Passenger plane almost crashed into mountain

[flight_mode]

This is the lead story here in Switzerland today. Sorry, I can't find anything in english: 20 Minuten - Passagierflugzeug zerschellte fast an Berg - Tessin (http://www.20min.ch/schweiz/tessin/story/Passagierflugzeug-zerschellte-fast-an-Berg-16135760)

Rough translation:

Passenger plane almost crashed into mountain.

It was pure coincidence that nothing bad happened.

An Austrian aircraft (On behalf of Swiss) with 59 people on board flying from Zurich to Lugano when, during the landing approach, the GPWS sounded. A pilot, who was reported to be a passenger on board, heard the warning signals from the cockpit: "Pull up!" The aircraft had climbed so quick that it reached nearly 1000 meters in ten seconds.

The Collina D'Oro mountain range, on which the Dash-8 almost crashed, was the reason for the neckbreaking maneuver. Radar records, which are available on the Aviation Herald, are intended to show that a collision was really imminent. There is also the question of whether the pilot could have flown the chosen route at all. The Swiss Safety Investigation Unit (SUST) considered the incident serious. An investigation was opened.

Austrian Airlines comments:

Austrian Airlines dismissed the problem as a "Missed Approach" but according to Florian Reitz of SUST "The true extent of the serious incident was not known until months later,"

Furthermore, the pilot, who sat at the controls on 13th October 2015, was temporarily suspended by the airline, but now sitting again in the cockpit. Austrian Airlines does not provide any detailed information; a report on the incident has so far been kept secret.

[Airbubba]

Here's Simon's Av Herald report of the incident with some discussion of the approach and charts in the comments:

Incident: Austrian DH8D at Lugano on Oct 13th 2015, GPWS warning on short ILS final (http://avherald.com/h?article=49344e2a&opt=0)

A brief STSB report in German:

https://www2.sust.admin.ch/pdfs/AV-berichte//OE-LGL.pdf

[Hotel Tango]

The report would suggest to me that the GPWS did its job and the crew did theirs (by immediately initiating the G/A).

[Count of Monte Bisto]

My personal opinion, for what it is worth, is that, even if the pilots were at fault in the first place, a good and appropriate response to a GPWS warning must be rewarded. The absolute instant the 'Pull Up' command is heard, the pilot must know that him making the correct response will result in praise rather than being fired. Just a few seconds doubt could be enough to bring about disaster. Good responses to bad situations have to produce a positive outcome for the pilots involved, whilst still leaving room for an airline to provide targeted training to prevent further repetitions of the event.

[DingerX]

I dunno, 20 minuten is what you use to protect railways seats from errant drops of fondue.
In this case, they cite their source from which they cribbed things: https://kurier.at/chronik/oesterreich/aua-flug-nur-zufall-verhinderte-katastrophe/247.097.110

Outside of the implied speculation that the crew tried to shoot a circling approach to 19 and turned early and mysteriously way too low, the alleged details (from "insiders") are:
A. The incident was reported three weeks later. It first came to the attention of the authorities because a deadheading pilot for another airline heard the GPWS from the cabin and reported it.
B. The (male) Captain (also PF) was suspended and later returned to duty. The (female) F/O was dismissed. On which AUA says that "Gender and Rank do not play a role in such decisions".

If that's so, an appropriate response to a GPWS warning probably involves making sure that your superiors hear about it from you directly.

[framer]

I sometimes wonder if a mixed gender crew is statistically less safe than a crew of either two males or two females.
I haven't looked into it but it seems quite common to me to have a mixed gender crew in the accident reports, almost like there is a distraction or communication difference.
Am I imagining it?

[vapilot2004]

This would have been an ATC bust in the US. Was limited radar coverage or Eurocontrol rule difference at play here?

If that's so, an appropriate response to a GPWS warning probably involves making sure that your superiors hear about it from you directly.

Absolutely. Sharing the knowledge of the crew's point of view might help a future crews avoid the same situation, or one with less desirable results.

Austrian Airlines dismissed the problem as a "Missed Approach"

More like "Missed Mountain".

[oldchina]

framer:
"I sometimes wonder if a mixed gender crew is statistically less safe than a crew of either two males or two females"
I'm waiting to see when will be the first post to denounce you in vile terms for ever suggesting such a thing. More worrying, if it were 'proved' statistically, there would be a reluctance to publish it. Imagine the poor originator being strung up on "social media" for daring to mention it.

