Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain

[alph2z]

Aviation Investigation Report A11H0002 (today)

Controlled flight into terrain
Bradley Air Services Limited (First Air)
Boeing 737-210C, C-GNWN
Resolute Bay, Nunavut
20 August 2011

Summary

On 20 August 2011, the Boeing 737-210C combi aircraft (registration C-GNWN, serial number 21067), operated by Bradley Air Services Limited under its business name First Air, was being flown as First Air charter flight 6560 from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut. At 1642 Coordinated Universal Time (1142 Central Daylight Time), during the approach to Runway 35T, First Air flight 6560 struck a hill about 1 nautical mile east of the runway. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and all 4 crew members sustained fatal injuries. The remaining 3 passengers sustained serious injuries and were rescued by Canadian military personnel, who were in Resolute Bay as part of a military exercise. The accident occurred during daylight hours. No emergency locator transmitter signal was emitted by the aircraft.

http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11h0002/a11h0002.pdf

Transportation Safety Board of Canada - Aviation Investigation Report A11H0002 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11h0002/a11h0002.asp)

Captain way off localizer with FO telling this to captain several times.

[clunckdriver]

The Canadian Military and Nav Canada got of lightly on this one, the extreame intercept angle and total lack of any real IFR operating knowledge, along with totally non standard procedures were in fact the first link in this train of events. There have been other recent incidents due to the the military trying to usurp Nav Canada/ ATC authority at mixed use airports, in this case not helped by an old aircraft with numerous avionics updates, lets hope this does not happen again.

[PEI_3721]

As above - slack Canadian TAWS requirement.
1998 US proposes TAWS requirement.
2001 US mandates the system.
2003 ICAO recommends TAWS, Annex 6 required TAWS after Jan 2007.
2008 EU mandates TAWS.

1995 Canadian TSB recommends TAWS after Sandy Bay accident.
2000 Canadian Aviation Regulation Advisory Council (CARAC) Recommends TAWS.
2011 Transport Canada Civil Aviation (TCCA) proposes regulations.
Canada finally mandated TAWS in July 2012 (no deviation from ICAO found), to be implemented by retrofit by July 2014.
A very tardy response, particularly when hosting ICAO headquarters.

[alioth]

The Canadian Military and Nav Canada got of lightly on this one, the extreame intercept angle and total lack of any real IFR operating knowledge, along with totally non standard procedures were in fact the first link in this train of events. There have been other recent incidents due to the the military trying to usurp Nav Canada/ ATC authority at mixed use airports, in this case not helped by an old aircraft with numerous avionics updates, lets hope this does not happen again.




It doesn't take a brain surgeon of a captain to figure out that if the localizer is showing full deflection on one or both of the instruments during the ILS and the FO is repeatedly saying that you are off course toward high terrain that it is time to go-around no matter what airport you are at. That is regardless of the stuff that happened earlier in the flight. There is always an excuse, but there is responsibility that comes with being PIC. Can't handle the obvious then don't take up the position.

[lear60fellow]

This is quite common in some companies, so let me explain my story on a future accident.

Last year I had to give line trainning to a captain fresh from sim on a new aircraft, 15.000 hours and had flown many different aircrafts. On the first days I noticed that something was going wrong with him. Another trainning captain took him over and had the same problems.

On my return with him I found out that he had no idea how to IFR, and I mean no idea!!! I don´t know how he passed sim at CAE. Further more asking other pilots they already new that, even OPS manager, but company didn´t care.

But that was not enough, he didn´t know how to read a METAR, avoid a thunderstorm or basic stuff like calculating fuel, etc.

We recommended to ground him and go back to basic flight school. What happened? company had him on trainning with a TRE for 10 months non-stop but still has no idea, fired us and let him fly...

[Hotel Tango]

The alarming thing for me is that despite all the emphasis on and training in CRM, and that this was in Canada, it still happened. Frightning!

[cockney steve]

After a quick skim through......
Copilot lacked assertiveness......he was aware of the danger , yet allowed himself to be browbeaten into accepting something he knew was wrong.

The Captain was complacent, lacking in humility and CRM.
IMO, As Commander, it was his duty to heed crew warnings and ask himself why Crew, GPS and Navaids all disagreed with the location he "thought" the Autopilot had them at.
I fail to see the relevance of the Military...they weren't flying the aircraft.

A very sad and sorry tale.."get there-itis?"

[Centaurus]

One of the finest air accident reports I have ever read in my over sixty years in the industry. A must read, especially for airline first officers whether brand new MPL's or highly experienced. It is a most comprehensive report and it is a dedicated pilot who will stick with it to the end. But it is gold standard.

[deefer dog]

A quote from the report.

In 2012, there were 24.4 million departures for a worldwide fleet of civil-operated, commercial, western-built jet airplanes heavier than 60 000 pounds maximum gross weight. 67 An article in AeroSafety World 68 stated that, while only 3.5% to 4% of approaches are unstable, 97% of unstable approaches are continued to a landing, with only 3% resulting in a go-around.

Are SOPS considered as guidance for wise men and for the obedience of fools?

[clunckdriver]

Alioth, like PEI372, I have spent a fair chunk of my life sitting around the edge, or sitting in, smoking holes in the ground trying not to puke and do my job, so forgive me if I find your assesment of this crash to be a little simplistic. I for one cannot find any reference to reading "needle impact traces" on the Captains HSI as to what his side of the office was in fact indicating, its maybe in there, but I havnt been able to find it as yet. The placing of a "lash up" military ATC l system using uncalerbrated equipment and personell was in fact the first link in this chain of events, this doesnt change the fact that the crew were in a state of obvious overload and confusion in the last seconds of flight, but it certainly played a part and deserves more than a passing mention in the report, if one adds in the highly modified state of the avionics on these older aircraft, with set ups which have many traps and pitfalls its suprising there are not more CFIT incidents. The post by PE1372 should be mandatory reading for all in Nav Canada and Transport Canada.

[alioth]

How many times you have been to a crash site means nothing and does not add anything to your argument.

There are many reasons why an aircraft can be off course. If your FO says to you multiple times things such as he is showing off course and full scale localizer deflection and that the GPS is also showing off course, reminds you about a hill that is on the off course track, suggests going around to figure things out and then you ignore him, continue and hit the hill, you are not going to look like a very professional pilot.


