QantasLink Sydney 26 Dec 08- astonishingly unsafe approach?

[paulg]

Late yesterday the independent air safety investigator, the ATSB released a damning report into an astonishingly unsafe approach to Sydney Airport by a QantasLink turbo-prop at the end of a flight from Moree on Boxing Day 2008.This is the view of Ben Sandilands today in Crikey.com.
Qantaslink cockpit failures exposed by ATSB report – Plane Talking (http://blogs.crikey.com.au/planetalking/2010/06/08/qantaslink-cockpit-screw-up-exposed-by-atsb-report/)

AO-2009-001 (http://atsb.gov.au/publications/investigation_reports/2008/aair/ao-2009-001.aspx)
I am not sure if this was "astonishingly unsafe" but there are some shades of recent accidents with unmonitored airspeed on final (Colgan at Buffalo).

Does this incident have serious safety implications which are being kept from public scrutiny as Sandilands seems to suggest or is his article another beat up? :confused:

[swh]

I am not sure if this was "astonishingly unsafe" but there are some shades of recent accidents with unmonitored airspeed on final (Colgan at Buffalo).

I agree, just an inexperienced FO that got overloaded.

Also I am not sure why the ATSB is associating a FAF with an ILS. Precision approaches have FAPs, not FAFs. Their reference to non-compliance to the SOPs excerpts listed does not make sense to me.

The FAF listed on the chart is for the non-precision approach (LOC 34), a pure ILS approach, like YMML ILS-X (the CAT II & CAT III) only has a FAP.

http://www.airservices.gov.au/publications/current/dap/MMLII04-123.pdf

[jungle drums]

Did I read that right?

At the time the PNF PIC was writing down a "Landing Clearance"....

Is that SOP peculiar to Qantaslink?

If this is indeed an expectation - that the PNF (and PIC in this instance) have a pen in one hand and something to write on in the other - at such a busy point in an approach then the world has indeed gone mad.

That is the layman's equivalent of writing, texting, GPS programming, while driving in traffic and the people that come up with these ridiculous 'ass covering' procedures should be held accountable.

In fact we need a sea change - they need to be made to chew on the indecipherable 800 page Ops Manuals that they, and the authorities, come up with.

[aditya104]

people that come up with these ridiculous 'ass covering' procedures should be held accountable.



a lot of flying training colleges use such procedures/rules to make more money and hours for instructors

[Wing Root]

ATSB is a little lacking on the detail here. Chatting with a Qlink mate about this a while ago I was told that with the landing clearance the tower also told them to exit at taxiway Foxtrot and it was this information that was written down.

[remoak]

Also I am not sure why the ATSB is associating a FAF with an ILS. Precision approaches have FAPs, not FAFs. Their reference to non-compliance to the SOPs excerpts listed does not make sense to me.FAF and FAP are exactly the same thing. FAF is the ICAO usage and FAP is the American usage. A fix is, by definition, a point, in this case a three-dimensional one. It is common to find FAP on Jepps and Jepp-derived charts, and FAF on plates supplied by regulatory authorities in non-US countries.

[Mud Skipper]

SWH

The FAP is co-incident with the FAF of a localizer-based non-precision approach in Australia.

What are you trying to refer to with the ML16 chart? Where do you think the FAF/FAP is? G/S intercept at 4000' or 3000' or where?

Clear as Mud.

[GUARD]

When I was at Eastern the technically correct procedure to comply with the FAM was to write down the landing clearance on the Landing Card.

So there you go.....Ass covering indeed. I think the captain involved was actually a checkie to boot !!!

GUARD:ok:

[Normasars]

When I was at Eastern the technically correct procedure to comply with the FAM was to write down the landing clearance on the Landing Card.

So there you go.....Ass covering indeed. I think the captain involved was actually a checkie to boot !!!

GUARD

Was never the case when I was there, and I was a Checkie, and not that long ago either.

[Doctor Smith]

So, was that the one with check Capt. Flan-diddly-anders and the cadet FO? Heard it was almost a loss of control event :E
From memory the taxi light was used for landing clearance.

[eocvictim]

That is the layman's equivalent of writing, texting, GPS programming, while driving in busy shopping centre...

Fixed for accuracy.

As a result of this occurrence, the operator has proactively implemented changes to its DHC-8 training syllabus, highlighted to its crews the destabilising effects of changes to an aircraft's configuration during an approach and emphasised to crews the importance of good communication in a multi-crew environment.

