Ryanair GPWS @ Bergerac

[Locked door]

I haven’t seen this one mentioned before, it seems the Swiss cheese nearly lined up.

https://www.flightglobal.com/safety/serious-ryanair-737-low-approach-incident-followed-procedural-confusion/139031.article

[Rt Hon Jim Hacker MP]

These types of approaches should have been banned a long time ago. They are not fit for purpose in the modern day and have a long history of tragic accidents associated with them.

Yes I can fly one. But the paying public sat in the back deserve better.

[Rt Hon Jim Hacker MP]

I did one on my IR test in 1989 in an Aztec. The next time I did one for real (needles don’t wander in a sim) was in the LHS of a Boeing 767 into HUY. Quite remarkable that we managed to safely land off it.

[wiggy]

These types of approaches should have been banned a long time ago. They are not fit for purpose in the modern day and have a long history of tragic accidents associated with them.

Yes I can fly one. But the paying public sat in the back deserve better.

Very very much agree, but TBF as the report states Bergerac did have/do have published RNAV procedures to that runway.

[FlightDetent]

Nothing to do with NDB navaid. Spatial disorientation, unable to use the FMS coding and/or get overwhelmed by it at the same time.

There's a step-down fix of 1460 ft over the NDB station, 4 miles out on the centre-line. The A/C descended through that altitude
- 20 degrees off the centerline track
- 10 miles away from the field
- on a heading that was almost perpendicular to the final track.

Missing a step-down fix on the final approach by 90 degrees of track error, .... can't blame the radio signal.

[wiggy]

Missing a step-down fix on the final approach by 90 degrees of track error​​​​​​

Did they do that?

As I understand it they approached the NDB ( "BGC") from the NNE, overflew it SSW bound (at about 90 degrees off inbound course) and then performed a direct join, left turn to fly downwind on the procedure hold at 2500 feet .. However as I see it then went all wrong when, immediately at the end of the downwind hold leg, at the start of the base turn, the pilot flying commenced a further descent rather than flying level until being established inbound towards the NDB.

Plates etc are here:

Incident: Ryanair B738 at Bergerac on Jan 29th 2015, descended below minimum safe altitude on NDB approach (http://avherald.com/h?article=48196bf2)

[FlightDetent]

Agreed. The point I was trying to make was they ended up ignoring the easily understandable vertical profile as well. That suggests the lateral guidance was not at fault, even if grossly misunderstood already. More likely the first victim, not the reason behind the disarray.

Donald Bateman was an angel who walked the Earth.

[wiggy]

Yep...OK, agreed ..It looks like for whatever reason the crew didn't comprehend the vertical profile depicted on the charts.

[Max Tow]

Does the final report have any explanation of the apparent investigation timescale, which on the face of it seems unbelievably poor?

[IRRenewal]

Crew lost SA and got it in a pickle. However, on receiving a GPWS hard warming they did what they were supposed to do and climbed back to 4000 feet (I would assume they performed the terrain escape manoeuvre but the flightglobal article doesn't use that expression).

If all crews who have found themselves in a similar situation over the years had done the same a lot of people would be alive who sadly now aren't.

[SASKATOON9999]

Glad to see the report was produced within a timely manner -

[CW247]

Lunch alone does not cut it. Must've been combined with a fag break.

[737 Jockey]

Does the final report have any explanation of the apparent investigation timescale, which on the face of it seems unbelievably poor?


They've probably been on strike Since then 😏

[ATC Watcher]

Hey give the BEA guys a break ! It is only an incident . They have had their hands full with major accidents in the last 5 years And they have only a limited number of staff . They are also asked for their expertise (and tools ) in almost all the last ones . Including now the Ukraine 737 in Iran for instance.
It is about priorities I guess

[sonicbum]

Guys, sh1t happens, they got got out of it in one piece and most likely got chewed out and retrained appropriately (at least I hope so).
I am more concerned by people claiming that it is unsafe to fly a Raw Data NDB approach with 2 engines and the autopilot.

[FullWings]

Interesting one. Many holes in the cheese but at least there was no confusion over what an EGPWS alert meant.

