So WestJet almost puts one of their 737 in the water while landing at St-Maarten...

[BluSdUp]

Also the main reason for getting low was disconnection AP, lowering the nose, AT still engaged and as speed increased AT reducing thrust in Level Change ( speed mode).
Before putting AT in ARM. This is contradictory to Boeing recommendation.

This is the most rubbish report I have read in some time considering how close they got. It sounds like TSB are making excuses with regards to the light setting and the information about the present WX state and specifically the vis.
As anyone with two hrs of IFR knows visibility in rain showers are transient and hard to judge. No mater: No runway, no lights, GO AROUND F15, SET GA THRUST!!
They were given the 2000 meters at one point , but did not acknowledge, so why are the Tower transcript not included , considering the CVR does not exist.

Take the Airbus crash, this one and the Taxiway C lowpass and it must be allowed to ask ; WTF are the airlines up to, and were are TSB and MOT in Canada!

[FlightDetent]

My slow connection only downloaded the coverpage... Is there a "Near Collision with Terrain" category? How lower than them you'd need to go to for it? :ugh:

[underfire]

Given that some of the approaches used by WestJet require a rate of descent of 1000 fpm or more, the FDM program is set to capture only rates of descent that exceed 1300 fpm for more than 2 seconds

The majority of WestJet’s 1596 unstable approaches in 2016 were characterized by rate-of descent exceedances, and during 609 of them the aircraft exceeded 1300 fpm for more than 2 seconds during descent between 1000 feet AGL and 500 feet AGL.

WoooHoooo!

Go around...wait for it, wait for it...jeezus, why did the ac not respond to thrust increase? No other actions other than driving it faster downward?

[Centaurus]

Similar close shave incident to a Nauru Airlines B737-400 attempting night NDB approach into Kosrae, Micronesia, Central Pacific region. In that incident, the crew forgot to set correct QRH and got to 370 feet over the water 4 miles out. They initially disregarded GPWS warnings. During subsequent go-around the pilot allowed the aircraft to descend at minus 2 degrees body angle before pulling up. Potentially deadly.
See report: https://www.atsb.gov.au/publications/investigation_reports/2015/aair/ao-2015-066/

In the case of the St Maartin incident, why did the crew use RNAV for the approach rather than use the VOR approach which is more accurate. Boeing FCTM recommends switching the autothrottle to OFF during manually flown approaches because leaving it in ARM can have has undesirable consequences. Judging by what happened, the Boeing recommendation was certainly valid

[RAT 5]

In the case of the St Maartin incident, why did the crew use RNAV for the approach rather than use the VOR approach which is more accurate.

Is that true? I left the fleet before RNAV was introduced as a standard type of approach, and so missed the training. However, I understand that the EU operator, given the choice, opts for the RNAV automatics flown approach when both are available. To be corrected, of course.

[CHfour]

In the case of the St Maartin incident, why did the crew use RNAV for the approach rather than use the VOR approach which is more accurate.

Is that true? I left the fleet before RNAV was introduced as a standard type of approach, and so missed the training. However, I understand that the EU operator, given the choice, opts for the RNAV automatics flown approach when both are available. To be corrected, of course.

Maybe they didn't have RNAV approval or possibly the pre flight raim check wasn't satisfactory?

[wiedehopf]

Checking the plates:
VOR Z Rwy 10 has a MDA of 500'
RNAV (GNSS) Rwy 10 has a MDA of 700'

Both have only LNAV minima.

The VOR is 2x the runway width to the right of the runway 10 threshold.
Both approaches are on track 96 degrees like the runway.

When GPS works properly you could basically use it to much lower minimums and be fine. But the integrity without augmentation system is not guaranteed and therefore the minimums are quite high (that's how i understand it).

So choosing or not choosing the RNAV is irrelevant here as they would've been required to fly visually even sooner. I doubt that lateral guidance would have helped much either. In the youtube video on avherald you can see they are more or less aligned with the runway but that didn't help.
If they kept the appropriate descent rate or somehow programmed themselves VNAV guidance maybe they would've even made the landing. Would still have been illegal to continue as far past the missed approach point as they did.

[scifi]

The role played by the weather conditions was not mentioned in the report. As any glider pilot will tell you, the area surrounding a CB has downdrafts of several hundreds of Ft/min. When you add this to their -700 ft/min glide-path, this should explain why they had an increased rate of descent prior to them taking their avoiding action.
.

[Capn Bloggs]

In the case of the St Maartin incident, why did the crew use RNAV for the approach rather than use the VOR approach which is more accurate.
A VOR is not "more accurate". Lateral tracking on a LNAV is more accurate; it puts you on the CL (as the boys at Mildura found; they would have died had they done a VOR). It is true that in this case the VOR had a lower MDA, but as the report says, they only loaded the LNAV "just in case"; the ATIS indicated, and they briefed for, a visual approach. So good on them for that.

Interesting that following this near-miss, Westjet created (or had created) an RNP (AR). Now they're getting serious. :D

Therefore, there is a long visual flight segment following the MAP where the crew is required to manage the descent to the runway threshold in order to complete the landing (Figure 4). It is not common for WestJet pilots to fly long visual segments of an IFR approach such as that of the RNAV (GNSS) Rwy 10 at TNCM. Even less common are long visual segments over water and with the type of weather encountered during the occurrence approach.
I think the TSB got this bit wrong. Even though the chart depicts a Visual Segment, 700ft/2nm is basically on a 3° profile, so no different to any other NPA flown as a CDFA. With a vis limit of 3600m, the runway should have been visible almost immediately.

[G4HQ]

Some posters are fond of saying we should wait for the report before commenting on an incident. On this thread there were 234 posts before the report, and 25 after it was published. Seems many have lost interest by the time the report comes out.

[AerocatS2A]

Before the report comes out it's all just speculation and we shouldn't speculate. After the report comes out the facts are known and so there's nothing to speculate about and nothing to talk about!

[Tee Emm]

When you add this to their -700 ft/min glide-path, this should explain why they had an increased rate of descent prior to them taking their avoiding action.

Disagree. Nothing to do with a CB and in any case the Investigation report stated the PF disconnected the autopilot and reduced the pitch from 0.5° nose up to 1.2° nose down. Incredible error and a potentially fatal action at that low altitude. Generally the result of slow scan rate while manually flying and thus poor instrument flying ability. A common trait with automation dependency.

[Carbon Bootprint]

Seems many have lost interest by the time the report comes out.Possibly, but it's often the case the report doesn't say much that hasn't already been concluded/conjectured here, even though the process may have been somewhat convoluted. :O

[RAT 5]

Investigation report stated the PF disconnected the autopilot and reduced the pitch from 0.5° nose up to 1.2° nose down.

Ouch! That's get the ROD screaming. I wonder what happened to the speed. Equally, one has to assume the a/c was basically in trim and on speed from the automatics at the time of disconnect. i.e. do nothing, but easy to say if no visual reference. However, why would you disconnect if no visual reference? The reduction of pitch and increase of ROD smacks of 2 heads outside searching for clues. EGPWS is not supposed to replace correct PM duties.

