Planned CFIT?

[planoramix]

Are there other ways to define a published procedure that guides an aircraft into the terrain?

It is not a joke and it should never have happened but somehow this procedure was approved, made the print and is now a potential accident.

Seychelles Intl – Aerad Breakcloud VOR X 13 – N1 - 19 Jun 08.

Have a look at the plate and feel the thrill
(I have tryed to attach plates AJ1, N1 and N2 without success. I will try again but If someone with more expertize can help .. thanks)

Since its introduction in the binders nobody has, obviously, managed to complete the procedure.
The closure of the high ground has, so far, made everyone tracking inbound R324 break left at around 1800 ft and continue visually.
Because the weather allowed it.
Now with a nice layer at 1300ft only Mr. GPWS will hopefully be there to save the day.

All the pilots involved talked about the bad feeling but no one dared confront the word of truth of the Authority (SCAA).
Pilots relay on charts because with them safety is assured.

Murphy’s law at work.

Finally somebody went all the way as far as possible:
B763 in landing configuration, on speed and check list completed. A/P on leaves 2500ft at SEY11d in V/S rate 700 ft/min down to 1120 ft. Backed by GPS the fellow is accurately tracking on R324 inbound.
At SEY8.5 passing 1600ft “Terrain Pull Up Terrain” GPWS warning and another one bites the dust!!!!!
I wish to know the kind of emotional surprise they proved but it must not have been nice by the tone and wording they used in their ASR.

What next?
Who is going to check who?
Which Authority will take action?
Have the airlines operating on SEZ been informed of the situation?

[alf5071h]

There are many other examples of charts which can be misinterpreted; see the incidents here. (www.icao.int/fsix/_Library%5CTAWS%20Saves%20plus%20add.pdf )
What to do? Submit a safety report to your national authority.

[planoramix]

http://www.allfreeportal.com/imghost/images/57234SEZ BC VOR X 13.JPGalf5071h is perfectly right!

Charts can be misinterpreted.

That is on the assumption for them to be flawless on the first place.
They must be, otherwise who could we trust?

But now, what if without misinterpretation a chart leads to GPWS warning or worst?

Here are the charts, check the minima and have a dry run while sitting at your desk and let me now were the profile puts You.


:uhoh:

[planoramix]

here are the minima

http://www.allfreeportal.com/imghost/images/243644SEZ Minima.JPG

[SNS3Guppy]

That procedure is quite different on the Jepp chart 13-1. The inbound turn is a right turn away from terrain, instead of into it, and the procedure as depicted on the Jepp chart places the inbound aircraft farther from terrain. It may be a different procedure entirely, but it's the only one in the Jepp volume that I see has the same name; VOR/DME 13, Cloud Break procedure.

[Xeque]

planoramix

Put the charts, in .jpg format, onto Image hosting, free photo sharing & video sharing at Photobucket (http://www.photobucket.com) (or similar) and then publish the location as a link in Pprune.

[threemiles]

That procedure is quite different on the Jepp chart 13-1.
Check the date?

must be missing something because 1600ft at 8.5d SEY is below the minimum altitude shown on the chart for the leg between 10d and 6.5d (1760ft)! Is it not obvious that this procedure can't be flown as a 3 degree slope from 11d to 4.5d?
It is misleading. Either it is 1760 at 10d and 1120 at 6.5d or it is 1760 at 6.5d and 1120 at 4.5d. Both doesn't fit for profile and text.

[The Real Slim Shady]

I always thought that was called a landing!

[BOAC]

It is misleading. Either it is 1760 at 10d and 1120 at 6.5d or it is 1760 at 6.5d and 1120 at 4.5d. Both doesn't fit for profile and text. - cannot read that any other way than NB1760 UNTIL 6.5D in which case the B763 'stuffed up' IMO and were lucky not to collect the terrain! It is certainly more than a 3 deg from 6.5D and a bit more from 4.5D (3.1nm to threshold/1110' ATE), but it looks 'do-able'?

[Starbear]

Certainly not the best chart ever produced and I would agree with BOAC's interpretation and it looks like the B767should not have been "passing 1600' at 8.5D.

And I would respectfully point out that as this is a circling approach, it is not meant to be "doable" from either 6.5D or 4.5D i.e. a landing. Surely on reaching MDA by 4.5D AND visual, one should proceed to circle over the airfield to land. If not visual by 4.5D then of course follow MAP.

Having said that it is a circling procedure, nothing precludes the pilot from making a straight in approach to land if he is visual early on in the procedure, in fact it is expected by ATC (in general) that he would do so.

What I think is quite wrong is the dotted line from 4.5D to the threshold almost inviting a final approach to land from that position which would be very steep (though from 6.5D it looks manageable even if not required)

[BOAC]

1110 feet in 3.1nm - not TOO difficult! I reckon the line-up is more of a challenge?

