runway).
The conclusion from a wide range of successful wet operations is that crews adapt and correct for the lower level of safety. However, occasionally crews either do not adapt or get caught out, and it is the solution to preventing these situations which the industry must concentrate on.

During the approach up to the point of touchdown, there was opportunity to correct the ‘error’ by flying a go around. The reason for this option being rejected and continue with the landing reside deep in human behavior, but probably these are similar behaviors to those in the original decision to make the approach, ‘press-on-itis’.

All of the crews landing in the stormy conditions were doing their best, but were let down by the limitations in the availability and accuracy of information describing the situation, the limits of human behavior, and the safety norms and values of modern operations.

The comprehensive report provides a well balanced view of the accident and the human involvement. However, the recommendation for training to help pilots to make better landing decisions in deteriorating weather still begs the question what exactly do we train?

Refs:
Safety aspects of aircraft performance on wet and contaminated runways. (www.nlr-atsi.com/publications.php)
Safety aspects of tailwind operations. (www.nlr-atsi.com/publications.php)
Aircraft Braking Performance on Wet Concrete Runway Surfaces. (www.tc.gc.ca/tdc/summary/14200/14273e.htm)
Wet Runway Friction: Literature and Information Review. (www.tc.gc.ca/tdc/summary/14000/14002e.htm)
Managing threats and errors during approach and landing. (www.flightsafety.org/ppt/managing_threat.ppt)

[keepin it in trim]

Just 2 thoughts on this, big hand to the cabin crew, who did a superb job and stopped this from being a disaster; pleased to see AF changed there sops to either crew member being able to call a go around after this event, however slightly concerned about what the previous position says about the cross cockpit authority gradient that could easily exist in such circumstances.

Overall, yes a hull loss, but thank goodness due to a combination of fortune and excellent cabin crew, no lives lost

[alf5071h]

Alph2z, Re #40, the problem with assumptions is that they are often wrong.

JAR-OPS 1.550 requires that the landing mass is sufficient for a landing within 60% of LDA (and for a wet runway the distance is 115% of the dry distance). Thus, provided the crew compares landing weight with the max allowable landing weight (wet) for a given runway, an operator meets the regulatory requirement; distance is a by-product of the calculation. (FAR 121.195 is similar ‘… weight of the airplane on arrival…’).
There is a further requirement in JAR for an in-flight check, which is probably more relevant to the circumstances of this accident, vis runway condition, safe landing, and missed approach.

JAR-OPS 1.400 “Before commencing an approach to land, the commander must satisfy himself that, according to the information available to him, the weather at the aerodrome and the condition of the runway intended to be used should not prevent a safe approach, landing or missed approach, having regard to the performance information contained in the Operations Manual.”

The problem which I think that you allude to is that most crews do not understand or cannot determine the margin of safety that is available during the landing which enable the safety requirement of JAR to be met (safety as such is not defined). However, considering safety as the need to minimize risk requires the Commander to have all pertinent information to evaluate the risks in the planned approach and landing, and thus confirm the safety of the operation.
The accident report refers to this as a margin for error; I prefer ‘margin of safety’, a margin in which risk is as far as possible quantified and controlled.
UK AIC 14/2006 refers to this margin as ‘field length factor’ which accounts for the normal operational variability that can be expected in day to day service such that the chances of a landing overrun are remote. Thus, any additional factor or error could reduce the margin of safety below that which we are familiar with in normal operations. The AIC concludes “It cannot be assumed that the scheduled landing distances can accommodate a landing in which all relevant parameters are at the limit of their tolerance in the adverse sense”; which again excludes additional error or adverse factors beyond the crews’ control (i.e. threats to a safe operation).

One of the fundamental problems which crews face is that they do not always have information enabling them to determine the runway condition, wind speed/direction, the precise weather (visibility/rainfall), etc, all of which affect the margin of safety.
Thus in this accident it was possible that from a crew perspective all of the parameters under their control were within normal operational variability (I am not saying that they were or were not, nor I as I interpret, did the report). However, the significant issues involved the late and rapid weather changes which invalidated the crew’s perception and plans, which reduced the margin of safety for operational tolerances to zero (220ft).
It might be debatable that a crew should have identified the potential for a wet contaminated runway at an earlier stage and reconsidered the landing distance (i.e. mass – too heavy for a short wet contaminated runway).

It may be appropriate for operators to require crews to adjust the planned margin of safety before landing in adverse conditions, e.g. tighten the stabilized approach criteria thus forcing an earlier go around, or reduce the landing weight. Unfortunately as illustrated in this accident, these changes still might not accommodate ‘normal’ human behavior (error prone) where the failure to perceive changing weather, runway state, visibility, or a long landing, may remove all of the margin of safety. In these rare events, the industry requires addition safety margins, preferably a good overrun area or increased landing distance requirements.