[slast]

Another TSB report of dubious quality in identifying the causes of a near catastrophe. Leaving aside the organisational failures to recognise the seriousness of this event, and the consequent loss of data which would devalue any report, the bottom line here is that the aircraft deviated very dangerously from the desired flight path below DH/MDA with neither pilot recognising it, but the report contains nothing to avoid such events in future.

The report only outlines how this deviation might have happened, but doesn't provide an answer to why. IMHO it is the combination of inadequate crew coordination procedures and Transport Canada's failure to adhere to ICAO SARPs in respect of required visual reference to continue an approach - identical to Air Canada's near catastrophe at Halifax in 2014.

ICAO Annex 6 requires the pilot landing to have visual references that have already confirmed the flight path is correct before leaving DH/MDA. Canada only requires that cues "enable" an assessment of it (report 1.18.2) - you can take as long as you like doing it, and may come to the conclusion that it's unsatisfactory. Which is what happened on reaching runway level at Halifax, resulting a crash that wrote off the aircraft. In this case it was at 40ft, and only after the second GPWS warning.

Here, incorrect identification of the cues at MDA, combined with the EXPECTATION of improvement, led the First Officer to wrongly assess the flight path. In his mind it now needed a correction, which de-stabilised the approach both laterally and vertically.

The difficulties of making this type of assessment are well described in 1.18.3, so no-one can claim that it's not a long recognised risk. Crew procedures that involve both pilots in the visual assessment inevitably make the situation worse, by deliberately exposing two pilots to the same risk of using inadequate visual cues, while perfectly valid instrument information slips out of sight and out of mind.

Also in this case, these problems were probably exacerbated by the fact that it was the F/O's leg. As being able to land had now become questionable, the Captain was likely concerned that the F/O's decision was in fact the correct one, causing his instrument monitoring to drop even further down his mental priority list. Result : 2 pilots head up, trying to make sense of the visual picture, and no-one registering that the flight path was into the water.

But unfortunately you can't rely on getting that sort of analysis in a TSB report. Notably, the "findings as to risk" look only at the consequences of (1) not implementing ICAO PANS-OPS regarding light settings, and (2) crew not identifying and managing threats. How about a few others?

"If Transport Canada regulations do not clearly identify that the pilot's visual references must have allowed him or her to complete an assessment of the aircraft position and rate of change of position before descending below an MDA or DH for a manual landing, as required by ICAO Annex 6, there is a risk that the assessment will not be completed in time to avoid impact with obstacles."

"If airline crew procedures are not based on a plan that the pilot flying the approach will execute a missed approach at DH/MDA unless the pilot landing has made a positive announcement that the aircraft's position and rate of change of position are suitable for continued approach, there is a risk that plan continuation bias will result in descent below DH/MDA without adequate visual cues to avoid obstacles or complete a safe landing."

"If crew procedures involve the pilot NOT intending to make the landing making visual assessments prior to, and/or on behalf of, the pilot who IS intending to make the landing doing so, there is an increased risk of a hazardous plan continuation bias."

"If crew procedures do not ensure that there is continuous instrument monitoring from the FAF until landing, there is a risk that essential instrument information and warnings will go unnoticed. "

"If the wording of crew procedures that require an exchange of instrument monitoring obligations does not specifically require announcement of exchanged tasks, there is a risk that instrument monitoring will not be continuous and essential instrument information and warnings will go unnoticed. "

"If procedural callouts alerting the pilot to arrival at DH/MDA (and the end of the decision process) are phrased as advisory (e.g. "minimums") rather than imperative (e.g. "Decide!") they risk being ineffective as salient triggers, allowing inadvertent descent without adequate visual reference."

Just a thought.....

[Capn Bloggs]

Very good, Slast. :ok:

[PEI_3721]

Steve, #265, somewhat harsh and narrow ‘thoughts’. The TSB made the best of what they had as enabled by other agencies.

A lot has been said about monitoring, but monitoring what and how. No precision guidance, visual only, with references of dubious quality, but as enabled by ICAO, the Regulator, or the Operator.

RNAV / GPS were widely promoted as ‘Precision-Like’ approaches, yet may be no better than most NPAs. Do these present an illusion of accuracy?

Who previously thought about deteriorating visibility over the sea.

Nose down pitch, equally likely due to an illusion due to reducing visual range in heavy rain where crews try to maintain the same slant visual range, but lacking the ground features to help combat it.

A habit of ‘ducking under’ at this airport; instruments were as expected.

Investigations and reports such as this cannot be expected to provide a complete explanation for human behaviour in the circumstances as presented.

Instead of requiring ‘findings as to risk’ or explanation, we must consider what has been published, and thus what we might learn, individually and collectively.

The actual cause of this accident should be of no consequence to our safety thoughts and actions.

Future safety depends on what we do, what we learn from the event; not what was wrong with reporting or in operations.

First how might the situation be avoided, then what help can be provided for the crew, especially for them to mitigate any unforeseen circumstances.

There may be as many views of what can be learnt as there are posts, but which are of greater value and most likely to be implemented.

[FlightDetent]

PEI, excellent heading for the discussion.

We do not need monitored approaches as long we have better understanding and discipline than the generations for whom it had been developed. That concept was most efficient in treating certain "childhood diseases".

And the report describes exactly one: actions of crew confused about the protocol of flying NPA in real weather. So did we outgrow that concept or not:? Or worse yet, how come we didn't?

[aterpster]

PEI, excellent heading for the discussion.

We do not need monitored approaches as long we have better understanding and discipline than the generations for whom it had been developed. That concept was most efficient in treating certain "child diseases". And the report describes exactly one: actions of crew confused about the protocol of flying NPA in real weather. So did we outgrow that concept or not:? Or worse yet, how come we didn't?

I am glad I got through that "childhood disease." No monitored approaches at TWA from my hire in 1964 until perhaps 1985. Whew!!

[FlightDetent]

Good for you. I just searched for an article out of "I learned about Flying from That", and found this instead https://www.flyingmag.com/aftermath-scud-run.

[PEI_3721]

FD, alterpster, :ok:

My point on monitoring relates to how the process of ‘monitoring’ - cross monitoring, checking, is undertaken. I did not wish to target the ‘monitored approach’ procedure specifically which has its place in flying with many benefits.

Many senior people in the industry quote ‘monitoring’ as a solution for the problems of approach and landing, yet provide little guidance on how this can be achieved in operation, instrument flying vs visual, workload, or which parameter is more important according to the situation - which implies awareness of the situation.
_

Other posts express their disbelief or failure to understand the human performance involved. Consider this; how with this inability, or unwillingness to comprehend a past situation might a similar future situation be avoided.

Our safety activity must involve reflection and learning, opposed to expecting an answer from an accident report. Individual effort beforehand is more likely to maintain safe operation and help with an attitude that ‘it wouldn’t happen to us’.