There are first links in the potential chain of events on every flight.

[ironbutt57]

When asked whether a go-around was required with full-scale deflection of the localizer, all pilots interviewed stated that this condition required a go-around. However, all pilots interviewed agreed that an FO could not command a go-around, and could not see an FO taking control from the captain. They stated that the FO would likely make a suggestion or negotiate with the captain regarding the need for action.

Hope they think differently now

[clunckdriver]

Alioth, I wish crash investigating was as simple as you seem to think it is, yes the aircraft was of track, yes the F/O stated this fact, but I can demostrate to you in the simulator how it is fairly easy to overlaod a pilot to the point that the computer between his/her ears just doesnt recieve or process what going into those ears, as for time spent at crash sites, Ive often thought that all pilots should do at least one "on site" investigation visit, it might make some pay more attention to to the little things which so often lead to such tragic events.

[Petercwelch]

It is difficult to understand how any captain, no matter how bone headed could ignore such concern from a first officer. Have any of the captains here ever had a first officer express such discomfort with an approach, and continue it, being certain in your own mind that he was wrong? Not having flown commercially, I have no knowledge of the range of communication/mis-communication in professional pilots cockpits.

[clunckdriver]

Peterwelch, the Captain was not a "bonehead", nor was he one to generate an atmosphere of intimidation in the flight deck, he was most likely in total overload and task saturation and/or task fixation, as I pointed out in a previous post we can replicate such conditions in the simulator with multipe distractions/mechanical failures. The final factor which doomed this flight was an EXPERIENCED non -asertive F/O, just the final factor in this sad affair, note I said "experienced" F/O, the USA has just increased the hours required to be in the right seat in a scheduled airline, Canada has just gone the other direction and introduced the "Multi Crew Lic",I can see problems with crewmembers ignoring an F/O who isnt allowed fly an aircraft solo and has less than a hundred hours of flight time, but that another discusion altogether.

[DLT1939]

I agree an excellent report, much to be preferred to the often anodyne reports that offer few lessons prevent future occurrences.

In some ways reminiscent of another excellent report into a CFIT incident to an American 757 at Cali, Columbia in 1995.

The report of the Columbian investigation is here:

Cali Accident Report (http://sunnyday.mit.edu/accidents/calirep.html)

but one pertinent extract is:

Researchers studying decision making in dynamic situations [22] have suggested that experienced persons can quickly make decisions based on cues that they match with those from previous experiences encountered in similar situations. A referenced text refers to this characteristic as Recognition Primed Decision Making, in which a decision maker's rapid assessment of the situation is almost immediately followed by the selection of an outcome. It states:
"Our research has shown that recognitional decision making is more likely when the decision maker is experienced, when time pressure is greater, and when conditions are less stable." [23]

22] Klein, G., (1993), Naturalistic Decision Making: Implications for Design. Wright-Patterson Air Force Base, Ohio: Crew System Ergonomics Information Analysis Center.
[23] Klein, G., (1993), A recognition primed decision (RPD) model of rapid decision making. In Klein, G. A., Orasanu, J., Calderwood, R., and Zsambok, C. E., (Eds.), Decision Making in Action: Models and Methods. Norwood, New Jersey, Ablex, p. 146.


The Cali investigators also commented on peoples reluctance to change a decision, once made, even in the face of new and conflicting information.


The Canadian report does not say how many times the Captain had operated
into Resolute Bay, but mentions that he had previously made several successful approaches in similarly difficult conditions and that he knew that another pilot had experienced a similar anomaly on that approach.

It seems that, 16 years on, we are still not recognising the dangers of Recognition Primed Decision Making. Nor are instrument approach charts graphically representing terrain near airports or flight paths as recommended in the Cali report

[Tee Emm]

While company SOP go into detail on what the PNF should do when an approach become dangerously unstable and requiring a go-around, it does not give specific advice - purely the correct warm and fuzzy words to say like please captain we are too high I suggest we go-around. As numerous accident reports have testified captains have ignored the official calls and the aircraft has crashed.

That point is well covered in the Canadian Boeing 737-200 accident report.
For some reason it is placed in to too hard tray and the PNF is left to use his own judgement on how to physically take control from an aggressive captain intent on pressing on regardless. The result of two pilots fighting each other to keep or take control at low altitude is bound to finish in tragedy.
One airline in Australia years ago, took the initiative and advised first officers that if their SOP calls for a go-around were deliberately disregarded by the captain, they should call once more for a go-around and if disregarded, they should select the landing gear to up. It was assumed that no captain would then deliberately land wheels up just to make a point and he would be forced to go-around.

While it was conceded that this action could place the aircraft in a dangerous position if close to landing, the alternative of a crash into terrain was infinitely worse. It was stressed that selecting the gear lever to up to force a go-around was essentially a last ditch action to prevent a certain CFIT. If that SOP had been used in most of the crashes known to have followed seriously unstable approaches - including the Canadian 737 accident - then these tragedies would likely to have been avoided.

[Jwscud]

I completely understand the Canadian reasoning regarding protecting of the CVR, but I do feel this is one of those cases where a proper transcript of the words the crew used would have been immensely illuminating.

As one in the right seat, what one would do if a Captain refused calls to Go Around is high in the mind. I am aware of an incident in gusty conditions a few years back where the crew received a hard windshear warning on final approach and the Captain continued to land the aircraft with the FO shouting "GO AROUND". The FO considered any attempt to take control from the Captain was too dangerous.

[4Greens]

CRM training thirty odd years ago emphasised the use of an airline specific emergency language by the FO and was incorporated in the Ops manual. Qantas was 'Captain you must listen to me'. If this was said then it was a mandatory incident report.

Different airlines and different cultures used different phrases. My favourite was Lufthansa -their response was to call the Captain by his christian name.

[philip2412]

4greens,

he did call the cpt by his christian name !

[neilki]

We had defined terminology too: "first name; i dont feel comfortable with this approach, do you think we should go around"
-followed by-
"This is Stupid"
The idea of raising the gear in what's already an unstable approach is, er interesting, but that brings all a host of other problems too; especially if the PF is fixated or saturated. TOGA is perhaps a better idea..
I fly by the simple missive; if there is ANY doubt, then there is NO doubt..
~blue skies. Horrible accident.