‘Landing Performance of Large Transport Aeroplanes’ UK AIC (www.ais.org.uk), free but registration required; then select PUBS / AIC / Pink.
Also, see AIC 86/2007 ‘Risks and factors associated with operations on runways affected by snow, slush or water’.

Safety aspects of tailwind operations. (www.nlr-atsi.com/publications.php)

[RatherBeFlying]

there is no evidence that a go around would have failedalf5071h

I beg to disagree. I experienced what I suspect was the same thunderstorm that AFR358 decided not to enter on a go-around. It brought highway traffic to a standstill; another cell that same hour washed out a major road bridge. I would not like to imagine flying any airplane in those conditions. I had also been following the weather radar updates; it's the only time I've seen a purple return.

Unfortunately TSB Canada has not yet seen fit to release the weather images that it obtained.

[alph2z]

....... To come to a full stop they would have needed an extra 1460 feet of concrete beyond the threshold lights........

I had used the simple constant deceleration equations along with the animation video.

I just found some other data hidden away in the TSB report after reading almost all of it. Doing some simple subtraction of their 3 numbers and I get 1474 ft .

Extra runway required beyond threshold
= touch down pt + rolling distance required - runway length

1474 ft = 3800 + 6674 - 9000

In other words I was off by only 14 ft (or 1%) !!!!!

Not bad, not bad. :}
.

[SPA83]

http://dangerpourlespassagers.*************/

[skiesfull]

As has been pointed out, the information regarding moderate to severe weather, is rarely transmitted to crews as accurately as it could be to make critical decisions. What the driving conditions are in the vicinity are never made known until after touchdown and I would dispute their total relevance. However, an improved method of communicating such vital information is required and essential.
This was a very experienced and competent crew at the outset of the approach. What part fatigue ( Captain's history of reduced flying due to fatigue and co-pilot's tiredness from a late-night simulator session, with minimum rest period) played in the ensuing mind-set to continue the approach with the intention of landing as opposed to going around and diverting with (uncormfortably) low fuel state, can be argued ad infinitum.
The difficulty in how to ensure a non-reoccurence by training, is how do we 'train-out' mind-set conditions? How many of us professional pilots would have fared any better, in making a difficult approach at the end of a long duty period as two-crew operation?
As for calculating landing distance in such conditions, the problem is that it only gives you a distance based on assumed conditions, including wear and tear of brakes and runway surfaces. This distance is than weighed up against the individual's previous experience of landing in similar conditions and the decision to continue or not is arrived at. Do not forget that in using such information, precise skills are required, such as speed control, touchdown point, application of brakes and selection of reverse.
I do not know the recommendations Air France have used to alter their SOP's, but will make the observation( which applies to Southwest's Midway accident and Qantas's accident in Bangkok) that if the PF is delegated as the reverse selector, then the PM must be prepared to call non-selection after touchdown immediately. Some airlines delegate the selection of reverse to the PM, on PF's command - it would not have prevented the overrun in this situation, primarily because of the water contamination and the deep landing.

[clevlandHD]

What would be the rate of climb of an A340 at that mass? On TO they don't climb very well (like other quads but the 345). Could they have outperformed a 6000 ft/min downburst?

[glad rag]

Well firstly I will state my non flying pedigree, is that OK?

Looking at the report from a non expert point of view I think the whole accident can be surmised in the saying

"sometimes you get handed the ****ty end of the stick"

The crew were left to make snap and instinctive decisions that on face value led to an overrun. However once presented with the full facts as known (and importantly some unknown to the crew) they "almost" got away with it.
Perhaps it would be better to focus on how the information reqd can be better disseminated to crews approaching this airport in the future?

rgds

Glad Rag.

[alf5071h]

RBF, re #48, we hold differing views of the subject, which is often the case in aviation with both positive and negative aspects (e.g. good CRM cross monitoring vs poor situation awareness).
My views relate to a generic situation and not that of the accident; in addition, I could be biased by certification experienced where aircraft are designed, built, and tested to withstand the theoretical worst case cb, and also my experience of flying in cbs (briefly) during tests.
If future data associates the YYZ cb with a microburst (mauve on the radar?), and that the crew were aware of this, then I can reconsider my views.

My concerns relate to how pilots might use information acquired during training and thereafter with experience. An out of context or casual remark (web comment) may form a bias, resulting in misunderstanding a situation or choosing an incorrect course of action, particularly in a stressful situation.

