Report on incident in DUB 2007

[PPRNkof]

Report out on the above.

Air Accident Investigation UnitFull List of Reports (http://www.aaiu.ie/AAIUviewitem.asp?id=11469&lang=ENG&loc=1652)

I can imagine what the garbled part of the communication at 23.35:12 was! :mad:

[Dougal McGuire]

Well worth reading IMO for low hour guys in particular (like me!):=

[Del Prado]

Shame this has been moved, very interesting report from ATC point of view too.

[PPRNkof]

I thought this was interesting news. Is it because it happened so long ago? Anybody?

[PEI_3721]

Re “Captain was fired after this incident”.
If this is true then the action does little to further the cause of aviation safety.
The incident is an example of a threat (TEM terminology) which was not, or could not be detected. This is typical of the hazards associated with visual misidentification / illusion, and similar to several of the incidents described "here (http://www.icao.int/fsix/_Library%5CTAWS%20Saves%20plus%20add.pdf)".

In these instances, both crew members can simultaneously suffer a failure in situation awareness, which does not enable or contribute to good cross monitoring.
Whilst the VOR could have been monitored more closely - SOPs were not followed, the report fails to identify why such a ‘failure’ (crew procedural violation) occurred. Similarly there is harsh wording about the crew’s failure to “comply” with the approach procedure – the crew did not check that the aircraft was following the procedure, … but why? Something we all might do when ‘visual’?

The report concludes the ‘probable cause’ as a crew decision failure with contributory factors; one of which was poor CRM. The report earlier defines CRM and crew responsibilities, and discusses error, but perhaps fails to support the conclusion of poor CRM, which IMHO together with the probable cause leaves the blame option open.

Was this aircraft fitted with EGPWS?
If so, at what altitude during this approach should an amber alert ‘Caution Terrain’ be given, together with the amber ND/radar display?
Was the EGPWS obstacle mode enabled?
Did the company SOP specify displaying the EGPWS map during the approach?

[mini]

Surprised this hasn't been tagged yet, sounds like an event that could happen more often in many places.

Aircraft misguided by lights on a hotel.

Air Accident Investigation UnitFull List of Reports (http://www.aaiu.ie/AAIUviewitem.asp?id=11469&lang=ENG&loc=1652)

[PEI_3721]

JJ83, so in addition to reiterating the investigation’s conclusions (and similarly failing to provide any explanation / solution), you accuse the crew of being ‘stupid’.

The purpose of investigating such incidents is “…. the prevention of accidents and incidents” (ICAO Annex 13).
The report identifies preventative measures in the recommendations. Changing the Tower lighting addresses the obvious hazard; yet in acknowledging this, it might be construed that the crew’s decision based on what they saw was correct.
However, the apparent failure to following the VOR procedure or the operational SOP appears to be grouped in the recommendation to review CRM training. No evidence was presented relating to poor training; indeed the crew’s training was assessed as being satisfactory and met all regulatory requirements. If the investigation considered that the standard of CRM was insufficient, either a higher regulatory standard might be justified, or an explanation of why the crew did not exhibit their assessed standard on the day of the incident should have been given.

Lest I should be accused of being overcritical of the investigation, the Irish AAIU should be congratulated on addressing the difficult area of human factors, which is often avoided in such investigations.
IMHO a more considered view of the crew’s performance might come from a speculative review of the crew’s behavior including the possibility (probability) that the errors identified in hindsight (misidentification, violating SOPs) were to be expected in the situation and were within the limits of human performance.
Using James Reason’s view of accidents – latent factors and an unsafe act, the latent factor of the lighting was identified together with the act - human nature – believing what is seen; but for the procedural factors, only the unsafe act was mentioned.

[Ber Nooly]

The Irish AAIU have released their report on a serious incident that happened at Dublin in August 2007 involving a Flightline MD-83 from Lisbon. Among the contributing factors was poor CRM of the flightcrew, who did not follow company SOPs.

