Our Airline (Nauru) seriously close shave during NDB approach [Archive]

gtseraf

16th Mar 2018, 22:40

interesting to see the PIC was experiencing fatigue, yet there does not appear too much in the recommendations to improve the situation.

It appears that this is a problem throughout the world, ICAO have recently made FRM a requirement, yet many operators pay lip service to this. Crew in many operations are reluctant to call fatigued as they may be penalised by the company, loss of pay/sick days. The pilot body worldwide , IFALPA (?), really needs to start doing something about this, fatigue has caused many accidents and has the potential to cause many more.

Captain Nomad

17th Mar 2018, 12:10

This occurrence highlights the importance of flight crews declaring any instances of acute fatigue and stress-inducing circumstances that may have an impact on their flying performance. Operators also need to remind flight crew of the importance of their decisions with regards to their fitness to fly.

A typical management style approach highlighting the fatigue onus being on the flight crew member (who is in the most difficult position to identify their level of fatigue) without any mention of work schedules/rostering/work practices which can contribute to said fatigue. It really is a joint responsibility but these days it seems crew are out on a limb all on their own these days when it comes to managing the 'f' word...

KRUSTY 34

18th Mar 2018, 06:02

Fatigue is an issue most airlines are reluctant to address. You have to look no further than the intense lobbying of a weak regulator by just about every operator in this country!

Then there’s the destination. Served only by a 1930’s era instrument approach! I mean is it such a stretch for a potential new carrier to insist on a minimum level of navaids? Or do they risk the entire operation because of an unacceptable number of holes in the cheese?

These are by no means isolated circumstances. One day when the unthinkable happens, will the investigation trace the real cause back to the source? Somehow I doubt it.

Judd

18th Mar 2018, 12:59

https://www.avherald.com/h?article=495d5883&opt=0 (https://www.avherald.com/h?article=495d5883&opt=0)

More discussion from avherald.com
Much to learn from this incident. The DME was at the airport and if the crew had constantly checked DME versus altitude (320 feet of altitude for every one nm) from 10 miles out it would have been obvious that the stepped down profile as depicted on the chart was going to put the aircraft extremely low over the sea and at night. Commercial pressures would not have helped, either.
The ATSB report stated: "From the time the captain set the thrust toTOGA until the aircraft was stabilised on the missed approach path (at about 0905), the recorded aircraft pitch angle varied from -0.35° to +16°.
That is a significant pitch change, with the aircraft attitude at one stage below the horizon and within seconds of hitting the sea. This suggests the PF was probably chasing flight director indications and over-controlling while doing so.

If there is one thing positive to be learned from this incident, it is this: CASA must seriously consider including a lot more emphasis on manual raw data instrument flying competency during re-currency training and for each IPC. Otherwise, history will inevitably repeat itself.

4 Holer

18th Mar 2018, 17:00

A Squared

18th Mar 2018, 17:21

A Squared

18th Mar 2018, 17:36

The DME was at the airport and if the crew had constantly checked DME versus altitude (320 feet of altitude for every one nm) from 10 miles out it would have been obvious that the stepped down profile as depicted on the chart was going to put the aircraft extremely low over the sea and at night.

My read of the report suggests (to me at least) that they had intentionally descended to the MDA as soon as possible (Vs a Continuous Descent Approach) If so, cross checking the distance and altitude wouldn't have proven anything because they knew they were below a CDA descent path.

JPJP

18th Mar 2018, 20:34

My read of the report suggests (to me at least) that they had intentionally descended to the MDA as soon as possible (Vs a Continuous Descent Approach) If so, cross checking the distance and altitude wouldn't have proven anything because they knew they were below a CDA descent path.

I wonder what the Radio Altimeter was indicating ........ ?

A Squared

18th Mar 2018, 20:46

I wonder what the Radar Altimeter was indicating ........ ?