Human behaviour is very hard to understand - ‘theres nowt so queer as folk’, and even more difficult to change, thus the need to focus on potential situations and precursors - ‘monitored thinking’ for regulators, management, and pilots.

[slast]

#267 - Good morning Dan. OK yes I was a bit harsh on the TSB, they did have very little to go on really. However, "Findings as to risk" is their term not mine, and they seemed to be a bit selective in picking up St. Maarten's non-compliance with ICAO but not Canada's! Interestingly it appears that Westjet added the recommendation to go consider going around if the runway is not visible 1/4 mile before the MAP - which pretty much WOULD meet the Annex 6 requirement in this case.

I'll also concede that in this instance a different procedure (PiCMA) would have been less likely to have affected the outcome here than in the Halifax accident, where it would have had a very high probability of preventing it. But it might have given the landing pilot more time to interpret the cues at the MDA, and put more emphasis on subsequent instrument monitoring by the Captain to pick up the pitch change, increased RoD and decreasing rad alt, rather than (apparently) being both head up to the exclusion of almost everything else .

FD, I'm not sure quite sure what the relevance of your (interesting) reference article is - is it that experience is no protection against plan continuation bias and getting sucked into increasingly bad situations? That is certainly a major human flaw - as is the tendency to get task fixated and tunnel vision and all the rest of it. Since we certainly haven't succeeded in growing or training ourselves out of it, surely we still need to use other defences against it, e.g. by more appropriate procedures. Similarly, nothing's changed about the fact that weather is not actually 100% predictable, communications aren't 100% reliable, facilities aren't 100% working, etc., etc. Surely all operations should be based on being prepared for the worst every time - these guys were going to a holiday resort where the weather's pretty near perfect most of the time, but things ganged up on them and they came scarily close to ending up in the water.

PEI is absolutely right that there are lots of pious platitudes about urging pilots to "monitor better" but precious little actual practical action on what that involves, both physically or psychologically. OK, we shouldn't expect that from an accident report, but we do need to take a serious look at why these things are still happening.

[aterpster]

Good for you. I just searched for an article out of "I learned about Flying from That", and found this instead https://www.flyingmag.com/aftermath-scud-run.
I am very familiar with that CFIT. He and his sons owned an FBO in the area and he had "get-home-itis by attempting a VFR flight through a very unforgiving area (not that far from where I live). He was a retired AAL 777 captain. So what, was my observation at the time of his CFIT. He was a light-twin GA pilot who made a very stupid decision that day. I don't see how his foolish decision is in any way related to instrument approach procedures and SOP at a Part 121 air carrier (or Canada's equivalent regulation).

[aterpster]

PEI is absolutely right that there are lots of pious platitudes about urging pilots to "monitor better" but precious little actual practical action on what that involves, both physically or psychologically. OK, we shouldn't expect that from an accident report, but we do need to take a serious look at why these things are still happening.
Isn't this near accident essentially an issue of lack of cockpit discipline resulting in busting minimums?

[PEI_3721]

at, #274, (as I assume you know) accidents or near misses are rarely a simple issue.
_

The crew expected visual conditions, they elected to fly a RNAV NPA. Unknown to them, and as explained in the report, the wx vis reduced below minimums (new, but unannounced ATIS).

The assumptions (and hazards) in NPAs are that the final approach will be completed visually, requiring contact with the airport environment, that the content of a visual scene is sufficient to determine position, and manoeuvre vertically and laterally towards the runway.

The crew appeared to have contact with the ‘ground’ - sea, the local coastline and hotel, but not necessarily the runway. Did the featureless seascape provide sufficient cues to establish pitch reference, altitude, and manoeuvre; were the costal features sufficient for navigation.

As the actual visibility in the rain shower was less than required we might assume that the cues were insufficient; the vis was below minima, but how would the crew know (old ATIS), how do you judge viability in rain over the sea. Would a crew fair any better in other circumstances e.g. night if allowed, snow covered terrain.

Does the regulator assume a reference glide path based on RNAV, but RNAV may not be approved below MDA, particularly if dependent on altitude-range.

If the above applies, or even if not, then what might we learn; what forethought might a regulator or operator apply in order to avoid a similar situation.

Do all operators duck under; we have records of what happens in incidents, but few (none) in normal operation. Why should we judge a single ‘non standard’ event when we have no ‘norm’ base line for comparison. No norm for approach path, for communication, wx / ATIS, navigation standard, crew and system procedures, etc?

What might we learn, as much we choose to?

[aterpster]

at, #274, (as I assume you know) accidents or near misses are rarely a simple issue.
_

The crew expected visual conditions, they elected to fly a RNAV NPA. Unknown to them, and as explained in the report, the wx vis reduced below minimums (new, but unannounced ATIS).

The assumptions (and hazards) in NPAs are that the final approach will be completed visually, requiring contact with the airport environment, that the content of a visual scene is sufficient to determine position, and manoeuvre vertically and laterally towards the runway.references for the intended runway is distinctly visible and identifiable to the pilot:

What I am bound to flying an FAA-registered aircraft below MDA or DA, at least one of the following:

(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as a reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.

(ii) The threshold.

(iii) The threshold markings.

(iv) The threshold lights.

(v) The runway end identifier lights.

(vi) The visual glideslope indicator.

(vii) The touchdown zone or touchdown zone markings.

(viii) The touchdown zone lights.

(ix) The runway or runway markings.

(x) The runway lights

[JammedStab]

Gents, if you look at the report again, you will see a significant amount of writing on how the hotel had the appearance of being the runway. The started flying toward the hotel for landing until they got closer and realized that the hotel was not the runway and that the runway was now in view to their right. This is when they levelled off(or reduced their rate of descent). Therefore, I interpret this incident to be a case of suddenly going after the first thing that comes into view(which led to their descending more quickly and laterally from final approach.

A case of visual illusion. As for required visual reference, I would assume that they felt they had the reference(what they felt to be the runway) although in fact they were mistaken. I have seen a guy suddenly go for something he thought was the runway when it wasn't even close to being the runway. It happens sometimes. The best we can do to learn from this experience is to ask ourselves how to avoid this happening to us. With most NPA now being near-equivalent to ILS approaches, it actually shouldn't be too difficult....maintain your stabilized approach and resist the temptation to change things suddenly based on an outside picture that may be legal but misleading.

[PEI_3721]

JS #277 has the gist of the issue.

Without actually knowing what the crew saw, or think that they saw, we should not cite deviation from the norm (poor discipline) as a conclusion.

Furthermore if we were to question what good discipline is, or what constitutes discipline, I suspect that there would be many lengthy ‘CRM’ type answers, dependant on cross - crew ‘monitoring’ and call outs; but most would overlook erroneous or illusionary instances where both crew could have the same situational awareness.

The safety problem is to identify these situations beforehand, thinking about ‘what - if’, with regular updating from incidents and accidents; the endless process of learning.

[pattern_is_full]

Let's just say that recent events seem to show a pattern of Canadian crews trying to land on something other than the runway (hillside/Resolute, approach lights/Halifax, occupied taxiway/SFO, water or hotel/St. Maarten). A tiny percentage of flights, certainly, but it does seem to recur.

