Skippers incident.

[metrodashbrazconkie]

http://blogs.crikey.com.au/planetalking/2013/12/06/atsb-skippers-aviation-flight-risked-crash-in-western-australia/

[haughtney1]

Impressive ROD in the flare though....:E

[BPA]

I'm surprised CASA allowed them to use 300' for stable approaches, considering industry best practice is 500'. I've flown turboprops for 3 different airlines and they all used 500' in VMC.

[VH-UFO]

Limited fault of the crew, are you serious?

[Mister Warning]

Slammer - that would be a good start.

[VH-UFO]

So Slam, you obviously are aware of problems at Skippers then, have you reported it?

No one pointed a gun at there heads and told them to be at 300ft in a 23 degree bank with a ridiculous sink rate.

That above scenario is beyond perceived problems at Skippers.

[Cactusjack]

Slam click doesn't work for Skippers, nor does he know what the internal problems are at the airline, he works for Skytrans.

[Capn Bloggs]

For you experts out there (and the ATSB), the stabilised approach critieria of 300ft would probably be to facilitate Visual Circling at 400ft.

The root cause, revealed by the FO but not taken up in the investigation after that, was the base turn at 10-15 sec. That will never work, regardless of what height you're at.

Skippers seemed quite active after re education...

[Bladeangle]

You're spot on with both points there Bloggs.

[Tee Emm]

Sometimes on occasions like this event, the captain should use his airmanship and conduct the approach personally. There is a tendency in Australian airlines for the captain, once having given "the leg" to the first officer, to show great reluctance to change his mind, no matter if the weather conditions have changed. Few captains will ever admit to this though. They feel it is wimpish to take back the leg.

They can rationalise as much as they want - but it often takes a bit of moral courage to say to the first officer "Sorry about this old chap, but I have control for the rest of this leg." There will always be sulky first officers who see this as a slight against their perceived "professionalism" and have no compunction in making their feelings known about the captain's decision. That shows poor discipline and that type of personality is usually a pain in the neck. Eventually, seniority means they become captains and heaven help their first officers after that happens. We have all seen this happen

In another era, the captain was expected to act as the captain. A first officer may be offered a take off or a landing - but the question of him flying "a leg" never arose. The game changed when someone invented the neutral terminology of PF and PNF or PM whichever. The word "captain" almost became a dirty word. Emasculated even.

Times have changed. And now, rightly or wrongly, depending on which side of the throttle quadrant you sit, we accept that it is a 50/50 split of 'legs` For all intents and purposes, the first officer, no matter his experience level, becomes the PF or captain and is encouraged to make all the command decisions while the real captain sits somewhat uneasily in his new role as PNF or co-pilot.

With the introduction of CRM, which, though designed as an a hint for captains to bring his crew into the decision making process, there were unintended consequences. Emboldened by enthusiastic non-pilot CRM authors and lecturers, a more aggressive attitude by first officers was encouraged. This may explain the reluctance by captains to assert their command authority and take over control of the aircraft from the first officer if circumstances warranted it

The cockpit is not a democracy. One man has the legal authority for the safety of the aircraft. If the captain is uneasy about conditions ahead and in his conscience feels he should take over, for whatever reason, (storms ahead, crosswind getting up, low vis, heavy rain over the airport, then he has a moral responsibility to act on that feeling and simply say "taking over". It really doesn't hurt at all.:ok:
If his first officer screams "FOUL" then stiff...

[Capn Bloggs]

Well said, Tee Emm. :ok:

[Capn Rex Havoc]

Tee Emm and Capn Bloggs-

Or the Captain, as pilot monitoring could have said "GO AROUND" when they got the EGPWS.

or he could have said "I have CONTROL"

I don't know if the weather conditions were so bad to preclude he FO from flying the sector or if the company SOPS had any ruling on weather conditions precluding the FO from landing.

The fact that the captain wasn't the pilot flying should have given him the situational awareness to see when the approach was going pear shaped and called for the go around.