The report seems to indicate that the radar altimeter was reading anywhere from 130-140 ft lower than the barometric altimeter. It mentions them levelling off at 500 ft indicated with the Radalt indicating 368 ft, then later: At 0903:19, the aircraft was at 4.31 DME, 480 ft indicated altitude and 340 ft radio altitude

and

The flight data recorder data showed that TOGA was
selected at 0903:47, at 448 ft indicated altitude, or 304 ft radio altitude (see Figure 3), and the aircraft was about 3.5 NM from the DME.

and

The aircraft was then at 384 ft indicated altitude, or 244 ft radio altitude

JPJP

18th Mar 2018, 20:53

3.5 miles from the DME on the field, at 300’ AGL. Shudder.

piratepete

18th Mar 2018, 21:39

I heard that the altimeters were never set to

piratepete

18th Mar 2018, 21:43

Sorry.Never set to QNH.This explains the very low radio altitude at times.If you have a look at flight safety site SKYBRARY.AERO you will find a section on go-around safety.Not only was the actual approach poorly flown, but the following G/A has many of the errors mentioned at Skybrary.This is a huge problem area in my opinion as an instructor.The all engines operating G/A is something that must get more practice during simulator training, not just the usual engine out exercise.

patagonianworelaud

18th Mar 2018, 22:09

4 Holer = NL - and he has an axe to grind.

compressor stall

18th Mar 2018, 22:18

The all engine go around is far more likely to be faced (than the OEI GA) and due to the general lack of currency on it, far more likely to be stuffed up.

A Squared

18th Mar 2018, 22:24

I heard that the altimeters were never set to QNH.

Yes, that's one of the facts from the report. They did not set altimeters to QNH descending through the transition level.

muffman

18th Mar 2018, 23:04

Surely a latent threat (along with many others) here is that the transition altitude in this airspace is so ridiculously low. They passed over the NDB at 5000ft which meant they needed to set the altimeters moments before station passage. I imagine this would be the same for many non precision approaches which often start up around 5000ft.

piratepete

19th Mar 2018, 00:18

Tee Emm

19th Mar 2018, 01:08

Only a matter of time for these porch monkeys flying in the middle of the pacific not a place for this type aircraft, limited fuel two baby engines, limited or no alternate ( Island alternate fuel for holding to hope for the best ) it will not end well.

Oh I don't know about that. That operator has been flying the 737-200 and now the 737 Classics all over the Western, Central and South Pacific since 1974 which is 44 years without an accident and crewed from the beginning by Australian pilots. Pretty good porch monkeys I would say, wouldn't you?:ok:

A Squared

19th Mar 2018, 03:15

Surely one of the descent/approach/landing checklist items is "altimeters".The fact that this action was missed indicates some kind of serious issue in the cockpit, perhaps stress or fatigue, could be anything.My other observation would be to ask why pilots in this current age are still flying a dive and drive method.

According to the ATSB report, they had completed the Descent Checklist (whcih contains altimeter setting) earlier, and had noted that the altimeter setting was not yet accomplished, as they were still above the rather low transition level ... and then the altimeter setting got forgotten when they did descend through the transition level.

piratepete

19th Mar 2018, 03:21

If what you are saying is that the checklist item "altimeters" is part of the DESCENT checklist, then this is a seriously flawed set up.On the Boeings that I fly, the checklist item "altimeters" is only actioned as part of the APPROACH checklist upon (or earlier) reaching the transition level, whatever that might be locally.As is commonly the case, the job of MONITORING often is not performed very well by many pilots, and I would suggest that more emphasis needs to be placed on this function during most training events.

Capt Fathom

19th Mar 2018, 05:06

If you read the ATSB report:

The crew had briefed the new transition level at top of descent and had briefly discussed the need
to conduct the approach checklist on passing through the transition level when they were
descending through FL 130 (the usual transition level). The crew had put a plan in place to
complete the checklist. However, as they were flying over the non-directional beacon at FL 050
and were looking at the runway in preparation for the commencement of the approach, workload
began to rise and they forgot to return to the approach checklist and complete it, as per a
prospective memory error.

witwiw

19th Mar 2018, 10:31

Only a matter of time for these porch monkeys flying old 737-300s out in the middle of the pacific not a place for this type aircraft, limited fuel two baby engines, limited or no alternate ( Island alternate fuel for holding to hope for the best ) it will not end well.