[ATC Watcher]

"I sometimes wonder if a mixed gender crew is statistically less safe than a crew of either two males or two females"

I seriously doubt it but very easy to check if you have time to dig into the ICAO archives of accidents/incidents reports . I don't :rolleyes:

[sierradelta21]

This would have been an ATC bust in the US. Was limited radar coverage or Eurocontrol rule difference at play here?

Absolutely. Sharing the knowledge of the crew's point of view might help a future crews avoid the same situation, or one with less desirable results.

More like "Missed Mountain".
In Lugano (LSZA) they don't use approach monitoring, they having procedural approach control. The first part of the approach is done by Milan APP then switched to Lugano TWR which give them the clearance for the type of app requested.

Depending on the weather they can have an IGS on RWY 01 or LOC LIM follow by a circling (Charlie or Foxtrot). All those different approaches are base on aircraft type, pilot qualifications and weather conditions.

I think we have to wait the investigation to understand what went wrong. I strongly believe that something was done in the wrong way initially but then recovered as requested when the GPWS triggered following the missed approach procedure.

[Tu.114]

So what do we know now?

- A crew got a bit closer to the mountains than intended on a rather demanding, definitely nonstandard approach into a small airfield encircled by the Alps.

- The GPWS worked as advertised, warned them of the threat and was correctly reacted to by applying the procedure the OM-B requires. The aircraft was landed safely at the diversion airfield, which was Milan-Malpensa (about 20 NM south of Lugano).

- This incident has been reported to SUST, be it immediately or a bit later, and is under investigation.

So far, so good. First and most importantly of all, no person was harmed and no metal was bent. The crew managed to get out of the situation. So why was there a need for punishment? If by analogy, one manages to screw up an ILS approach and correctly calls a go around to get out of this situation, this will not be second-guessed in nearly every company and definitely not be grounds for dismissal or other reprimands.

The alleged delay in reporting it to the authorities, if true, needs not be the fault of the crew either. Normally, crews are required to report such incidents (a list of reportable circumstances is published in the OM-A) to the company, where a competent person will read the text and then decide on whether or not this is to be reported to the authority. He, not the crew involved, will then forward the text as needed.

So why the crew was hanged for this is beyond me.

[MungoP]

Let's not become too blase' about a GPWS event. We don't fly around thinking that the GPWS will save us. This sounds like an accident. It didn't become one only because a last ditch 'Get Out of Jail Free' card was available.
The event should be widely published to maintain awareness.

[HeartyMeatballs]

I don't recall such a backlash when a certain red tailed jet also had a GPWS warning during a benign visual approach to MEL. Lessons were learned. We moved on. This incident should be no different. Following an internal investigation it appears that the case was answered to and we moved on. This nonsense of 'one strike and you're out' is not a boost to safety whatsoever.

[MungoP]

during a benign visual approach to MEL

Hardly compares with the immediate and rapid climb described above.. it would suggest a lack of visual awareness of the terrain. Altogether different.

[safetypee]

Will someone please clarify the facts.

Much discussion on GPWS, but was this aircraft fitted with EGPWS (TAWS). If so then there should have been advanced alerting - Terrain Ahead - and possibly a map display; which if not seen / heeded could imply a much more serious event.
Knowledge of the differences between the two systems (E-GPWS), and the operational attitudes in their use, could be vital in operations with challenging terrain.

Was the aircraft actually flying an ILS, vs IGS (which is not authorised?). Given the obstacle clearance requirements for an instrument approach, then any alert is very serious.
How is ILS differentiated from an IGS; instrument display, annunciation, Flight Director / autopilot, ...

EGPWS is an error detection system; yours, someone else, an un-alerted technical malfunction, or a combination of these or unforeseen factors.

[sleeper]

So what do we know now?

- A crew got a bit closer to the mountains than intended on a rather demanding, definitely nonstandard approach into a small airfield encircled by the Alps.

- The GPWS worked as advertised, warned them of the threat and was correctly reacted to by applying the procedure the OM-B requires. The aircraft was landed safely at the diversion airfield, which was Milan-Malpensa (about 20 NM south of Lugano).

