Virgin Australia Boeing 777 dirty dive at Melbourne 34

[sheppey]

Latest Flight International has a report on a Virgin Australia Boeing 777 doing an unexpectedly rapid descent on autopilot and low level approach to Melbourne Runway 34. The media report said the ATSB inquiry will focus on how data was incorrectly inserted into the FMC and remained undetected.

Rather than hang the crew on incorrect data input that occurred earlier in the cruise, it would be more beneficial if ATSB focused on why the company SOP emphasis to stick with the autopilot until the last few seconds of a visual approach, led to a potentially critical situation. Surely it is not that hard to hand fly a 777 on a visual approach from over Essendon to touch down on Melbourne 34 without resorting to heads down on automatics until the last minute. Talk about company induced automation dependency. No wonder airline pilots are reputed to be losing basic handling skills.

Perhaps VA management and also ATSB could learn something useful about automation dependency by attending the USA conference on the Asiana 777 accident. See below.


WASHINGTON - The National Transportation Safety Board is conveninga 2-day investigative hearing to discuss the ongoing investigation into the crash of Asiana Airlines Flight 214 and to gather additional factual information. The hearing, which will be held December 10-11, 2013, at the NTSB's Board Room and Conference Center in Washington, DC, will focus on pilot awareness in highly automated aircraft, emergency response, and cabin safety. Parties participating in the investigative hearing will be announced at a later time.

[Wally Mk2]

This 'event' am sure has been played out here on Pprune in details a while ago


Wmk2

[Jack Ranga]

Ya root one goat.......

[A37575]

Interesting bulletin from the FAA. Maybe the OP is on the right track after all?

Subject: Manual Flight Operations
Purpose: This SAFO encourages operators to promote manual flight operations when appropriate.
Background: A recent analysis of flight operations data (including normal flight operations, incidents, and accidents) identified an increase in manual handling errors. The Federal Aviation Administration (FAA) believes maintaining and improving the knowledge and skills for manual flight operations is necessary for safe flight operations.
Discussion: Modern aircraft are commonly operated using autoflight systems (e.g., autopilot or autothrottle/autothrust). Unfortunately, continuous use of those systems does not reinforce a pilot’s knowledge and skills in manual flight operations. Autoflight systems are useful tools for pilots and have improved safety and workload management, and thus enabled more precise operations. However, continuous use of autoflight systems could lead to degradation of the pilot’s ability to quickly recover the aircraft from an undesired state.

[RAD_ALT_ALIVE]

Effective threat and error management starts from the time you prepare to leave home/hotel until you complete the parking checklist; it is then constantly re-evaluated and modified to suit the circumstances at the time.

If the crew involved in this event did have interrupted rest (which in my experience is the norm on every longhaul duty) - I fail to see how turbulence enroute can be used as a contributing factor - then an alternative open to them was to require (not request) the RNAV or VOR approach onto 34.

Or if VA management want to enjoy the benefit of uninterrupted rest while curled up next to Mrs VA management, do as EK have done for years and mandate that visual approaches are not permitted whenever there is an instrument approach available to the duty runway (for longhaul ops).

But having said that, the 34 visual approach via SHEED is no biggie if given a few minutes of considered thought. The last time I did it was the first time in about 7 years (some guy living near the final approach to 34 had barricaded himself in his house and was firing shots...thus no IAP to that runway). The old queues were there; MCDU showing 5nm to lose nearly 2200' and visual confirmation at SHEED that we were high.

It also re-ignites the old Airbus v. Boeing thing; team A recommend (and have done so for years) that AP is off for any visual approach, while Boeing don't appear to. Whether it is 'better' than not, I don't know - I do know that it takes away any ambiguity about how the approach will be flown and focuses the mind before the approach even starts. It also means that any botch-up is IMMEDIATELY manageable by a suitable control input. With AP engaged, a departure from the expected takes necessarily longer to correct; identify the excursion, evaluate the reason, determine if it can be saved using the AP, decide it can't, change mindset to that of taking over earlier than planned, recover (which is then far later than it probably should be).

[schlong hauler]

The visual approach over Essendon for 34 YMML is really questionable in this day and age. Why are we still doing this approach to satisfy some dumb airspace requirements. If you have any quartering tailwind on base then you need 1000'/minute at least if around Vapp 145-150 with G/S of 160 plus. Fine for a slower aircraft but for modern jets and restrictive parameters one must question the need for this approach when a safer easier approach via Rnav/Gnss is available. If the crew had just flown through the night then I can understand completely how this situation transpired. I have come close to being unstable numerous times in a heavy NG due to the rate of decent required. CFIT and unstable approaches are the number one safety issue and ATC expecting this sort of approach after a long duty is plain irresponsible. I bet more crew will request the longer arrival after this!

[Capn Bloggs]

JetX, that was a good spray but largely misguided. Sheppey never suggested hand-flying in a thunderstorm with one engine out on limited panel with jammed asymmetric flaps on a circling approach so he could keep current.

As for
I believe the crew did the right thing, trapped the error & managed it.
I'm not sure that the outcome would indicate that. They saved the day but seem to have got caught out to a certain extent (as I have been too).

The old queues were there; MCDU showing 5nm to lose nearly 2200' and visual confirmation at SHEED that we were high.
They are the cues present for all Sheed arrivals; you have to be "high" at Sheed. The problem has the incorrectly entered altitude for the "finals" waypoint, and apart from the Active Plan altitudes in the box, nothing would be out of the ordinary until after passing Sheed, then down she goes.

Shlong Hauler, well said. :D

[Roller Merlin]

Simply ask yourself why MEL ATC issue the Sheed arrival to any Aussie airline, but almost never to a foreign airline. There is a cultural aspect here - the design is poor, there is an expectation that locals will be ready and do it and foreigners shouldn't. Apparently many foreign carriers prohibit the approach. Not appropriate for an international airport.

I once saw a Korean airline attempt it and woefully stuff it up.

[Tee Emm]

I once saw a Korean airline attempt it and woefully stuff it up

That is to be expected of course. Ops normal.:E

[gordonfvckingramsay]

Can't blame ATC for issuing the arrival, they do what they believe will get approaches and arrivals processed as expediently as possible.