[Petercwelch]

Clunkdriver, thanks for starting to educate me re: task saturation. How easy is it to create this in the sim, and are there any signs of it that identiy it well enough that in and of themselves could be a sign to go around. My apologies for use of the bonehead term. I know this poor guy didn't want to crash.

[Tee Emm]

TOGA is perhaps a better idea..


TOGA will certainly be an effective method of forcing a GA. But the strong pitch up caused by GA thrust would certainly catch the offending captain completely by surprise. Especially in IMC he may not have a clue what the co-pilot is up to and by the time he twigs to what's happening allow the aircraft to reach an alarmingly high body angles which could lead to a stall which is not what the co-pilot had in mind!! TOGA can be dangerous if unexpected...

[Aluminium shuffler]

But the PNF who pressed TOGA is expecting it and can help an overloaded PF by taking control or applying pressure or trim.

It's more a psychological issue of having FOs trusting Captains and believing that their vocal inputs will get them back in the groove. I've been there - I had two events where in hindsight the Captain was more incapacitated or confused than I had perceived and taking control would have been the better course of action rather than continued vocal intervention. I think it's something that really could be helped by training in the sim, where the Captain is told quietly by the TRI to start making mistakes and misjudgements but the FO isn't made aware of the scenario, a bit like when the typical RTO with incapacitated pilot is done, but much subtler. The idea is to show that mild incapacitation might allow the PF to give all the SOP responses but to make poor decisions and fail to react to other indications and that the FO has to make a decision to take control even though the other guy appears concious. Incapacitation training seems to be far to obvious at the moment, with the incapacitations always being total.

[PEI_3721]

This report is a good example of how human factors can be considered by investigators; however it is disappointing that all of this effort could not be followed through with recommendations. This is not to criticise the report, but more to recognise the difficulties of applying suppositions of HF and the limitations of international reporting formats.
Thus it is up to organisations and individuals to form their own conclusions and consider areas of safety activity.

Regulators and operators must consider the increasing reliance on human intervention for the growing complexity of the operating environment. This aircraft like many others had system updates and additions with little opportunity for integration, thus different AP / FD operation, mode annunciations, GPS inputs, etc had to be managed with increasing workload. Often each change is seen in isolation – ‘the crew will manage with training’, yet the cumulative effects could be significant. Thus the conjunction of these factors together with a ‘tight’ approach and compass problem exceeded the crew’s mental resources with unfortunate results.
Who will say ‘No’ to these situations? The crew as the last line of defence, yet most likely to be affected by the workload? No, these issues must be addressed at the organisational level, where time and resources are available to balance the competing pressures.

Those who see CRM, assertiveness, or monitoring pilot intervention as solutions perhaps overlook the effect of hindsight bias. Why should a monitoring pilot have the better understanding of the situation; the more experienced pilot might have, but if the monitoring pilot’s perception is incorrect then any intervention could be hazardous.
In this accident each pilot appears to have had a different understanding of the situation, and at that time there was no quick means of establishing which was correct. With hindsight, and assuming that the difference in awareness was recognised, discontinuing the approach and reassessing is a solution may have helped, but with problems of high workload, human bias, and limiting mental resources then these defences (CRM) cannot be expected to work. See the BEA ASAGA study – ‘the concept of CRM is flawed’.

Solutions to these types of accident resided at much higher levels of organisation and regulation than with the crew. If the accumulative effects of system ‘enhancements’ are recognised, then either operational or technical restrictions should be applied, or mandate additional safety defences – EGPWS, before operational approval is given.

[Aluminium shuffler]

Very true. It is sometimes very ard for someone who has become disorientated or gone down a wrong mental avenue to recognise it, and so is difficult for them to agree with a PNF telling them a contradicting tale...

[Two's in]

The final factor which doomed this flight was an EXPERIENCED non -asertive F/O,

A trawl through any accident database will demonstrate that on the day experience counts for very little. There are just as many memorials to experienced crews as there are to inexperienced crews. The goal is to always be effective as crew, that way you may also live to be experienced.

[lederhosen]

According to the report the FO had just over 100 hours on the 737, so was recently line released. He was previously a turboprop captain and does not seem to have had any other jet experience. He gets paired up with a guy who should know what he is doing. The captain mishandles the approach and the FO who is obviously well behind the aircraft knows something is wrong but clearly cannot quite believe what is happening. I would not say that the FO was particularly experienced in this case at least on a relevant aircraft. In any case it is a sobering report. As they say better one go-around too many rather than one too few.

[PEI_3721]

lederhosen, IMHO you overlook the key issue. If the crew, individually or jointly, have reach the limit of their mental capacity in attempting to understand the situation, then there is no further mental resource either to intervene with a warning, or achieve and execute a decision to go around.
These situations represent a boundary of human capability in aiding safety, thus interventions must be found elsewhere.

Experience is just one of many contributing factors in human behaviour, but as we have difficulty in defining and teaching experience, and fewer opportunities of ‘being there’, these circumstances should be of some concern particularly with the apparent reducing emphasis on training and skill level.
The industry has to reconsider the operating environment in which the human is expected to manage and the demands being made on human mental resource, both in knowledge and skill, as well as how close modern complex operations are to an acceptable safety boundary.

[MountainBear]

There is a lot of hindsight bias going on in this thread. :mad: It's easy to talk about what the FO could have done or might have done and the assume that everything works perfectly from there on out--maybe it does and maybe it doesn't. Maybe the aircraft gets into a situation where the FO is doing one thing and the Captain is doing another and it winds up in the dirt anyway.

What caught my eye is this:
1641:16.3 Captain makes statement indicating similar situation happened to another pilot previously
So thirty seconds before the crash the Captain is in a mental place where he has got it all figured out. He's seen this before. And he is following this cognitive map in his head despite the fact that the FO officer is telling him the map is wrong.

So let me play the troublemaker a little bit.

1639:13 to1639:30 FO makes 5 statements regarding aircraft lateral displacement from desired track.I wonder how much the FO nagging added to the Captain's task saturation. Perhaps at some point in time the Captain simply started to tune him out. The Captain is may be thinking, "I've got it all figured out. Why the hell is he bugging me?" Maybe if the FO had just shut up the pressure would have been off and the Captian would have figured it out on his own.

There is more than one way to engage in hindsight.

[Tee Emm]

But the PNF who pressed TOGA is expecting it and can help an overloaded PF by taking control or applying pressure or trim.


