Eurocypria Airlines LTD Incident EPKT 2009-11-09 [Archive]

Ptkay

9th Dec 2009, 11:07

Another hair rising incident by a Cyprus airline Eurocypria Airlines LTD.
Aircraft reg. 5B-DBV
Boeing 737-800
Date: 2009-11-09, 20:36 LT

Rough translation of the report of the Polish Accident Investigation Board:
http://www.mi.gov.pl/files/0/30675/2009962RW.pdf

Flight from the airport, situated at one of the Canary Islands-Fuerteventura (GCFV) to Katowice (EPKT) was the second flight of the crew landing in Katowice. The crew conducted the approach to runway 27 at epkt by ils system at atmospheric conditions at the airport at 19.30 utc: wind 210 °/2 kt, rvr for runway 27 was 350 m by the presence of fog, and the lower limit of clouds was determined to 100 ft
Minima for airport and crew for the approach in CAT I are: rvr _ 550m and cloud base 200 ft. After touch down to the left of the centre line the aircraft left main and front gear left the runway and then for approximately 373 m remained outside of the runway damaging part of the two edge lamps. The right main landing gear wheel during this time, remained on the asphalt of the runway.
The aircraft returned to the runway and has eventually stooped.
In his submission, the pilot (cpt) stated, that he probably took left edge light for non-existent central line lights. After parking on stand crew did not report any observations. FO of the anding crew provided the information for the crew from Katowice to Warsaw, that he will do the PFI– CPT of amending crew accepted this.
As a result, FO of the previous crew checked only left main landing gear without performing properly throughout the PDI-pre departure inspection.
When doing this FO did not have a flash-light for lighting of aircraft elements contained in the PDI procedure. As a result, he skipped checking the front landing gear, the right main landing gear and other items subject to PDI. In the action FO, has not detected damaged tyres of the front gear, right front wheel rim and headlamp on the protectors of the gears. Undetected remained corruption of the tyres right main landing gear internal wheels.
Each of these faults should have resulted in the inability of the aircraft for further flight until Exchange all damaged items. After returning to the aircraft FO reported to the CPT for the crew to Warsaw, aircraft is OK.
During the push back person monitoring this process on the ground, reported broken landing headlamp to CPT.
CPT asked FO of the previous flight (previous crew was returning to Warsaw on board of the aircraft) if when executing PDI he noted any damaged headlamp, FO reported "negative".
Therefore, the CPT minimum equipment list (MEL) allows him to complete the flight to Warsaw and has no objection to the efficiency of the aircraft. After loading in Warsaw and checking the status and tyres of the front gear, CPT wrote a ASR report entry, has filed it to the logbook, handed over the aircraft to the technical personnel, and then both crews proceeded to the hotel.

:mad::mad::mad:

Ptkay

9th Dec 2009, 18:31

This is just a preliminary report, I will keep you informed a.s.a. any news emerge.

act700

9th Dec 2009, 20:54

I wouldn't necessarily pin this on a "Cyprus" outfit. This ignorance and oblioviousness is a systemic tumor that goes waaaayyyyyyy deeper than geographic location.

When you mix recklessness with inexperience, you get a dangerous cocktail.

If people only knew what they're paying for!!!:ugh:

RoyHudd

9th Dec 2009, 21:09

Standards are low and falling. Experience is diminishing. Commercial pressures are ramping up.

These people were fortunate. (Passengers and crew). Expect more such events in 2010 and beyond. And they won't be confined to small carriers.

act700

9th Dec 2009, 21:37

Just read the original incident report.

The behavior of the inbound crew was plain criminal! If these cats didn't realize that there was something not right with that landing/roll out, they're f:mad:g retarded!
But I suspect the inbound FO volunteering to do the walkaround for the outbound crew, that they knew.

What's criminal is the fact that this pi..ant comes back and with a cool conscience tells the Captain that the a/c is ok?! WTF?
Maybe they are retarded, cause in the end they got on the outbound plane as a deadheading crew....

According to the report, the left main, as well as the nose gears were off the runway. How do you not feel that??

I'm not sure how the euro authorities handle things, but on the other side of the pond, these knuckleheads would have gotten an automatic violation for shooting an approach that was below applicable mins.

Whatever happened to screwing up and taking responsibility for it??

Admiral346

9th Dec 2009, 22:22

Whatever happened to screwing up and taking responsibility for it??

Seems to be dying out... and not just in aviation - just look at the ones that put the economy into the crisis we are just getting over!

Nic

act700

10th Dec 2009, 09:25

Seems to be dying out... and not just in aviation - just look at the ones that put the economy into the crisis we are just getting over!

Nic

You're right, that's not exactly setting the right example, is it?!

10th Dec 2009, 09:51

This one is cut-n-dry in my opinion.

1. Continued approach below published minima.

2. Luckily the (blissfully unaware) passengers weren't harmed.

3. In essence the crew conspired to cover up their deed - :mad:

Both should have their licence/rating revoked. No room for cowboys in our work environment - I'm sure there are many more able and consciencious crew out there currently looking for work.

No bleeding heart boo hoos please. These guys are grade one idiots and should be grounded immediately.

A4

Ptkay

10th Dec 2009, 10:40

I am not sure about the follow up of this event by the Polish authorities,
but Cyprus is in the EU and EASA should react immediately.

If these morons are not to be taken to responsibility, the airline should be.

Put them immediately on the black list!

cargo boy

10th Dec 2009, 11:09

I am not sure about the follow up of this event by the Polish authorities, but Cyprus is in the EU and EASA should react immediately.

So is Poland. Duh! :ugh:

Ptkay

10th Dec 2009, 11:40

Nothing will happen to them.
Cypriots aviation community sticks together.
Most of them are somehow linked together trough family relations or other interests.. This includes the investigators!

Therefore the airline should be hit hard.
Only this can stop this horror.

And regarding investigators, this is under Polish jurisdiction,
and I can assure you, will be handled properly.

So is Poland. Duh!

What is your problem, cargo-boy?