I would not disagree with a view that all of the hazards of flight in cbs can be known, but at least some of the ‘cb accidents’ resulted from inappropriate crew actions and not due to the strength of an aircraft. Similarly, we cannot be sure of the results of an overrun, events usually precipitated by crew action.
Pilots do not choose to fly in cbs nor experience an overrun. However, the choice between the two when there are apparently no other options, might be represented a pilot’s perception of the level of risk s/he allocates to each. This judgment is influenced by knowledge, experience, situation assessment, and thinking behavior; the latter can be affected by bias and false knowledge.
The point of my previous post was to illustrate that it is unusual for any situation to be clear cut and a ‘this or that’ statement, relating to a specific accident provides opportunity for the unwary to form a (subconscious) bias, which may not apply to all situations; i.e. whilst accidents do repeat themselves, it is rarely a specific one, thus the choices of action should be judged on the situation at the time and not on any preconceptions.

How Good Pilots Make Bad Decisions. (http://home.ec.rr.com/delexsystems/How%20Good%20Pilots%20Make%20Bad%20Decisions.pdf)
Errors in Aviation Decision Making. (www.dcs.gla.ac.uk/~johnson/papers/seattle_hessd/judithlynne-p.pdf)
Explanations for Seemingly Irrational Choices. (www.insightassessment.com/pdf_files/IJAP_Analysis_Paper.pdf)

[PJ2]

Fine series of posts, alf507ih, thank you.

[alph2z]

alf5071h Re.: #47 long post.

In this post I'm not going to discuss the pathetically low visibility over the runway, whatever they were, and therefore a call to over-shoot.

The pilots have to be given, as much as possible, very accurate data to make proper decisions.

Obviously, perfect data is not always possible.

In this case, extremely surprisingly, the management abandoned the pilots with missing, confusing, or wrong data.

I thought this had been already resolved with all the previous over-runs.

The way I would do this is as such (there could be better solutions):

The pilots determine their safety margin for the actual runway finally used (in this case a pitiful 220 ft; see report and below).

When passing the theoretical touch-down point (i.e. ILS GS going offscale), if the pilot hasn't touched down within 1 sec (220 ft) then over-shoot anytime prior to reverse thrust initiation.

Keep in mind that the pilots seem to have had "I can do this landing"-itis.

From the Air France MANEX performance information, the predicted landing distance needed
for the landing in Toronto on a contaminated runway with zero wind and no thrust reverser
was 8780 feet. For Runway 24L, the extra margin was only 220 feet. This very small landing
distance margin was eaten up by the long flare during the landing. With a tailwind, there was
negative margin, which would mean an overrun. The pilots were not aware that the MANEX–
predicted landing distance when landing with a tailwind exceeded the length of Runway 24L.
In the absence of knowledge of the required landing distance under varying performance
conditions, crews will not be aware of rapidly developing overrun situations. Because of this,
there is a high potential that crews will make inadequate go/no-go decisions, thereby
increasing the risk of damage to persons, property, and the environment.
Therefore, the Board recommends that:
The Department of Transport and other civil aviation authorities require
crews to establish the margin of error between landing distance available
and landing distance required before conducting an approach into
deteriorating weather.
.

[alf5071h]

Alph2Z, I agree with many of your points, but I suggest that careful consideration is required when searching for solutions so as not to fix the problems of one specific accident and in doing so leave open opportunities for future ones.

Visibility was a specific issue at YYZ, but the generic points (the YYZ crew did not know that the visibility had changed) are the limitations in the ground based detecting and reporting systems.
It could be argued that crews could interpret weather radar indications such that ‘red’ zones indicate reduced visibility – but reduced by how much, limiting or not limiting? The natural weaknesses of human performance do not guarantee the crew using radar in this way nor making such inference.
In routine operations wx radar detects rainfall rate which is used to infer convective weather (normal inference from training), but with these indications during the approach it is probably more important to consider the effects of heavy rain on the runway state – contaminated or not, rather than convection (although I recognise the concerns over the threat of windshear etc in the event of a GA). The state of the runway - braking effectiveness is another key item where crews have limited information; like visibility it could be inferred from radar (see refs @ #45). Then there is wind! See ref @#47.

Re the calculation of landing distance (YYZ), I think that you have overlooked the point that the crew may not have appreciated that the runway was contaminated (investigation hindsight), so from the crew’s perspective, their planned landing distance did have the required margin of safety.
Although the recommendation for a pre landing check of conditions is a positive step, the ‘how to’ remains open. Check the many references to working groups and meetings on aircraft performance on contaminated runways, the nearest workable solution so far is CRFI, but IIRC it does not correlate well with water contamination; then how often is the runway to be checked – at YYZ the required frequency might have been between each landing.