I find it fascinating that a crew can get spatially disoriented when there is an electronic map in front of them showing exactly where they are relative to the final approach track and giving distance to the runway. Mode confusion, dissimilar mental models, decreasing SA... It’s all there to learn from.

[macdo]

Time was we did non precision approaches to places in the eastern med on a weekly basis, they needed you to be well briefed and on point mentally if the weather was anything but cavok. I would guess the vast majority of modern pilots do an old fashioned hdg/vs NPA rarely to never, even in the sim. Recipe for an ASR. Fair play, correct reaction to the GPWS is re-assuring.

[Herod]

The old saying "there are two types of pilot; those who have screwed up, and those who are going to". Screwed up many times. These guys got it wrong (it happens) but took the correct action when needed. No passengers were scared, and the paint wasn't scratched. Result.

[Maninthebar]

How about biscuits -do you think they were eaten :-) ?

[A320LGW]

Given the airline in question I imagine it was bring your own?

[macdo]

Herod

I don't disagree with your sentiment. But, it is possible that modern day crews are not trained or practiced enough to do NPA without the RNAV overlay and all the automatics helping. I don't think it is anything particularly to do with this crew's abilities. I can't remember when raw data NDB apprs' were taken out of our LPC/OPC's, but it was years ago and I'd frankly not elect to do one unless it was the only option.

[172_driver]

A raw data NDB (no A/P) was part of the sim profile at the interview for that airline. Seems like flying ability has only degraded since flight school.

[Banana Joe]

When was that?
What I and many others had was a procedural NDB ILS approach. Not as hard as a pure NDB approach.

[booze]

I did my assessment with them back in January 2017 for a NTR DEC position and also had a raw data NDB for GLA or EDI (can't remember anymore).

[HundredPercentPlease]

Are some getting confused with an NDB-DME? This is an NDB only with no accurately defined descent point, and therefore no way of knowing if you are on a 3 degree path for stability criteria, and almost certainly will result in a dive and drive which again has been outlawed for decades.

It used to be a sim scenario at MyTravel. The crew would (naughtily) define a descent point by GPS. The instructor would simulate a GPS fault (map shift), because you are only meant to use the NDB and a stopwatch. All sorts of fun then ensued.

The conclusion is that dive and drive NDB approaches are only for operations without any stable approach requirements. Which is why I have never attempted one in 20 years!

[172_driver]

What I and many others had was a procedural NDB ILS approach. Not as hard as a pure NDB approach.

10 years ago. It was a pure NDB, no ILS behind, no RNAV overlay

[Ray_Y]

NDB with timing table.
Questions: Did the pilots know of the ILS/DME u/s in advance (per NOTAM) or just when arriving?
Fair enough, they briefed before TOD, which is generally acceptable. Still it looks like they didn't get it together in the FMC. And such approach is really out of the norm for .
What's the truth regarding RNAV permission at FR - too greedy to buy all modern data sources? Or crew error?

[HundredPercentPlease]

10 years ago. It was a pure NDB, no ILS behind, no RNAV overlay

Which is odd, because it's so easy. No height and distance checks, just wang it round the corner, descend at constant v/s, track the beacon in/out until you hit one of many conditions that force you to g/a. An NDB-DME would be more of a test, because you have to fly a prescribed slope.

[Rt Hon Jim Hacker MP]

Guys, sh1t happens, they got got out of it in one piece and most likely got chewed out and retrained appropriately (at least I hope so).

I am more concerned by people claiming that it is unsafe to fly a Raw Data NDB approach with 2 engines and the autopilot.


The simple fact is that an NDB approach is probably the most challenging. The majority of CFIT accidents have occurred on non-precision approaches in perfectly serviceable aeroplanes. All engines with an autopilot.


My point is this. These types of approaches are statistically way less safe than a conventional ILS. If you apply TEM, an NDB should be at the very bottom of your list of preferred approaches.

[LXGB]

Scary stuff!

I agree 100% that airliners shouldn't be flying NDB approaches anymore. A big hurdle to implementation of GPS approaches at many small regional airports is the high cost of the required consultations needed for regulatory compliance. Here's a link to the BEA investigation page where the full report, currently only available in French, can be downloaded.