The report has been published, nobody is hiding anything,
I only wrote, that I don't know what is being undertaken,
which doesn't mean, that nothing is happening.

Normally in such cases any actions are taken on the basis of the final report,
and not preliminary.

I am sure this will be properly taken care of by the Polish authorities (and EASA).

This is just 30 days since the incident happened.

act700

10th Dec 2009, 13:09

Nothing will happen to them.
Cypriots aviation community sticks together.
Most of them are somehow linked together trough family relations or other interests.. This includes the investigators!

In Cyprus maybe not, may be you are correct. However, the investigating country ought to have a say as well, and even if these loony tunes get off free down there, it sure would set a tone if the airline were to be punished by EASA.

Wojtus

10th Dec 2009, 14:26

Slightly better translation at: Aviation Herald:
Incident: Eurocypria B738 at Katowice on Nov 9th 2009, runway excursion on landing (http://avherald.com/h?article=423fbc75&opt=0)

Remembering "similar" Air Europe's incident two years ago, I still can't imagine why are these guys hoping to leave the scene undetected? Shame.

DirectFly

10th Dec 2009, 14:30

If the Polish CAA is to carry out this investigation it will last for at least 3 years. In 3 years the EuroCypria will say that was 3 years ago, today we operate much better.

duckbelly

11th Dec 2009, 03:32

The most important thing with any incident is that no-one was hurt, regardless of the degree of culpability.
As for Eurcypria as an airline, I had the privilege of flying with them for two years 2006/7. I've flown with several airlines over the years in Europe, SE Asia, Australia and I found the ECA standard to be equal to the best.
No airline is imune to incidents and I certainly hope that Eurocypria as a whole doesn't get unfairly pilliored over this.

tcas1

11th Dec 2009, 07:05

So as far as a very Experienced rocket scientist,JUDGE, fighter pilot,AIB investigator etc etc Mr Ptkay has decided that the crew should be fired and the airline put on the black list!!!
So what do you recommend we should do to Air France?They lost two a/c in the last 3 years.What about BA?? They lost one in London last year.
We are all waiting for your judgment.
I'm not sure what exactly happened and what was going through the mind of the crew but until the investigation is over i guess the only thing the airline can do is suspend them.
In my aviation career i learnt to never point a finger at someone. There are those who screwed up and those who will at some point. And that goes from the most minor to the most major incident.
I remind you of the top KLM Captain who many years ago was involved in the biggest aviation accident in Teneriffe. He was the first the airline called so he could help in the investigation only to find out that he was actually involved in it.
What i am trying to say is that it can happen to the best of us and that is something we should all keep in mind.
Safe flying !!

Ptkay

11th Dec 2009, 07:39

Dear Tcas1,

I appreciate your sense of humour.

But I kindly remind you, that it is not the case "sh#t happens",
bit a cover up story following a landing in breach of all rules.

Those rules were written exactly to avoid such incidents or accidents.
Breaking them is criminal.

In the process of cover up the CPT and FO put their colegues
on the flight EPKT to EPWA at risk, not mentoning the plane
and pax (if there were any on board.)

As others mentioned above it is a mater of the "new culture" in the
aviation, when landing below the minima is becoming a rule,
pilots doing a go around or diverting are being put under pressure
not to do so again...

This time there were just 2 lamps and a few tires.

Do you suggest we should look away again and wait until something
more serious happens???

Many happy landings (below minima)

Truly yours

PTKay

Avman

11th Dec 2009, 08:34

Exactly! Duckbelly and tcas1, the issue is not the incident itself, but the attempt to cover it up. That is criminal.

His dudeness

11th Dec 2009, 09:01

Never flown for 'lines', but I do my outside check myself, if not avoidable my F/O on duty does it. Can you delegate that to a guy technically not on duty?

If all legal arguments are not worthwhile considering them, the attempt to put the blame in the shoes of the following crew is just...just...unbelievable low morale. As the follow on captain I´d kick the s... out of them for trying to blame me. How low can it get?

TheBat

11th Dec 2009, 09:08

Yes dear Ptkay.
You could be right. Breaking those rules might make somebody a criminal, but nothing makes you the prosecutor, the judge, and the executor all at the same time!!!!
I wonder, have you ever done a CRM course? Did anybody ever teach you that specially as a pilot you shouldn't jump into conclusions right away? Did you ever hear the phrase "assumption is the mother of all fu*k-ups?" (probably assumption was a contributing factor into this f*ck-up as well). Please give some credit to the rest of the common mortals!!

Coming back to the subject, I am sure there's more to it than what it seems, as is the case in every serious incident / accident. As far as I can tell, nobody here suggested that we should look away (again??? you mention??) until something more serious happen, so why do you jump immediately into that?
No case is black or white. If the crew mis-behaved in any way, I am sure that there are professional people out there that will do their job properly.

deeceethree

11th Dec 2009, 09:10

tcas1So what do you recommend we should do to Air France?They lost two a/c in the last 3 years.What about BA?? They lost one in London last year.Are you for real? The Air France accident needs to find data and voice recorders before they can truly state what happened there, in terms of culpability.

But how can you pigeon-hole the BA 777 accident, with this 737 incident? The BA accident, although investigations are not yet complete, was apparently caused by a technical/design problem (fuel-oil heat exchanger), yet you seem content to compare it to this wilfully negligent Eurocypria 737 incident, which is compounded by attempts to cover up what happened. I find that offensive!

The Eurocypria crew should be suspended immediately, and once their actions have been investigated (and right now they appear to be very serious allegations of endangering the aircraft and occupants, and covering up afterwards), they should face the appropriate punishment. Whatever that punishment is, it is likely to be heavy.

Admiral346

11th Dec 2009, 19:30

Where I am from, one is assumed to be innocent until proven guilty,

HOWEVER

if a judge finds reason to believe there is a risk of flight or the suspect might be trying to cover up or destroy evidence, you go to jail, and are held there until the trial finds you guilty or innocent. If the first is the case, the time spent gets subtracted off the sentence, if the latter is the case, you get reimbursed.