- This incident has been reported to SUST, be it immediately or a bit later, and is under investigation.

So far, so good. First and most importantly of all, no person was harmed and no metal was bent. The crew managed to get out of the situation. So why was there a need for punishment? If by analogy, one manages to screw up an ILS approach and correctly calls a go around to get out of this situation, this will not be second-guessed in nearly every company and definitely not be grounds for dismissal or other reprimands.

The alleged delay in reporting it to the authorities, if true, needs not be the fault of the crew either. Normally, crews are required to report such incidents (a list of reportable circumstances is published in the OM-A) to the company, where a competent person will read the text and then decide on whether or not this is to be reported to the authority. He, not the crew involved, will then forward the text as needed.

So why the crew was hanged for this is beyond me.
Not saying the crew should be hanged, but............

When gpws warns the crew with a "terrain" or "pull up" warning, it is a last resort safety card. Something seriously has gone wrong before that. The crew is responsible for getting in that situation in the first place. So, investigate why they got there and then decide wether it is a slap on the wrist or worse.

Gpws is a lifesaver, but activation should not be downplayed to a normal occurence if pilots react appropriately. They came very close to crashing.

[SunchaserMIA]

The story is relatively old and for some reason was now brought back again by the media. It is well known that LUG is not an easy airport to fly. The airport requires special training and with adverse weather conditions the route is very often cancelled or flights diverted to MXP.

I've flown this route many times as a PAX and it definitely has some special character to it, apart from the spectacular views that you can get.

[pax britanica]

I am certainly not looking to open the gender can of worms but was wondering why the FO got dismissed and captain retrained . Not saying he should have been treated more harshly or she less so but what can the FO do short of deliberate negligence if as indicated they were PM.

[MungoP]

The answer to that is... We don't know.

[PENKO]

Could be anything, probation, fixed term contract, training, voluntary...
The report Will be interesting.
Someone mentioned circling, but that seems very odd in relation to just 2 knot tw.

[hoss183]

I sometimes wonder if a mixed gender crew is statistically less safe than a crew of either two males or two females.
I haven't looked into it but it seems quite common to me to have a mixed gender crew in the accident reports, almost like there is a distraction or communication difference.
Am I imagining it?

Well statistically crew will fall into one of 3 bins - MM, MF and FF. So if you are suggesting that 1/3 of incident/accident reports fall into that category, and 33% we would all regard as a 'common' occurrence then you are saying nothing of note.

[PENKO]

You might want to try to run those statistics again :)

[Herod]

I sometimes wonder if a mixed gender crew is statistically less safe than a crew of either two males or two females.
I haven't looked into it but it seems quite common to me to have a mixed gender crew in the accident reports, almost like there is a distraction or communication difference.
Am I imagining it?

Having had two serious incidents in my career, one was an all-male flight deck, the other a male/female crew. The young lady was PF when the incident occurred and handled it correctly and safely. I eventually took control for the approach and landing (after all, I'd signed for the aircraft), and she was, as expected, excellent as PM. During the subsequent operation on the ground, (emergency diversion to a military base, and we left the runway during landing) she provided me with all the support one could expect. Females pilots? All for it. Most are A-star.

[JumpJumpJump]

Well statistically crew will fall into one of 3 bins - MM, MF and FF. So if you are suggesting that 1/3 of incident/accident reports fall into that category, and 33% we would all regard as a 'common' occurrence then you are saying nothing of note.

You are assuming that there are as many female pilots as there are male pilots.

[pattern_is_full]

Was the aircraft actually flying an ILS, vs IGS (which is not authorised?). Given the obstacle clearance requirements for an instrument approach, then any alert is very serious.
How is ILS differentiated from an IGS; instrument display, annunciation, Flight Director / autopilot, ...


1. There is no ILS at Lugano. Only the IGS. Not sure what you mean by "unauthorised" - the IGS is obviously authorized and charted officially. Or did you mean the Q400 is not authorized to fly an IGS?

2. In this case, the IGS is different from an ILS in that it has a DH/MAP of 1290 feet above runway - much higher than a normal ILS. Due to terrain all quadrants. You have to be visual with the airport/runway environment farther away and higher than ILS Cat. I standards allow (even thought, unlike many IGS approaches, the approach track is aligned with the runway heading).