I would have thought the last thing you want is having both pilots putting inputs into the controls at the same time and possibly in opposition. Recipe for confusion and disaster.


If the PNF is actuating the stab trim without the PF being aware of it, it is possible the PF may think he has a runaway (uncommanded) stab trim movement and act as per QRH Runaway Stabilizer which is Control column...Hold firmly. Stab Trim Cutout switches....Cutout.


Meanwhile the nose is rearing up under full thrust. The mind boggles at the scenario

[RatherBeFlying]

A few decades ago, I was right seat in a Viscount simulator when PF managed to get inverted (with the help of a white on black WWII vintage AH) at 16,000'.

I spent the next minute or so shouting in his ear that:
We're upside down!
Roll it back up!


His auditory channel had very firmly shut down:uhoh:

I had a little talk with myself about how hard it is to take over -- and that if I want to walk away from a similar situation in a real a/c, I'll have to take over in time to recover.

There's major psychosocial barriers to the FO taking over.

I second the suggestion that the simulator is a good place for PF to set up a situation where PM has to intervene.

[Tee Emm]

In some people's eyes, a go-around in the circumstances described in the 737 accident, is seen as an admission of mistake and a "it can't happen to me" mindset takes over momentarily. The wavering of the first officer is understandable as he contemplates the awful realisation the captain is wrong and yet the F/O is reluctant to shove open the power and haul back on the stick since he knows the consequences for his job if indeed the captain was right. I doubt all the SOP or education in the world can cover the situation that any first officer finds himself under similar circumstances.

It might even boil down to one's personal physical courage. I believe that to be the case here. An F/O is seen as making serious waves if he forcibly takes over the controls at any time. Ethnic culture also plays a large part in this sort of lack of decision making as we have frequently seen in accidents such as the Asiana B777 crash at SFO. Not that appeared to be a problem in the 737 accident.

As an avid reader of accident reports, instilled in me from my early years as a military pilot - and where these reports were always readily available in military crew rooms, I believe each operator's flight safety manager should ensure that both overseas and local (own country) accident and incident reports should be readily available to crews. It is all very well having to regurgitate endless published bumpf on CRM and TEM or whatever is the next fancy name. But studying the cold hard facts in an accident report should never be boring and will generally be remembered.


What should interest a professional pilot is why a pilot made or failed to make a critical decision and the deadly result. An accident report tells you that. It should not be left to individual pilots to research for themselves because few will, in my experience. They have too many other activities to concern them - unless they live for flying (and devour Pprune accident reports!)

"There but for the Grace of God go I" reading of accident reports is a powerful educational tool. Those of us who have followed this particular thread will have already learned a valuable lesson IMHO and hopefully apply it when they go flying next time. Forgive the somewhat inarticulate rambling on a tricky subject...

[lederhosen]

PEI_3721 it is blindingly obvious that the crew got beyond their limits. Various posters including the one before my original post made reference to the co-pilot being experienced and like you seem to suggest it is not a relevant factor. Fact is that the first officer had very little time on type. It is also a fact that they crashed. A lot of other things being said are assertion.

I have been flying the 737 for many years with increasingly inexperienced co-pilots due to the way our industry is changing. I make plenty of mistakes like most people so I have a keen interest that crew resource management works. Airline management also would like to think that experience is not a safety issue. I do not agree.

In this specific case the mental overload occurred at least partly because the crew jointly allowed the aircraft to get well above path and rushed the approach. There seems to have been considerable confusion in the nav set up and approach briefing. The sops for callouts and other relevant items were not complied with. Surely more support from the pilot non flying would have reduced the workload on the captain and avoided his becoming task saturated?

[Judd]

Surely more support from the pilot non flying would have reduced the workload on the captain and avoided his becoming task saturated?


More "support" from the PNF can be interpreted two ways. From the PF point of view or the PNF point of view. Too much"supporting" is often seen by the PF as irritating, superfluous and worse still, distracting. It all depends on from whose viewpoint.


We have all seen the situation where the PNF thinks he is doing what he thinks is the right thing and offering ideas, and advice but which drives the other pilot nuts dealing with the stream of words of encouragement - some of which is out of pure nervousness and even arse covering for the sake of the CVR and Big Brother..


In reality, the PNF is only verbalising what his own mind is thinking - all of which is not genuine SOP support but a chatter. In turn, this becomes counter productive as the PF is forced to acknowledge each transmission or comment or risk the PNF thinking "the bastard is incapacitated or in the "Red Zone" and needs more help and so the babbling continues.


There is something to be said for the old days before CRM was invented as a cottage industry. Then the PNF closely monitored an approach and silence was golden allowing the PF to concentrate on flying. Only if something was out of the ordinary would the PNF assess the flight path progress or whatever concerned him, and then would make a succinct comment which nowadays would be called a "support" call.

[Aluminium shuffler]

TeeEmm, I have probably got the wrong end of the stick, but it sounds to me like you are stating the main CRM element comes down to how advocational/confident the PNF is. As my posts say, it's not down to character strength, confidence, fear of the Captain or company reaction that is the often the problem, and the standard accident response to that effect is part of the issue. It's more down to the PNF not realising just how mind-f***ed the PF is. Hindsight is a wonderful thing, and that is how we learn. PNFs must learn that unless they see corrective action promptly, they need to assume the overload or incapacitation of the PF is more extreme and they need to take physical control of the aircraft. It is not an unwillingness to speak up, as these transcripts clearly demonstrate, it's the lack of understanding by the PNF of how disorientated the PF is.

I have a very open, relaxed culture on my aircraft - I'm horrified at the company recommendation above that the Captain's first name be used in these circumstances - I expect all of my crew, even the newest cabin crew, to call me by name all the time, and my FOs are relaxed enough to banter and take the pee out of me as I do them during the non-critical times of the day (this has been the norm at all the companies where I have worked, with only a few Cpts being stern, pompous and moody). Even so, I have made mistakes where the FO should have commented but failed to do so because they thought I had some other cunning plan, despite deviating from the brief, and that's been with green and experienced FOs alike - it wasn't fear of my reaction but their over confidence in me that was at fault.

Because things normally run smoothly, I don't think many FOs realise how quickly things can go catastrophically wrong. That's why I think practicing more insidious incapacitations without warning or briefing in the sim may be useful, just like practicing missed approaches from below minimums with surprises like runway incursions and wind shear to eliminate the "we're through minimums, so we're in" mentality.