It is us pilots who should be coping the blame for accepting it. As Roller Merlin said, local guys and girls seem to be the only ones to take what ATC dish out. If you are not happy with the approach given, all you have to do is say "sorry I can't accept that, require XXX approach" and they will have no choice but to give it to you, and they will get over it.

Besides, it is only a handful of extra track miles and a minute or so V's a go-around or worse. Try it one day.

[Lookleft]

When Qantas first started operating 767s on domestic routes their pilots would "require" 16R when allocated 16L. It didn't take long before a stop was put to that presumably after some phone calls between ATC and QF. The argument over the SHEED approach is that it there is no valid reason for an approach to be designed in a way that requires high descent rates for it to place an aircraft in the correct position for a landing. ATC allocate it because they have to. Pilots accept it but there are better ways to process aircraft that don't require non-standard configurations and descent profiles.

[Tee Emm]

Some contributors have disregarded the main point made by the OP. After all ATSB, did not question the flyability or otherwise of this particular STAR.

It was more a question of why the captain did not promptly stop the automatic pilot placing the aircraft further into the steep angle of descent to the degree that it did. By the time he took action the autopilot had already done the dirty on him and the aircraft was very low on final.

The reluctance of crews to disengage the automatic pilot and revert to manual flight to correct an undesirable flight path is a re-occurring factor frequently noted by flight safety researchers into the subject of automation dependency.

However, continuous use of autoflight systems could lead to degradation of the pilot’s ability to quickly recover the aircraft from an undesired state.

A case in point?

[Wally Mk2]

'Lookyleft' the SkyGods (QF) still think they own R16R! & I don't care what anyone says they get 'looked' after to.
Am not to sure what all the Hoo Hah is here, I mean gee it's not rocket science to fly a modern day Airliner in basic flight mode, I mean after all it's a visual App & if yr ahead of the A/C then via Sheed is no more difficult than staying ahead of the game.


Wmk2

[waren9]

then re read some of the posts by the lh guys working oseas wallly and give them some thought.

mostly its about being human

[Wally Mk2]

'ratty' that sums it up well there:) It is probably the last 'fun' App left & can be a challenge in windy conditions but still very doable knowing it's always ok to Go- Around:ok:

Good 2 C you acknowledge even with tongue in cheek that the SkyGods are being looked after, perhaps the beer is better handed over to ATC at xmas time:E


Wmk2

[spelling_nazi]

This approach is fun. But it's being made more difficult by the Qf new rule of maximum rod is limited to the height agl such that.

< 3000 max rod 3000fpm
< 2000 max 2000 fpm
<1500 is 1500 fpm
Etc

Often with light winds you need an initial high rod just after sheed to get back on profile .

I find myself concentrating more on not tripping a qAr event than flying the bloody thing

[Centaurus]

I find myself concentrating more on not tripping a qAr event than flying the bloody thing
.

Isn't that so true in airline operations nowadays? Worse still the tendency for some operators to pounce on the QAR as a punitive issue rather than a flight safety trend issue.

[Potsie Weber]

This approach is fun. But it's being made more difficult by the Qf new rule of maximum rod is limited to the height agl such that.

< 3000 max rod 3000fpm
< 2000 max 2000 fpm
<1500 is 1500 fpm

That was brought in to comply with the IOSA standards manual for the IOSA Audit.

[Derfred]

If you find yourself exceeding 2000 fpm after Sheed then I think a little chat with someone probably IS in order.

[Wally Mk2]

'centy' it's called "Just Culture", another one of those feel good comments:ugh:
Sure we know yr human & accept that, so the Co's say, but just don't F*ck it up!!!

The ROD is conducive to the ground speed, flying into a H/W straight after Sheed means you have more time to get down, T/W from Sheed means don't dilly dally once you start down from Sheed. Pretty easy seeing as we are meant to be pilots although Co's seem to want more puppets these days!!:-)



Wmk2

[Keg]

If approaches from SHEED were tripping the various QAR parameters then I suspect something would be done about it. The reality is that for most people that fly the visual from SHEED, it's a non event.

I've seen a couple of guys leave the automatics in after SHEED and disconnect when aligned with final. Have to say I'm not a big fan of it. Much prefer to disconnect and do it myself. :ok:

[judge.oversteer]

Huh?
What's the difference with this approach and the JFK 13L Canarsie approach? How on earth did we ever get on with the 13 IGS at Kai Tak??
Have to agree with you Keg.
JO.

[Centaurus]

How on earth did we ever get on with the 13 IGS at Kai Tak??
Have to agree with you Keg.

Actually that is a pertinent point. Having flown the Kai Tak 13 IGS approach many times in another life, it was nowhere as difficult as I was led to believe.
With a modicum of basic jet handling skills it was most enjoyable to hand fly the approach and gave one a great sense of satisfaction to complete the turn on to final without S turning.

I don't envy todays pilots where it seems to me they are forced into hanging on to the automatics to satisfy their company standard operating procedures. Then when they go click click and fly by hand because they enjoy flying the aeroplane rather than continue with button pushing until the last few hundred feet, they run the risk of tea and bikkies because big brother QAR is waiting to catch you.

It should be a seamless transition from automatic flight to manual flight providing the pilot has the confidence in his own ability to do so without scaring people

No one is saying after a long flight you should disengage the automatics at 15,000 ft just to get hand flying skills up. Time and time again we see sarcastic remarks on Pprune pages when someone dares to suggest they enjoy the pleasure and personal satisfaction of flying by hand.

What has happened in the last 30 years since automation became increasingly reliable and sophisticated, is that there are airline pilots secretly apprehensive of switching over from automatic flight to manual flight paths because they have got rusty and don't want to look a fool in front of the other pilot. They then rationalise by mumbling that autopilot flying is smoother and safer. And of course it is under certain circumstances.

A recent analysis of flight operations data (including normal flight operations, incidents, and accidents) identified an increase in manual handling errors. The Federal Aviation Administration (FAA) believes maintaining and improving the knowledge and skills for manual flight operations is necessary for safe flight operations

There are even Australian regional airlines mandating full use of automation from barely airborne to short final. And that is in CAVOK:rolleyes: No wonder this breeds a pilot totally dependant on his automatic pilot and flight director. The cadet system does just that.