Serious Incident: McDonnell Douglas MD-83, G-FLTM, Santry Cross near Dublin Airport, 16 August 2007: Report No 2009-010


21 April 2009


SYNOPSIS


The aircraft departed Lisbon with the Co-pilot as Pilot Flying (PF). The flight progressed without incident until commencing its approach to Dublin Airport. The approach was made at night; the weather and visibility were good. Due to scheduled maintenance on the main runway (RWY 10-28), RWY 34 was in use for landing. The flight was cleared by Air Traffic Control (ATC) to carry out a non-precision approach to RWY 34. During the approach, at approximately 5 nautical miles (nm) from touchdown, the aircraft began to deviate left of the approach course. This deviation was due to the Flight Crew mis-identifying the lights of a hotel at Santry Cross as those of the runway approach lighting system on RWY 34. The aircraft continued to descend below the Minimum Descent Altitude (MDA) without proper visual identification of the runway in use, and continued to descend to an altitude of 580 ft above mean sea level (AMSL) before executing a go-around.

At the point the go-around commenced, the aircraft was approximately 1,700 ft from the building and 200 ft above it. On the instructions of ATC the aircraft turned right and climbed to a safe altitude. The aircraft subsequently landed without further incident. There were no injuries.

Full report here Air Accident Investigation UnitFull List of Reports (http://www.aaiu.ie/AAIUviewitem.asp?id=11469&lang=ENG&loc=1652)

[Mohit_C]

At the point the go-around commenced, the aircraft was approximately 1,700 ft from the building and 200 ft above it.




Is it just me or does the sentence make no sense?

[wiggy]

I assume ( I know...) they are saying the aircraft was 1700 feet laterally from the building and 200 feet higher than the top of the building.

[Checkboard]

So they went around above 500 feet, and half a kilometre from the mis-identified building, a year and a half ago. :eek:

:rolleyes:

[Woodsy]

This sounds like a knock knock joke. Why is a hotel lit up in the vicinity of an airport in such a way that it may be mistaken for a runway? Is there no local authority planning for the arrangement of lighting of buildings near airports. OK vmc conditions were in operation at the time of the incident but had the visibility been marginal it could have happened to any crew.

I hope this long delayed report has caused some head scratching at the local authority if they ever get to read it.

Rant over

woodsy

[oxenos]

Checkboard
They went around from 580' AMSL. Dublin airport, as I recall, is 325 AMSL, and the hotel well may have been above the level of the airport. Hence the 200' clearance. Personally, I used to try and miss sticky uppy pieces of the land scape by something more than 200' vertical seperation.

[safetypee]

Discussion on the safety and human factors aspects of this incident is running here:- http://www.pprune.org/safety-crm-qa-emergency-response-planning/371026-report-incident-dub-2007-a.html#post4878565

One question asked (as yet unanswered), was if the aircraft was fitted with EGPWS. Presuming that it was then at what altitude would an alert be given?
I think that the incident provides a salutary lesson, particularly with the similarities of those incidents described in TAWS Saves. (www.icao.int/fsix/_Library%5CTAWS%20Saves%20plus%20add.pdf)

[dontdoit]

A couple of clowns on a day out in a jet that was going faster than they were. Who are they flying for now, so I can go and fly with someone else?

[PEI_3721]

dontdoit, to avoid being labeled in the same manner as you address the incident crew, I suggest that you read the report in detail and the link to similar incidents above.
Then reflect on the behaviors reported, consider the incident crew’s perspective, and the human issues which you or anyone else might encounter in similar circumstances.

[Brian Abraham]

dontdoit, Who are you flying for now, so I can go and fly with someone else? :E
Ever hear of the saying "There but for the grace of God go I"? Or you one of those chaps whose only mistake was the time you thought you made a mistake? ;)

[Ber Nooly]

At a final approach speed of 130kts, they were less than 8 seconds from the hotel......I'm sure guests in the top floor got a fright as the go-around was initiated! :eek:

As the report states, if the crew had bothered to read the NOTAM beforehand then this in all probability wouldn't have happened. They were lucky this time..