I believe the cover up takes the hole event from incident to criminal act.

Nic

act700

11th Dec 2009, 20:24

I think a lot of you are missing the point!

This is not, or at least it shouldn't be a pi:mad:ing contest about judging others and solving accidents.

tcas1, after reading your comment, which to me completely misses the point, I would just like to know, if you've learnt in your aviation career to accept responsibility for your screw ups?

Maybe I'm just way off here, but I don't know how the hell you drive an a/c-or half of it- through the grass/dirt and not have an incline that something was "off"; to at least get you to go out and "investigate" a little?!

His dudeness,
I don't think an FO's capability to do a walk around is at debate.
What seems interesting, at the very least, is that one of the players involved in a booboo volunteers to go do it.

Ethics, unlike procedures, cannot be taught.

tcas1

12th Dec 2009, 05:04

OK. Let me make myself clear.
By reference to the AF, BA and KLM accidents what i am trying to point out is that accidents can occur to the best airlines and pilots.
Nobody had the right to judge until all facts are analysed. Never rush into assumptions and buring someone or the airline involved. The point is to learn from peoples mistakes and procedures improved to avoid the same thing happening again.
As for taking responsibility for what I,or anyone does it is not a matter of only punishing the person involved but obviously so others can learn from our mistakes.
Finally something for everyone to think about and again not trying to take the part of the crew's lawyer. Do you really think that the crew involved realised the severity of the incident and then stayed on board and deadheaded to WAW after doing a PDI themselves? I would like to think they didn't.
And as far as the minima involved ,flying into poland myself time and time again we get info for airports where vis given is 1500m and rvr 350.Not that it cannot happen but a bit confusing and misleading.
Finally something else for everyone to think about is that by doing some furhter research into the incident you find out that a LOT a/c landed only few mins before the incident.

LNAV VNAV -

12th Dec 2009, 05:23

It would be interesting to find out then what, if any, RVR reading was given by the tower to the LOT aircraft. :E

12th Dec 2009, 08:49

Do you really think that the crew involved realised the severity of the incident ..........

Having spent most of yesterday trudling around Europe which involved 3 Autolands down to 300m, it IS inconcievable that the crew would not have realised that they had left the "hard stuff".

An RVR of 350m is nothing like an RVR of 75m - that may sound like a stupid statement, but the point is IT WOULD HAVE BEEN PLAINLY OBVIOUS to the crew concerned that the event hadn't gone quite to plan!!

On the information given so far this would appear to be an act of wilful negligence in carrying out the approach in the first place and perhaps criminal in not entering it in the Techlog and actively trying to cover it up. Did they seriously think they would get away with it?

Perhaps the more serious question is why do crews, on occasion, go completely against the rule book? I was told many years ago that if ever I was facing a scenario which was "pushing the envelope" of acceptable practice, I should picture, in my head, me with my best "courtroom voice" justifying why I did what I did to the management or even a Jury.

The usual pressure is time. Does it really matter that much? Is it so important that you are prepared to put your passengers, aircraft, licence at risk? Being late/diverting is a pain in the ar$e - but it's a lot more palatable than the other options which WILL eventually catch up with you. If you got away with it once you're likely to "push" again...may be a bit more this time. And then you push.... and push.... and push..... and you end up sticking the mains off the side doing an illegal autoland...... and then you try to cover it up. :ugh:

Fly safe everyone.

A4

act700

12th Dec 2009, 09:19

..,flying into poland myself time and time again we get info for airports where vis given is 1500m and rvr 350.Not that it cannot happen but a bit confusing and misleading...

tcas1,
Fair enough-but, wouldn't the prudent thing to do, be to abandon the approach at the bottom? Surely, we've all come down the slope only to have to go around, after arriving at DH?!
And yes, I did call you Shirley!!:E

Again, I don't think anyone is "judging" the crew on starting or flying the approach; at least I see no problem there.
What is at debate is how they dealt with the aftermath.

Ptkay

12th Dec 2009, 14:08

And as far as the minima involved ,flying into poland myself time and time again we get info for airports where vis given is 1500m and rvr 350.Not that it cannot happen but a bit confusing and misleading.

Tcas1,

Now you become nasty.

Here are the METARS:

EPKT 092130Z VRB01KT 0400 R27/0500N FG VV001 07/07 Q1010
EPKT 092100Z 24002KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 092030Z 28002KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 092000Z 00000KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 091930Z 21002KT 130V250 0050 R27/0350N FG VV001 07/07 Q1010
EPKT 091900Z 23003KT 180V260 0050 R27/0300N FG VV001 07/07 Q1009
EPKT 091830Z 13001KT 0050 R27/0300N FG VV001 08/08 Q1009
EPKT 091800Z 13002KT 0100 R27/0350N FG VV001 08/08 Q1009
EPKT 091730Z 13004KT 0100 R27/0300N FG VV001 08/08 Q1009
EPKT 091700Z 12004KT 0300 R27/0350D FG VV001 08/08 Q1009

What is it, that makes you think that is specially "Polish" in them.???

You have steady and continuous RVR of 350m for over 4 hours,
with fog and 100ft ceiling.

Finally something else for everyone to think about is that by doing some further research into the incident you find out that a LOT a/c landed only few mins before the incident.

And this is exactly why such incident should be treated with all available severity.

The LOT guys went away with it (maybe).
(You don't know their aircraft equipment and crew skills.) ;)

Nevertheless Polish CAA has insisted on ATC to report any and all landings
below minima at Polish airports since the incidents become more and more
frequent. (See the former one in EPKT.)

Also recently Just Culture committee was established by the CAA allowing
pilots or any other person involved to report anonymously about the incidents
they witnessed.

This is the "old boys" culture of cover ups and
"don't puke into your own nest" that makes the fight with
such reckless flying practices so difficult.
And also gives the management of the airlines an argument to put pressure
on the crews to fly below minima, because they can always say,
"Look, you will get away with it, everybody does".