I think this (and the TSB's "sympathetic" attitude) may stem from Canada's internal aviation environment, which, like Indonesia, involves a lot of necessary flying to remote places inaccesible to any other form of transport, often with bad weather. If one doesn't "press on regardless" at such places, people may go hungry. The problem is if that becomes a habit and transitions to flights elsewhere.

[PEI_3721]

pattern is full, #279.
Unsubstantiated, unjustified, and unfair conclusion.
Correlation is not cause; human kind is designed to see patterns, but less well equipped to extract meaning.

Consider the incidents: https://www.icao.int/safety/fsix/Library/TAWS%20Saves%20plus%20add.pdf
All unreported via formal channels, modern well equipped aircraft, associated with ‘major’ operators, in different countries, but as might be expected the majority in the one with the larger number of aircraft.

Note incident #4, and particularly #5 soon after 9/11, and #7 and #8, close to home.

‘Stones and glasshouses’; or realisation that all of us operate in a very fragile environment which can fall in on us as happenstance; except on occasion, in the majority, we are able to intervene and manage situations as we perceived them, and achieve a sufficiently safe outcome.

[aterpster]

pattern is full, #279.
Unsubstantiated, unjustified, and unfair conclusion.
Correlation is not cause; human kind is designed to see patterns, but less well equipped to extract meaning.

Consider the incidents: https://www.icao.int/safety/fsix/Library/TAWS%20Saves%20plus%20add.pdf
All unreported via formal channels, modern well equipped aircraft, associated with ‘major’ operators, in different countries, but as might be expected the majority in the one with the larger number of aircraft.

Note incident #4, and particularly #5 soon after 9/11, and #7 and #8, close to home.

‘Stones and glasshouses’; or realisation that all of us operate in a very fragile environment which can fall in on us as happenstance; except on occasion, in the majority, we are able to intervene and manage situations as we perceived them, and achieve a sufficiently safe outcome.



I come down somewhere between you and Pattern is Full. :sad:

[pattern_is_full]

pattern is full, #279.
Unsubstantiated, unjustified, and unfair conclusion..

Not a conclusion at all. Just a noting of a coincidence of events, that perhaps TSB might want to examine as signs of a possible endemic problem. Maybe their conclusion will be that there is nothing there, and then again, they might conclude there is a "cultural" problem - not a defect in any one crew or individual - that needs to be addressed.

[slast]

I am with PEI, I don't think anyone should just attribute this to "lack of discipline" and "busting minima". There's no real evidence of that IMO.

However it has become clear from my own reading of about 120 reports of approach accidents over the last 25 years that a very common factor (as in this case), is when valid instrument information is discarded prematurely in favour of dubious or inadequate visual cues. This is very frequently associated with an expectation that things can only get better, when in fact it doesn't .

There MAY be cultural / psychology elements contributing to some of these. For example in the current case we have two extremely experienced (14,000 and 12,500 hours) Canadian pilots who are used to "real" bad weather. Surely a few Caribbean shower clouds are not going to be a big deal for them. Nevertheless, being professionals they prepared for an instrument approach anyway. On the way in, they know about the shower clouds, but NOT that the visibility has now gone below minimum. Would it have been prudent to ask? Would that imply acknowledging that getting in might actually be questionable - "don't ask, don't tell"? I emphasise I'm only speculating here. In any case visibility minima don't guarantee that sufficient visual reference WILL be available at DH/MDA, only that it's reasonably likely, and there's no evidence of this crew deliberately ignoring minima.

But in this case, just prior to reaching the MAP both pilots seem to have switched to using the very poor visual references as their primary guidance. Quote from the report: "given that THEY [plural] had the shoreline in sight and expected to see the runway shortly afterward, they would continue the approach visually." So the F/O must have been at least peripherally aware that some visual cues exist, and now concentrated on identifying anything that looks appropriate as being the "right" cues. He must have been sure he was looking at the "runway" within 1/2 mile of the MAP because he disconnected the autopilot and then pitched down. Pitch down is a known instinctive reaction to a reducing visual segment or to distortion caused by rain on the windshield. The 50% increase in descent rate caused the autothrust to reduce, following which it was disconnected and apparently stayed at 52% until the eventual go-around. Then, "As the crew crossed MAPON, the PF advised that he had the runway in sight. He began to roll left."

Just after the MAP they entered a heavy shower and were subject to much reduced visibility for about 20 seconds. Even though the aircraft track was maintained towards the "runway" (actually the hotel), the vertical path was significantly steeper than it should have been, with no means of detecting this visually, because since the "runway" wasn't one it obviously wouldn't give the necessary cues. On leaving the shower, the dominant feature was the lateral asymmetry of the runway being off to the right, so that was the instinctive priority to correct.

Understanding the new visual picture is such a compelling and demanding task that with no approach lights, limited runway lighting and no surface texture, the vertical displacement and rate was so much harder to detect that it was still not fully recognised. The F/O increased thrust from 52% to 75% as he made the first correcting turn, but that did not bring the RoD back to the correct value, let alone regain the correct descent path. Even after the first GPWS alert there was only a partial understanding of the situation, and a full realisation and response is delayed until after the second warning 9 seconds later.

In my opinion this crew were persuaded to become mentally committed to landing by two things: sight of the absolute minimum of appropriate information at the MAP, and the expectation that this would increase. This expectation was based on their own experience that usually it does, and reinforced by the report from the previous landing aircraft. Having made this decision, they were simply unable to reverse it until forcibly reminded by a totally independent external stimulus - the GPWS.

Human nature is such that when exposed to such a visual puzzle it is extremely easy to become absorbed in it to the exclusion of other things, and no amount of exhortation about emphasising cross-monitoring of instruments etc. is going to change it. There's nothing cultural or ill-disciplined about it. To me, this sort of thing is a compelling reason NOT to deliberately expose both pilots to the same potential problem.

But regarding "sight of the absolute minimum of appropriate information" there may also be a specifically Canadian issue. I think Canada's rules, and by implication underlying training, may actually encourage this hazardous decision making. (It may be true elsewhere but I have no knowledge of that).

At some past date, someone must have made a specific decision that ICAO standards about what constitutes "adequate visual reference" to allow descent below DH/MDA were inappropriate for Canada. In my opinion the subsequent wording is much less conservative (i.e. less biased to the safe side).

The ICAO pilot's decision is "I've ALREADY seen enough to be sure of where we are and where we are going, and I can maintain a safe flight path using those listed elements - lights, markings, runway etc". (ICAO: The cues "should have been in view for sufficient time for the pilot to HAVE MADE an assessment of the aircraft position and rate of change of position in relation.... ").

Someone in Canada decided this should read : [the cues] "ENABLE the pilot to make an assessment of the aircraft position and rate of change of position...... ", followed by the CAP laundry list of items to be "distinctly visible and identifiable" including "the runway". Lawyers would doubtless have a field day about the difference but it seems to me that for practical purposes this can be interpreted as meaning "the runway being distinctly visible and identifiable at MDA enables you to make an assessment of position and flight path: consequently you may continue". Which rapidly becomes just "if I can see the runway at MDA I can continue".