[Jetfella]

I disagree,a change of runway is something we deal with on a regular basis.Ok,the notams should have been read to avoid a double brief,but even if they had read the notes,does that mean they wouldnt make the same mistake?

Althought initially high,my reading of the report is that they stabilised in good time.

The nighttime photos are frightening,I empathise with this crew I have to say,a very human error,and lets be honest we have all had our moments.

34 at Dublin is always least favored by pilots and ATC,the FAF distance makes it look like you got oodles of time,but the VOR is away out in North Co.Dublin.

I was amazed they got planning for this particular eyesore of a hotel,taller than any other structure within a close radius of the airport.There is a mention of planning guideline rules regarding structures in the report.And a suggestion that rules were not followed,I wonder if that will be followed up?Probably not.

[BOAC]

A nasty 'event'.

Thanks to PPRNkof (http://www.pprune.org/members/220892-pprnkof) for posting the link to the report or we might have missed it. This thread has finished up in a typical PPRune 'Pickle', and in defence of PPRNkof (http://www.pprune.org/members/220892-pprnkof) I would point out that it would have been quite hard to find the original thread - you'd need to be really clever - like some of our contributors on the closed thread. It is a pity the responsible mod did not do that homework himself and add the post to the old thread which would have then popped up very neatly in R&N. However - I think this forum is just fine for it now. I've no doubt PPRNkof (http://www.pprune.org/members/220892-pprnkof) considers him/herself fully chided.

[Liffy 1M]

I live under the approach to runway 34 at DUB and over the years I have on occasion observed significant lateral variation in the approach paths taken by aircraft on this non-precision approach. In particular I recall an A300 freighter one snowy night which seemed to be lining up with the nearby M1 motorway before making a go-around.

Although this runway is not heavily used, it can be needed when 10/28 is unexpectedly blocked and the winds rule out using 16, which has the ILS. In bad weather aircraft may only be breaking cloud two miles or less from the runway. The MD-83 report referred to the difficulty of picking out the runway lights from the suburban lighting. I wonder whether flashing lead-in lighting to 34 à la the famous Canarsie approach to JFK runway 13L would help in this regard?

[PPRNkof]

BOAC - thanks for the thanks! No accident this ended up here. However I agree, probably better off here (real disucsion, less muppets/media). As a result (in retrospect) I'm not too chided, 'cause there's a reason!

I've been onto the AAIU to query the lack of info on EGPWS: see below for interesting points:
(reply to my original query)
thank you for your interest in the above Final Report, of which I was Investigator-in-charge. As you can appreciate, the report only contains information directly relevant to the incident, as the aircraft was stable and configured in the landing configuration, the EGPWS would not activate in the circumstances encountered.

(my reply)
You mentioned that the EGPWS system was de-activated as the plane was in it's final landing configuration. My understanding of the EGPWS (as opposed to GPWS) is that it includes the Terrain Clearance Floor (TCF) function, which provides GPWS protection even in the landing configuration. Given this and the fact that the vast majority of commercial aircraft were using EGPWS in 2007 (approx 95%) I would be interested in knowing was the aircraft fitted with EGPWS?

-end.

I have also incuded a few other queries (related to EGPWS) and we'll see what the man says.

JetFella and Liffey 1M mentioned lighting improvements for the runway/hotel (agree) sounds similar to other recent threads on similar incidents (after Aug 2007 interestingly enough) where planes were landing where they're not meant to (taxiways etc - nothing new there I guess). I just hope the real issues associated with this incident are investigate, identified and sorted.

I think the main issues with this scenario are:
1 - blame culture results in coverup mode, not problem solving (captain was fired after incident.....).
2 - hysterical/inaccurate reporting by media, which feeds point 1, not just in aviation terms. The media should be a positive force in aviation safety (accurate, investigative journalism, rather than headline grabbing drama), instead they've become the opposite.
3 - potential incompetance on the investigators part (given the reply given) -could be connected to point 1.