Apologies for thread drift.:ok:

[Keg]

Tony Kern made an interesting point at a safety seminar I was lucky enough to attend once.

He compared airline flying to target shooting and suggested that to be an airline pilot you need to be able to 'shoot' about an 84. He said if you consistently shot 85 but never higher than an 88 you may think you're ticking all the boxes…… until that one day where if you don't shoot a 93+, you're going to die in a plane wreck. If you've never tried to shoot 93+ previously, what are your chances of doing it when you suddenly need to?

From that day on I resolved to do as much hand flying and be as accurate as possible all the time when the conditions permitted. Sometimes that means that I'm auto coupled to 100' (or lower). Other times I'm disconnecting at FL150. Sometimes it means in the sim hand flying a 100m vis approach once the rest of the session is completed or engaging in various other things designed to improve my scan, handling ability, etc.

We've taken the love of automation WAY too far. Don't get me wrong, it's a great tool in the arsenal but if we neglect our own stick and rudder skills then the day we need THAT tool to survive we're not going to be able to use it properly.

[donkey123]

Funny thing is, you would expect the guys that chuck the automatics in at 500' and take them out at similar altitude the other end to be fairly 'current' when it comes to managing the automatics versus the guy that regularly hand flys to transition and on approach (when conditions permit).

In my experience that's not really case. I haven't flown the Victor approach to 34 for a couple of years, but in my observations the guys that regularly relied on the automatics were the same ones who started playing piano on the MCP once passed Sheed then quickly disconnected and battled with the machine all the way to touchdown. This is usually followed by some statement about that "bloody vnav" on the taxi in.

So it's a double edged sword, the guys that don't regularly practice hand flying seem to be the same guys that have to disconnect (unplanned) and hand fly after mismanaging the automatics on approach.

I guess it's kinda what keg was just saying, you need that currency one day when it all goes wrong.

[Anthill]

RWY 13 IGS was a fairly easy approach to fly: a LOC and G/S to take you to a pre-determined point at 700' and then SFL to guide you to a 60m wide RWY that had PAPI on both sides and an abundance of approach lights. I thank that the hype came from the fact that the approach meant operation in close proximity to buildings and a lot of journalistic beat-up in the travel press. The IGS was similar to the approach into NVVV. AS a further comparison, the similar IGS into Macau is tighter and less forgiving if you aren't tracking properly. Closer to home, I've seen more people stuff a visual approach to a 5nm final on RWY 16 at YMML than I have the RWY13 IGS. :rolleyes:

The appropriate use of automatics as a risk mitigation tool is what is important. Why hand fly at FL370 when it is safer to use the autopilot? It's nice to hand fly an approach, but if you are tired and there are parallel RWY operations, isn't it safer to intercept the LOC with A/P?

During my career, I have flown SHEED in B737, B747, B767 and B777 aircraft. I've never had an issue with it. As for this particular incident, why there is so much discussion? So, what are the facts? A crew flew the approach with A/P connected, VNAV apparently commanded a higher rate of descent than the crew were happy with, the A/P was disconnected and the aeroplane landed safely without any stability parameters requiring a go-around being broken. The crew then self-reported a perceived safety issue.

Big Deal. :hmm:

[waren9]

dead right mr anthill

still, its not yet got to 93 posts like the bne taxiway thread.

thats aussie aviation for ya tho'. an severe obsession with the trivial :zzz:

[A37575]

why there is so much discussion? So, what are the facts?

Facts as read from ATSB:

after passing waypoint SHEED,4 the final waypoint in the STAR, the autopilot increased the rate of descent from about 700 feet per minute (fpm) to about 1,500 fpm. This was a greater rate than the crew were expecting. They discussed the anomalous descent and, expecting it to stabilise at the anticipated rate, they decided to monitor the aircraft’s rate of descent further.

Noting that the captain was concentrating on the information presented on the aircraft’s instruments, the first officer turned his attention outside of the cockpit to visually monitor the approach to the runway, which he had sighted to the right of the aircraft. The first officer noted that the approach to the runway visually appeared to be too low and alerted the captain, who agreed and attempted to reduce the rate of descent using the vertical speed mode of the automatic flight control system. After realising that this would not be effective, the captain disconnected the autopilot and took manual control of the aircraft. The aircraft was levelled off at about 700 ft above mean sea level (AMSL), or about 500 ft above ground level, and turned to the right to align with the runway.

The aircraft was flown level until the 3° approach glideslope was intercepted using the runway 34 precision approach path indicator (PAPI) and a normal approach and landing carried out.


No big deal someone remarked? Scarping in level flight at 500 ft agl until intercepting a three degree approach angle, isn't exactly a normal standard procedure for a wide-body is it?:D

thats aussie aviation for ya tho'. an severe obsession with the trivial

500 ft agl - that's trivial??

[Anthill]

Stabilisation height criteria for such an approach is 500' AAL. No stabilisation rules were broken. The crew put in a report.

So..??!

[hoss]

Intercepting PAPI from beneath, on a level segment, on the SHEED arrival.....priceless.

Might of ticked the boxes but I bet it was ugly!

[Lookleft]

Stabilisation height criteria for such an approach is 500' AAL. No stabilisation rules were broken. The crew put in a report.

I think even VA stabilized approach criteria might make reference to being on the correct approach path! Turning onto final on that approach you should be at least 1500'. Must have been interesting driving up the Calder that day to see a 777 fill your windscreen!

[spelling_nazi]

If you find yourself exceeding 2000 fpm after Sheed then I think a little chat with someone probably IS in order.

Not at all, the initial pitch over to regain path often demands a tad over 2000fpm . Only for a second or two but hardly unsafe

[Capn Bloggs]

Stabilisation height criteria for such an approach is 500' AAL. No stabilisation rules were broken. The crew put in a report.

I think even VA stabilized approach criteria might make reference to being on the correct approach path!
So what is the point/altitude that you must be on-slope?