That would still be acting like a Captain would it not? :ok:

[Capn Bloggs]

Havoc,

or he could have said "I have CONTROL"
that's what Tee Emm was saying.

It is reasonable to assume that the captain was more-skilled, and therefore, had he been flying the approach, wouldn't have placed them in a position where the GPWS was going to go off in the first place. That's what Tee Emm's thrust is. While the option to Go Around is always there, one doesn't deliberately increase the chance of having to do one by letting the FO do a difficult approach.

Possibly, they decided that a right circle with the FO flying was a better option than a left circle with the captain flying. In that case, that was what they were stuck with...

[tmpffisch]

I wonder whether the circling approach off the DGA (a circling approach) was even briefed, or if they assumed they'd get to circling minima and continue straight in on 07 without any hassles.

[josephfeatherweight]

I operate in an environment where, when possible, we conduct 50/50 operations (PF vs PM) - there is, however, no doubt as to who the captain is. Pre-briefing is a must - something along the lines of "The conditions are going to be a bit challenging - I'm sure you can handle it and I'd like to give you the chance to try, however if my comfort level is being stretched, I may take over - don't take this as a slight against your abilities, just understand that the responsibility is mine and I like to be conservative." This sort of "pre-brief" need probably only be given in such detail once with a new copilot - they understand the situation. Once the situation exceeds your comfort level, it can take more skill than one would desire to get it back on the rails. If you did end up having to take over, a post flight debrief would also be appropriate reinforcing the fact that you believe they could probably have handled it (if that's true!) but that your comfort levels were being stretched - if you didn't need to takeover, well, good job copilot!

[Bladeangle]

Totally agree Jo, your ship, your responsibility.

But what if the shoe was on the other foot, and it was the skipper driving at the time, and this skipper was getting on in age a bit, but with prevailing weather conditions he found himself a little out of his depth, warnings going off, SOP's not being complied with, how should an FO respond to this scenario?

[haughtney1]

Tee Emm and Capn Bloggs-

Or the Captain, as pilot monitoring could have said "GO AROUND" when they got the EGPWS.

or he could have said "I have CONTROL"

I don't know if the weather conditions were so bad to preclude he FO from flying the sector or if the company SOPS had any ruling on weather conditions precluding the FO from landing.

The fact that the captain wasn't the pilot flying should have given him the situational awareness to see when the approach was going pear shaped and called for the go around.

That would still be acting like a Captain would it not?

Quite succinct and accurate, moreover that would be as I expect it to be done.

Reading between the lines, it would appear that the approach, or more to the point the type of approach it turned into was inappropriate for the conditions (essentially benign with a bit of patchy cloud/fog about) e.g. bloody near a split arse turn!
Quite frankly I'm astounded that this type of maneuver was even contemplated..and speaks volumes about the company culture and the commanders mindset/comfort level in allowing it to continue.
The report reads like the two individuals concerned were PERFECTLY happy to pole the a/c about in this fashion....and only when the EGPWS started chirping was anything said, again for me..volumes being spoken right there.
I don't think this is an issue regarding PM v PF or PIC v 2IC, this has far more to do with a mindset and potentially a flight Ops culture, the reason I say potentially about the fly Ops culture is that the two individuals chose not to report the incident...

[metrodashbrazconkie]

Flight ops culture?


You mean, too scared to report because of fear of the repercussions to the individual? or, no need to report because flight ops like you to "get the job done"?


On second thoughts, it doesn't matter, it's all bad either way.


Both have left, probably flying jets full of blissfully unaware people thinking they're in safe hands.

[haughtney1]

Metrodash....exactly, I have no idea what the Flt Ops culture is/was, but actions or inaction speaks louder than words.
It is very telling that they chose not to report the incident.