Since these pilots clearly thought they HAD identified the runway (perhaps the "distinctly" visible is bit iffy!) they were not deliberately breaking any rules - any more than the AC crew at Halifax were by descending solely on the sight of the "rabbit" ODALS. Arguably, the Canadian rule is simply unsafe, since in essence it can be interpreted as allowing a look-see operation, which was never intended when the concept of DH was put into place.

Anyone Canadian AWOPs experts out there know the origin of this wording?

[Capn Bloggs]

Gotta hand it to you, Slast, that (and your previous) was good! :D :ok:

[RAT 5]

To me, this sort of thing is a compelling reason NOT to deliberately expose both pilots to the same potential problem.

If I interpret this as to what I think you mean, are you leaning towards the Monitored Approach concept when conditions become close to minima. I operated under the more old fashioned conventional of PF makes all the decisions to a MA as an SOP when conditions required it. Indeed, one time after making a GA under the old conventional method we briefed a MA for the 2nd approach and succeeded. I'll admit it was not an SOP, it just seemed like a good idea at the time and the F/O PF, who flew both approaches, agreed. It was not a problem as it was just like a single channel LVO approach, which was an MA as SOP.
IMHO crew discipline on NPA's is critical. One head in one head in/out approaching cloud base and then head out approaching DA. PF is 'the GA guy'.

Is that what you meant by not exposing both pilots to the same problem? Anything to avoid 2 heads out close to the ground. This is exacerbated by captain as PM. He's 2 responsibilities being PM and also captain with overall responsibility for the flight and trying to help PF acquire the clues. Clear defined duties for both would help avoid this. Asking not what Canada's CAA guidance is on what to do at DA, what does Westjet's NPA SOP say? That is an approved document? is it well written, unambiguous and sensible; or does it need rewriting to prevent reoccurrence?

[PJ2]

Yep, excellent writing, slast, particularly your first point regarding 'valid instrument information', which is primary training material regarding cockpit discipline, as far as I'm concerned. Thanks.

[slast]

Thankee, Capn! :)

[scifi]

Do you think that for the price of a bucket of paint, the airport authorities could prevent a re-occurrence, by offering to paint the Hotel with a suitable design that would not be confused with a runway.
.

[PEI_3721]

RAT et al, re #285.
The weakness with the monitored approach and safety calls for even more monitoring, depends on having parameters of relevance and accuracy, which can be monitored meaningfully.
It is the lack of these that are part of the hazards of NPAs. Either there is no glide-slope or if FMS generated (RNAV / GPS) it might not be sufficiently accurate below MDA.

A table of altitude distance is very useful during the initial approach, but less so when closer to the runway due to its resolution - accuracy requires threshold referenced DME and use of Rad Alt which may not be precise due terrain.

When below MDA, what might the head down pilot (PM) look at, and why. Airspeed, yes. Attitude, VS, Hdg, might vary when manoeuvring to line up with the runway - NPAs do not guarantee precision.
What boundaries should be placed on any ‘deviations’, what is the norm, cf estimated glide path, actual wind speed/direction, and expected VS, … .

Alternatively if the PM looks up this might this help avoid cue misidentification, or help cross check the flight path with respect to the runway, use of external cues - those used for a visual landing. It still necessary to monitor airspeed, split scan, acceptable for two crew operations just as it is for single pilot ops.

There is no ‘perfect’ solution or procedure due to the ill defined context and situation.

An alternative is to provide crews with knowledge and guidelines of how to assess situations and manage the inherent variability, highlight potential hazards of situations - as should happen every flight. However due to the uncertainty of ‘the world’, human performance, people - crew, management, regulator; and procedures, equipment, weather, … …, then occasionally the variability overwhelms the crew’s ability to manage the situation.

[Capn Bloggs]

PEI, you have hit the nail on the head. If you do not have accurate in-cockpit slope reference ie RNP-AR, IAN in the 737? or a GS, then the only hope of staying on-slope is by reference to the PAPI (or more basically, "that runway looks very flat"). The fundamental mistake here was that the crew pressed on when they obviously could not see the runway and the PAPI. My takeaway here is it is critical that, before proceeding below the MDA/DDA, the runway and very shortly after the PAPI is clearly visible. As Slast has pointed out, the Canadian rules are "sus" in this area, apparently allowing descent without seeing the actual runway/PAPI.

[RAT 5]

As Slast has pointed out, the Canadian rules are "sus" in this area, apparently allowing descent without seeing the actual runway/PAPI.

Indeed; if reported correctly, they seem to be. However, even if allowed, I ask who would feel comfortable descending in manual flight below DA without the target insight. Scratching around at low level, on your own in a spam-can with ground contact at 80kts, is one thing. Descending semi-blind in a pax laden medium jet at 140kts is quite another. I'm not talking from legality it's from a self-preservation aspect. I'd be scared poo-less.

Regarding split crew duties, even MA's, it is human nature that PM, below DA with visual references, would be head in/out. They would confirm that the visual queues were correct & performance parameters were correct, but also that the visual flight path was safe. It's a glance in/out that would not reduce significantly the PM instrument scan. PF would be more out than in, PM doing both.
Regarding the hotel illusion: If that was the perceived target for visual profile, vertically, how/why did they descend so far short of that? PF did increase the ROD, but as with any landing the touchdown target is kept stationary in the window. In this scenario that could not have been the case, and for quite a long time. It must have been very scary wondering when the 'expected' runway really was going to become visible. It is a human trait that a pitch down when visual with approach lights in low vis is not uncommon. I once called a GA in a biz-jet, when the captaining was 'pinching a bit' at DH and did just that. Like I said, a bit in/out <DH. Glad I did; long before GPWS.

[slast]

As Slast has pointed out, the Canadian rules are "sus" in this area, apparently allowing descent without seeing the actual runway/PAPI.
To clarify, I think all XAAs allow descent without seeing the actual runway/PAPI - provided you have something else in the laundry list such as approach lights.My point is that ICAO requires you to have seen whatever it is for long enough to confirm that your flight path to it is safe, BEFORE leaving DH/MDA. Canada appears to allow you to descend purely because you have seen whatever it is - you can assess whether your flight path is safe below DH.

who would feel comfortable descending in manual flight below DA without the target in sight.?

But that's exactly what existing minima expect you to do. For example at 200ft on a 3deg. slope you are 4,000ft / 1,200m from the target, but if you have 550m/1,800ft RVR you can only expect to see the initial approach lights at DH. That's exactly why ICAO requires you to have confirmed that what you have seen combined with your training tells you that you are on a stable safe flight path to the (still invisible) target, BEFORE going below DH. Theoretically, provided it is, ballistics or momentum will get you safely down the next 100ft, with the visual segment continuously expanding until the TDZ (target) DOES come into view at 100ft when you are 550m from it.