It is also twice as steep as a normal ILS (6.65°) - but then, so are the ILS's into London City (5.5°), so that alone isn't the difference. It does mean a RoD of over 1000 fpm at any groundspeed above 90 kts (1300 fpm @ 110 kts). Which does make me wonder exactly what kind of GPWS alert it was - an actual altitude call-out, or a "Pull UP" due to ground closure rate.

But in any event, you need to get slow and dirty before catching the G/S. Not a lot of room to lose speed and descend that fast - short of a DH6.

[Hussar 54]

I've flown into LSZA a couple of times - although of all of them in the jumpseat.

From the way the crews were having to work and communicate, I think I'd have it as one of the more ( most ? ) difficult let downs and approaches in Europe and the odd ' let's try that again ' moment, especially at night, should be expected.

I'm fairly sure I wouldn't want night time approaches into LSZA on my rosters too often....[

[GrumpyOldFart]

Count of Monte Bisto:

the correct response will result in praise rather than being fired

As in 'fired posthumously'?

[safetypee]

pattern, thanks #24, re #14

Without an ILS GS a 'steep' approach path has to be constructed (NPA); altitude and DME, but with FMS VNAV it can be computed. A halfway option is to use FMS positions for distance, and manual altitude.
There was a previous thread reference to IGS, possibly a typo or that if FMS equipped, then the aircraft system is not authorised.

FMS could be used to 'enhance awareness' with position checks, often promoted by operators and some regulators, but this introduces an opportunity for error. The ease of FMS use, or misbelief in its accuracy, then it is used erroneously for the approach.
Perhaps this is a similar situation to incidents in http://www.icao.int/safety/fsix/Library/TAWS%20Saves%20plus%20add.pdf

Still looking for confirmation if EGPWS was fitted in the aircraft opposed to the basic GPWS.
Good point about the type of ground prox alert.
Is the dash 8-400 cleared for steep approach GS, which would involve GPWS switching, but not required for a steep NPA.

[aterpster]

safetypee:

How is ILS differentiated from an IGS; instrument display, annunciation, Flight Director / autopilot, ...

My guess is that the angle of the glidepath of 6.65 degrees exceeds the ICAO definition for an ILS.

[safetypee]

aterpster, thanks.
My poor wording at #14, which referred to the aircraft.

EU Rules require aircraft certification for approaches and straight-in-landing for GS > 4deg; this should also involve EGPWS switching (avoiding misleading alerts).
NPA steep approach-paths above 4deg can have an independent operational approval but this will require a transition to a lower angle for final landing. This does not require an EGPWS change.

LUG, many years ago, involved a steep NPA transitioning to 4 deg visual (PAPI) below DH. I do not know what the current approach procedures involve, nor the aircraft certification or details of operational approval.

Swiss (LX) had operational approval and some certificated aircraft - used at LCY, but a loaner / contracted-out flight (Austrian Airlines) might not have a steep approach certificated aircraft, hence an unmodified GPWS.
However, if more likely the relatively new aircraft has EGPWS then alerts could have given earlier, but not much earlier when on the correct approach path.

[jaytee54]

I presume that an unexpected GPWS "pull Up" event warrants an ASR so it will all come out in the long run.
I would expect a concluding remark of "you shouldn't have been there, but good response."

[Deep and fast]

IGS the glide path is 6.65 followed to d3ILU then the papis are set at 6.0
You could have an interesting situation if you coupled the aircraft to the glide path. Our procedure for this is loc and vs, and flown as a non precision approach.
Sion is similar and in my view as unappetising with a steep approach into a narrow valley at 6.0 degrees !

[Sorry Dog]

I seriously doubt it but very easy to check if you have time to dig into the ICAO archives of accidents/incidents reports . I don't :rolleyes:

I doubt it will easy or even possible at all to have a statistically sound comparison. I imagine the sample size of serious incidents involving an all female crew is probably small enough to give problems in most types of statistical analysis.... especially when trying to determine correlation versus causation.

[ExSp33db1rd]

Approaching Zurich,Cat II wx. night, cloud, mountains. Just intercepting the LOC ILS inbound, "Terrain ! Terrain ! warning. "When in doubt, lash out" During the go around the F/O asked why I had gone around ! 'cos it's night, in cloud, and the gadget said so. But we were on the Loc. and G/s. How do you know ? 'cos the needles were crossed and centred ! No comment.