And the incident we discuss here is a perfect example of such cover up mentality.

levantes

12th Dec 2009, 18:00

[QUOTE]You don't know their aircraft equipment and crew skills/QUOTE]

Do you know? Can you please explain to all of the non judgemental members?

Clandestino

12th Dec 2009, 20:48

Last time I've checked, Katowice had CAT I ILS. Lack of centerline lights indicates no significant change since then. Shooting CAT I ILS with RVR below 550m is illegal, for reasons that have once more become painfully obvious.

So the crew made high speed runway excursion and went dead-heading on the same aeroplane, without maintenance checking the aeroplane.

Never mind the legal consequences, they'll have hard time explaining the occurrence at next medical renewal.

act700

12th Dec 2009, 21:23

The LOT guys went away with it (maybe).
(You don't know their aircraft equipment and crew skills.)

Wouldn't the airport have to be certified for anything more than CAT1, besides aircrew and aircraft?
In which case the LOT plane would be "discovered" (if it did land as said), ironically not b/c of their own doing!

"don't puke into your own nest"

It's all good, unless we're talking safety of flight stuff.

TBSC

12th Dec 2009, 23:04

Just to confirm: KTW is CAT I., minimum is RVR 550. They do not even have an LVP (actually they have one prepared since months but it's not signed by one of their 2000 authority, agency or bureau) therefore even the take-off minima is 400m.
Poland does not have a single CAT III runway for 10+ airports with considerable traffic and population approx. 40 million. But at least their weather is s...ty every autumn/winter. :)

tcas1

13th Dec 2009, 06:11

levantes

13th Dec 2009, 07:00

No tcas1, it's probably one of LOT's old boys that the Polish CAA is trying put some sense to!

[QUOTE]Poland does not have a single CAT III runway for 10+ airports with considerable traffic and population approx. 40 million/QUOTE]

And to add: The only CAT II runway at EPWA was downgraded to CAT I for 3 weeks in November!
Where do all these guys land when foggy weather comes in? In BERLIN???

LNAV VNAV -

13th Dec 2009, 08:24

Tcas1,

Now you become nasty.

Here are the METARS:

EPKT 092130Z VRB01KT 0400 R27/0500N FG VV001 07/07 Q1010
EPKT 092100Z 24002KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 092030Z 28002KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 092000Z 00000KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 091930Z 21002KT 130V250 0050 R27/0350N FG VV001 07/07 Q1010
EPKT 091900Z 23003KT 180V260 0050 R27/0300N FG VV001 07/07 Q1009

Does KTW have ATIS??

If not, do you know what the RVRs passed to the crews of either aircraft were? Are you sure that they were the ones shown in the metars above?

Ptkay

13th Dec 2009, 14:38

Does KTW have ATIS??

If not, do you know what the RVRs passed to the crews of either aircraft were? Are you sure that they were the ones shown in the metars above?

No, they don't.

But I would be very surprised if TWR would pass anything else than
listed in the quoted METARS, by such constat conditions.

Ptkay

13th Dec 2009, 14:42

You don't know their aircraft equipment and crew skills

Do you know? Can you please explain to all of the non judgemental members?

lventes,

no, I don't know either, and this comment was meant "tongue in cheek".
(I edited it with some emoticon to make it clear.)

;)

Ptkay

13th Dec 2009, 14:49

So if i was ptkay and rushed into conclusions, the LOT a/c landed below minima and then covered up their wrong doing by not reporting it!!! Thats criminal... lets suck the crew and blacklist the airline!!!!

(You don't know their aircraft equipment and crew skills.)

I love your comment ptkay.Its actually the most ammusing thing i read on this thread. So let me get it right. The LOT crew are extremely skilled and experienced in landing below minima and have equipment that allows them to do that!!!???!!! AMAZING!!!!

Tcas1,

I am happy I was able to amuse you.

As I mentioned above, the remark was meant "tongue in cheek",
which obviously didn't come through.

So if i was ptkay and rushed into conclusions, the LOT a/c landed below minima and then covered up their wrong doing by not reporting it!!! Thats criminal... lets suck the crew and blacklist the airline!!!!

Tcas1, I fully agree with you.

Please, kindly read the whole of my post, where I express my concern
about rising frequency of such breaches of rules and suggest
introducing Just Culture.

I will quote myself for your comfort:

Nevertheless Polish CAA has insisted on ATC to report any and all landings
below minima at Polish airports since the incidents become more and more
frequent. (See the former one in EPKT.)

Also recently Just Culture committee was established by the CAA allowing
pilots or any other person involved to report anonymously about the incidents
they witnessed.

So why wouldn't you, anonymously, report the LOT crew to the Polish CAA,
to do the matter just.

Or you rather wouldn't, just to stick together with your chaps???

Ptkay

13th Dec 2009, 14:56

No tcas1, it's probably one of LOT's old boys that the Polish CAA is trying put some sense to!

Poland does not have a single CAT III runway for 10+ airports with considerable traffic and population approx. 40 million

And to add: The only CAT II runway at EPWA was downgraded to CAT I for 3 weeks in November!
Where do all these guys land when foggy weather comes in? In BERLIN???

Levantes,

you are right, the situation in Poland is really critical regarding CAT.
And you are right, the only choice is sometimes Berlin, although
usually POZ has much better weather than KK, KT, or WA.

Regarding the LOT old boys, if not tcas1, then maybe you will
report the violation through the Just Culture scheme to Polish CAA,
to finally stop this "accident waiting to happen".

BTW: on DEC07 32th meeting of the Provisional Council ( PC) of the EUROCONTROL took place in Brussels.
Among others the Safety Regulation Commission reported on introduction
of "Just Culture" and once again stressed the importance of this tool
to improve flight safety.

levantes

13th Dec 2009, 15:04

[QUOTE]But I would be very surprised if TWR would pass anything else than
listed in the quoted METARS, by such constat conditions./QUOTE]

My friend ptkay you are again assuming and jumping to conclusions!
As you see the METAR's you uploaded are 30 min apart!
I would be a very unhappy man if I was in holding pattern over KTW waiting for the weather to improve and TWR gave me weather updates every 30min!:ugh:
I ASSUME (I'm stating it!!!!) that there is RVR indicator in the TWR giving readings to aircraft!;)
Its easy to judge the weather conditions constant NOW but at real time nothing is constant at these conditions.