Incident to the Boeing B737-800 registered EI-EMK operated by Ryanair on 01/29/2015 when approaching AD Bergerac-Roumanière (24) (https://www.bea.aero/les-enquetes/evenements-notifies/detail/event/incident-du-boeing-b737-800-immatricule-ei-emk-exploite-par-ryanair-survenu-le-29012015-en-approch/)

Direct link to report pdf (https://www.bea.aero/uploads/tx_elydbrapports/BEA2015-0037.pdf)

[macdo]

The last few posts seem to miss the point. It is not the ability to have been taught to do any type of NPA procedure and then use it in the sim for an interview that counts. If it had been me taking that interview, I'd be doing them by the dozen on my PC at home to get the brain functioning properly. The relevant point is, can the average crew do one, in anger, with poor weather, when they least expect it. My contention, is that unless it forms a part of a regular LPC/OPC you probably can, but with much reduced safety margins.

[Check Airman]

I don’t understand. Didn’t the crew have a working ND? How’d they get so disoriented? Good job of fixing the situation though.

[HundredPercentPlease]

macdo,

Nothing wrong with with an NPA. Especially with a GNSS overlay. But only if you have a distance indication, which they all do other than this one. The NDB-only is not compatible with a stabilised approach philosophy, which is a requirement of modern ops.

[Bergerie1]

That is why, in my day, everyone had to fly an NDB non-precision approach, sometimes with an engine out, and in a strong cross-wind on every six-monthly sim detail. Hard work, but invaluable basic instrument flying practise.

[JPJP]

HundredPercentPlease

Regarding the distance indication; inserting RW28 in the fix page will give the distance to the end of the runway. And putting it in the Descent page will show all sorts of magic, including a constantly updating required rate of descent to said runway.

One of the many puzzling factors is this; The aircraft being (inadvertently) left in LNAV, yet their track didn’t bring them out on the inbound course to the NDB. They are identical. Perhaps the FMS wasn’t programmed or sequenced correctly. Or there’s another hold over BGC ?

The irony is that the entire NDB approach could have been flown in LNAV/VNAV. Or, worst case LNAV/VS, whilst backing up the Descent page guidance with timing from the approach chart. And the ADF confirming the LNAV guidance.

I’m glad none of our aircraft have an ADF :E

[svhar]

In PNG all the copper cables from the local NDB´s were stolen every few days so they stopped replacing them. No big losss.

[HundredPercentPlease]

JPJP,

I know that's what people do (I have 18 years on 737/A320). The distance shown is derived from GPS. GPS is not a primary navaid for the approach, yet it is used for navigation - descent no less. If you are going to use GPS, then you should use RNAV procedures.

[twistedenginestarter]

The irony is that the entire NDB approach could have been flown in LNAV/VNAV. Or, worst case LNAV/VS, whilst backing up the Descent page guidance with timing from the approach chart. And the ADF confirming the LNAV guidance.

I'm glad someone said this. I was completely baffled why they seemed not to be making best use of available computer navigation. It reads like they were flying in 1965 and not 2015.

[a5in_the_sim]

What’s interesting to me is the cockpit conversation that precluded the decision to conduct the NDB approach. The tortuous complexity of crew and airline approvals and nomenclature that surround the GPS based approaches is madness. FFS. The industry needs to get a handle on this quickly. GPS has the potential to makes approaches so much safer and more straightforward. How have we found ourselves in this mire of descriptors that leave crew so perplexed and confused? GPS, GNSS, RNAV (GNSS), PRNAV, PBN.......

[Fursty Ferret]

I'm glad someone said this. I was completely baffled why they seemed not to be making best use of available computer navigation. It reads like they were flying in 1965 and not 2015.

Training flight, was it not? I recall when I first started on the A320 at a big UK operator my training folder had a big table with required items on it to complete during line-training, and one of them was a raw data non-precision approach in selected modes. Having said that I still cheat and glance at the calculated vertical profile from the FMS whenever I fly a non-precision or even a visual approach, provided it has something sensible loaded in it. I think it's vitally important that the FMS is loaded with what you expect to fly regardless of how you're going to fly it, whether that's the full procedure or just the runway extended centre line.

I hasten to add that I've not flown an NDB (timed) approach since I climbed out of the vile Seneca for the last time.