What I want known out of this is:
Was there an issue with the operation of EGPWS that needs to be addressed?
Was there an issue with location of the building with regard to planning permission that needs to be addressed (to prevent other encroachment in the future) - would lighting improvements mitigate this - was the building entered into the appropriate database for the EGPWS - is there a process in the Ireland for doing this for new high rises (note it would appear that Ireland is about to move from a low density PP mentailty to a higher density PP perspective) & is this something that has to be addressed in other countries?

Just to spell it out - this thread should be about real issues, not ripping strips off contributors or being disrespectful (as so often happens on this site, JJ83, I hope you're listening there fella). I skip posts where the poster starts bashing, personnally I want to hear about cause and effect and lessons learned.

[safetypee]

After further thought and research, with help from the most useful web site EGPWS.com, it is unlikely that Terrain Ahead alert was given. The aircraft appeared to remain just above the terrain clearance floor (TCF) boundary (approx 100ft/nm above field elev out to 4nm), but if the erroneous approach had progressed further, then an alert and warning could have occurred … but when.
Assumptions:- that EGPWS was fitted to the aircraft and it was serviceable (UK registered aircraft / JAR operation) – (N.B. in a recent European MD 83 CFIT accident the EGPWS was reported as being unserviceable).
that the FDR was inspected for an EGPWS event; also note that the EGPWS computer will store up to 100 events in its memory.
The TCF warning boundary depends on the mod state of the EGPWS software – operators should check that they have the latest version and an updated terrain database.

It has not been possible to establish if the obstacle mode was activated (free mod for all operators). However, even if this aircraft had the facility, then an alert was unlikely as I understand no obstacle database info is available for Ireland. (I wonder why? Normally Honeywell will use any/all approved data where available – problems with co-ordinate systems etc – what’s the problem with Ireland?)
If all of the obstacle mode requirements were available, then an alert would have been given some 60 sec ahead of the aircraft (circa 3nm).

If EGPWS had been considered during the investigation then the issues of obstacle mode activation / data base availability might have resulted in a safety recommendation – i.e. EASA to ‘recommend’ that all operators activate the obstacle mode (no cost?).
Consider a future scenario where ATC might not be as vigilant as in Dublin – EGPWS would be the last chance, and the obstacle mode would give the earliest alert.
Of similar intrigue, as a UK registered aircraft the UK AAIB could have been involved – did they miss the EGPWS issues also?

[PPRNkof]

I'm getting stonewalled by the AAIU, so I'm escalating to the department of transport about this. I am very disappointed with the AAIU. After all their mandate for investigations is "THE SOLE PURPOSE OF THESE INVESTIGATIONS IS TO PREVENT AVIATION ACCIDENTS".

I don't have much faith in the Irish Government, but maybe I'll be pleasantly surprised!

[Sober Lark]

With reference to the report 1.13.2 "Information contained on the CVR was not preserved by the flight crew and consequently was not available to the investigation."

Does this mean the flight crew can erase such recordings or does it mean the recording was automatically recorded over? What do they need to do to preserve a recording?

[turbocharged]

data is recorded on a loop and starts to over-write when it gets back to the beginning of the loop. SOPs usually have provision for tripping the CB after an event to preserve the evidence. It's not unknown for crews to leave the CVR running so that critical conversations are over-written.

[mtanz0]

It must be the famous 'Runway Hotel' in Dublin.

[Sober Lark]

Many thanks for your interesting reply Turbocharged.

[PPRNkof]

I passed the following email onto my local TD (MP, member of house of representatives):

I refer to a report that was recently published by the Air Accident Investigation Unit (AAIU) regarding a a serious incident in Dublin.

I am gravely concerned that the air accident investigation into this incident was flawed and that a critical element of the investigation was omitted. The details of this report can be found at the following location: http://aaiu.ie/AAIUviewitem.asp?id=11469&lang=ENG&loc=1652.