[Lookleft]

Turning final would be an appropriate place on an approach like that. You do bring up a good point though, if it is difficult to determine from the approach where the aircraft should be stabilized then the approach is flawed and should be replaced with one where it is possible to determine if you are going to meet the stabilized approach criteria. An RNP approach would take care of it (as long as it is not designed by ASA).

[Sarcs]

Given this incident has now led to two dedicated threads (Operational non-compliance involving a Boeing 777,VH-VPH, near Melbourne Airport (http://www.pprune.org/australia-new-zealand-pacific/521932-operational-non-compliance-involving-boeing-777-vh-vph-near-melbourne-airport.html))and numerous references in many others, I think full credit should be given to the crew for properly reporting this incident to the ATSB.:D

Here is the bare bones summary of the VA crew initial report (as listed in the ATSB weekly summary): During the approach, the autopilot commanded a high rate of descent. The crew disconnected the autopilot and manually continued the approach. The investigation is continuing.
And here is where the ATSB investigation currently is at: AO-2013-130 (http://atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-130.aspx)

The healthy debate that has so far occurred in both threads dealing with this incident just goes to show the value of learning from such occurrences when they are properly reported and in this case investigated.:ok:

Although the crew in this incident appear to have appropriately recovered the situation (automated dirty dive that could have had dire consequences otherwise :{) there have been several recent incidents/accidents where the outcome, to say the least, has been less desirable.

sheppey mentions one of them:Perhaps VA management and also ATSB could learn something useful about automation dependency by attending the USA conference on the Asiana 777 accident. See below. NTSB Announces Investigative Hearing on Asiana Flight 214 (https://www.ntsb.gov/news/2013/131025.html)
Note: I would also suggest that there are a lot more stakeholders (other than VA management & the ATSB) that would benefit from attending the NTSB conference.

sheppey’s comment also highlights one of the chestnut safety issues that is troubling the worldwide aviation community and is being proactively tackled by the likes of the NTSB and the Flight Safety Foundation.

A bit of google research on the subject of Asiana Flight 214 and automation dependency brings up some interesting articles/references but surprisingly one of the most informative comes from a group of investigative journalists called the NBC Bay Area Investigative Unit: AnAutomation Trap for Pilots? (http://www.nbcbayarea.com/investigations/An-Automation-Trap-for-Pilots-221875391.html)

There is also another side effect of automation dependency and that is sudden and unexpected a/p disconnection (which amongst other things has got experts rethinking cockpit design): Redesign for Sudden Autopilot Disconnection Needed, Say Flight Safety Experts (http://www.aircraftsystemsafety.com/default.asp?item=&iId=GEMMDF&iPostID=KGIMG#KGIMG)

Flight safety experts studying recent high-profile plane crashes found sudden autopilot disconnection to be a design flaw that creates unnecessary emergencies by surprising pilots during critical, high-workload episodes.

"The sudden disengagement of autopilot is analogous to a pilot suddenly throwing up his or her hands and blurting to the copilot, 'Your Plane!'" says Eric E. Geiselman, lead author of a recently published two-article Ergonomics in Design series, "Flight Deck Automation: Invaluable Collaborator or Insidious Enabler" (July issue) and "A Call for Context-Aware Logic to Improve Safety" (October issue).

Eric E. Geiselman, along with coauthors Christopher M. Johnson, David R. Buck, and Timothy Patrick, have combined expertise as pilots, crew resource management instructors, and human factors researchers. They studied the 2009 Colgan Air crash in Buffalo, New York, and the 2009 Air France crash off the coast of Brazil with a focus on how humans and machines can best communicate on the flight deck.

The authors recommend that autopilot systems transfer controls following the same protocols crew members use -- with acknowledgment by the receiving pilot that he or she has assumed control. FAA regulations require a visual and auditory warning to occur following autopilot shutoff, but Geiselman et al. emphasize that such warning should occur before -- not after -- autopilot is disengaged.

Geiselman et al. report on many other design-level safety issues in these articles and offer prototypes featuring solutions that can be affordably implemented with available technology. They believe better design of automation technology on planes can prevent future accidents and that more pilot training shouldn't be the only solution pursued by the industry.
The other safety issue chestnut, that the VA 777 incident appears to be invoking debate on, is the parameters of a stabilised approach and when to initiate a go around. In light of Asiana Flight 214,amongst other similar incidents/accidents in recent years, the Flight Safety Foundation took the initiative to investigate what is regarded as the leading causal factor for runway excursions i.e. unstable approaches. The following is a FSF article on the subject which should help to liven up the debate: Failure to Mitigate (http://flightsafety.org/aerosafety-world-magazine/feb-2013/failure-to-mitigate)

And a quote from that article to (hopefully) kick off some robust comments :E: Example of a Go-Around Experience

1. At a point immediately above SAH, the pilot’s “gut,” or what we refer to as affective awareness, subtly signals him or her to confirm that the aircraft’s flight characteristics and profile are normal. In a near-instantaneous and seamless fashion, this might be followed by

2. A visual check, or what we refer to as a check to provide functional awareness, which would be made where the pilot’s expert knowledge and ability to understand the instruments plays a key role in confirming whether the cue from their gut was, in fact, correct. Simultaneously, there is …

3. An immediate and confirmatory statement from the pilot’s network of past experiences, or critical awareness, occurs, in which professional experience confirms the presence of a “normal” flight profile. Seconds later, however, imagine that in continuing its descent below SAH, the aircraft encounters significant turbulence with headwinds shifting to tailwinds and downdrafts altering VREF (reference landing speed) by +21 kt, accompanied by a vertical descent now greater than 1,100 fpm. Instantly, …

4. The pilot’s anticipatory awareness, the ability to see these threats, registers in harmony with the reactivated gut, expert instrument knowledge and experience — all awarenesses that are now signaling a non-normal event — and there arises an immediate need for a signal from...