[Hempy]

Lots of talk about the FO on here. The fact that he lacked assertiveness hardly mitigates the fact that the Captain, in spite of repeated calls from the FO, continued a unstable approach in IMC in hilly terrain with full deflection on the LLZ. Short of hitting TOGA and taking control (and if they subsequently never saw the ground losing his career), I don't see what else he reasonably could have done to save the aircraft from the PICs decisions

[Petercwelch]

Why can't the fact that there is a disagreement between the Captain and the FO, IN AND OF ITSELF, be a requirement to go around when it occurs during an approach? That seems to me a simple solution. How often do such events occur?

[McGinty]

Petercwelch's suggestion is a simple and brilliant one. Perhaps the PF should be trained to go around if he or she hears the words "Disagreement, go around" from the FO. No need to explain the cause of the disagreement, just have the word as a 911/999 emergency call?

[MountainBear]

Why can't the fact that there is a disagreement between the Captain and the FO, IN AND OF ITSELF, be a requirement to go around when it occurs during an approach? That seems to me a simple solution. How often do such events occur?

This is the type of proposal that strikes me as "trying to solve the last accident". I am skeptical that it would do much good for two reasons. First, it might just transfer the indecision of a FO from one dilemma to another dilemma viz. from does he take control to how much disagreement is enough disagreement to call for a go around. Second, if the mere existence of any level of disagreement is enough to cause a go around then the number of go arounds will go through the roof. While a go around in an isolated location such as the one in this accident is no big deal a large increase in go arounds in congested airspace like NYC might cause far more problems that it solves.

One should avoid the temptation to solve the last accident. In this case the PNF was correct and the PF was incorrect. But how many times have the PNF been wrong and the plane landed without incident?

[SLFinAZ]

If the approach was unstable and it was absolutely clear that the airplane was not actually on the plotted approach then did the FO as PM have responsibility to abort the approach? Would seem that he commented 3 times to many. If he felt strongly enough to comment twice while situation was still salvageable then he had a professional obligation to act. (just an SLF opinion)

[Petercwelch]

Seems to me that we really have no idea of the frequency with which such a disagreement occurs. Only way to know wouldbe to have an independent entity review a large number of routine CVRs of approaches to see if this is in fact a rare event or not. Although I obviously don't know, I suspectthat probably no one here does either. Many of you have years of experience in such situations. Does this often, rarely or occasionally happen?

[Petercwelch]

Thinking about it, it might have prevented the Asiana crash too.

[BOAC]

Does this often, rarely or occasionally happen? - very rare in my experience in either direction, and if it happened, a correction was immediately applied.

[Petercwelch]

If such circumstances are indeed rare, then the rule would not cause many unnecessary go arounds. Lots of room for judgement with such a rule.

[MountainBear]

Lots of room for judgement with such a rule. :ugh:

That's exactly the point. Most of the posts in this thread are questioning the FO judgement. Yet if the FO has weak character or otherwise feels psychology inhibited from performing an action moving that decision making point to another location on the causal chain doesn't help him. The problem is not where the decision making should take place the problem is whether the FO should feel empowered to make the decision. Giving more room for judgement to a psychologically inhibited pilot isn't going to make him more decisive but less decisive because of the additional mental room he has to find excuses to do nothing.

The question here is age-old: what is the proper steepness of the command gradient between Captain and FO and when, if ever, can the FO violate that gradient? If there were easy or simple answers to that question they'd have been figured out and implemented by now.

At the end of the day there is one easy proposal to prevent every airline accident--everyone stay home. Once one accepts that this isn't a realistic solution then it simply becomes a question of trade-offs and risk management. Good luck trying to convince the industry that every time there is nervous Nellie as PM that a go-around is required. :{

[Methersgate]

This is a cautious suggestion from a non-pilot with quite extensive involvement in maritime CRM.

Would it be practical to give the express authority to order a go around to the PNF, in all cases?

Obviously the PF can go around at his/her discretion. No need to change that.

The PNF is looking at the same instruments and the same view out of the windows. The PNF is very much less likely to become task saturated.

If the PNF has formal authority to command a GA at her/his sole discretion then the PF, even if task saturated, is much more likely to comply instantly.

[McGinty]

MountainBear says that Yet if the FO has weak character or otherwise feels psychology inhibited from performing an action moving that decision making point to another location on the causal chain doesn't help him. The problem is not where the decision making should take place the problem is whether the FO should feel empowered to make the decision. Giving more room for judgement to a psychologically inhibited pilot isn't going to make him more decisive but less decisive because of the additional mental room he has to find excuses to do nothing.

The question here is age-old: what is the proper steepness of the command gradient between Captain and FO and when, if ever, can the FO violate that gradient? If there were easy or simple answers to that question they'd have been figured out and implemented by now.

I think this issue was figured out a long time ago regarding US ICBM missile launches - you need two crew members to turn their keys at the same time to launch a missile. Was there not a movie about a US nuclear missile submarine recently that featured exactly this dilemma? The decision of the second officer is always required before a positive commitment.

Surely, MountainBear, modern airlines are acutely aware of the need to eliminate the possibility of letting any pilot get through a training process so as arrive at the situation that you describe, viz: "FO has weak character or otherwise feels psychology inhibited from performing an action."

I support Methersgate's revision of my PNF veto idea - the PNF should have an express authority to order a go around.

[BOAC]

There always has (rightly) been, in UK ops, the 'authority' for an F/O to order a g/a. For decades we have worked on the '3 challenges then assume incapacitation' rule although commonsense suggests if getting near 'invisible' Cumulo-granitus one might speed up that process.

[ExSp33db1rd]

Different airlines and different cultures used different phrases. My favourite was Lufthansa -their response was to call the Captain by his christian name.

Said it before ... as a fairly new Nav-S/O on the crew commanded by one of the "older" WWII bomber pilots that we nicknamed the North Atantic Barons, I addressed the co-pilot by his christian name. The Captain swung around and announced in his best Parade Ground voice - "we do NOT use christian names on the flight deck MR xxxxxx "

CRM wasn't even a gleam in anyones' eye at that stage, Sir was God.