Well, well, well - there's a pot trying to call the kettle black. Where do I start?

https://www.youtube.com/watch?v=MWsgs3AArvc
https://www.youtube.com/watch?v=iWdLrylEydg

Is this not your aircraft, fitted with the possibly same CFM (baby) engines as the 737's?

"limited or no alternate". Better let United know that - their destinations include Chuuk, Pohnpei, Yap, Majuro, Kosrae, Kwajalein, Koror - all in the "middle of the pacific".

I'm reliably informed that three of Nauru's "old" 737s are the last ones off the Boeing production line around 1997, maybe later. Of the others, neither is anywhere near 50 years old like this DC-8.

An interesting read:
Incident: Skybus DC87 at Rionegro on Jan 21st 2018, unsafe departure (http://avherald.com/h?article=4b414b6e)

I didn't see anything in the ATSB report about a downwind takeoff at a performance critical airport - and you refer to Porch Monkeys? Best look elsewhere, methinks.

To quote you "It will not end well" - not if the DC-8's are operated like that.

It appears you are harbouring some sort of grudge with this nonsensical rant against an operation with, overall, a pretty good record. They haven't put anything into Botany Bay - not everyone can claim that?

.

4 Holer

19th Mar 2018, 19:01

No idea, NASA have DC8s so they must be OK and that mob own 6 x DC8-70s and couple MD11s out of LAS and Miami.

Back to the thread. 3.5 DME at 300 feet with a bunch of pax in the back "forgot to adjust the QNH " unreal stuff, 16 year old schoolkid student pilots even do it, presume the chief pilot / Dir Ops got fired for letting Monkeys fly.

Tiger lost their AOC for less than that so Nauru must have a nice " arrangement " with the Civil Aviation ......down there in White Africa.

witwiw

19th Mar 2018, 19:24

"Back to the thread" = avoid the questions.

have a nice " arrangement " with the Civil Aviation ......down there in White Africa.

Ah, yes, you don't like CASA either. Would that be because a ramp check on a 727 in Cairns saw that aircraft grounded? That and how Botany Bay got their attention.

Sour grapes springs to mind.

I think the only monkeys here were the ones in the trees at the end of the runway, and whose bowels probably evacuated rapidly when they saw a DC-8 looming at them. :-)

Car RAMROD

19th Mar 2018, 21:56

..... these porch monkeys...

Racist much?

BPB737

19th Mar 2018, 23:07

HEY 4 HOLER.
Seem to remember the only thing that didn't end well was the F/O that was PIC that ended up in Botany Bay in a DC 3 VH-EDC !!!!!

porch monkey

20th Mar 2018, 12:26

Hey 4 holer, I know you have an axe to grind against almost everybody, but lay off the porch monkeys. Some can fly.

Capn Bloggs

21st Mar 2018, 09:33

ATSB
- Called it a Dive and Drive. It isn't. Could have been flown as a CDFA using the DME for a profile (as done for decades by some Australian RPT jet operators). Nice load of motherhood and brotherhood from FSF though...
-Mish mash of approach charts: half of the Jepp chart but profile diagram of the FAA chart! Publish the complete chart used by the crew. FAA "remain within 10nm" not on Jepp chart.
-No comment on the apparent absence of the charted procedure turn.
-No recommendation to review/increase the TA. Ridiculous to have it at 5000ft.
-No analysis of company procedures to re-initialise the IRS on the threshold prior to takeoff (810m error before takeoff). In any case, actual map shift was irrelevant to this incident (even though the crew cancelled the first EGPWS warning on map=shift concerns).
-No mention of any VASI.
-Failure to hammer Aviate Navigate Communicate in relation to the Flight Info Service updates (page 17).
-risk amplified by "the location and height of the missed approach point, which was well below a normal 3 approach profile" Seriously??