[Capn Rex Havoc]

Bloggs- Not quite the same. I was referring to taking over when the approach became unstable. Tee Emm was inferring to not giving the FO the leg from the outset. Now I was not sure about the forecast or actual weather conditions, and I am not saying that a Captain shouldn't take the leg when he/she feels it is appropriate, but in this case I didn't see anything that would have warranted the Captain taking over the leg from the outset. (Unless the SOPS preclude an FO from doing a Non precision approach).
TM said
Sometimes on occasions like this event, the captain should use his airmanship and conduct the approach personally.
I don't agree that this was such an occasion.
Where the captain Did not use his airmanship or show command, was in not either calling for the go around, or taking control.
:)

[aussie027]

From the report-
At 0751:36, at 730 ft, the peak rate of descent derived from the recorded data was about 2,500 ft/min. At 0751:48, while passing 300 ft the derived rate of descent was still about 1,800 ft/min, the speed was 11 kt above the reference approach speed (Vref) and the aircraft was banked 23° to the left as the runway centreline was intercepted. At 0751:55, at 100 ft, the derived rate of descent was about 1,200 ft/min as the landing flare was commenced and a small amount of power reintroduced. The touchdown on the 1,800 m paved runway was normal at 0752:12.

A circling approach in IMC requires a normal RoD and normal manoeuvres for the type for a landing within the runway touchdown zone in order to descend below MDA along with the required viz and clear of cloud etc.

Everything stated is obviously grossly in excess of that requirement. According to the above report they went from 730' to touchdown including a power on flare in 36sec total!!

This extreme dive for the runway is beyond exceptional in any circumstance. A jet commencing a 3 degree descent from altitude at a 500KTAS / GS would be using a 2500fpm descent rate. This rate was achieved at some point above 1000 ft and was still maintained passing 730!

Everyone above has made comments on the Capt and FO roles and behaviour etc and I certainly agree with most of those comments.

The point I want to make, and not just in this particular incident and for every pilot is that these type of extreme manouvres suggest a get in at all costs mentality in order to save potentially nothing more than a few minutes of time.
A few lousy minutes at what cost?
In this case a potentially crashed large aeroplane and 53 lives lost! Seriously?

Surely even before commencing descent from MDA if it is apparent the cloud, viz or aircraft positioning is not going to enable a safe normal, stabilized appch and landing then flying another low level circuit to better position oneself will take at most another what, 0.1 hr, ie 6 odd minutes.
If the cloud , viz doesnt allow this then the conditions are obviously below circling mins in which case a MAppch is required and maybe another approach and circling attempt , another 10-20 odd min max or at most a diversion to altn or a brief holding period before a reattempt depending on conditions, fuel etc.

In NO CIRCUMSTANCE does the saving of a few minutes of time and thus a relatively few associated dollars justify any attempt to do so at the risk of an accident and loss of any number of lives.
How would any of us be able to live with ourselves afterward if we did so and survived a disaster when others did not??

If we were running late for work, how many of us would drive 30kmh plus or more over the speed limit and run every red light in order to make up the 5-15min we might be late??

Our lifelong training to operate efficiently and thus save time and money even if only a few minutes sets up a sub conscious mentality to do the type of things Ive described above that only clear rational thought and consideration of the consequences can override.

[Monopole]

Tee Emm was inferring to not giving the FO the leg from the outset.


I do this often, simply by saying that that particular leg is mine. No need to give an explanation and if one is sort for, I just say I need an RNAV/ILS or whatever for recency.

[haughtney1]

Tee Emm was inferring to not giving the FO the leg from the outset.


I do this often, simply by saying that that particular leg is mine. No need to give an explanation and if one is sort for, I just say I need an RNAV/ILS or whatever for recency.

Good grief, this is starting to sound like a "gear up and shut up" type situation, do you guys honestly operate that way?

[Monopole]

Nope not at all. But if in the planing stage you are already in the mindset of possibly taking over for whatever reason, then way give it to the other pilot in the first place? BTW, I was more referring to the wx hovering around the conditions where our Ops manual states should be a captains approach or departure. I personally would rather fly it from the get-go instead of taking over during an approach or once it gets out of hand.