Edit: I agree with your 'circling inclination', but is does say 'VOR X R13' and not just 'cloudbreak'.

[Starbear]

You may have missed them but Planormix posted the minima tables at post #4 which makes it clear it is circling only.

Incidentally I made it 1100' from only about 2.6 nm hence my too steep comment, perhaps with the offset you figure may be closer.

[Vref+10.....to 44]

All very unclear.

What does one do between 11d and 10d?........?

Why is the FAF at 10d...with not altitude check, or reference?

The way the minimum altitudes (if thats what they are) that are in the shaded areas are displayed, bear no resemblance to other aerads ....including the Legend in the aerad explanations/legend booklet.

A dangerous , misleading plate, that should of not made it off the press.

[bArt2]

You may have missed them but Planormix posted the minima tables at post #4 which makes it clear it is circling only.


The name of the approach already makes it clear that it is a circling approach.

VOR X 13, the suffix X means it is a circling approach (it can be any suffix: A, B, C,....)


From 2500at 10.0 DME to 1760 at 6.5 DME is a 2,1 degree slope and from 1760 at 6.5 DME to CIRCLING MDA 1120 at 4.5 DME is a 3.2 degree slope, that is no problem.

Remains the GPWS


Bart

[bArt2]

http://www.ebzw.be/FSIA.jpg

[BOAC]

You may have missed them - yes, my apologies. I would prefer the chart were renamed 'Cloudbreak R13'. Not familiar with Aerad/Seychelles. I still think it qualifies for a 'straight-in' from circling minima, and the extra track miles will probably give a 3 deg slope, although you would have your work cut out from the MAP. VOR 'C' R13 is clearly a circling app while VOR 'Z' is again drawn for a 'dog-leg straight-in'. It is strange that 'VOR Z' approach for R31 is also a 'straight-in while the 'A' is clearly circling. I would anyway expect this a/port to be CatC and all this covered by company brief. Check this against Jepp 13-2 for R23 at LPMA which is titled 'Circling VOR DME Rwy 23' and is similar in plan. It is of note that the Jepp for FSIA R13 does NOT show the word 'circling'??

Vref - I agree with your "unclear", but suggest that if you descend from 11D to 1760' by 6.5D at an appropriate rate that would be fine. I'm sure someone has talked about the shaded areas before on Aerad. I've looked at the Jepp which is a lot better, and indeed shows the profile I suggest. It also shows spot heights and the highest on the approach is 1503' at around 8D, hence the comments on the B763:eek:. Again, a thorough look at the chart/briefing should have sorted that out.

Some time ago in another discussion it was suggested that vertical terrain profile plus perhaps a 'critical' radalt check would be a good inclusion on charts.

Thank heavens I don't have to go there:)

[bookworm]

The depiction of the step-down fixes on the Aerad charts is very misleading. The minimum level at the SDF should be printed beside the SDF, but it is not. The Jepp chart offers a much clearer depiction.

What next?
Who is going to check who?
Which Authority will take action?
Have the airlines operating on SEZ been informed of the situation?

Had you considered simply picking up the phone to EAG (http://www.euronautical.com/osc/main.asp?display=node&id=26)? The editors' names and telephone numbers are in that link.

[point8six]

Landed many times on SEZ rwy 13 -(since 1978). Mostly either visual, arriving from the west, or from the south via a published circling approach, breaking off from the Rwy 31 ILS at 1120ft. into a left-hand circuit with published VOR radials and DMEs. The difficulty in lining up occurs with a strong SE wind due to rotors from the cliff to the south of the runway and strong downdrafts.
My interpretation of the chart above is that you should maintain 2500ft until 10DME (FAF) and then descend to be 1760ft by 6.5DME,then descend to 1120ft by 4.5DME at which point if not visual, perform the published missed approach. None of the above descents require excessive rates- of- descent, and of course if visual before MAP then adjust the approach accordingly.
I'm not sure why the 763 left 2500ft at 11d, nor why it continued descending to 1120ft and ignored the 6.5d altitude check, unless the crew were visual early in the approach. The trick is to be in the landing configuration before starting descent at 10d - it reduces the approach speed and consequently the RoD.
A "fun" approach in a large aircraft along with JFK -Carnasie 13 and the old Hong Kong (Kai Tak) IGS 13:ok:

[Denti]

The EAG charts look kinda different once again.

http://i323.photobucket.com/albums/nn476/Soordhin/FSIA_VOR_13_CloudBreak_VOR176.jpg

http://i323.photobucket.com/albums/nn476/Soordhin/FSIA_visual_13.jpg

Never was there so i cannot possibly comment on the approach or any other peculiarities, was just curious how that approach is depicted on the EAG chart system. There is no other approach to Runway 13 available in our documentation.