[fireflybob]

The irony is that the entire NDB approach could have been flown in LNAV/VNAV. Or, worst case LNAV/VS, whilst backing up the Descent page guidance with timing from the approach chart. And the ADF confirming the LNAV guidance.

I think you will find their SOPs say that if the approach is not "coded" in the FMC then it is not permitted to engage LNAV/VNAV to fly the approach, or words to that effect.
I'm not saying I agree with that but that was certainly the case when I was with said airline some years ago now.

[wiggy]

I agree with a heck of a lot of the above (especially the comment about nomenclature) but we almost certainly would not be having this discussion if a simple agreement had been reached by the crew as to when the published procedure permitted leaving 2500' and what NBD indications were required. Regardless of what mode the aircraft was navigating in laterally, this was an NDB approach.

I do accept that workload/SA wasn't helped by the modes used and there may have been restrictions on modes available...

[Herod]

JPJP
And the ADF confirming the LNAV guidance.

Wiggy
Regardless of what mode the aircraft was navigating in laterally, this was an NDB approach.

Agree with Wiggy. What is should be is LNAV confirming the ADF guidance. Not the other way round.

[safetypee]

And displaying EGPWS Terrain Map to monitor the 'mind'.

[jmmoric]

There's something called information overload.... the procedure is based on an NDB.... the more systems you ask the pilots to monitor and confirm with.... the higher the risk is them missing something.

Not that some sort of "defenses" are not usefull, like the MSAW at the controllers position and the EGPWS in the cockpit, but we have to be carefull not to overload pilots with information.

In my opinion there is a tendency, and has been for the last 20 years or so, of throwing a lot of stuff at people, stuff that may seem "nice to know", but essentially is only clogging up systems.

[FlightDetent]

And setting the step-down fix as a hard limit on the MCP (procedure with no FAF)

It seems a quite straight forward case of a crew not competent to fly any NPA drill whatsoever.

[safetypee]

jmmoric, not denying overload is a concern; priorities must be considered by value. Need to know vs nice to know, but do we know. :ok:

If LNAV is not approved, then why use it to monitor the approved navigation system.

We choose to display weather radar; decisions based on that system would be more strategic - delay the approach.

Whereas EGPWS display is more tactical, potential to detect inadvertent changes to plan, position, altitude. Why wait for (depend on) the EGPWS alert / warning.

ADF, compass, stopwatch, map (procedure / terrain), altimeter, airspeed …

[Busta]

I used to treat non precision approaches as emergency procedures, both pilots checking and cross checking throughout; if there's any doubt, there's no doubt.

I agree with Wiggy, hope you are well! Mebbe see you in November?

[jmmoric]

So you wouldn't do that during a precision approach? :E

[beamer]

I remember arriving at Bournemouth early in the morning returning from Orlando, to be informed the ILS and Radar was u/s and that we should have to fly a procedural NDB to Rw 27. Probably not at our sharpest after a night flight and notams had given us no reason to expect anything other than Radar to ILS. Fortunately the weather was not too bad so the procedure became in effect an NDB to cloudbreak followed by a visuaL.

It seems ludicrous that modern aircraft should have to fly a procedural NDB in this day and age bearing in mind the alternatives which should be available.

[172_driver]

I don't know about you but we fly any NPA (incl. VOR, NDB, LOC) in the exact same manner as an RNP (or RNAV, to use other terminology) approach. LNAV/VNAV magenta highway bang on the centerline. Yes, you should monitor raw data but I am sure you'd get away with it your whole career if you didn't. So why curse the NDBs when we praise RNP appr.?

[clark y]

Looking at the Avherald report, I can't see any obvious problem with the lateral navigation. The aircraft seemed to join down wind in the hold and looking at the trajectory graphic, it even seemed to turn inbound at roughly the correct time. Compare it to the 10nm range on each.
I wonder about the comment- "The autopilot initiated a second left turn again consistent with a hold pattern rather than joining the final approach course." Was someone expecting it to turn the other way? Looking at the charts, it appears to be the same lateral path so why would that comment be made? Is it because of the diagram for the Cat A/B versus the Cat C holding?