Ptkay

13th Dec 2009, 15:12

Poland does not have a single CAT III runway for 10+ airports with considerable traffic and population approx. 40 million. But at least their weather is s...ty every autumn/winter.

TBSC, you are absolutely right, this is crazy and hard to understand.
But isn't the incident, we just discuss, the best example, why it is so?

The pilots keep landing below minima (also LOT), delays and diversions
are avoided, so no pressure on the authorities to change the situation...

Let's save the money, f**k the fog, the "good old boys" will land anyway.

It's cheaper.

It always remind me of the saying:

"If you think safety is expensive, try to have an accident."

RedFoxy_PL

14th Dec 2009, 11:16

to LNAV VNAV
It would be interesting to find out then what, if any, RVR reading was given by the tower to the LOT aircraft.

I am not sure what RVR was given but I am sure that LOT crew made diversion to EPKK in LO306 (2 hr before incident).

to tcas1
the LOT a/c landed below minima
If you are not sure what was done by LOT crew, please do not make assumption and do not blame somebody. (look above)

This particular incident like many others is not simple and I think many factors where involved here. Hope final report will describe all factors and make proper recommendation to prevent in future similar incidents.

Best regards

rmac

14th Dec 2009, 12:04

I have to admit that the logical analysis process of some of the posters in this thread leaves a little to be desired, and leaves me a little bit worried that some of you are driving me around Europe in your buses in this current bout of foggy weather........:eek:

Ptkay

14th Dec 2009, 14:29

Red, thank you for the first hand information
preventing tcas1 from spreading gossip.

jargarcze1

14th Dec 2009, 20:23

RVR given by KTW TWR to LOT was 600m ,so :D
brgs Jarek

levantes

14th Dec 2009, 20:45

So why did they divert to EPKK?:confused::confused:

LNAV VNAV -

14th Dec 2009, 20:49

That's a bit strange given the metars in the previous page. :confused:

Do you know what time that was?

Plectron

14th Dec 2009, 22:53

Anyone have any idea what the fuel was at block in?

Ptkay

15th Dec 2009, 08:14

So why did they divert to EPKK?

Levantes,

probably because the ceiling was 100ft, so at the DA of 200ft
they still couldn't see the runway and executed go around and diversion.

This is what prudent pilots do under such circumstances,
instead on flying blind into the ground and landing on the grass off the runway.

RVR is one thing, DA and ceiling is another.

Just my $0.02 worth...

LNAV VNAV -

15th Dec 2009, 08:41

Sooo then, isn't it even remotely posible that the ECA crew were also given 600m RVR, started the approach and saw lights at 200ft but mistook the edge lights for centreline lights (which of course don't exist)??

In other words, shouldn't you wait for the investigation report before jumping into conclusions, judging and condemning pilots, airlines and countries???

Ptkay

15th Dec 2009, 10:18

Sooo then, isn't it even remotely possible that the ECA crew were also given 600m RVR, started the approach and saw lights at 200ft but mistook the edge lights for centreline lights (which of course don't exist)??

Of course this is quite possible, and it is probably what they will report for protocol.
Nevertheless it is clearly stated in the AIP for EPKT: RCLL none
(no centreline lights.)

They certainly should have seen the Calvert system lights,
but isn't the decision altitude (DA) referring to having "runway in sight"
and not the Calvert HI flashes?

If you are a pilot, would you land if you would see just ONE string of lights,
and having no visual of the other two strings of lights supposed to be
the side lights?

Are there any CAT I runways having just RCLL and no side lights?

I dare to suggest: NO.

In other words, shouldn't you wait for the investigation report before jumping into conclusions, judging and condemning pilots, airlines and countries???

I certainly agree with you, and will patiently wait for the final report.

Nevertheless, I hope that bringing public attention to such incidents
will stop the craziness of airlines pushing pilots to land below minima
and stop pilots from risking their lives, and the lives of the passengers
doing so.

I hope also, you have enough imagination, that with little less luck,
with wet and soft grass off the runway, you would end up
with the main gear braking off and eventually,
in a pile of burning scrap metal.

I rest my case now.

EOT

quickturnaround

15th Dec 2009, 10:22

It shows once more the importance of a proper pre approach briefing when LOVIS prevail. A thorough look at the airport/rwy lights table would have shown that rwy/ctrlts did not exist, If you know that before you start the approach, you will not be surprised when you break out low level.

levantes

15th Dec 2009, 14:27

Thanks for your 2p ptkay!

[QUOTE]RVR given by KTW TWR to LOT was 600m ,so :D/QUOTE]

The above rather confusing 1st posting from our Polish friend with the emoticon gives the impression of a successful landing at KTW.

Lastly I totally agree with quickturnaround's comment!:ok:

FlightDetent

16th Dec 2009, 13:44

Sooo then, isn't it even remotely posible that the ECA crew were also given 600m RVR, started the approach and saw lights at 200ft but mistook the edge lights for centreline lights (which of course don't exist)?? Not very likely. 200 ft DH is 1200 meters from TDZ if a crew could see lights it would have been the approach centerline. The transition to runway LT system would clearly show the offset position of runway edge lights especially as EPKT is 60 m wide.

FD
(the un-real)

petesevenseven

19th Dec 2009, 03:49

Ok Guy's here's my two penny's worth,

To keep it as simple as possible. An incident has occurred here. For me as an aviator this is understandable incidents happen in aviation all the time we are always managing risk when we leave the ground to minimise incidents in aviation this is what CRM is all about.

The big issue here is the actions of the crew/crews involved. It would appear that rather than reporting this very serious incident immediately so that in the long term steps could be taken to improve company operating procedures and training to minimise the chances of this type of incident happening again a decision was made to try to cover it up.