Obviously the cadet programs are skipping the basics of GFPT. :hmm:

Next they'll overshoot the turn onto final because of a crosswind. :rolleyes:

[Offchocks]

Where does it say the FO was a cadet. Having 2100hrs total including 220hrs on type is more than enough to operate as an FO. I am afraid it was just a stuff up, luckily no sad outcome!

[desmotronic]

Having 2200hrs total including 220hrs on type is more than enough to operate as an FO

Obviously not in this case and why no ATPL. :hmm:

[Offchocks]

desmotronic

Very true, but you could ask, what was the Captain who was very experienced doing?
How would an ATPL make a difference in this case?

[desmotronic]

How would an ATPL make a difference in this case?

That depends on why he didnt have one.

you could ask, what was the Captain who was very experienced doing?


The captain told him to go around and yet he tried to continue.:ugh:

[Snowyflier]

From desmotronic (http://www.pprune.org/members/99152-desmotronic)
Obviously not in this case and why no ATPL.


What difference does "no ATPL make? I never completed my ATPL exams until 6,000hrs plus. Am now a Q300 Captain with in excess of 11,000 hrs

[desmotronic]

I never completed my ATPL exams until 6,000hrs plus. Am now a Q300 Captain with in excess of 11,000 hrs

Congratulations snowy you have risen to dizzy heights.:8


What difference does "no ATPL make? If he had less than 75 hours instrument flight time then that might have made a difference in this case.:ok: For other possibilities please refer to CAR 5.172.

[ozbiggles]

Immediate report
2 pilots a CVR,FDR and radar tapes.
And it takes 18 months to issue this final report?
And it doesn't even talk to much about the FOs training?

[remoak]

Am now a Q300 Captain with in excess of 11,000 hrs

Well done!

Mind you, I was a 146 captain when I had around 3800 hours... yeah i don't think many people are going to be impressed with your progress at 11,000 hours!

[tea & bikkies]

I sense a bit of dick waving going on here. Lets get real guys, we all do sims..
we are all human..know what I mean.

[swh]

FAF and FAP are exactly the same thing. FAF is the ICAO usage and FAP is the American usage.

Incorrect, they are not the same.

On an ILS the intercept point to the final approach segment is known at the final approach point. It is not a fix since the exact location varies depending on how the approach is flown, where the wind is coming from, the speed of the airplane, and other variables.

If you look at this approach for RW 16 at MEL, the LOC is overlaid. This chart has the two published FAPs as the ILS only chart I linked above, (3000 STAR and 4000) for the ILS, and one FAF for the LOC (6NM ML DME).

The Australian AIP includes references to both the FAF and FAP.

The FAP is co-incident with the FAF of a localizer-based non-precision approach in Australia.

Incorrect

What are you trying to refer to with the ML16 chart?

It was the only ILS chart I could think of in Australia that does not have the non-precision LOC approach overlaid on the chart. You will notice that on the chart it refers to a FAP in the notes in the bottom RH corner.

The ILS/LOC charts for the same runway refer to the FAF, as they have the LOC approach overlaid.


Where do you think the FAF/FAP is? G/S intercept at 4000' or 3000' or where?

That depends on how you are instructed to intercept the ILS.

If you were doing a STAR it would be at 3000 STAR, otherwise 4000. They are the published minimum altitudes that intercept the glide slope.

[eocvictim]

I sense a bit of dick waving going on here. Lets get real guys, we all do sims..
we are all human..know what I mean.


I'm sure I've missed your point. You cant be saying that a shaker while conducting an ILS is every acceptable under and circumstance?

[tea & bikkies]

m sure I've missed your point. You cant be saying that a shaker while conducting an ILS is every acceptable under and circumstance

Yes, you are exactly correct, it is not acceptable. Should never happen under training or check, if it did the crew member/s involved would not be on line in the first instance, my point is that it goes to show how human we all are.

[remoak]

On an ILS the intercept point to the final approach segment is known at the final approach point. It is not a fix since the exact location varies depending on how the approach is flown, where the wind is coming from, the speed of the airplane, and other variables.

Don't think so. All ILS plates show an ideal approach profile and there is no latitude for weather conditions, that is why it is called a PRECISION approach. The FAP/FAF is a defined point in space. Maybe there is an odd Australian interpretation that you have found, but it certainly isn't in line with the ICAO definition.

If you were talking about non-precision approaches, then you could say that the FAP lies within an area 5 degrees either side of the approach axis... but not for an ILS, where it is on the localiser at a specific height and/or distance.

I'm not sure what the point is that you are trying to make from the chart, as it doesn't define any FAP that I can see (other than by inference).