But if it isn't already confirmed as you pass DH, all bets are off. It's also all bets off if you do the common instinctive thing of reacting to a visual segment (e.g. lights) which don't expand as fast as you're accustomed to seeing, by pushing the nose down..... just as you (RAT) experienced in the bizjet. Or if the shape, texture etc of a hotel mistaken for a runway doesn't change as you expect a runway to do.

Regarding split crew duties, even MA's, it is human nature that PM, below DA with visual references, would be head in/out. They would confirm that the visual queues were correct & performance parameters were correct, but also that the visual flight path was safe. It's a glance in/out that would not reduce significantly the PM instrument scan. PF would be more out than in, PM doing both.

That's quite right. I have never said that it's essential that below DH the co-pilot (as PM) should be rigidly locked head-down until touchdown in all conditions. That's neither necessary, desirable or achievable. The key is to avoid exposing both pilots to the potentially serious "information gap" just before and after DH, where as PEI says, instrument guidance becomes progressively less reliable, but visual information is not adequate to replace it. The less adequate the visual cues, the harder they are to interpret and the more compelling it is to strive to do so and NOT go back to instruments, even if the SOP says the PM should. That's how we get events where both pilots are head up below DH with inadequate visual reference, especially on NPAs - Birmingham, Kathmandu, Hiroshima, Halifax to name some in the last few years.

In most operations - probably 99% of the time - it turns out that there's way more than enough visual information, well above DH. In a small percentage, when operating close to the approved minima, it's marginal but approaches are stable enough to get across the gap. But on a tiny number of occasions, both things occur - the information gap is significant AND the flight path either is or becomes wrong. Fortunately most pilots will never experience this. Neither will they experience the other critical case - total loss of thrust just before V1 on a weight -limited take-off. We prepare and brief for that every day. But nearly all approaches are flown based on various reasons why "the problems that actually lead to "crew-caused" events won't affect us today", so we don't need to deal with them.

At top of descent the Westjet crew were told "unlimited visibility, few clouds at 1400ft, weather nil", but still came within a few moments of hitting the sea. Is there some cognitive dissonance in our industry?

[BluSdUp]

Gentlemen
Some excellent analysis here, and some more productive then the report!
I would love to have the SOP and training manual for WJ at hand, but at the end of the day ANY NPA must be laterally and vertically " monitored " or checked somehow!
I was not a big fan of the monitored approach when we started it, but now I love it! Gives me all the time in the world to supervise the approach if Jr is a low timer.
He is the Approach PF and the GA PF, and I get to asses the cues as we approach minima. If happy , " My controls, Click Click."
He backs me up on speed vertical and transits outside as Papi , CL becomes primary.

Anyway
Lets imagine this was a line check or a sim check !!
It would be a FAIL, the crew is clearly not competent and would have been grounded.
And, a NPA is a simple ting , BUT some very basic rules has to be applied and respected.
Know were You are , horizontally and vertically and make sure you land at the intended runway.

[RAT 5]

who would feel comfortable descending in manual flight below DA without the target in sight.?
But that's exactly what existing minima expect you to do

Indeed; I expressed it badly. By target I meant one more of the 'required shopping list' of items. Required visual reference as we call it. They are official approved aerodrome structures, not car parks or even just 'lights'. There have been enough NPA CFIT crashes where we heard the PM call "ground contact" well before MDA and sucked PF into continuing into the gloom. Vertical visibility at 500' is not 2400m forward vis.
Now someone has told us the published meteo it is even easier to understand how they became sucked into being relaxed and continuing. If correct that is a very large swiss hole in the process.

[slast]

This is exacerbated by captain as PM. He's 2 responsibilities being PM and also captain with overall responsibility for the flight and trying to help PF acquire the clues. Clear defined duties for both would help avoid this.

Gives me all the time in the world to supervise the approach if Jr is a low timer.

Too much harmony here! ;) How about this to make a real splash in the water!

This event occurred with the (very experienced) F/O as PF throughout. This will be heresy to many readers but IMO you need different limits for a F/O's leg regardless of how experienced the F/O is, and if the weather is worse than that you need to revert to the Captain landing.

F/Os are normally capable of flying just as well as Captains, and in very many cases better. I know there are lots of operator variations of what F/Os can do when it's "their" leg, so bear with me. On an F/O leg the F/O should be (at least in my thinking) acting as "pilot in charge UNDER SUPERVISION", which means the Captain's overall responsibility for the safety of the flight gives him an additional obligation to confirm that the F/O's decisions are in fact safe and sensible.

The minima numbers are set based on the concept that "the pilot's decision" at DH/MDA will be final and correct - it's land or go-around and there's no allowance for corrections. And we know that the fewer the cues the more demanding and time-consuming the task of figuring out if the flight path is correct etc. Pop out of a 200ft cloud-base with 10km underneath - easy (but rare). 200ft DH and 550m RVR - challenging.

If you don't want to expose both pilots to this dilemma, you use the same procedure regardless of whose leg it is. So how to square the circle of doing this, while still giving the Captain the ability to check the F/O's decision when it's his/her leg - and hence procedurally his or her decision?

Practically, and accepting that there are no perfect solutions, you need to make the Captain's "supervisory" decision as easy as possible - and also allow for the possibility of reversing an unsafe one by the F/O. A dangerous one would normally only be an inappropriate decision to land, as a go-around might be inappropriate but will usually be a safe option. So to do this legally, the Captain needs to be able to make HIS decision very fast, and above the actual DH.

A practical way to do this would be to say, if it's the F/O's leg, procedure-wise raise the DH by 50 ft and set the minimum visibility to be such that the touchdown point can be expected to be visible at that height. E.g. if "normal" minima: 200ft/550m, F/O minima for the same approach would be say 250ft and 1400m. That gives the Captain an opportunity to take a quick look and crucially, there should be more than enough cues to make a very rapid decision as to whether the conditions really are suitable for landing, and call go-around if not. Since he will already be "in control" and primed for a go-around that should not present a significant risk.

In practice the principle of "different F/O limits" is applied anyway by most operators for Cat 2 and 3 - if it turns out to be Cat 2 on a F/O's leg he/she loses the landing.

As I said, it's heresy to many people to suggest this. But in my opinion, it's a reason some operators now apparently restrict F/O flying to a ridiculous extent. The "all or nothing" attitude ends up depriving young and inexperienced pilots of perfectly valid experience which could safely be obtained with a bit of lateral thinking about what actually needs to be achieved. Counter arguments?

[FullWings]

Now someone has told us the published meteo it is even easier to understand how they became sucked into being relaxed and continuing. If correct that is a very large swiss hole in the process.
It’s generally regarded as easier (psychologically) to carry on with an approach than it is to throw it away. Not long ago, we changed one of our responses at minimums to “Continue” instead of “Land” to reduce the fixation.