[sonicbum]

The simple fact is that an NDB approach is probably the most challenging. The majority of CFIT accidents have occurred on non-precision approaches in perfectly serviceable aeroplanes. All engines with an autopilot.


My point is this. These types of approaches are statistically way less safe than a conventional ILS. If you apply TEM, an NDB should be at the very bottom of your list of preferred approaches.

If You apply TEM You can safely fly an NDB approach when no better approaches are available, such as ILS, RNPs, etc..
From what I have understood out of this report, the crew was not sure whether they were allowed to fly an RNP approach at Bergerac (knowledge problem within the crew ? Company information confusing?) and hence reverted to the NDB which was also mismanaged. The consequential errors were finally mitigated by the crew reacting appropriately to the EGPWS warning.

[wiggy]

Looking at the Avherald report, I can't see any obvious problem with the lateral navigation. The aircraft seemed to join down wind in the hold and looking at the trajectory graphic, it even seemed to turn inbound at roughly the correct time. Compare it to the 10nm range on each.

I've never been able to see a major problem with the lateral side of the join and the downwind portion of the approach either, I'll bet that procedure has seen a lot worse..:uhoh:

[Procrastinus]

This is the sort of mistake made in the early stages of training for an IMC rating. How on earth did they pass the initial IRT?

[FullWings]

If I was a betting man, I’d put money on the “how” element being missed or only cursorily covered in briefing. It appears there were inappropriate lateral mode and height selections, which opened the door to the subsequent poor performance.

It’s difficult to ascertain without knowing the SOPs they were operating under, but for us, a non-database NPA with a runway-aligned FAT says fly it as an overlay or RWY EXT in LNAV/VNAV. If you’re not allowed to do that, at least put the approach in so you have something to compare with the raw data. As others have said, a timing-only NPA can be incompatible with many operators' SAC requirements, especially if you are not acquiring a visual reference until <1,000R. Non-CDA also needs specific approval in my airline.

We did one of these in the sim a few years back and much of the emphasis was on the planning stage. Once you’ve got that sorted out it becomes much easier to implement.

[jmmoric]

I not sure how many places does it, but how about radar vectoring to final on an NDB approach? That would eliviate some of the problems in navigating the entire approach.

(We do it, though I've experienced once that an aircraft couldn't accept vectoring to final, he required the entire procedure)

[FlyingStone]

I not sure how many places does it, but how about radar vectoring to final on an NDB approach? That would eliviate some of the problems in navigating the entire approach.

In this particular procedure, how would you know when are you safe to descent towards the NDB? You can't get vectors for a timed NDB approach without a FAF.

[deltahotel]

This happened 5 years ago. I can’t find a plate for RNP approach for 2015 - current issue is brand new (Apr 2020).

The investigation states that the RNP plate wasn’t in the company booklet so the Cp assumed he wasn’t able to fly it - (AR) annotated perhaps?

[jmmoric]

In this particular procedure, how would you know when are you safe to descent towards the NDB? You can't get vectors for a timed NDB approach without a FAF.

Makes sense, didn't think of that.

In our case the NDB is inside the point we line them up on the final course, and the timing starts at the NDB. Of course if the timing starts outside the point of line up..... yeah....

[wiggy]

In this particular procedure, how would you know when are you safe to descent towards the NDB?

? this particular procedure meaning the BGC one that went wrong for FR?

If that's the case the answer is two things:
1. Correct downwind timing.
2. Only leave platform altitude when established inbound.

[jmmoric]

Why do they publish an MDA(H) om the chart? Isn't the operator supposed to determine that themselves based on the OCA(H)?

[lederhosen]

From a human factors point of view this is an interesting one. There obviously was a RNAV approach available because the controller offered it. Not having the plate is the tricky bit as with one it would clearly have been the safest option. Nobody wants to hold their hand up and say they are incompetent to fly an NDB, but raw data in a 737 it is far from a regular procedure. A bit of finger trouble in the FMC with a under confident FO and it is surprising that so few of these incidents occur. In the good old, bad old days I suspect some people would have accepted the RNAV approach programmed it in the box (or as an ILS overlay) and without a chart used the NDB minimum. Given the cloud base it would not have been an issue. I am not for a moment suggesting this is the right thing to do. But a weak crew with a lack of situational awareness would have been better off than trying to fly this in vertical speed and heading select. Building a distance ring around the runway at 7 miles or suchlike would also have helped with determining distance to height. I strongly suspect that the ILS out of service was only properly understood just before top of descent and that with a bit more notice they would have been better prepared.