That operator has been flying the 737-200 and now the 737 Classics all over the Western, Central and South Pacific since 1974 which is 44 years without an accident and crewed from the beginning by Australian pilots. Pretty good porch monkeys I would say, wouldn't you?
Not sure I'd agree with that, TM. That must have been a regular approach, but there appeared to be no SOPs for conducting it, based on what the ATSB said eg distance cutoff for landing straight in on 05, lack of profile...

That Airbus incident is a bit of a worry too, particularly the (in) actions below 1000ft...

As usual, lots of lessons for us all, pity that the standard of the report and lack of punchy criticisms/recommendations by the ATSB means learning opportunities lost...

ivan ellerbai

21st Mar 2018, 10:12

"That must have been a regular approach,"

Read the report - the inaugural flight.

"No analysis of company procedures to re-initialise the IRS on the threshold prior to takeoff "

Do you "re-initialise" the IRS or do you update it on the threshold? However, as you say, it wasn't relevant as they should have been on raw data seeing it wasn't updating via GPS.

"Could have been flown as a CDFA using the DME for a profile"

Is the DME valid when it's an offset approach - in those circumstances DME does not represent track miles to run? Having said that, it is possibly better than nothing.

"but there appeared to be no SOPs for conducting it".

And that comes from where? Looking at their network, they operate into Ponape (offset approach to the east) and recently, I'm told, had Vila in their operation operating for Vanuatu Airlines (another offset approach onto the south-eastern runway). I expect they would have offset approaches adequately covered in their SOP's.

"As usual, lots of lessons for us all, pity that the standard of the report and lack of punchy criticisms/recommendations by the ATSB means learning opportunities lost..."

Couldn't agree more.

.

Capn Bloggs

21st Mar 2018, 10:38

"That must have been a regular approach,"

Read the report - the inaugural flight.

I did. I was referring to Teeemms comment that Aussies had been flying in the area for years.

Is the DME valid when it's an offset approach - in those circumstances DME does not represent track miles to run?
30° offset, of course it does.

but there appeared to be no SOPs for conducting it".

And that comes from where?
Because none are mentioned by the ATSB, as I said.

I expect they would have offset approaches adequately covered in their SOP's.
If that approach was following their SOPs...

ivan ellerbai

21st Mar 2018, 10:50

"I did. I was referring to Teeemms comment that Aussies had been flying in the area for years."

Yes, they have, for decades, but that doesn't mean this particular crew had that experience. An "inaugural" flight would indicate that it was new to the current network. It may well have been a destination in years past, but that's irrelevant to current crews if the place hadn't been flown into for some time.

"30° offset, of course it does."

It's more than 30 degrees, closer to 40 degrees.

"Because none are mentioned by the ATSB, as I said."

So because the ATSB don't mention them, they have none? What rubbish.

"If that approach was following their SOPs..."

And the evidence is where that it wasn't?

"the location and height of the missed approach point, which was well below a normal 3 approach profile" Seriously??"

Yes, seriously. Look at the chart - missed approach at 500' at 2.9 DME. How is that on a 3 degree profile?.

maggot

21st Mar 2018, 12:01

Yeah iirc the 737 classic had a runway position update button on the MCDU, not a full re init I would think

Capn Bloggs

21st Mar 2018, 12:31

Hmm. Kicked a hornet's nest here, I have.

It's more than 30 degrees, closer to 40 degrees.
Semantics! The DME could have been used to put the aeroplane on a 3° approach profile that would have been far better than what happened. It doesn't matter that it's offset! You manoeuvre visually to the right to join Final. The approach analysis (in the office, by Flight Ops beforehand) should have worked out a DME cutoff after which a Straight-in must not be attempted. And what went on during the route-proving flight? Surely such a difficult approach would have been test-flown?