I asked ATC if they had been watching me on radar, and were we indeed properly established ? They admitted that they hadn't been watching at that precise time, but would on the next approach, so I agreed that if they thought I was on the LOC and G/s and I thought I was in the LOC and G/s then I would ignore the warning. No problem. ATC "suggested' that they had initially vectored us a little "tight" and taken us over a noted "spot height" which had triggered the warning.

What's wrong about obeying a "pull up" warning ? What would be wrong would be to ignore it.

[Mr Magnetic]

Gender, Communication, and Aviation Incidents/Accidents | Archer | Journal of Media Critiques [JMC] (http://www.mediacritiques.net/index.php/jmc/article/view/43)

[IcePack]

If you can't see you have to comply with the warning. Proved without a shadow of a doubt by the A320 into Addis some years back. (Vor was incorrect)

[p1fel]

Females pilots? All for it. Most are A-star.

I agree Herod, I've flown with excellent lady f.o's in my career on varying types, SD3-60, FK27, B734 and B763, also two Captains together (although a bad practise in my book) the lady captain was also A-Star.

[OldLurker]

The paper cited by Mr Magnetic, apparently written in 2015 (no explicit date in the PDF that I can see) writes in terms of binary difference between male pilots and female pilots. But in today's world the person in the other seat may be M or F or anywhere in the LGBTQ spectrum – and Ms and Fs are spectrums in themselves, too, varying a lot in personality and ability to communicate. What matters is that the captain and FO can work together professionally, whatever their gender or other characteristics. If they can't or won't, they're an accident waiting to happen, as many actual accidents have shown. Never forget that it was an M sky-god captain who initiated take-off in fog so thick that he couldn't see, until it was too late, the lights of a 747 backtracking towards him (which he knew was out there but didn't make certain of its position), ignoring his M junior co-pilot's attempt to warn him that that 747 was not clear.

[Herod]

p1fel. I believe that at one time Airuk had more female pilots that the rest of the UK industry put together. I always found there were no mediocre female pilots. They were always very good (majority) or very bad (a tiny minority). A lot went on to become captains with the big airlines.

[wiggy]

Herod

You're probably right...I do get uncomfortable with claims such as "all the female pilots I have flown with were brilliant" - it might well be true for the individual making the claim , but from what I have seen just like the blokes there are a few out there of the female gender who have had questionable skills.

[Sunamer]

Originally Posted by Tu.114 View Post
So what do we know now?

- A crew got a bit closer to the mountains [....]

- This incident has been reported to SUST, be it immediately or a bit later[....]


You seem to be having a very stretchable definition of A BIT.
I wonder, what would be not "A BIT" by your standards...excluding a crash, of course.

[vapilot2004]

So again, I ask for anyone that may know this: In the states this incident likely would have been an ATC bust. Does Eurocontrol operate differently and is reporting (ATC) 'optional' in a case like this?

[ATC Watcher]

Does Eurocontrol operate differently and is reporting (ATC) 'optional' in a case like this

First as far as I know there is no "Eurocontrol" specific IGS regulation, ATC monitoring/reporting deviations on this , rather each individual State determine his rules, Common sense dictates that any Go around is normally reported on the ATC log. But this was not an ATC incident.
Remember also this was not an ILS but and IGS . You have a visual part in the end., and it is the pilot who is responsible for terrain clearance, not ATC.

On the Av Herald page there is a very interesting comment :

The IGS is not used by the DH8 due to systemic limitations with regards to maximum glideslope angle. The only approaches approved and used are the two LOC approaches leading to a circling into 19 and a visual approach into 01. No other approaches are executed.

This sounds to come from someone who knows what he is talking about, but ok this is Internet... :rolleyes:

If true, then they were on a visual leg, and the incident is an interesting one..and explains why the SUST is looking into it seriously.

[vapilot2004]

Thank you for the insight, ATC Watcher - an apropos user name, good sir. :ok:

I am surprised there lacks a cohesive set of rules in an area where borders are both numerous and near. I might guess then that the Swiss rules do not record an approach deviation in terminal airspace. On the airline side, there must have been no FOQA.