[A37575]

something along the lines of "The conditions are going to be a bit challenging - I'm sure you can handle it and I'd like to give you the chance to try, however if my comfort level is being stretched, I may take over - don't take this as a slight against your abilities, just understand that the responsibility is mine and I like to be conservative."


Why say in 60 words when you can say it in three "I have control".

[haughtney1]

Fair enough Mono, and in the instance you describe, you would expect a professional pilot in the F/O role to be cognizant of that, and who you would hope would have a similar level of expectation.
A good commander IMHO should be able to identify the legs where their superior experience allows them to avoid situations that require their superior piloting skills:E
i.e. the mythical Capts weather...:}

[Capn Rex Havoc]

Monopole- I must admit to being perplexed here. In my company, the FO cannot do cat II/III approaches, that is for the skipper. But if I am going to a cat I only destination, like sydney, for example, and the weather is happens to be hovering around minima, I am still perfectly happy for the FO to fly it. Why? because, he is just as capable to do the job as I am. If we get to minima and not visual - Then I expect him to say "go around Flaps" and off we go.

If the FO is capable of doing a non precision approach and the weather was around minima, it makes no difference. As I have stated, the problem here goes way beyond the Captain taking the leg. Basic command skills, Pilot monitoring skill, SOP stability adherence, EGPWS alerts, and non reporting of the event are all serious issues that appear to swept aside by those who simply state-

"The Captain should have taken the leg", to which I reiterate - is bollocks. :)

[Buttscratcher]

...... Also consider that the FO probably flew that circ app without seeing the runway because it was on the Capt's side
The blind leading the blind?

[Capn Bloggs]

...... Also consider that the FO probably flew that circ app without seeing the runway because it was on the Capt's side
The blind leading the blind?
No, they circled right.

[Capn Bloggs]

In my company, the FO cannot do cat II/III approaches, that is for the skipper. But if I am going to a cat I only destination, like sydney, for example, and the weather is happens to be hovering around minima, I am still perfectly happy for the FO to fly it.Why? because, he is just as capable to do the job as I am. If we get to minima and not visual - Then I expect him to say "go around Flaps" and off we go.

If the FO is capable of doing a non precision approach and the weather was around minima, it makes no difference.
Bit simplistic there, Havoc. Benign wx with only low cloud on a Straight-In ILS, fair enough. In a top-level airline with experienced crews, also fair enough. But that doesn't happen all the time in the lower level operators.

Do you expect a FO with 100 hours or less in the aircraft to do as good a job as the skipper in crap weather? Of course not. Would you give him the leg or not change your mind and take over before the approach if things were nastier than forecast? Of course not. I see no reason to give a tricky approach to an FO who then may reasonably put me in a position that forces me to either take over or issue a GA command, or scare himself so much that he decides to GA.

[Capn Rex Havoc]

Bloggs- Do you expect a FO with 100 hours or less in the aircraft to do as good a job as the skipper in crap weather? Well, do you mean fly a non precision approach in an RPT aircraft, for which you have been rated on, trained on etc to minima?
Yes I do expect them to be able to do it. Do i expect the Captain to be effective in a Pilot Monitoring role - Yes.

Would you give him the leg or not change your mind and take over before the approach if things were nastier than forecast?
Nastier than forecast how? Crosswinds? Turbulence, snow showers? Yes.

If it is a 'Tricky approach' like the RNP-AR approach into Seychelles, then surely there would be company SOPS outlining who gets to fly it.

I am sorry, we will have to agree to disagree on this one.
The Captain was within his rights to and showed no lack of airmanship in allowing the FO to do the leg (as I said, provided it did not contravene SOPS).

All the Focus of this discussion should be on the subsequent poor flying and poor pilot monitoring that went on and the issues it raised of insufficient training in EGPWS warnings and stabilisation awareness.