I contacted the air accident investigator assigned to this case to query this omission and his initial response was inadequate. I queried this again (with more detail) and he then declined to respond to my queries. I have since tried to contact the chief investigator at the AAIU and then the Irish Aviation authority to try to progress this and have not heard back from either.

I believe that failure to address this omission (Enhanced GPWS - obstacle mode activation / data base availability for Ireland) in the investigation and subsequent report means that the EASA do not have the visibility of the issue and cannot make recommendations to ensure that the issue is addressed. This could result in disasterous accident in Irish airspace, in the future.

I am not a crank and this is a very real issue. The fact the AAIU are not interested in responding to inconvenient but very real issues, is also of great concern to me.

I hope you can forward this email to the appropriate person, who is responsible for oversight of the AAIU.

I look forward to hearing from you.

Yours sincerely,

XXX

----------------
In fairness to my TD (Finian McGrath, Indipendant), he did raise a question in the Dail (Parilament/House of Representatives) about this and forwarded on the response from the department of Transport. The main elements of the response are below:

"The investigation of the Serious Incident was conducted in accordance with the Annex 13 provisions to the convention on International Civil Aviation and Incident Investigation...."

( The following is taken from the AAIU website in relation to Annex 13 provisions:
"The Air Accident Investigation Unit conducts its investigations of aviation accidents and incidents in accordance with Annex 13 to the International Civil Aviation Organisation Convention, European Union Council Directive 94/56/EC, and Statutory Instrument No. 205 of 1997. The fundamental purpose of such investigations is to determine the circumstances and causes of these events, with a view to the preservation of life and the avoidance of similar occurrences in the future. It is not the purpose of such investigations to apportion blame or liability.")

".... Consequently, the AAIU is satisfied that all signifcant factors relating to the occurence were addressed in the Report. Ther warning system referred to by the Deputy's correspondence was in fact considered by the investigation and was not a factor in the occurence. I am advised that the AAIU responded to the corrrespondent within 24 hours of his initial query and will respond further to him in writing when required information becomes available."

OH MY ACHING ARSE!!! The amount of time and effort I have put into this Wild Goose chase at this stage is amazing. I have 2 kids under three and have hardly got the energy left when the day is done to shag my wife - and I'm bering given the run around like this! I cannot believe that the department of Transport's role of oversight for the AAIU (when a relevant/coherant point is raised with them offically) comes down to them being satisfied that the AAIU is satisfied! Oversight my sphincter!

In relation to the last point raised in the response to the Dail question, I provided my address to the AAIU (specificaly Leo Murray in person, over a month ago (at his request - this was the last contact I had with him, despite several emails and telephone calls since) and have recieved no feedback since.

I am convinced that the AAIU is covering up an incomplete investigation and that this is an ominous sign for air safety in Ireland. The response from the department of Transport is even more vacuous and disturbing.

I will try to progress this, but it seems that this endevour is doomed - I'm running out of options.

I'll try to keep up the pressure and keep you posted.

[IGh]

An investigative-err, mentioned in Slot 32, “the air accident investigation into this incident was flawed and that a critical element of the investigation was omitted….”
Don’t think that you are the only man confronting investigator-err. The AAIU is better than the USA’s authority, re’ err -recognition and err-correction.

Here are the words of "C.O." from thirty years ago – still the same unwillingness to confront investigator err:"There is reason to believe that because of the excessive workload, the inadequacy of investigations, or the questionable nature of some board members' qualifications, some views of parties associated with a particular case are not communicated or understood by the Board's members. Petitions for reconsideration of the determination of cause or, more importantly, for changes in the report to present a fuller presentation or discussion of the facts, appear to be treated summarily without the objectivity which normally characterize the Board's actions. It is rare for the Board to present in its report the contrary views of competent parties unless one of the members elects to write a minority opinion supporting such a view. Such dissents are infrequent."
["Aviation Accident investigation: Functional and Legal Perspectives," an article by Mr. C.O. Miller, past Director of the Bureau of Aviation Safety of the NTSB; Journal of Air Law and Commerce (Dallas, Tx.: SMU School of Law).]