So because the ATSB don't mention them, they have none? What rubbish.
OK, the ATSB didn't mention them (as I have already said). You indicate pretty firmly ("What rubbish") that they do have SOPs. What are they, for this type of approach?

And the evidence is where that it wasn't?
Are you seriously suggesting that they were following an SOP?

Yes, seriously. Look at the chart - missed approach at 500' at 2.9 DME. How is that on a 3 degree profile?.
Again, my remark on this is directed at the ATSB "this was a dive and drive" comment. With a MAPt at 2.9DME, it is your choice to be at 500ft. My comment re "profile" relates to how you get there. I'll spell it out. 3x-400ft. That clears the 5DME step and provides a constant descent profile to hit the MAPt at the MDA. Fly a lower profile if you like. Just fly A profile. You will obviously be way below the runway profile but you would know that it was planned that way and so it shouldn't be a "threat", per se. Let the aeroplane level off and do the circle (you would obviously be too far offset to land straight-in at that point).

Now the EGPWS may not like you being at that point, but that should've become evident during the route-proving flight.

A Squared

21st Mar 2018, 17:45

-Mish mash of approach charts: half of the Jepp chart but profile diagram of the FAA chart! Publish the complete chart used by the crew.

Well, true, but what *real* difference does that make? Is there some critical item of information whcih is germane to the incident at hand, whcih is missing on one or the other?

FAA "remain within 10nm" not on Jepp chart.

FAA chart has "Remain within 10 NM" (obviously from UKS D5) and

Jepp chart has "10 NM from D5.0", positioned so that it is clear it is the limit of the procedure turn maneuvering area.

Seems to me that it's the idential information presented in 2 slightly different ways. What relevance to this incident is the procedure turn distance?

Capn Bloggs

23rd Mar 2018, 05:04

Well, true, but what *real* difference does that make?
If you're going to publish a report on a stuffed-up NPA, why wouldn't you publish the whole chart that was being used?

Typical Americans. FAA giving a distance limit on a DME distance. Jepp not saying it's a limit. What about for both, "Max distance during Proc Turn 15 DME UKS".

A Squared

23rd Mar 2018, 05:28

Jepp not saying it's a limit.

Huh??? is this your first time looking at a Jepp chart? Do you not know that that is the way Jepp displays the limit of the procedure turn limit? If you're confused about what the information displayed Jeppesen's approach charts means, you probably ought to get some remidial instruction in that before you use them in flight. I can help you out, that particular tidbit of information can be found in the Approach Chart Legend, under "profile view" it's explained in Note 5.

Apart from your rather astonishing ignorance of Jepp charts, can you explain what difference the procedure turn distance makes to the incident at hand?

Capn Bloggs

23rd Mar 2018, 06:03

My bad, I'll take some spelling lessons too.

Never seen one of those "don't go outside XXnm from D5 UKS" on a procedure turn before. I learn something every day.

can you explain what difference the procedure turn distance makes to the incident at hand?
Did I say it did? Sorry for throwing in all these tangents. I will in future preface all such comments with "Thread drift". On the subject, it does seem a bit odd that there is a 10nm limit from a fix that in all likelihood the crew has no displayed distance to it (unless they had a GPS-updated FMS). It would be much simpler to have the limit based on the DME.

Thread Drift: why would there be a 15DME (10 on 5) limit on the proc turn? Doesn't seem to be any limiting obstacles...

A Squared

23rd Mar 2018, 07:32

On the subject, it does seem a bit odd that there is a 10nm limit from a fix that in all likelihood the crew has no displayed distance to it (unless they had a GPS-updated FMS). It would be much simpler to have the limit based on the DME.