If indeed there was a cover up and proven so. It is Eurocypria's responsibility for the sake of the paying public of Cyprus and indeed Europe as well as its own staff to take immediate steps to ensure that this type of attitude does not become company culture.

Pete77:ok:

500 above

1st Jan 2010, 10:37

"A EUROCYPRIA pilot breached safety procedures by failing to complete pre-flight checks on a plane that was damaged during landing when it partly missed the runway, it emerged yesterday.
No passengers were hurt during the botched landing; however under other conditions such an oversight could have spelled disaster.
The oversight, described as a "serious incident" by an official at the airline, occurred on November 9 at Katowice airport, Poland, when a Boeing 737 carrying around 170 passengers, partly missed the runway and sustained damage to the front landing gear, reflectors and headlamps.
The pilot reported that he had mistaken the leftmost strip of lights for central runway lights. However, the Polish Accident Investigation Board report shows that the plane commenced landing with insufficient visibility. The report states that the minimum "Runway Visual Range" (RVR) for was 550 metres but due to fog, RVR on the day was only 350 metres.
Captain Xanthos Yerolemou, Safety Officer at Eurocypria said yesterday: "Probably one of the reasons he missed was because of low RVR".
After landing, one of the landing crew inspected the left side of the plane that had missed the runway. However he failed to check the rest of the plane which had sustained damage during the landing, the report said.
Had this damage been reported, the plane would not have been allowed to fly, Yerolemou said. "This was the result of human error. If you have reason to believe you have left the runway, then you have to inspect the aircraft. It seems they did not check the right side because they believed it was okay,” he said.
Asked if he thought the inspecting pilot had been negligent, Yerolemou said "Yes. In fact the walk-around must be done before every flight, so they had not completed their tasks."
Alarmingly, the Katowice ground crew had even reported the broken light to the captain of the onward flight. However, said Yerolemou, the captain could not understand the message, because of the language barrier. He therefore sought clarification from the landing crew pilot who had conducted the checks. When asked if he knew of a broken light, he replied that he did not.
Eurocypria has now completed its preliminary report on the incident which has been shown to Cypriot, Polish and European Aviation bodies. The company will decide on disciplinary proceedings soon. "We are looking very seriously into the matter, and dismissal is a possibility."
Lucas Hadjiconstantinou, an electrical engineer with Cyprus Airways, said "Ninety per cent of the time that this type of damage occurs, there will be no incident, and serious accidents are unlikely. However, as Concorde showed, small pieces of debris can cause crashes." In 2000 a Concorde crashed after a 45cm by 3 cm strip of metal tore the plane's tires, which in turn struck and ignited the fuel tanks.
Andreas Georgiades, President of Aircraft Engineers International, said yesterday "The basic issue is that there was an incident and it was not properly reported." Asked about consequences of such damage, Georgiades was clear.
"Any defect, however small, definitely endangers the airplane and crew. You have to report it in a technical log and have certified mechanics sign it off. What people don't understand is that every incident reduces the safety margin, and if this is eroded over time it can end in disaster."
So, could this type of incident happen again? Giorgiades thinks so. "With current EU aviation safety regulations, I would say yes. Pilots are under increasing pressure to operate their planes." He explains that this problem highlights a broader issue of commercial pressures on airlines. Both He and Hadjiconstantinou agree that completely safe procedures are expensive, with lower burdens feeling the pressure more.
While rumours of cover ups and cost-cutting manoeuvres abound on pilots’ web forums, such as www.pprune.org (http://www.pprune.org/), the facts suggest this incident was much like the “perfect storm”. Poor weather, inadequate infrastructure, lack of communication and a failure to follow rules combined to risk hundreds of lives.
However Yerolemou was keen to stress that this was exceptional, that Eurocypria has an excellent safety record, follows all safety manuals and laws and been successfully audited by the European Aviation Standards Authority"

In the Cyprus Mail 1st January 10 by Patrick Dewhurst.

1st Jan 2010, 12:03

......the facts suggest this incident was much like the “perfect storm”. Poor weather, inadequate infrastructure, lack of communication and a failure to follow rules combined to risk ....

I disagree. Poor weather and inadequate infrastructure (CAT 1 only) are everyday occurances - nothing exceptional. This whole sequence of events was soley down to the decision of the Commander to commence/continue an approach below the legal minima. This is why we have rules - to protect the travelling public. Rules which can only be broken to prevent imminent harm to the aircraft or its passengers - not to keep the schedule running to time.

The final get out should have been at 1000' agl when a go-around would have broken the chain - assuming the RVR was below 550m at that point (probably was judging by METAR's).

The subsequent (in)actions on the ground demand only one solution.

A4

act700

2nd Jan 2010, 18:15

Quote:
......the facts suggest this incident was much like the “perfect storm”. Poor weather, inadequate infrastructure, lack of communication and a failure to follow rules combined to risk ....
I disagree. Poor weather and inadequate infrastructure (CAT 1 only) are everyday occurances - nothing exceptional. This whole sequence of events was soley down to the decision of the Commander to commence/continue an approach below the legal minima. This is why we have rules - to protect the travelling public. Rules which can only be broken to prevent imminent harm to the aircraft or its passengers - not to keep the schedule running to time.

The final get out should have been at 1000' agl when a go-around would have broken the chain - assuming the RVR was below 550m at that point (probably was judging by METAR's).

The subsequent (in)actions on the ground demand only one solution.

A4I agree with A4...the inadequate infrastructure is only an argument to deflect pointed fingers at the operator.

More so, this has less to do with cover ups and conspiracy, rather ignorance, incompetance, or both.

A4, what do you mean with "the final get out....1000ft.."? I'm not sure I understand?!
Break out, as in breaking out of the bottoms? On a Cat 1 Ils to mins, 1000ft agl sure sounds a bit high..

cupoftea

2nd Jan 2010, 18:30

ACT700 :I guess you have never heared of a approach ban?:ooh:

time to get back in the books mate, no time for that stuff while you are on an approach......:=

act700

2nd Jan 2010, 18:47

cupoftea, not in those terms!