The USA's Board refuses to even recognize most of their investigator-errs.

= = = edit = = = \/ = ==

Checking a few decades back, before our industry had matured, the earlier participants were disappointed with the quality of investigations. Here's a headline, describing an ISASI gathering in the early '70's:

"Air Crash Probers Called Amateurs", _The Toronto Star_, August 30, 1973.

The annual ISASI Proceedings of 1981 included several papers which question quality of investigations, see pages 94+:

"Significant accident prevention information is not being obtained." [pg 98]

"The diminished quality of NTSB reports and needed new approach... The elimination of an independent ... quality control function within the Board (1973-4)...." [pg 98]

[PPRNkof]

Looks like the AAIU are still following up with this as I have (finally) received some feedback from them. I managed to get the Chief Air Investigator via the department of transport and sent him the following email:
---
I'm concerned that EGPWS was not included in the report and I believe that it is an important factor in acting as a final safety net in preventing an accident, if there's a future similar event - either with this building or in a different scenario (here or abroad). My only motivation in this is to ensure that the correct lessons are adopted from this incident to ensure that aviation safety is improved. I could not live with myself if I did nothing and an accident did occur, where I felt that previously I had not acted.

As EGPWS is standard now, I think that we can assume that the aircraft was fitted with it and that the following recommendations be added to the report, so that they can be escalated to EASA and relevant government departments.

EGPWS obstacle mode should be enabled on EGPWS.
EGPWS obstacle mode should be selected during a visual approach.
EGPWS terrain database is required for Ireland and the relevant information should be complied and forwarded to the EGPWS manufacturer (Honeywell I assume). This will also require inclusion nationally, in the planning process, when new tall buildings are constructed close to airports/flight paths.

Fell free to contact me if you have any queries or comments.
---

Received the following reply:
---
Thanks for that.
As previously advised it has always been our intention to provide you with a written reply to your queries. The IIC is seeking further clarification from interested parties to the investigation, but as the Operator has gone into administration, coupled with the aircraft being returned to the USA, you will appreciate that particular answers to additional queries are not readily available and have now to be sourced from other parties in other countries who have nothing to do with the original investigation.

I can confirm that the aircraft was equipped with EGPWS and was reported by the flight crew to be serviceable. The Investigation determined that the flightcrew did not receive a EGPWS warning and this was confirmed by analysis of the FDR, therefore the focus of the investigation was primarily related to the optical illusion created by the hotel and its associated lighting at night time.

The AAIU will respond in writing to you if and when we receive responses from the interested parties. On receipt of any response I will then consider whether further clarification is required in the published Final Report.
---
Still not ideal, but at least some progress. Maybe some light at the end of the tunnel.

I don't think that I'll be getting a Christmas card from the AAIU or Department of Transport!

[PPRNkof]

From AAIU

"Specifically to your question ..to check has the building in question been added..I can confirm that the Honeywell Service Information Letter Publication Number EGPWS-MKVII- 64 shows that the building has been added to the obstacle database."

Well I guess that's all folks.

Will let you know if anything else comes up on this in the future.

[safetypee]

“Well I guess that's all folks.”
Not quite. Operators must ensure that they have enabled the obstacle mode of EGPWS in their aircraft and updated the database to include the building, and of course checked to see that they have the latest software revision which provides the appropriate terrain floor for the alerts and warnings.

[PPRNkof]

As you'll see from the AAIU response in post 34, the AAIU are trying to get further information and will add further detail to the report if they feel it's required.

Not much more I can do about it at this stage. Like I said, I'll let you know if I hear anything back on this.

PS The release of the terrain database where the building was included in the terrain database, was released on 27 Mar 08. So in fairness, it seems to have been added to a timely manner after the incident (mid 07).