[planoramix]

ooooops:=



NOTAM

--------------------------------------------------------------------------

Issued 0806300605

08070300907-081103400 FSIA A00048/08

DUE TO INCREASING REPORTS OF GPWS WARNINGS OCCURING PRIOR TO THE MAPT, THE FOLLOWING PROCEDURES HAVE BEEN CANCELLED AND WITHDRAWN WITH IMMEDIATE EFFECT:

FSIA VOR X 13

PILOTS ARE ADVISED THAT ON SOME OTHER INSTRUMENT PROCEDURES (INCLUDING CIRCLING FOR RWY 13), GPWS WARNINGS MAY ALSO BE ACTIVATED IN THE VISUAL SEGMENT PAST THE MAPT DUE TO THE TERRAIN AND TOPOGRAPHY. PILOT TO EXERCISE CAUTION


--------------------------------------------------------------------------

[Starbear]

VOR X 13, the suffix X means it is a circling approach (it can be any suffix: A, B, C,....)I have to confess, I never knew that, about the suffixes I mean. I thought I had been around a long time too. rather embarrassing

1120 at 4.5 DME is a 3.2 degree slope, that is no problem.I agree it is not as steep as I first thought as I was using 4.5 D =2.8nm to threshold but I see now it is 3.1 as first stated by BOAC,apologies.

These discussions are without doubt an example of the huge benefits of sites like these.

[BOAC]

Seconded. A useful discussion - and polite too. A rarity these days here.:)

[point8six]

SEZ rwy 13 requires careful planning, not only in how the approach to a visual conclusion will be flown, but the fact that as a destination it requires " island reserve fuel". In other words, if the weather is marginal, the alternate is at least 2 hours away. If the weather is indeed marginal in terms of cloudbase and surface wind, then it is a difficult decision to make, whether or not to 'press on' or divert from a reasonable altitude. If the approach is to be attempted in such conditions, then it needs precise flying and I would suggest the possibilty that GPWS warnings are triggered when 'going visual' and inadvertently increasing the RoD to slot into the rather dim PAPIS. At that time, the aircraft is pointing more at the cliff immediately south of the runway.

[alf5071h]

… the possibility that GPWS warnings are triggered when 'going visual' and inadvertently increasing the RoD
I assume that the onboard equipment is “Enhanced GPWS”. If so, then an alternative is that the ‘look ahead’ function could detect the hill as the turn is made towards it. If this is truly a nuisance warning, then Honeywell, when provided with aircraft type and example alerts (downloadable from the EGPWS box), may be able to adjust the terrain database whilst still maintaining a safe warning boundary.

There have been several EGPWS incidents involving the types of misinterpretation or misjudgement indicated in this thread – except that they occurred in flight with much higher safety risk. The statistics involving unwarranted alerts also suggests that there could be many more incidents involving these problems, except that they may not be reported or investigated.
With EGPWS there is no such thing as a false warning – there is always a reason for it. Always react to a warning by climbing to a safe altitude; then and only then consider the reasons for the alert, don’t assume - check.
So that the industry may learn, as above, submit an incident report, download the EGPWS data, investigate, and publish the results. In my experience Honeywell have always been most receptive to helping in these processes.

I hope that an operator to SEZ will submit a safety report on the poor chart format; it should be changed.
I suggest that any other approach chart showing similar problems be listed in this forum. Please only post the identifier with a link – not a picture; I still used dial-up internet, and then at half speed!

[OzExpat]

I still used dial-up internet, and then at half speed!
Me too alf. The problem is, however, that the specific problems with an approach are usually best seen with a picture. A verbal description just can't do it the same justice without being an overly long post detailing location and nature of obstacles as well as tracks and altitudes.

I have the same problem as you but accept the problems associated with the extra download time, for the sake of seeing the picture. One picture is still worth a thousand words and, as my internet access is probably the most costly in the world (not to mention least reliable!), the picture is also worth a thousand sheckels... or something. :ouch:

[reynoldsno1]

B763 in landing configuration, on speed and check list completed. A/P on leaves 2500ft at SEY11d in V/S rate 700 ft/min down to 1120 ft. Backed by GPS the fellow is accurately tracking on R324 inbound.
At SEY8.5 passing 1600ft “Terrain Pull Up Terrain” GPWS warning and another one bites the dust!!!!!

Stuff up - the chart quite clearly shows the OCA is 1760 ft to D6.5. This procedure is definitely not a straight-in approach, nor is it circling really. A "cloudbreak" or "point-in-space" procedure is normally prescribed to enable IFR aircraft to establish visual reference for VFR flight to the aerodrome. They most definitely are not stabilised approaches, and trying to fly or code them using the FMS/FD is going to create more problems than solutions.

[alf5071h]

OzExpat, the charts could be linked, which enables download in quite periods or when reading other threads in Pprune.