In my experience, it is rare in real life to encounter conditions that deteriorate to the extent that there is an adequate reference at DA(H)/MDA but not later on in the approach, so when it does happen, it’s something unfamiliar that requires positive action to remedy, especially if the deterioration is slow or subtle. Has happened to me twice in 25 years. I agree about the “shopping list” in terms of references, especially on a NPA, and just because you have managed to tick one of them off, doesn’t mean that you are stable and/or can successfully land off the approach.

As I said, it's heresy to many people to suggest this. But in my opinion, it's a reason some operators now apparently restrict F/O flying to a ridiculous extent. The "all or nothing" attitude ends up depriving young and inexperienced pilots of perfectly valid experience which could safely be obtained with a bit of lateral thinking about what actually needs to be achieved. Counter arguments?
We practice complete role reversal down to CAT I minima. Our SOP is also to use the lowest available minima when the conditions are likely to be close to limiting, therefore if we had higher numbers for a FO landing the captain would end up doing it anyway, even just for commercial reasons.

What happens when you don’t get adequate references on an approach using FO minima? You could carry on to the legal minima but that would involve a control/decision making handover at low level, which adds another layer of complication and potential for misunderstanding. Not to mention reselecting minima on the alerting system, which may or may not work.

IMHO the ideal is to provide good enough training that someone with <200hrs fresh into the RHS can operate safely and with confidence to normal minima. It could be that certain operators don’t want to invest the time and money doing this, so apply blanket restrictions instead?

[RAT 5]

Fullwings:
In my experience, it is rare in real life to encounter conditions that deteriorate to the extent that there is an adequate reference at DA(H)/MDA but not later on in the approach, so when it does happen, it’s something unfamiliar that requires positive action to remedy, especially if the deterioration is slow or subtle. Has happened to me twice in 25 years. I agree about the “shopping list” in terms of references, especially on a NPA, and just because you have managed to tick one of them off, doesn’t mean that you are stable and/or can successfully land off the approach.

We are debating NPA techniques and crew duties to try and avoid further similar dangerous scenarios. But back to root cause of the dangerous nature that eschewed; there was a perception that a 'visual clue' had been obtained, and the Canadian rules allowed them to continue, plus the earlier ATC meteo data. Would EASA or FAA rules have allowed them to continue? It would seem No. The 'hotel', or whatever, was not on the shopping list. Thus does a major root cause go back to the Canadian rules? Different crew duties and techniques might not have prevented such a low descent. Descending below MDA in manual flight without positive visual reference is an airmanship thing. Limitations of the a/c, without a glide slope, require disconnection, but scratching around over the sea, semi blind, is not calm or relaxing. That's a self preservation thing.
CAA rules are one thing, but risk to my own health & safety is another. Limits are limits, but you can always impose your own buffer.
What pressure is there for Canada to review its rules? Surely after the recent incidents/accidents they are incumbent to do so. If a threat is perceived and demonstrated does it not need to be addressed? I know it's early days, but any nudie knowledge? It is within the remit of operators to change their own rules more in line with EASA & FAA.

[underfire]

Cant see that the report has been posted:

Risk of collision with terrain WestJet Boeing 737-800, C-GWSV Princess Juliana International Airport, Sint Maarten 07 March 2017 (http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2017/a17f0052/a17f0052.pdf)

Any of this sound familiar?

The features of a hotel located to the left of the runway, such as its colour, shape, and location, made it more conspicuous than the runway environment and led the crew to misidentify it as the runway..

Because the occurrence was originally assessed by WestJet as a non-reportable event, the cockpit voice recorder and the digital flight data recorder data were overwritten and were not available to the investigation.


https://cimg2.ibsrv.net/gimg/www.gmforum.com-vbulletin/864x354/a17f0052_figure_02_8404c3d80d81518d9aa230bb434d04e872259e81. jpg

The reference to the hotel seems to be suspect, they never lined up on the hotel.

https://cimg9.ibsrv.net/gimg/www.gmforum.com-vbulletin/864x476/a17f0052_figure_03_3c0515bf8587b7e2d76b284b8f3d3027c73c0c51. jpg
https://cimg2.ibsrv.net/gimg/www.gmforum.com-vbulletin/749x444/2017_03_07_c_gwsv_b738_wja_stmaarten_lowappr_map1_db00e850e2 925338c5be78d7e10293b4ff594caa.png

[Airbubba]

Cant see that the report has been posted:

Risk of collision with terrain WestJet Boeing 737-800, C-GWSV Princess Juliana International Airport, Sint Maarten 07 March 2017 (http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2017/a17f0052/a17f0052.pdf)

Any of this sound familiar?

The link to the report was posted here on June 4:
For those interested the TSB has just released the report into this incident. http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2017/a17f0052/a17f0052.pdf

[underfire]

Thanks, sorry all, I really did try to find it!

[BluSdUp]

Thats what they said too;)

[underfire]

the hotel looks like a runway, open water, taxiway full of aircraft looks like a runway, snowbank looks like a runway...

what doesnt AC consider a runway...besides an actual runway?

I like where AC says they want an RNP procedure into the airport, but because of the hurricane, the airport lost their paperwork....(RNP procedure for a non-GPS aircraft)

[underfire]

Do you think that for the price of a bucket of paint, the airport authorities could prevent a re-occurrence, by offering to paint the Hotel with a suitable design that would not be confused with a runway.

Never headed for the hotel, that is but an excuse. Look at the flightpath.


https://cimg8.ibsrv.net/gimg/www.gmforum.com-vbulletin/749x444/woug1hx_329aaf5ea73ee0a065098432248838acedf23252.jpg

[Jet Jockey A4]

the hotel looks like a runway, open water, taxiway full of aircraft looks like a runway, snowbank looks like a runway...

what doesnt AC consider a runway...besides an actual runway?

I like where AC says they want an RNP procedure into the airport, but because of the hurricane, the airport lost their paperwork....(RNP procedure for a non-GPS aircraft)

Why Is Air Canada brought up when this is a West Jet incident?

[underfire]

oh crap....sorry....been a long week!
Thanks for the correction...there was the general discussion about Canadian rules, and I blended all the mishaps from AC with WJ.

actually, WJ does have very good RNP AR capabilities.

[FlightDetent]

actually, WJ does have very good RNP AR capabilities. Does that not open even more questions? THY effectively did the first RNAV autoland about two years ago, and almost got away with it.

AFAIK the b737 RNP capabilities, including the cockpit presentation are top of the game.

[Airbanda]

Why Is Air Canada brought up when this is a West Jet incident?

There are similarities - excursion below correct approach height on non-precision approach and transient changes in visibility - with AC accident at Halifax in March 2015.

[scifi]

Even Liverpool has gantry mounted approach lights, (in the Mersey.), but I suppose that with this being a holiday resort, they would not consider that to be an important option.
.

[India Four Two]

scfi,

Besides the Mersey not being a holiday destination, the other big difference is that Liverpool doesn’t get hurricanes.

The issue here was not related to the lack of approach lights, but losing sight of the airfield.

My first experience of flying to a Caribbean island was AA into Providenciales. There was a small shower parked over the approach, so the captain announced we would hold for 15 minutes until it had moved on. The WestJet crew should have done the same.