5. Task-empirical awareness, the pilot’s expert knowledge of the safe operational envelope limits of the aircraft. Imagine further that this expert knowledge confirms that although the aircraft is now unstable, it still remains within the safe operational envelope. However, before concluding that parameters are now safe or unsafe, manageable or unmanageable, this developing event requires immediate input from another awareness competency …

6. Compensatory awareness, or the ability to understand how to compensate correctly for non-normal events, occurs by referencing through functional awareness whether the aircraft and the instruments will direct the flight state back to a normal condition if acted upon. Whether the answer, not yet fully formed but informed by critical awareness, is likely to be “yes,” “no” or uncertain, imagine that the pilot is also simultaneously receiving …

7. Through relational awareness — the pilots’ knowledge of how they use their relationships to protect safety — input from a crewmember that re-enlivens a memory trace of a prior verbal signal, based on a conversation and agreement earlier in the approach initiated by the pilot monitoring, that a go-around might be necessary should the aircraft become unstable at or below SAH, which …

8. Informs and motivates the pilot to engage hierarchical awareness, or the individual’s expert knowledge of operational procedures under specific operational conditions, so as to confirm their ability to safely fly a go-around if necessary. Finally, with the pilot-in-command and other crew rapidly coming to a common assessment of, and agreement about, the risks inherent in continuing with the unstable situation that faces them, in comparison with the inherent risks of any go-around maneuver, and...

9. Confident that their company would support a decision to initiate a go-around, and in an expression of their environmental awareness concerning the wider organizational reward structures surrounding support for safety, the pilot flying puts all of these elements of awareness together to judge that the risks confronting the flight crew are not fully manageable, and so decides to call for a go-around. Some more articles from FSF on this safety issue: The Rare Go-Around (http://flightsafety.org/aerosafety-world-magazine/march-2012/the-rare-go-around) & Why Do We Forgo the Go-Around? (http://flightsafety.org/aerosafety-world-magazine/apr-2013/why-forgo-go-around)

Fill your boots...and IMO three cheers to the VA crew! :D:D:ok:

[A37575]

Informs and motivates the pilot to engage hierarchical awareness, or the individual’s expert knowledge of operational procedures under specific operational conditions]

A thoughtful and most pertinent observation. That said, and I agree with the post, I often wonder if the 250 hour overseas cadet pilots now commonly occupying the second in command position in the 737, 777, A330 and other jet transports can possibly have all those attributes listed. After all, those qualifications only come with been there-done that, experience.

[Berealgetreal]

That approach is fun on a clear day when well fed and rested. In other circumstances it can be a handful.

[Potsie Weber]

The latent failure in this incident was the SOP of the company to change the RW34 altitude to 380'. It is as simple as that. This was the root cause of the incident.

Who the hell derived an SOP to complicate a quite simple visual maneuver by adding 50' to the RW34 waypoint in the FMC to produce a more accurate VNAV path for a "VISUAL" procedure?

On a visual procedure do you really need to have an accurate VNAV path to within 50' over the threshold?

How this SOP to alter the FMC altitude was derived, approved and implemented by flight ops management is what needs investigating.

This incident has very little to do with the operating crew.

The crew were following utterly ridiculous policy and resultingly made a simple error by putting the 380' at the runway extension waypoint instead of the threshold. An obvious potential threat with such a flawed and unnecessary SOP.

To me this potentially indicates an immature organisational structure within flight operations management where policy is implemented with little understanding or review of the potential adverse outcomes of seemingly innocuous standard operating procedures implementation.

[UnderneathTheRadar]

C'mon Potsie - tell us what you really think.... :-)

[maui]

Potsie

If this is an SOP, it must be published somewhere. It would be helpful if you could advise where such publication lurks, cos I am stuffed if I have seen it.

If it is not published in a controlled document, it is not an SOP. On that basis "caveat emptor" would be appropriate.

This is a relatively straight forward VISUAL procedure. The STAR finishes at SHEED and the charts used by this crew indicate a visual segment from that point. Why o why do we continue to complicate our job by fiddling with boxes, when a good old mk 1 eyeball is what is required.

In days of old, (before it was called SHEED and before 250 below 10) this approach was regularly flown at up to 300 clean at the 26 EN threshold, then stabilised at 500. And that is before we had glass and stabilised criteria. It was even done by F/O's and graduate cadets, (horror).

That is not to suggest that we can indulge in that style of operation in today's environment, nor should we. It does however suggest that this approach is not overly difficult for a crew that is on top of their game.

If the weather is crappy, don't do the SHEED, it's a VISUAL approach. If you are tired and not feeling up to it, don't do the SHEED, have ago at one of the less stressful options. If you choose to do SHEED (if your company will let you), don't complicate it with unecessary procedures, and above all look out the friggin window, it's a visual approach.
If you think it is beyond you when well rested and in visual conditions, look for another line of work. It aint rocket science!

These comments are not directed at the crew of this particular flight as I have little knowledge of who what when or why. These comments are directed at the mish mash of pious drivel appearing in the thread, many of whose contributors clearly have issues, real or imagined.

Feels better

M

[point76]

As others have said-this is a Visual approach.The only reason it exists with its minimal margin for error ( unlike most procedures in Airline flying ) is geographical, ie-Melbourne Airports close proximity to Essendon Airport. By flying down the EN Runway 26 centreline it allows ATC to do simultaneous take-off & landings to the North at both airports without worrying about separation issues. Initially you flew the EN 26 localiser to EN NDB not below 2500', now its an RNAV route to SHEEDS which gives slightly more room to move. I believe the intent though ( like the 'breakout' manouevre for a PRM approach at SYD ) is that it is a hand flown visual approach ( & which commences about 500' too high on to a 2.8 nm final ). Trying to fly this approach on automatics is always going to leave a crew wide open to a major stuff-up and there are already plenty of examples of that on this approach.

[Potsie Weber]

From the ATSB Investigation AO-2013-130 (http://atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-130.aspx)

The altitude for RW34 defaulted to the runway threshold altitude, in this case 330 ft and the altitude of RX34 was automatically calculated by the FMC. The operator’s SOP advised flight crews to amend the runway 34 threshold altitude to 380 ft, resulting in a 50 ft threshold crossing height at RW34. At the time of the occurrence, the procedure did not include an altitude constraint for RX34 and hence the FMC-calculated altitude for RX34 was to be accepted by flight crews.