Scratching my head here. It would be based on the DME. the IAF is at D5.0 and remaining within 10 NM of that fix would be D15.0 approximately, technically being at D15.0 right at the furthest point on your PT would put you slightly farther than 10.0 nm from the D5.0 fix because the distances aren't all on the same line. But that wouldn't be enough to be operationally significant. Normally procedure turn limits are referenced to the IAF.

Thread Drift: why would there be a 15DME (10 on 5) limit on the proc turn? Doesn't seem to be any limiting obstacles...

Well, all procedure turns have some maximum distance established. The normal procedure turn distance from the IAF is 10 NM (unless there is a need for something different) so procedure turn protected areas are established for obstruction clearance out to 10 nm, plus a stepped and tapered buffer margin. Obviously in this case you could go 100nm in that general direction and not find anything higher than a ship's mast. But, the normal procedure is to evaluate obstacle clearance for a PT with 10 NM of the IAF, and unless the approach designers need the additional distance for some reason, why expand the normal protected area when it's not needed? I think it's not that there's a specific reason (like high terrain) limiting the PT distance, but just that's the extent built into the design of the approach and "beyond here be dragons".

Square Bear

23rd Mar 2018, 08:33

On the subject, it does seem a bit odd that there is a 10nm limit from a fix that in all likelihood the crew has no displayed distance to it (unless they had a GPS-updated FMS). It would be much simpler to have the limit based on the DME.

The Approach is a NDB DME-A. The DME Freq is 115.3. My take is that to complete the approach both the NDB and the DME needs to be working, (or you have approval to use GPS in lieu of DME - not in this case obviously)

As to the Holding pattern distances, I would agree that there is a limit, but it seems poorly described (10NM from D5.0!). In this case it did not have any effect as the approach was joined from the arc.

Unfortunately poor countries in the Pacific struggle to keep the navaids operating, let alone updating to something more "modern" like a VOR. (PNG is a prime example and it has much more resourses and cash than FSM).

WRT the why the ATSB did not address the fact that the Transition Level was at A050 (as someone complained in an earlier post)...I would say that it is not up to the Australian ATSB to make comment on how other States run their airspace, just to comment on how the crew failed to adhere to what was there.

What I take from this as a lesson is that systems knowledge if paramount (crew not understanding that the EGPWS had its own GPS and was not subject to map shift was another a pretty big hole in the cheese after the QNH issue), and that unless it is DAY VMC you do not disregard a hard warning from the EGPS.

Nice to see that the crew have not been slagged off at here on PPruNe, incidents like this are for us all to learn from....especially when one is not flying from ILS to ILS in First World Countries.

Judd

23rd Mar 2018, 14:12

Nice to see that the crew have not been slagged off at here on PPRuNe, incidents like this are for us all to learn fromAgree. One would hope that the operator learns from that incident and give its crews specific simulator training on IMC go-arounds involving missed approaches where an immediate change of heading to almost a reversal track is required while climbing.

In instances such as this particular case, because of the close proximity of hilly terrain, it may be more expedient when conducting the go-around to simply switch off the flight director and automatics and conduct the climbing turn manual raw data until established on the outbound track of the missed approach procedure, when at crew leisure, the crew could re-engage the automatics as required for the occasion. All pilots should be able to perform such a manoeuvre with no problem providing they are competent to do so without sweat.
From the ATSB report which stated the pilot went at one stage from 15 degrees nose up during the go-around to suddenly minus 0.3 degree nose down, it would suggest that instrument flying skills were somewhat rusty? Automation dependency maybe? Certainly a good simulator exercise in IMC. Fiddling with the automatics in that situation may not be the wisest thing to do. Boeing cover that in their 737 FCTM when it states: "Early intervention prevents unsatisfactory airplane performance or a degraded flight path. Reducing the automation as far as manual flight may be necessary to ensure proper control of the airplane is maintained. The pilot should attempt to restore higher levels of automation only after airplane control is assured."

Cairns ILS Runway 15 missed approach procedure has a similar missed approach procedure to Kosrae so the reversal turn is nothing new