[training wheels]

The ATSB report seems a little on the 'thin' side. What was the reason for the PF not going around after the captain called for it? Loss of face?

[43Inches]

All from AIP GEN 2.2 (definitions);


Final Approach Fix (FAF): A specified point on a non‐precision instrument approach which identifies the commencement of the final segment.

Final Approach Point (FAP): A specified point on the glide path of a precision instrument approach which identifies the commencement of the final segment.
Note: The FAP is co‐incident with the FAF of a localiser based non precision approach.


Simple FAP equals same location as FAF for localiser approach, regardless of where you join the ILS.

[swh]

All ILS plates show an ideal approach profile and there is no latitude for weather conditions, that is why it is called a PRECISION approach.

That is incorrect, in the chart design takes into account a range of temperatures and QNH, as well as aircraft performance.

An aircraft maintaining 3000 ft, is not an absolute 3000 ft, it is not QFE, is it subject to the local variations in the column of air that the aircraft is flying in, i.e. temperature, lapse rates, QNH, inversions etc all change the altitude.

Also the ILS is still an analogue style approach aid, it is the onboard equipment that looks at the various lobes to come up the ILS path.

The FAP/FAF is a defined point in space.

The FAP is a fixed point in space (e.g. where the altitude 3000' intercepts the glide slope), the FAF is fixed relative to the ground, e.g. . 6NM ML DME.

Maybe there is an odd Australian interpretation that you have found, but it certainly isn't in line with the ICAO definition.

It is as per the current Australian AIP and ICAO.

Simple FAP equals same location as FAF for localiser approach, regardless of where you join the ILS.

Thanks for posting the definitions, however this comment is incorrect.

The FAP is "A specified point on the glide path of a precision instrument approach which identifies the commencement of the final segment."

The note "The FAP is co‐incident with the FAF of a localiser based non precision approach.", this is for when the glide slope is U/S. It is not the non-precision LOC approach, not the ILS.

For your comment to be correct you should have written "Simple FAP equals same location as FAF for localiser approach, regardless of where you join the LOC."

[43Inches]

Sorry SWH but your interpretation is incorrect, the FAP on runway 16 at melbourne is at 5.7 IMS (ILS-Z) passing 2240 AMSL on descent. The aircraft must be established in the final approach configuration passing this altitude/distance.

The only way you can specify a point on the glidepath is by altitude or distance from a fix. The FAF for the localiser is at a DME distance or the OM which gives you a horizontal fix point on the glideslope which should be coincident with descent passing the FAP height.

At an ILS with no DME measure then the Outer Marker is usually the FAF/P.

It is at the same DME distance as the LLZ FAF but the aircraft will be established on the Glideslope as well.

For the ML 16 ILSZ Bolida is the IAF (STARS and vectoring aside), 2240AMSL passing 5.7IMS on slope is the FAP. Therefore initial segment and speeds from BOL to 2240 on descent then final segment and speeds to the DA.


The note "The FAP is co‐incident with the FAF of a localiser based non precision approach.", this is for when the glide slope is U/S. It is not the non-precision LOC approach, not the ILS.



If the glideslope is U/S or fails you can not fly an ILS and the FAP no longer exists. There is no such thing as an in-between or half ILS/LLZ aproach, you are doing one or the other. You may switch to the LLZ approach if safe to do so.

As a final note please refer to the Sydney ILS PRM plates, the LLZ is not permitted and not charted. In these cases the FAP is marked, not at the glideslope intercept.

[Icarus53]

Unless any of you want to assert that the differences (if any) between a FAF and FAP had some kind of effect on how the aircraft was or should have been operated in this incident, how about you take it somewhere else.

This incident clearly highlights some substantial CRM issues, and I for one would have liked to see a more thorough discussion by ATSB and the company as to how they can/have/should be addressed.

Perhaps if we could dispense with irrelevancies, we might have a reasonable discussion between professionals here?

[paulg]

Yes Icarus you have pointed to the real issues. Also should the ATSB processes and airline's responses be more transparent and open to public scrutiny?

[Fly-by-Desire]

Shoulda', coulda', woulda'! DeHavilland didnt install stick shakers for fun, they knew something...

[Capt Fathom]

Oh.. for the perfect world! Sh#t happens....

Get over it! :ugh:

PS. People die every day on our roads! Why do we make such a fuss over avaition incidents!

[prospector]

PS. People die every day on our roads! Why do we make such a fuss over avaition incidents!

Very probably because if such a fuss was not made over incidents there would be more accidents.