What? So someone is lying to the ATSB? There was no SOP to alter the altitude?

[maui]

Again. Where is it or was it published? If published, was it a controlled document.
An SOP is different to a discussion in a sim session

M

[Vorsicht]

In days of old, (before it was called SHEED and before 250 below 10) this approach was regularly flown at up to 300 clean at the 26 EN threshold

Gee you guys must have been awesome in the old days, and I bet nobody ever screwed that up either. Tis a pity that us mere mortals of the digital age aren't capable of such manly feats of aviation, or is it just that as an industry we have got a bit smarter and don't do that sort of macho sh!t anymore because the only person it impresses is the idiot behind the control column.

:ugh::ugh::ugh::ugh:

[maui]

Vorsicht


That is not to suggest that we can indulge in that style of operation in
today's environment, nor should we.


I wasn't a matter of being awesome or macho. That was just the way it was done.

Circumstances and knowledge evolve.:ugh:

Maui

[Lookleft]

Circumstances and knowledge evolve


Precisely! So why are we still doing a visual approach off a STAR that positions you at a point that requires a non-standard configuration and an initial RoD greater than the standard accepted for a stabilized approach?

Not being pious or have issues but the approach is a hangover from dem olden dayz and should no longer be necessary.

[Capn Bloggs]

Gee you guys must have been awesome in the old days,
If you're going to rip into Maui on the basis of

In days of old, (before it was called SHEED and before 250 below 10) this approach was regularly flown at up to 300 clean at the 26 EN threshold

then at least also quote what he said next:

That is not to suggest that we can indulge in that style of operation in today's environment, nor should we. It does however suggest that this approach is not overly difficult for a crew that is on top of their game.

requires a non-standard configuration and an initial RoD greater than the standard accepted for a stabilized approach?
In all likelihood this was a stabilised approach. Don't confuse a "normal" approach verses an unstable approach. Just because you're doing 1500ft/min at 1500ft doesn't mean the approach is unstable. The "accepted standard" for a "comfortable" approach could be anything; the ops manual will detail the actual requirements of a "stable approach".

Good on the crew for reporting it. Lots of good lessons from it. I hope they don't get carpeted given that, from the interim report, it appears the aircraft was never "unstable".

[maui]

Lookleft.

At the point where a higher than normal ROD is required, the aircraft is not yet at the point where stabilisation is mandatory, so criteria are for reference only at that point.

If you are properly configured, on speed, and commence descent immediately you pass overhead SHEED, unless you have a screaming easterly, you will have no trouble getting on slope and stabilised within the criteria.

On that basis, what is the "non standard configuration" you talk of. Is being configured for landing with 5 or 6 miles to run a big ask. Pretty normal in other parts of the world. What do you do when the turkey in front slows up too early and you get "reduce to approach speed"? Do you respond with "no I am too far out to configure", and initiate a missed approach because you would require a "non standard" configuration? Doubt it.

To the question of "why are we still doing"
It is not compulsory.
Airspace restrictions
Traffic flow
It can be done within all required parameters
Economics

There are far more challenging approaches than this one lurking away in the wider world.

Maui

[Wally Mk2]

I love reading this thread, one of the most interesting out of the lot here on PRRune:-):ok:
Cm' on guys it's a simple Viz App flying an aeroplane, remember we are pilots you know guys/gals who manipulate the controls of a heavier than air machine to put it where YOU want to put it, man has been doing it since the "Wrong Bro's" started this whole mess:)
This is dead easy if yr ahead of yr charge & the planes not flying you, 3x time yr dist to run less any correction for RWY elevation, real basic raw pilotman-ship
If this App gets cocked up big time then it's obvious that someone is not minding the shop:ok:


Wmk2

[Capn Bloggs]

3x time yr dist to run less any correction for RWY elevation, real basic raw pilotman-ship

Errr, how about 600-odd feet high with about 5 track miles to run. Work out the 3x for that. ;)

[jbr76]

A fantastic video which relates to this thread is called Children of the Magenta.

Goes in depth into the various facets regarding automation dependency.

Automation Dependency 0001 - YouTube

[Capt Fathom]

Cm' on guys it's a simple Viz App flying an aeroplane

Wally by name, Wally by nature! One of your better ones!

[Wally Mk2]

'blogsy' the 3x's thingy is once you have washed off any access height initially, then it's std stuff.

'CF' that's fine I've been called worse & if it makes you feel more like a man knock yourself out there buddy:E


Wmk2

[Lookleft]

I love all the qualifications that accompany why this is a "standard" visual approach:


once you have washed off any access height initially



If you are properly configured, on speed, and commence
descent immediately you pass overhead SHEED, unless you have a screaming easterly, you will have no trouble getting on slope and stabilised within the criteria.

Just because you're doing 1500ft/min at 1500ft doesn't mean the approach is unstable.

There is no other visual approach off a STAR in Australia that requires any special considerations in terms of descent profile or configuration. All the others put you at 10 miles 3000' which is a standard descent point and profile with the aircraft being configured as the descent is maintained. The only reason this approach exists is because "we've always done it this way". If that is a valid reason for not changing anything then why not continue with the practice of 300kts to 20 miles, after all that would be the most economical and quickest way of processing traffic in the TMA. Its the way it used to be done and it was a lot of fun as well.

[Red Jet]

The only reason this approach exists is because "we've always done it this way".
Actually - I believe the only reason this approach exist, is due to the proximity of Essendon airport and that it allows an efficient utilization of both airports - Tulla AND Essendon, when a northerly landing is required or desirable due to the existing wind.

As has been pointed out - this ain't rocket science, it is a STAR that puts you on a Right Base turn onto the second longest runway in Australia and it is only used in good weather conditions. If it doesn't suit your operations, I believe the terminology "REQUIRE" RNAV or VOR for Runway 34 will sort it out henceforth.

[Lookleft]

I'm no airspace designer but what about moving the position that aircraft join final onto 34 further to the south so that aircraft into Essendon can join their final off a short base. Like I said "its always been done this way".

Just as I can't require a high speed descent into Melbourne because of personal preference I can't require another STAR because of personal preference. The word require is not to be used on a whim or to make a point. If its allocated I'll fly it but it is not without an elevated level of risk as the VA crew discovered.