A psychiatrist died and went to heaven, St. Peter met him at the Pearly Gates, and said " Glad you've come, we're having a little trouble with God, he thinks he's a BOAC Captain "

[pax britanica]

Cultural issues can vary from country to country even within Europe. Re the comment about Lufthansa pilots using the captains first name to get his (her) attention is perfectly sensible since even now Germans seldom use first names in business contexts and so it does make some sense.

Point brought home to me when discussing a meeting I had in Germany with a former colleague who now worked at that company and had arranged the meeting. I could not remember the name of one of the German attendees and so asked my friend on the basis that 'Gert something had told me.....' , my friends reply was that he could not help, as he put it 'I would not know the first name , the man would just be Herr X to me.'

However that also illustrates the point that in most societies there is a degree of deference to senior figures, its brave junior in almost any part of the world who publicly corrects his boss in a meeting even if a serious mistake has been made. On a flight deck the consequences are much more serious but also the reluctance factor perhaps reinforced by the fact that the captain is 'THE captain, often wearing insignia to denote that and the clear traditional left seat right seat hierarchy and of course there is often very little time between noticing something is wrong and a possible disaster.

At least in the business context sometimes the junior in rank is more experienced or more expert than the higher ranking manager and they certainly are not wearing uniforms to denote rank and status. So I think this makes it harder on the flight deck , if I can make that observation as passenger, to correct/criticise the boss is always awkward at the very least and in some places virtually unthinkable.

One point that does come across in this debate is the idea of a 'disagree call' when the aircraft reaches minimums or decision height , does seem to take rank out of thinks quite bit.
All in all though this is battling human conditioned attitude and just underlines that a pilot is a different job from most others because the time between mistake and disaster can be very very short

[de facto]

I have used the TOGA switch option when a first officer didnt respond to my 2 go around requests,(unstable around 100ft)seeing the FD going up "woke him up" and after a "flaps 15?"remark he then continued the maneuver as normal and did the next approach without problem.
One of the reasons i use the AT ARM mode on the 737.

[Centaurus]

One of the reasons i use the AT ARM mode on the 737.



Some would argue it is not really a satisfactory or logical reason to go against the Boeing 737 FCTM recommendation that the AT should be off if conducting a manual flying (as against autoland) approach and landing.
If the F/O ignores your initial warning of unstable approach then simply take over control and if a GA in needed it is quite easy to push open the thrust levers manually. :ok:

[slast]

I would be interested to know what readers of this thread think might have happened if the crew had been flying a Pilot-Monitored Approach, i.e. the Captain had been the PM during the approach, planning to take control for landing, and the First Officer PF for the approach and go-around, so it is still very much "the Captain's leg".

In this conjecture, the F/O then flies the aircraft just as the PF does in the report. The Captain makes the PNF's observations etc. again just as in the report. Do you think it more likely that a go-around would have been initiated much earlier, or would it have made no difference?

[PEI_3721]

Steve, there could be merit in using a shared monitored approach. The more experienced pilot, relieved of the flying workload might have detected the deteriorating situation earlier. However, this view should not assume that the more experience pilot will always provide a better understanding or have sufficient mental resource for establishing the situation and deciding to act. Also, there are some very experienced and capable First Officers in the industry – yet over time we all have to learn and thus could be vulnerable at some point.
An encouraging aspect is that many HF texts relate decisions to the quality of understanding; thus any procedure which enhances situation awareness and use of experience to aid understanding should contribute to safety.

Too often the industry, and as in this thread, assumes that the monitoring pilot will be able to understand the situation and decide to act. It is equally likely that in this accident the FO/PM crossed-checked the PF displays to improve his understanding, and noticing the disparity, accepted the PF display and actions as being better than his, thus there was no intervention.
Based on what we now know this view might be considered as a failure in understanding and intervention (hindsight bias), but the behaviour was exactly the same as would expected if the Capt/PF displays were correct and the FO/PM were in error; the disparity might have been noticed but not commented on, except with good mentoring the Captain could have debriefed it after landing.

A problem in some parts of the industry is the belief that SOPs and CRM (human activity) will provide adequate safety in all circumstances. This is not an anti SOP / CRM view, but acknowledging that these tools have limits in particular circumstances, which operations appear to be encountering more frequently.
Thus anything which questions this attitude and considers alternative procedures will be of benefit.

[A37575]

the Captain had been the PM during the approach, planning to take control for landing, and the First Officer PF for the approach and go-around, so it is still very much "the Captain's leg".

I wonder how many years ago, airline policy changed from the captain saying "you can do this take off - or you can do the landing?" Not "it is "your sector" or "your leg".

Over the years it has evolved into the captain's "leg" or the first officer's "leg" with the perceived dumbing down of the captain's authority to being the PNF. Recently I heard of the case where it was the first officer's "leg" on a five hour sector and radar showed storms ahead. The captain called ATC and asked for deviation 20 miles from track due weather. ATC approved the deviation. The F/O then turned to the captain, who was keeping a close eye on the radar, and said "I understood it was MY leg and that means MY decisions." The captains response was rightly unprintable.

Too many captains are reluctant to step in simply because it is the first officer's "leg" and the captain feels it is maybe wimpish to exert his legal authority to run the show. There is nothing wrong with the captain saying to his first officer "would you like to do this take off and departure?: And then when it suited him, just take over control for the rest of the flight. Where he need several breaks he simply hands over control to the first officer until it suits him to take over again. He may then use his discretion to offer the first officer the approach and landing. It is not the God Almighty "right" of the first officer to be given a leg at all - and never has been. He is employed as the support pilot in a two man crew - not a pseudo captain.

[RESA]

As a once earth bound provider of signals, I have this observation:

Report seems spot-on but for maybe one point; the perceived inadvertent movement (by a pilot) of control yoke during the capture phase of the approach.
The ILS (30-yr. old parts, relocated to YRB, contrary to ICAO SARPs) is known to radiate False-Capture (FC) signals. This antenna can further increase FCs in high humidity (fog, rain). FC complaints resulted in TC posting “Safety Notices” to switch from capture to approach only within ~ 8-degrees of centreline (re-Posted by NC, ~ 2010). Flight Inspection(s) don’t report FC, Safety Notice eliminates the need. But, ancillary facilities are required if flight crews are to identify a FC. All that being said; the captain didn’t catch the FC for whatever reason (A/C switched to “coast mode” on flight-director???) Seems the FO noticed something wrong, the captain eventually did, but too late. If the “RU” NDB (2.1 NM before threshold, on centreline) was in service (decommissioned just months prior) they may have realised sooner how far “inland” they were?