If you guys are talking about abandoning an approach after not having the required "stuff" at minimums, that's all good stuff.

What I'm not getting is, abandoning an ILS (which is what they were doing) at a 1000ft agl?!

2nd Jan 2010, 19:12

Yes, I'm talking about the approach ban. There is nothing to stop an aircraft commencing an approach. It could be 75m RVR on your CAT 1 runway - you need 550m - but you can start an approach in the hope that the RVR will improve. However, the RVR must have improved by the time you reach 1000' ARTE (above runway threshold elevation). The outer marker or 4 miles are also usable as alternatives. If at the "approach ban" point (1000') the RVR is still below the required value - you MUST go around.

If the value is above required at 1000' - you can continue. If it falls below required RVR after you have passed the ban point, you can continue down to your applicable minima to land or go-around as required.

So on the incident in question is it highly likely that RVR was below required at the approach ban point so a go-around should have been executed....... breaking the sequence which lead to the subsequent events.

Clear? :)

A4

act700

2nd Jan 2010, 19:25

A4, right on, thx mate.

On the west side of the lake you can't even start an approach unless you have the required landing minimums. Hence the confusion.
A bit different here. Maybe I'm one of the few on this board who learned something?!

Cupoftea,

see how it's done?? I saved myself the trouble of hitting the books and doing all that work, and just had it explained to me!!
Now, if that's not efficient....:p

sweetie76

2nd Jan 2010, 20:46

FlightDetent

3rd Jan 2010, 13:30

Perhaps I could attempt to help clarify few country-specific issues.

"Approach ban" is a descriptive term for a UK specific procedure, which is definitely not applicable in Polish sovereign airspace and I pretty much doubt that Cypriot operator would be affected either. Hence it is quite possible for even the smartest of folk to never have heard of it, until they are trained for UK ops.

This UK specific procedure enables ATC to (verbally) prohibit aircraft from continuing approach if met conditions are below some sort of "absolute minimum". There even exist a RT phrase that shall be cited to the commander of offending A/C.

The EU-OPS (by today's status a pan European aviation law) has a similar provision that targets shooting an approach below MNM. EU-OPS is uniformly applicable to all operators from EASA states - Cyprus included.
OPS 1.405 Commencement and continuation of approach
(a) The commander or the pilot to whom conduct of the flight has been delegated may commence an instrument approach regardless of the reported RVR/visibility but the approach shall not be continued beyond the outer marker, or equivalent position, if the reported RVR/visibility is less than the applicable minima.
(b) /.......removed for simplicity...../
(c) If, after passing the outer marker or equivalent position in accordance with (a) above, the reported RVR/visibility falls below the applicable minimum, the approach may be continued to DA/H or MDA/H.
(d) /.......removed for simplicity...../
(e) The approach may be continued below DA/H or MDA/H and the landing may be completed provided that the required visual reference is established at the DA/H or MDA/H and is maintained.
(f) The touch-down zone RVR is always controlling. /.......removed for simplicity...../
Sure it seems that among others the investigator will need to pull these drawers out:
- what was the reported RVR over OM/eq. position, i.e. was the crew legal to continue to DH?
- was the required visual reference achieved at and maintained below DH, i.e. was the crew legal not to go around?

I understand that you'll had been saying this for few posts upwards already, just wanted to make sure you don’t rip yer head off over different lingo while in agreement otherwise. Of course, I will be most happy and stand by to be educated further. Point one: I recall the definitions of "required visual reference" for CAT II, CAT IIIa, and CAT IIIb with DH. Could you help me pull out the official specs of required visual reference for CAT I?

Yours,
FD (the un-real)

BOAC

3rd Jan 2010, 14:23

FD - while I'm sure your question was rhetorical:), I will paste EU-OPS for CATI visual references from Appendix 1 (new) to Ops 1.430 Table2/4/b/6 (my bold) for the benefit of all -

6. Visual reference. A pilot may not continue an approach below MDA/MDH unless at least one of the following visual references for the intended runway is distinctly visible and identifiable to the pilot:
(i) elements of the approach light system;
(ii) the threshold;
(iii) the threshold markings;
(iv) the threshold lights;
(v) the threshold identification lights;
(vi) the visual glide slope indicator;
(vii) the touchdown zone or touchdown zone markings;
(viii) the touchdown zone lights;
(ix) runway edge lights; or
(x) other visual references accepted by the Authority.

In other words, just about anything that will let the dog find the rabbit.:)

FlightDetent

3rd Jan 2010, 15:41

:ok: The version I have just found on-line seems to indicate that your paragraph was copied from non-precision section of App to 1.430. Needless to say the CAT I paragraph says pretty much the same with exempt of (x).

The vague principles for required visual reference at (M)DA for NPAs and CAT I are based on one very important premise. That being the RVR is 550 or more (nee 300!).

Only then, one could decide to continue with only one distinctly visible and identifiable cue knowing that further down the approach the visual field will expand enabling the pilot to see clearly for the flare, touchdown, and rollout even with simple light facilities. Unlike the (most demanding - no HUD) CAT II manual where lateral and longitudal elements are mandatory at the decision for the sole purpose of making the last seconds of flight and subsequent landing possible for Mk1 eyeball at all.

Yours, FD
(the un-real)

BOAC: You indicate Appendinx (NEW) to OPS 1.430 but the text within still has MDA/H for NPAs. Out of sheer curiousity shouldn't that be DA/H? See, we still operate App (OLD) so I am clueless here...

BOAC

3rd Jan 2010, 22:12

Too late in the evening to look at your last para, FD, but you are indeed correct on the rest. The copy of EU-OPS I have jumbles together NPA and Cat I vis requirements in the same para. The heading of para b in which lies /6

(b) Category I, APV and non-precision approach operations

and x) is there!

Maybe it has been tidied up since my copy?

act700

4th Jan 2010, 09:21

FD, thanks for that (first) post clearing things up.

In that case, I take back what I said about things being different on the left side of the ocean, as really, by reading the last 2 or 3 posts, it boils down to the same thing!