You might want to define what "good weather conditions" are. If you exclude the wind then CAVOK=good weather conditions. Gusty northerlies and its associated turbulence does not mean good weather. Ask the people of the Blue Mountains whether they have been experiencing good weather conditions over the past few weeks.

[Red Jet]

Not saying you should do this, or anything else "on a whim". To REQUIRE another STAR is quite simply telling ATC that you cannot accept the SHEED approach. They will not make you do it, nor will they ask you to explain WHY. Quite simple - no really, it is!

[framer]

This is dead easy if yr ahead of yr charge & the planes not flying you, 3x time yr dist to run less any correction for RWY elevation, real basic raw pilotman-ship
If this App gets cocked up big time then it's obvious that someone is not minding the shop
Or......someone has been given less and less opportunity to fly the aircraft over the last decade as their sim time fills up with RNP procedures, low viz procedures, more V1 cuts, circling approaches with the automatics in etc yet no more sim time has been mandated to cover the changes. Eventually they lose confidence and skill and proficiency and elect to keep the automatics in when they shouldn't.
How many times a year would a long haul pilot do a visual approach hand flown?
The only way we will claw it back ( the skill set) is if companies are forced to train flying the aircraft.
Framer
Ps I hand fly often so I'm not making excuses but I can see why the skills are fading.

[C441]

Perhaps in response to this and other events, Qantas has advised their 747 and A380 crew not to accept the 34 Sheed arrival.
The approach is currently part of the simulator program for some fleets and will continue to be practiced there.

[Tipsy Barossa]

[QUOTE]C441 Perhaps in response to this and other events, Qantas has advised their 747 and A380 crew not to accept the 34 Sheed arrival.
The approach is currently part of the simulator program for some fleets and will continue to be practiced there.
[QUOTE]

Now, now, now...I thought only Asian chicken little airlines react this way! How the Yanks and misguided skygods laugh when some Asian airlines ban LAHSO procedures and some unfamiliar visual procedures? Not to excuse downright incompetence as the OZ214 crew's performance, but us westerners are good at covering our yellow spines under superfluous PR codswallop, smoke and mirrors. Rant over, got to finish my swig!:E:E:E

[Molokai]

Big problem : HYPOCRISY! ( taking into account the drift of TB's post )

Sensible and " carefully " erred on the side of caution.....errrr..uuhmmmmm....ahemmmmmm, why only now?

[Keg]

There's a review process underway. My hope is its not a permanent ban. Time will tell.

[blow.n.gasket]

Perhaps in response to this and other events, Qantas has advised their 747 and A380 crew not to accept the 34 Sheed arrival.


Have Management finally worked out that due to the amount of assigned leave being doled out on these fleets that flying skills might suffer if pilots only get to fly once in a blue moon!:eek:

[point76]

And then of course there was the 747 crew that attempted to land on Essendon Rwy 35 off this approach ( the pre-SHEED version ).That was an extreme approach and is why Rwy34 at ML has the flashing threshold strobe lights! ( 'report the strobes in sight' was standard at ML for a long time afterward )

[underfire]

I have been on this 34 APP several times in the 747, and it really is a horrible procedure. That last turn to final is quite the adventure, even on a good day.
LAHSO and Missed dont go well at all together, and the HS exits arent usable.

With QANTAS and few other auth RNP, I very seldom see ATC clear for RNP. Too mnay non-RNP in the queue to blend right. Not that one cant tell when RNP is enabled...it is a virtual overlay anyways.

[Keg]

I have been on this 34 APP several times in the 747, and it really is a horrible procedure. That last turn to final is quite the adventure, even on a good day.

I've done it in a 747 a number of times with no dramas though admittedly that was after 9 years of doing it in a 767. In reality it's no harder in a 747 than any other type. Currency and awareness make it easier- particularly on days where you note tailwind component across base.

[OpsNormal]

Bloggs wrote:

Errr, how about 600-odd feet high with about 5 track miles to run. Work out the 3x for that.

Easy, add 120'/nm to it... which will exceed the stabilised approach criteria of just about any company in the last 1000'.

Please do not take this personally..... It has certainly sparked some interesting debate here, which is good.... But it also seems it is good enough to throw at your company's potential candidates sitting a stressful enough first glass/jet ride/turbine of any type interview sim.

You folks did it to two of us on the same day earlier this year (repositioning the sim so as to be way high on profile and above glidepath), fast and clean, and pointedly ignoring the published multi crew calls you provide in your pre-interview litrature and what you pointedly brief your candidates on, therefore making the task impossible for candidates warned to NEVER close the power levers on a jet...

This is not aimed at you personally, however glass houses and all that....:=

The vid about "Flying the Magenta Line" is a must-see for anyone who inputs into an FMS during the course of their employment.

[Capn Bloggs]

Ops Normal, wot are you on about? My comment was directed at Wally, and if you thought-through my post you'd realise that I was saying his simplistic "use 3x" cannot work. I am not suggesting that we try a 450ft/nm descent after Sheed. As for "you folks" I haven't the foggiest about which you talk/write.

[FYSTI]

candidates warned to NEVER close the power levers on a jet..Sorry, I must have been asleep in that lecture, who's policy is this?

[Sarcs]

sheppey:Perhaps VA management and also ATSB could learn something useful about automation dependency by attending the USA conference on the Asiana 777 accident. See below.
Not sure if VA or the bureau attended but none the less there are some interesting prelim findings coming out of the NTSB hearing...:cool:

Flightglobal on NTSB factual summary: Investigators detail flight mode changes in moments prior to Asiana crash (http://www.flightglobal.com/news/articles/investigators-detail-flight-mode-changes-in-moments-prior-to-asiana-crash-394015/?cmpid=SOC%7CFGFG%7Ctwitterfeed%7CFG_safety&utm_source=twitterfeed&utm_medium=twitter)

The pilots of the Asiana Boeing 777-200ER (http://www.flightglobal.com/landingpage/Boeing%20777-200ER.html) that crashed 6 July in San Francisco (http://www.flightglobal.com/landingpage/San%20Francisco%20International.html) made a number of changes to the aircraft’s autopilot system in the moments prior to the crash, according to the US National Transportation Safety Board (NTSB).