. . . just my observations as a once once earth-bound provider . . . .

[gimpgimp]

Interesting discussion highlights the lack of training in how to get the PF's attention after all the usual attempts. A suggestion I have passed on is to place your palm two inches in front of the PF's face/eyes with a loud "look at me look at me" then when the PF reacts by pushing your hand away or looking at you say "you must go around." or whatever.

No actual physical interference with the PF or the controls.
If he cant see he cant fly but you WILL get his or her attention.

if it does not and the aircraft is in danger save yourself any way you can you have a big problem sitting next to you.


Works with kids too.

[cockney steve]

if it does not and the aircraft is in danger save yourself any way you can you have a big problem sitting next to you.
Which is exactly what the PNF was aware of, and failed to act upon.

He KNEW the instruments were overwhelmingly telling him they were off-course
heKNEWthere was high ground ahead
heKNEW they were in breach of SOP's
he KNEW his own life and the lives of the Pax and crew were at risk
he KNEW the Captain was following a wrongful course of conduct.

Under those circumstances, I would suggest thatself-preservation and duty to obey safety=rules should transcendall deference to another, wilfully violating crewmember.

Take control, mitigate the danger, argue about it on the ground.
Had the results not been so tragic, the Captain would have had to concede he failed to execute his professional duties.
The paying public had a right to expect better than they got.

[DOVES]

A Pilot incapacitation can be either overt or subtle.
In order to diagnose the second some airlines have adopted the following:
If the other crew member does not answer any of three calls after he made a deviation from a SOP
or only once if his behavior has affected the safety of the flight, his subtle incapacitation can be assumed.
And then the other pilot has to declare: "Emergency athority! I have control!"

Learn from John Wayne:
The High and the Mighty Promo - IMDb

And let's hope and pray that this ends the series:

http://www.pprune.org/rumours-news/523005-they-d-all-walking-talking-alive-if-they-went-around.html

[Sidebar]

First Air had a 2-communication rule. Here is what the TSB said in their analysis (section 2.9 of report):
The company’s two-communication rule in the FOM Footnote 163 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11h0002/a11h0002.asp#fnb163) authorized the FO to assume control of the aircraft and fly it to a safe situation in the event that the pilot flying (PF) became obviously or subtly incapacitated. The captain of FAB6560 was verbally responsive to the FO’s comments and suggestions, and was making control inputs. Therefore, the captain was not obviously incapacitated. However, his persistence in following his course of action despite the FO’s verbal advisories indicates that he was experiencing subtle incapacitation, which was likely due to the stress associated with the deteriorating approach parameters and associated workload.

It is likely that the FO did not recognize the captain’s behaviour as that of subtle incapacitation. If the FO considered the two-communication rule, it is likely that he concluded that the captain was not incapacitated and the rule did not apply.

The FO’s non-application of the two-communication rule highlights a deficiency in the rule, in that the rule relies on the judgment of the PNF to determine whether subtle incapacitation exists. Recognition of subtle incapacitation may take considerable time, and it may not occur at all. Outside of the two-communication rule, there was no guidance provided to address a situation in which the PF is responsive but is not changing an unsafe course of action. This situation presented a unique problem for the FO of FAB6560; that is, how far should he allow the aircraft to deviate before taking over control from the captain?

There is a history of incidents and accidents in which the FO was the PNF and warned of a deteriorating situation, but did not take control when the captain continued an unsafe course of action (section 1.17.8.5). In all of these occurrences, the company had some form of two-communication rule, but the defence failed because the FO did not intervene and take control of the aircraft. Some likely reasons for this failure are difficulty in identifying subtle incapacitation, ambiguity in the wording of the procedure, or inhibitions on the part of FOs to take the drastic measure of taking control from a captain.

At the time of the First Air accident, there was no training or guidance within the company on how an FO would escalate a concern to the point that a go-around or change of control could be commanded. In the absence of policies and procedures, such as PACE (probing, alerting, challenging, and emergency warning), enabling the FO to escalate his concern as well as providing the authority to take control of the aircraft from the captain, the FO was limited to an advisory role. The FO was clearly aware of the increasing risk. The approach had continued beyond 2 points at which a go-around was required: first, when there is full localizer deflection, and second, in an unstable approach below 1000 feet. At both of these points, the FO attempted to communicate the need to go around to the captain. While not as definitively and clearly expressed as they could have been, these attempts are indicators that the FO was continuing his efforts to change the captain’s course of action.

The FO had previously flown as captain on another aircraft type with the company. However, he was new to the B737, and although obviously uncomfortable with the navigational situation, deferred to the captain.
There was no policy specifically authorizing an FO to escalate his role from advisory to taking control, and this FO likely felt inhibited from doing so. The FO made many attempts to communicate his concerns and suggest a go-around, but did not take control of the aircraft from the captain.
This accident and the other 3 occurrences cited (section 1.17.8.5) are indicators that failure of FOs to take control in deteriorating situations will occasionally result in catastrophic consequences in the global fleet of transport aircraft. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some FOs may feel inhibited from doing so.

[PEI_3721]

A First Officer might not have ‘the right’, but s/he has many rights as a supportive crew member. Also, consider how these pilots are to become Captains, or indeed how current Captains made the transition.

cockney s, all of the ‘knowing’ is based on hindsight - outcome bias. All that we might know is what was said and to some extent what was done, and even based on that the events are a creation of our minds. Factual knowledge might have been taught, or refreshed during an approach briefing, but there is no guarantee that this knowledge will be call on in situations requiring many thoughtful activities.
The report discusses these aspects, but without knowing exactly what the crew saw and understood – as related by them, there cannot be any clear conclusion – other than perhaps that they 'did not know' and that both crew members did not act as expected. Thus the post-accident questions should consider why appropriate action was not taken – what were the contributing factors, or even why we should have such an expectation that the crew will always manage.

Most modern aircraft have compass comparators, did this aircraft have such a system, would it work in gyro mode. If not, then crew procedures should be strengthen when setting and cross-checking the gyro mode.
Aircraft with comparators pose similar problems as crew cross-checks; a disparity can be identified, but without a third reference then the erroneous system cannot be identified. Humans tend to give technology greater credence than verbal warnings, thus with an attention getting system alert a GA might have been flown and the problem resolved at a safe altitude, but not crosschecking the st-by compass during an ILS.