In laymen's terms...you can't continue past the OM or equivalent, unless you have required visibility/RVR (for the type of approach you are conducting). And if vis goes down below req'd mins, once inside the OM/FAF, you can continue to DH/MDA "and have a look"!!
Continuing to land only if you have all the other stuff BOAC mentioned, otherwise MAP.

Correct me if I'm wrong, but over here (Euro/JARland) you also must have the minimum ceiling, whereas in the US only visibility is a controlling factor on whether you can start an approach or not (precision or non).

FlightDetent

4th Jan 2010, 09:40

No, for ILS approaches the meteorological minimum is only expressed by terms of RVR (VIS). No ceiling required. (based on JAR-OPS1 a.k.a. EU-OPS (old)).

FD (the un-real)

BOAC

4th Jan 2010, 11:15

act - I think the 'ceiling' thing is an 'historic' from those 'cut off by the English Channel' and I believe even 'les' have come in line.

Ptkay

7th Jan 2010, 10:11

Just to throw some more light on the conditions on that day,
the Wizzair A320 scheduled to EPKT diverted (without starting approach)
to EPKK, where the conditions were bad enough to cause a go-around.

No further approach attempt was undertaken at EPKK and the a/c eventually
diverted and landed in EPWA.

(Source: Polish AAIB web site, events register.)

stansdead

7th Jan 2010, 13:28

The Wizzair aircraft that diverted to EPKK had a system failure that required a mandatory Go Around very close to the Barometric minima.

Enough fuel was on board to still divert to WAW and land, in CAT1 conditions with over 1900 kg in tanks on shutdown. An airline with sensible fuel policy. Especially in Winter.

That is my understanding of events.

7th Jan 2010, 14:14

..... had a system failure that required a mandatory Go Around very close to the Barometric minima.

:confused:

So presumably it was Cat 1 or better at EPKK? Below Cat 1 you operate to a DH (Decision Height) based on RA (RadAlt) not to a Baro DA (Decision Altitude).

If the were indeed autolanding then they followed the correct procedure to go around for the failure - any more detail on what it was Stan?

A4

1+F

9th Feb 2010, 19:41

The Captain resigned almost three weeks ago.

Ptkay

11th Feb 2010, 07:58

Any more details. please?

Welcome to HEL

11th Feb 2010, 09:22

Well as I know it you dont need ALL of the visual cues. Initially (on minima) you will see approach lights which means contact and you can land. As you get further, the more you will see... My experience tells me that during night with 550m RVR you will see approach lights between 300-200ft RH. (very roughly depending on the fog and lights of course..)

w.t.HEL

stansdead

11th Feb 2010, 09:31

Welcome to HEL,

Extract from our "OM A" with the requirements for a CAT1 ILS approach, in terms of visual references required at MDA:

Visual reference
No pilot may continue a precision approach below the CAT-I decision height as
determined above, unless at least one of the following visual references for the
intended runway is distinctly visible to and identifiable to the pilot.
Elements of the approach light system;
The threshold;
The threshold markings;
The threshold lights;
The threshold identification lights;
The visual glide slope indicator;
The touchdown zone or touchdown zone markings;
The touchdown zone lights;
The runway edge lights.

That should make things clear for everyone. I hope.

Welcome to HEL

11th Feb 2010, 09:36

Yes act700 wrote "Continuing to land only if you have all the other stuff BOAC mentioned, otherwise MAP" and I opposed to the word "all".

w.t.HEL

Ptkay

10th Sep 2010, 12:13

The album with the photos of the damages to the runway and a/c,
as well as some documents has been published on the PKBWL (Polish AAIB) page:

http://www.mi.gov.pl/files/0/1792161/2009962A.pdf

1) This album contains pictures provided by the ports and LAX KTW
and made by PKBWL.
2) As part of describing the album contains pictures of damage to wheels wheels
mounted on an airplane (ie, under load) and pictures of disassembled wheel
( made in the hangar). Images depicting a mounted wheel
show the image as to be seen by the pilots.
3) According to Boeing, and the documentation:
â ˘ 737-6/7/8/9 AMM-ILF ILF-D633A102-rev. 40-Oct 15/2009,
â ˘ Task 32-45-00-700-803,
the damages on each damaged tire eliminates it from service.

It seems they were damn lucky to be able to take off from EPKT and
land in EPWA with such damages to wheels and tires without incident...

:mad:

Also the final report, unfortunately in Polish, but good images and drawings.

http://www.mi.gov.pl/files/0/1792161/2009962RKPKBWL.pdf

Ptkay

10th Sep 2010, 13:30

The comment of the Polish Board in the final report:
(crew "A" was landing in KTW, crew "B" continued to WAW.)

The Commission draws attention to the unethical behaviour of the crew "A" in relation to
Crew 'B' and failure of current procedures contained in the
Operator Procedures, and international law. The Commission is aware that the crew of the "A"
was in a very big stress after landing, but comparing the damage to the
aircraft, damage to the runway edge lights and the grass
loading it seems unlikely that the crew was not aware
they rolled off the runway. You must emphasize here the importance of
mutual trust and the importance of the flight crew compliance with operating procedures,
which are the final barrier to prevent the occurrence of aviation incident or accident.
In light of all the analysis you must
note that although the captain is
entitled to delegate tasks to his crew and "other
skilled staff" it, after all, that power does not release him, or his F/O from the requirement to comply with the pre-flight check of the aircraft as
described in the procedures of the Operator. Loading Crew 'A' has not completed
the notification of the incident, and did not transfer ABSOLUTELY NO information and comments to the crew of "B"
and the lack of implementation of the PDI procedure by the crew of "B" - because of her confidence
to the crew of "A" - testified to the lack of awareness of the current technical condition of the
plane. As a result, made a flight from KTW to WAW on a malfunctioning airplane.
This whole chain of events led to a big threat to the flight safety
the return flight to WAW and, as a further consequence, the execution of subsequent three commercial flights
without the implementation of the structural review of the aircraft as prescribed by the "after hard landing" procedure.

(sorry for my poor translation)