In opening remarks held during a hearing in Washington, DC, the board adds that investigators have found no evidence of mechanical problems with the aircraft, which operated flight 214 from Incheon International (http://www.flightglobal.com/landingpage/Incheon%20International.html) Airport near Seoul (http://www.flightglobal.com/landingpage/Incheon%20International.html).

The crash, which led to three fatalities, was the first fatal 777 (http://www.flightglobal.com/landingpage/Boeing%20777.html) accident.

“The investigation to date has not identified any anomalies with the airplane prior to impact, although airplane systems testing and performance evaluation is on-going,” says the NTSB in opening remarks.

The board says that shortly after the aircraft descended through 4,800ft, the crew switched the autopilot to “vertical speed mode” with a commanded descent rate of 1,000ft per minute.

They also switched the autothrottle system to “speed mode” with a selected speed of 172kt.

But the rate of descent was not fast enough to remain on the normal glidepath, causing the aircraft to diverge above the normal angle, the board says.

When the aircraft was 5.2nm from the runway and descending through 2,400ft at 175kt, the altitude in the aircraft’s “mode control panel” was set to 3,000ft to prepare for a possible go-around, a normal action, the board says.

Then, at an altitude of about 1,600ft and 3nm from the runway, data indicates the flight level change switch, an autopilot mode normally used to climb or descend to a selected altitude, was activated.

That caused the autopilot to pitch the aircraft up and increase power in an effort to climb to 3,000ft, says the board.

The pilot responded by disconnecting the autopilot and manually pulling the throttles to idle, which moved the autothrottle switch into “hold” mode, meaning it no longer controlled the aircraft’s speed, says the board.

“When the flight level change mode was set... [the aircraft] wanted to climb... When [the pilot] overrode that mode by disconnecting the autopilot, he was telling the system... that he wanted to fly manually,” witness John Cashman, a retired Boeing 777 (http://www.flightglobal.com/landingpage/Boeing%20777.html) chief test pilot, explained to the board.

“He is flying away from the requested commands of the system, which would normally be controlling the speed,” Cashman says.

The pilots then changed the selected airspeed to 137kt, but the aircraft slowed below that target as it descended through the glidepath and continued “rapidly decelerating”, says the board.

At the same time, the pilot applied back pressure to the control column, increasing the aircraft’s pitch attitude.

“But there was no mention of the decaying speed on the recorders at this time. The thrust levers remained at idle, [the] airplane continued to lose airspeed and sink below the glidepath,” says the board.


Culture and automation dependency:

From Alarm, but Insufficient Response, in Moments Before Asiana Airlines Crash (http://www.nytimes.com/2013/12/12/us/asiana-airlines-crash-san-francisco-airport.html?_r=1&)

..."In the minutes before Asiana Airlines flight 214 crashed at San Francisco International Airport on July 6, one of the three pilots in the cockpit called out three times that the plane was descending too fast. But none of the pilots noticed that they were flying the plane too slowly until shortly before it hit the sea wall at the end of runway 28 Left.

..."The captain, Lee Kang Kuk, who was flying the plane, told investigators that any of the three pilots could have decided to break off the approach, but for “the low-level people,” including himself because he was being supervised by an instructor pilot, “it’s very hard,” he said.
Documents released on Wednesday by the National Transportation Safety Board, which held a daylong hearing on the crash, show that inexperience and Korean culture played a role in the way the pilots handled the landing..."

..."The documents indicated that there was confusion among the crew about how the Boeing 777’s auto throttles worked. Captain Lee had just 35 hours experience in that model, and in an interview with investigators he appeared to have confused some details of the automation system with that of the Airbus A320, with which he had extensive experience..."

From NTSB probes fatal Asiana Flight 214 crash (http://edition.cnn.com/2013/12/11/us/ntsb-hearing-asiana-flight-214/)

..."Bong said the crew practiced "cockpit resource management," training that encourages subordinates to speak up about safety concerns to other crew members, despite their senior rank, experience or seniority. But when the student captain was asked whether he had contemplated an aborted landing as the plane descended, Lee Kang Kuk said it was a "very hard" decision to make, given the deference shown in Korean culture...

By the time he pushed the throttle forward, just seconds before impact, he discovered the instructor pilot had already done so.

Culture also kept the pilot flying from wearing sunglasses, the interviews suggest. That was a factor momentarily when the student captain saw a flash of light as the plane descended through 500 feet.

Asked whether he wore sunglasses in the cockpit he said no, because it would have been considered impolite for him to wear them when he was flying with his PM. He said it was very important in their culture," the NTSB report says..."

...."The NTSB is focusing on what it says may have been the pilot's overreliance on autopilot and other automation on the sophisticated Boeing 777 aircraft.

Investigators asked the three-pilot crew about their understanding of auto-thrust, which controls the plane's power. The NTSB has previously said the pilots believed the auto-thrust was engaged, but it was not..."

Much still to be learnt from Asiana Flight 214...:ok:

Addendum: Totally agree Bloggsy the two events are like 'chalk and cheese' or in another perspective 'proactive' vs 'reactive' (reactions being about 2 miles behind the aircraft in FL214's case..:=) but sheppey did initiate the thread with the NTSB media release of the planned hearing (held yesterday), so..why not try to learn from it?? :ok:

[Capn Bloggs]

I'm unconvinced of the commonality of the two, Sarcs. Sure, the VA crew were using the automation, probably a reasonable thing to do after that (I assume long) flight (just as Asiana did), especially on the Sheed where you cannot afford to be level through Sheed; you need to clip 2500ft going down so as not to go higher still; VNAV helps to achieve that.

It would seem a simple waypoint/target altitude programming error was made by VA, subsequently picked up quickly and resolved. Asiana, however was different: unaware of what controls speed when in FLCH and continued inability to either notice or do anything about it. With VA, it was noticed and something done.

sophisticated Boeing 777 aircraft
Not very sophisticated if it lets a crew get well below Vref with it doing anything about it?