[A4]

The issue here was not related to the lack of approach lights, but losing sight of the airfield

....er, isn’t the former a major contributor to the latter? If there’d been Approach lights their SA would have been somewhat enhanced.....I’ve mistaken other objects for a runway in the past in reduced vis, but a set of bright approach lights removes the threat of accidentally seeing what you want to see......

A4

[aterpster]

Does that not open even more questions? THY effectively did the first RNAV autoland about two years ago, and almost got away with it.

AFAIK the b737 RNP capabilities, including the cockpit presentation are top of the game.

The question it opens in my mind is why they didn't have a company special RNP AR approach when they commenced operations into St. Maarten. They have RNP AR specials at many of their Canadian airports.Indeed, the 737 from the -400 on, has been fully RNP AR capable.

[underfire]

Yes, they do have AR into most of their airports in Canada. BUT, AFAIK, they have not been very successful with approvals outside of Canada..in the press, they say they had one submitted, but the airport lost it...

It takes virtually nothing to get an RNP AR approved in Canada, I was rattling off a few RNP-AR procedures a week.

AFAIK the b737 RNP capabilities, including the cockpit presentation are top of the game.

Well, I would not say that categorically. Depending on the box, and the MMR, but is seems many of the RNP procedures are much easier with the bus. I have had to do far many more workarounds with the Smiths box than the Honeywell box. It is getting better. There are many things the Smiths box just wont do, that Honeywell does nicely, especially AR. Note that into Lhasa and Cuzco, it was AB, not lazy B.
Same for RNAP AR CATIII autoland, and RNP-AR transition to GBAS final...no way on a lazy B..I have a few CAT III GBAS autoland in military ops...

[BluSdUp]

I think we will find that this crew was incompetent .
WHO in the right mind descends below 200 feet without the runway insight on a nonprecition! Never mind 100 , 50 40,,,,,,,,,
Total lack of vertical profile awareness . Not fit for flight . End off!

[aterpster]

Note that into Lhasa and Cuzco, it was AB, not lazy B.
Isn't a Peruvian operator into Cuzco doing those great RNP AR IAPs (and DPs) with fairly late model B737s?

[Escape Path]

I think we will find that this crew was incompetent .
WHO in the right mind descends below 200 feet without the runway insight on a nonprecition! Never mind 100 , 50 40,,,,,,,,,
Total lack of vertical profile awareness . Not fit for flight . End off!

Im not the type of making these statements, but I agree with you on this one

[FlightDetent]

Yep. Even if they had mistaken the Hotel initially, was the VNAV not showing a thing? If you decided to bust minima, would you not just follow the VNAV which could take you to RWY? So many questions.

[underfire]

sn't a Peruvian operator into Cuzco doing those great RNP AR IAPs (and DPs) with fairly late model B737s?

Yes, eventually.
In the beginning, the box simply would not accept a runway endpoint over 10,000 feet. No matter what we tried, PINS, waypoint on threshold, unless the waypoint is RWY terminator, and in the database as such, just no way. The lazy B had so many things hard and soft coded into the logic and systems with 10,000 so that pilots would not bust the check ride, it took a while to weed it out.
They did eventually fix this, but it took sometime, especially with Jepp as a competitor, so I think you know how that went.

This is why so many of the real challenging airports were AB first.
Cuzco, Lhasa, Linzhi, Queenstown, etc...

[aterpster]

Yes, eventually.
In the beginning, the box simply would not accept a runway endpoint over 10,000 feet. No matter what we tried, PINS, waypoint on threshold, unless the waypoint is RWY terminator, and in the database as such, just no way. The lazy B had so many things hard and soft coded into the logic and systems with 10,000 so that pilots would not bust the check ride, it took a while to weed it out.
They did eventually fix this, but it took sometime, especially with Jepp as a competitor, so I think you know how that went.

This is why so many of the real challenging airports were AB first.
Cuzco, Lhasa, Linzhi, Queenstown, etc...
I guess this is why the FAA is so insistent on operator and airframe specific validation of the integrity and performance of an RNP AR procedure.

From a pilot's perspective Cuzco is betting on the come, so to speak, because the missed approach is arduous and problematic in the event of an engine failure. I doubt the FAA would approve those Cuzco approaches for a U.S. 121 operator because of the missed approach.

Nonetheless, "buckets" of tourists go from Lima to Cuzco everyday during the season. I suspect the pilots are very conservative about the minimums.

[Derfred]

This is why so many of the real challenging airports were AB first.
Cuzco, Lhasa, Linzhi, Queenstown, etc...

Really? I thought QF pioneered the RNP-AR at Queenstown with their 737's years before any Airbus was authorised to fly it.

[underfire]

Yes, this is true, it did begin with QF on the first iteration to 0.3RNP. I forgot about that one. The 0.1 was with ANZ and the bus.
Damn, cant believe that is about 15 years ago...

[4runner]

I love how Airbus pilots call Boeing’s “old” technology. True, a 737 is the aeronautical equivalent of a record player and the NG is a brand new record player, with a digital display...however, think about this, the 76 is 2 years older than a 320 and the production line is booked solid for the next 15 years. 30 year old 737’s are still very much in service worldwide and are being converted to freighters in the NG(digital record player) model already as opposed to being converted into beer cans. Another fantastic feature of 200 year old technology is that the Captain can see what FO spike hair instachat is doing with the controls.

[industry insider]

Reading the report, I am a bit confused

In 2016, 1596 unstable approaches were captured, which equates to 0.86% of all approaches conducted by WestJet. Of those, 1452 (approximately 91%) continued to a landing and 144 (approximately 9%) resulted in a go-around. The majority of WestJet’s 1596 unstable approaches in 2016 were characterized by rate-of-descent exceedances, and during 609 of them the aircraft exceeded 1300 fpm for more than 2 seconds during descent between 1000 feet AGL and 500 feet AGL.

In many of the OM I have read, being "unstable" requires a mandatory go around?

[sansmoteur]

Another fantastic feature of 200 year old technology is that the Captain can see what FO spike hair instachat is doing with the controls.

Laughing hard !!!

[KenV]

Another fantastic feature of 200 year old technology is that the Captain can see what FO spike hair instachat is doing with the controls.Oddly enough, there's plenty of "modern" FBW technology that lets the pilot know what the other pilot or the computer is doing with the controls. The F-35, F-18, F-15, 777, 787, 777X all have back driven controls that provide visual and tactile feedback of what is going on. So there's really no reason for a flight control architecture that does not have back driven controls.

[aterpster]

Oddly enough, there's plenty of "modern" FBW technology that lets the pilot know what the other pilot or the computer is doing with the controls. The F-35, F-18, F-15, 777, 787, 777X all have back driven controls that provide visual and tactile feedback of what is going on. So there's really no reason for a flight control architecture that does not have back driven controls.

You missed the point. :)

[KenV]

You missed the point. :)There's a lot of that going around lately ;)

[glad rag]

And around we go again...