The points above build a case for crews to use radar in a wide ranging sense, making inferences and decisions at critical periods during the approach often associated with high workload. This can be done, but it would be more easily achieved with the aid of ‘trigger items’ cueing crews to think in this manner, still subject to all of the human limitations in such situations. This is not to excuse crews, but they do need help; knowledge, training, and technology.

I agree that the operational management have a role to play in there areas, so too the regulator, but there are also wider issues. There are ever increasing commercial pressures, public perception of safety (when you are already good any accident is seen as a negative trend), and complacency, particularly from the successes in normal operations where we may not question just how close we are to the ‘edge of safety’. I urge everyone (pilots, management, regulators) to read the ref @ #54 particularly re irrational decisions.

We should avoid criticism and implied blame when pointing out how others should be doing ‘something’; instead use meaningful critique of the facts from the mounting evidence of many overrun incidents and accidents to identify items for action. As asked previously re training, what do we train? Or more to the point what can we, the collective operational team or individually, do to improve safety.

I disagree with your point on the use of ILS GS re touch down point. If you recall the GS consists of a reflected beam along the approach path, thus at very low altitude when approaching the transmitter, the beam has a parabolic path. If you are able to view it at such time the GS starts increasing, but hopefully at that time the receiver would flag red.
The touchdown zone is marked on the runway, this and distance markers along the runway require good visibility and spare mental effort to appreciate them. In the YYZ accident both of these parameters were out of limit.

Many of my points refer to the human aspects, which would seek alleviation for an "I can do this landing-itis” attitude (irrational decision). However there are many aspects of management, including SOPs, training, and increased margins for scheduled landing distance, all of which could reduce the risks of an overrun, primarily by reducing the opportunities for error.
There is also much more that can be done in mitigating activities to counter the inevitable ‘hole in the cheese’, by improving overrun areas and increasing landing distance requirements.

To avoid arguing to agree violently, I concede that we are seeking the same objective, but perhaps taking slightly different views.

[alf5071h]

The TC report calls for more training, one of many possible initiatives to minimize risk or exposure to potentially hazardous situations. In a previous post, I asked “What do we train?”
To avoid responses being too focused on this specific accident - we require generic solutions which should help prevent any future events, - I have started a new thread in CRM and Safety. Avoiding an overrun: what should be trained?

http://www.pprune.org/forums/showthread.php?t=306748

[Yankee Whisky]

See pages 19 thru 25 for extensive weather info.

[xxgunnerxx]

While I'm just a SLF, I was reading through the report and found out that the FO disengaged the autopilot at around 100 feet AGL. I'm wondering if that could have been a cause in the crash, since the weather was pretty bad in the last few seconds and therefore wouldn't you want to have a good "feel" of the situation before putting the plane down. It's kind of hard to explain, but an analogy would be taking a soccer player who didn't play for a while and then simply telling him to go play, without any warm ups.

[sleeper]

Quote "you want to have a good "feel" of the situation before putting the plane down"unquote


In my (professional) view, you're supposition is totaly correct.
Either handfly the approach from at least 2000 feet down, or autoland. To take over manual at 100 feet in gusty weatherconditions is very difficult (unless you make a go-around) for the exact reason that you do not have a feel yet for the inputs required. The few seconds before landing (about 10) will not give you that feel.

[IcePack]

Trouble with Auto Lands is they tend to float and land deep anyway. See increased LDR for Auto Lands. I suspect the system would be struggling with the gusts anyway:hmm:

[sleeper]

quote "Trouble with Auto Lands is they tend to float and land deep anyway" unquote

That depends on the type of aircraft. My remark, autoland or fly manual, was made in general terms. In this case it would have been more prudent to land manually, although not from 100 feet.

[Baade152]

They are suing the company that manufactured the devices (the escape slides) that saved their lives? I don't get it - a few friction burns, maybe a torn panty hose or even a sprained or broken ankle is far better then no slide at all - then what - people refusing to jump and a blocked exit with pax being trampled to death! I also think the Cabin Crew deserve high praise for a superior job in evacuating this aircraft and getting everyone out alive - I think the press should have given them the accolades they justly deserve - well done!

[MarkD]

Baade152 - in these situations I am informed you sue everyone in sight up front and then drop them as the case proceeds and proof of involvement and liability is demanded.

[Baade152]

I'll guess I'll just wait for the final and official version of the entire events to be publicised - AKA: The Midday Movie. Mind you programs like Air Crash Investigations and Seconds To Disaster go a long way in presenting a balanced approach - does anyone know what happened to the FD crew - are they still flying?