[redsnail]

Just as an aside, Flight Safety Foundation via Skybrary say

during a circling approach wings should be level on final when the aircraft reaches 300 feet above airport elevation;

SKYbrary - Stabilised Approach (http://www.skybrary.aero/index.php/Stabilised_Approach)

[framer]

For all intents and purposes, the first officer, no matter his experience level, becomes the PF or captain and is encouraged to make all the command decisions while the real captain sits somewhat uneasily in his new role as PNF or co-pilot
That is not how it is in any of the airlines I have flown in. The F/O becomes the PF but doesn't magically morph into the Captain. For example, if the F/O is PF and wants to cruise at a higher level than they currently are,he or she would probably say something like " I'd like to climb to 380, are you happy with that?" and the Captain responds with whatever they want.
Sometimes it is more appropriate for the f/o to fly a non precision in poor weather, the FSF lists Captain as PF as a risk factor for CFIT, it's pretty obvious why.

[Paragraph377]

As an outsider looking in, it sounds like the crew gradient at Skippers is poor. Some Human Factors issues coming into play. The 2007 Garuda at Yogyakarta is the perfect example. The F/O had around 10 opportunities to take control of the aircraft and tell the Captain he was 'taking over'. The aircraft was horribly unstable and the aural warnings were repetitive. Ironically post accident the Captain went to jail, and the F/O never received so much as a written warning!
The point being is that a Captain and F/O work as a team, with only a slight authority gradient. I thought we had come a lot further than this in 2013.

[Capn Bloggs]

When I pranged my dad's new car, he didn't blame the 'safety culture' of my family. He taught me to take some damn responsibility for my driving.
Good one. Bit late to teach you (or crews) to take responsibility for driving after you've pranged his car/aeroplane. Apart from your (lack of) skill level/inexperience (Rex!) I'd say the family safety culture had a lot to do with you pranging your Dad's car...

[Centaurus]

The F/O had around 10 opportunities to take control of the aircraft and tell the Captain he was 'taking over'.

Interestingly, few if any company operations manuals that this Ppruner is aware of advise the specifics of how the F/O will "take over" if he doesn't like what he perceives as a dodgy approach flown by his captain.

In the example of captain as PNF and F/O as PF, if the captain doesn't like the way the F/O is flying an approach, all he has to do is say "I have control" and it is generally accepted the F/O will immediately relinquish control to the captain without an argument.

Place the boot on the other foot and the captain is now PF and the F/O gets nervous and doesn't like what he sees, so he does what his company SOP says and says "I have control"

Can you honestly imagine that the captain will meekly abrogate his command responsibility and saying "Handing over, Bloggs"? Of course not. If the F/O grabs the controls from the captain the chances are there will be a struggle for control. That will be infinitely more dangerous.

During a court case in Singapore on the Silk Air B737 suicide crash, evidence was given in court of the same captain of that flight, pressing on regardless, during a previous flight. His approach was high and fast and he then used the technique of using full aileron to the stops in each direction in a misguided attempt to use spoiler operation to increase drag and reduce speed on short final. His New Zealand F/O urged him to go-around but the captain was having none of it. He was going to get in or else.

The F/O knew it would be impossible to fight the captain for control even all the time he called for the captain to go-around. Finally as the 737 passed 900 ft agl over the fence, the F/O shoved open the thrust levers while the captain still had both hands on the control wheel. In other words the F/O used that window of opportunity to force a go-around. It worked and the captain had no choice except to go-around.

So while airline management can blithely come up with an SOP that says the F/O should take over control (disregarding the obvious case of incapacitation of course), there is no guidance as to how to physically take over control if the captain refuses to acquiesce.

Selecting gear up is the last resort to force a go-around if there is a battle over the controls and no captain will then deliberately land gear up to make his point. So why not have that as SOP for the F/O to hang his hat on. Better than nothing which is the current situation...

[Toruk Macto]

Agree that as a last resort all the F/O can do is put the gear up to force a go around . Aussie told me he did it at mapati many years ago so as to force a go around from a high , fast app into a valley with a cpt who's ego was out of control . Lost his job .