I don’t have the plates for the following, but I would be interested if there have been any changes.

1. Ajaccio; see the link and incident report - ‘Ajaccio near CFIT’ (http://uk.geocities.com/[email protected]/alf5071h.htm) and the graphic below.

2. Gibraltar, where the radar to visual procedure has no published missed approach in the event of loss of visual contact after the turn, and a procedure that enables ATC to reduce the intensity of the strobe lights when visual contact is called.

[OzExpat]

the charts could be linked, which enables download in quite periods or when reading other threads in Pprune.
Sounds fair to me.


Ajaccio; see the link and incident report - ‘Ajaccio near CFIT’ and the graphic below.
I tried to download it but the file was corrupted - probably because of the slow linespeed. I can't afford to try that download again but the graphic reveals a most interesting approach for sure!

[planoramix]

Dear Reynoldsno1

I agree with Your statement but then, what of the depicted level flight from SEY 6.5 to SEY 4.4?
Is it not strange for the 1760ft OCH to appear lower than the supposedly 1120ft minima at SEY 4.5?


The Jeppesen chart appears to have all the required "vital" informations relative to the instrument portion, looks like another approach altogether, hence:

Can an unsafe approach plate make it into the destinations binder?

Considering that the approach plate has been withdrawn 11 days after first appearance ....................................


-----------------
more notams limiting use of approach plates in SEZ have been issued, apparently GPWS achitecture was not taken into consideration by the artist.

[BOAC]

While I agree the vertical profile appears to have been drawn by a lunatic, I do not see the plate as 'unsafe'. Anyone who launches in there, seeing a terrain envelope of 2500' on the approach and 4000' just right of centreline and is not aware, prepared and briefed for the terrain on the chart....................? To then dive straight down towards (presumably?) 1120' with no apparent terrain awareness defies belief.

Of course there will be possible EGPWS issues, especially if you turn towards finals from MAP, but again, terrain in sight - expected, prepared and briefed? Not very different to FNC in that respect. I would not expect any GPWS warnings (apart from a possible 'Terrain') during a correctly flown inbound descent.

Again, surely each operator will have a specific brief for such a destination? Was there one for that 763?

[reynoldsno1]

I agree with Your statement but then, what of the depicted level flight from SEY 6.5 to SEY 4.4?
Is it not strange for the 1760ft OCH to appear lower than the supposedly 1120ft minima at SEY 4.5?

It doesn't actually - the shaded portions (very faint) represent the OCA. The profile depiction is diabolical, and doesn't really represent anything - I suspect they didn't really know what to do. The JEPP depiction is better, but follows the dive and drive principle.

A 5% descent gradient (300ft/NM) to 1120ft does not work as you will be 1720 ft at D6.5 - IMHO would have been better to publish a 5.2% gradient (3 deg/320ft/NM)) profile back from 1120ft at D4.5 (and publish the descent angle) - 1760ft @ D6.5 and 2880ft @ D10.0 - with a distance/procedure advisory altitude table to match, or the procedure altitudes at the relevant distances, or both!

Be careful out there....:ooh:

[bookworm]

The profile depiction is diabolical

I think you're being overly generous. The devil plays fairer than that. ;)

Not only are the 1760 and 1120 numbers depicted at the wrong end of the segment, but the profile appears to descend from 11d. No level is given for the FAF. That makes it even more plausible that the 1760 number is the minimum height at the 10d FAF rather than at the 6.5d SDF as is really the case.

[Jumbo Driver]

Apologies for my late arrival to this thread - a fascinating discussion, which I confess I have only just come across.

My recollections are of early (1972-on) trips to Seychelles (SEZ) in the VC10, very soon after the new airport at Mahé was opened. As the VC10 was not equipped with GPWS in those days, a "straight-in" approach to R/W 13 over the hills was often used. This certainly was exciting but of course had to cease with the introduction of GPWS. Does anyone else recall these "fun" arrivals?

Landed many times on SEZ rwy 13 -(since 1978). Mostly either visual, arriving from the west, or from the south via a published circling approach, breaking off from the Rwy 31 ILS at 1120ft. into a left-hand circuit with published VOR radials and DMEs. The difficulty in lining up occurs with a strong SE wind due to rotors from the cliff to the south of the runway and strong downdrafts.

I agree; many of my later landings would involve this break-off from ILS or VOR/DME instrument approach to 31, followed by the published visual LH circuit (night or day) round St Anne's island, with VOR / DME checks.

A "fun" approach in a large aircraft along with JFK -Carnasie 13 and the old Hong Kong (Kai Tak) IGS 13:ok:

Yes, these were indeed all "fun" approaches. Incidentally, I have often thought it strange that all these "curved" approaches were also all, quite co-incidentally, on to a Runway 13 ... ?


JD
:)