[Sidebar]

The airplane did have a comparator system. See Appendix E of the report.

[MrSnuggles]

He KNEW the instruments were overwhelmingly telling him they were off-course
heKNEWthere was high ground ahead
heKNEW they were in breach of SOP's
he KNEW his own life and the lives of the Pax and crew were at risk
he KNEW the Captain was following a wrongful course of conduct.

This sadly shows that noone is free from blame regarding experience gradients in the pointy end.

An accident that is in a few ways a bit similar to this is the Korean Cargo 8590 where the Capt buried a 747 into a field just outside London. The unfortunate FO didn't dare speak his mind, but the FE did, to no avail. This was blamed on the Korean culture, but it seems Westerners are not so outstanding at CRM as some would like to claim.

Really really sad.

[MountainBear]

Under those circumstances, I would suggest thatself-preservation and duty to obey safety=rules should transcendall deference to another, wilfully violating crewmember.I agree yet understand that there is no way to standardize this criteria because "self-preservation" in the heat of the moment is not a rational instinct. It's about one's "gut" or "intuition" or whatever one wants to call it. "Self-preservation" is not something that can be added to the MEL!

It is likely that the FO did not recognize the captain’s behaviour as that of subtle incapacitation.I laughed when I first read that. That word--subtle--does not mean what one thinks it means. By definition if something is subtle that means its not easy to detect. How can one blame the PM for not detecting something that is by definition difficult to detect?

The underlying point is that while rules, procedures, CRM and the whole lot are important and have saved lives they are not a panacea. They can't substitute for what the poster above called the instinct for self-preservation. By definition that is not something that can be trained for.

Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some FOs may feel inhibited from doing so.
This is true but it is only 1/2 the story. The other half is the problems that can arise when the FO misjudges the situation in the other direction and takes control when the Captain is not incapacitated in any way. So these two competing concerns must be balanced and this balance shouldn't be influenced by the most recent accident.

[Jacobite_Glasgow]

First, I'm not a pilot, but someone who has undertaken research of aviation CRM in order to compare it with another system (law, as it happens).

It struck me that the safest course of action would be for either PF or PNF to be able independently to initiate a go around. Is that the case - could the FO have declared go around instead of asking, or is it still the PF's discretion?

I presume the only situation where a go around would be inhibited by the circumstances would be critical low fuel (which, I'm guessing would be briefed and obvious). In any other situation, I'd have expected any doubts about continuing the approach to mean an executed go around, with a discussion as to those doubts afterwards - is that generally SOP?

[MountainBear]

First, I'm not a pilot, but someone who has undertaken research of aviation CRM in order to compare it with another system (law, as it happens).
Interesting. If you have any links to published research it would be great to share them with the forum.

[harrryw]

@ mountainbear
If the FO misjudged the situation all are still alive and the only cost is a bit of fuel and a red face. It provides an oportunity to decide after if the action was wise or not.
A training oportunity that is lost if the aircraft has allready spread itself over the ground.

[DOVES]

Words, words, words.
We can make it as long as we like it, but.
We're not talking about philosophy nor of rhetoric, but of aviation.
Also if the solution of the two flight crew members in commercial aviation is not perfect, it is certainly effective for the management of a situation in which one of the pilots fails.
It follows that it is essential for the two to coordinate and integrate themselves, namely they have to know moment by moment what the other is doing and is about to do, and is sure that everyone knows.
This is achieved through the slavish observance of Standard Operations and Calls.
Undoubtedly a single pilot decides, executes and controls at his libido all flight operations, such as the extension of flaps, landing gear etc. (but for sure he has no passengers on his plane).
In the cockpit of an airplane with two members that would be very very wrong.
If I remember correctly the Pilot Flying was ordering the execution of a manoeuvre (such as the extension of the gear), Pilot Not Flying (now Pilot Monitoring), after checking that there were each and every conditions (for example speed limit) for the execution, complied, repeating the order. Upon reaching the new configuration, the PM always gave verbal confirmation.

During the approach, there were calls to be made in case of exceeding the normal parameters:
- Configuration
- Speed (if the speed was more than +10 / -5)
- Attitude (if it was +/- 5°)
- Vertical speed (if the variometer was more than -1000 ft / min)
- Localizer (if Loc was more than half dot from the center)
- Glide (the same as above)
If at the third one of those calls (in this case "Localizer! Localizer! Localizer") there was no response from the PF, the other had to intervene: "Emergency Authority. I have control! Go Around!"

An unnecessary GO AROUND is better than a CFIT

And believe me: in the end everybody will be thankful to you.

[Prazum]

Perhaps there should be a rule, that if the FO calls for a go around, regardless of the Captains view, a go around MUST be performed, without question.

That can be SOP for anyone.

[aterpster]

Prazum:

Perhaps there should be a rule, that if the FO calls for a go around, regardless of the Captains view, a go around MUST be performed, without question.

That can be SOP for anyone

With good CRM, the captain and the F/O would have been more in sync.

Having said that, in general, the F/O needs to be an experienced pro, not a 200 hour "shot gun" ride along.

[Petercwelch]

See my post # 42. Still makes sense to me. Have heard no argument that this is not a good idea!

[autoflight]

Despite a few unstable approaches in thousands of airliner approaches, my F/O has never suggested a go-around. Pre-emptive action by the captain almost invariably makes such calls unnecessary, and I have never seen the situation deliberately set up in a sim. In fact, simulator time constraints usually mean such go-around calls by PNF will disrupt the program and these calls are usually avoided. Both pilots and the sim instructor/checker are aware of this deviation, but it is bad practice for the crew.
Sometimes sim PNF is discretely briefed to avoid out of configuration or go-around calls to force PF initiation of corrective measures. I can see a rare need for this, but an unwanted result can be contribution to risk of aircraft CFIT.
In fact, many airlines are unknowingly training F/Os to not make go-around calls. If it is difficult for a Canadian F/O to call and then force the issue, how much more difficult must it be for a Korean crew?

[MrSnuggles]

This.

If it is difficult for a Canadian F/O to call and then force the issue, how much more difficult must it be for a Korean crew?

Thankyou autoflight.