[Herod]

Wiggy: plus one. Seems you are the only one on here who knows how to fly an NDB. The worst bit to me, apart from being badly positioned, is that when the EGPWS went off, they were already 400' BELOW the beacon crossing height. Retires to box, awaiting comments.

[Bergerie1]

I'm with wiggy - established inbound means you must be within 5degs of the bearing, if my memory is correct. If not, you don't descend, you go round the pattern and try again.

[JPJP]

Wiggy: plus one. Seems you are the only one on here who knows how to fly an NDB. The worst bit to me, apart from being badly positioned, is that when the EGPWS went off, they were already 400' BELOW the beacon crossing height. Retires to box, awaiting comments.

With respect, there’s two discussions going on, and you’re missing one of them. I understand where you’re coming from; I flew the 300/500 and now the NG (and MAX during its brief appearance). The fact that the NDB approach went awry is established. As well as how the approach would be flown ‘traditionally’. The method you’re stuck on is the least safe, the least accurate and the most screwed up. As evidenced by this event.

What you’re missing is the fact that an NDB approach in 2015, in an NG could be flown using more than one method, depending on the Ops Spec and equipment (and we haven’t even started on IAN yet).

BTW - An NDB app would be flown in HDG mode - If you’d run out of ideas, or you’re a masochist or stuck in 1970. LNAV is also an option with the ADF being monitored. You can’t “confirm with LNAV”, it’s a mode. And you can’t have both at once. You can confirm your lateral track, which is what I assume you meant.

Cheers

[wiggy]

I'm sure you're right...my comment ( if you're indirectly talking to me) was a generic one to address the concerns of those who seemed concerned or bemused by the lack of a electronically defined descent point or similar on the paperwork for what is by current standards a somewhat minimalistic procedure.

I don't disagree with you that in reality these days you'd up the automation a notch or two or three..even on something like the relatively steam driven "sans IANS" T7 you'd at least try find a suitable overlay or use runway extension and track in LNAV if you could, but have the needles displayed to confirm lateral tracking (you'd still need to know when it was legit to begin the descent down the slope though ;)).

[lederhosen]

I have vague memories of an Airtours 767 in Orlando diverting because the ILS was out and they said they were not allowed to fly NDB approaches any more. This must have been around 20 years ago. I remember being shocked at the time. But now that NDBs are being removed, GPS has resulted in NDB approaches being well on the way to becoming like Consol and other old navigation systems just a memory. You don't even have to fly an ILS on the EASA single engine instrument rating test, GPS approaches will do. This may be keeping up with the times, but I was still surprised.

[Alex Whittingham]

To help me understand, those of you that are suggesting an RNAV approach do you mean an RNAV approach to a particular standard such as RNAV/RNP1 or RNP APCH? If so, is it not a requirement that the approach in the database matches the plate, and how can you check that without the plate? I'm aware that you can 'gash up' an RNAV approach based on manual waypoint entries and an NDB plate because that is what we used to do 40 years ago, but I thought that sort of practice was long ago banned! Genuine question, as I have never flown to modern PBN standards.

[deltahotel]

Good question Alex and what I was sort of alluding to a few posts back. Without the plate you can’t cross check waypoint sequencing and height restrictions so it doesn’t seem unreasonable not to fly the RNP approach. The investigation states that DME not available, so the NDB Z not available, which only leaves the NDB Y.

There’s no reason why LNAV couldn’t be used (backed up by raw data and taken over by Hdg Sel if required) but the error was the early descent below platform.

The big save was response to the GPWS warning. We’re doing EGPWS in our current sim sequence and a big discussion area is ‘can you imagine how difficult it would be to have to ditch the SA you thought you had and carry out the manoeuvre? And then to have to rebuild that SA prior to having another go. And then to have to prep and fly the return flight knowing that there will be awkward conversations to come.’

[lederhosen]

I think we are all on the same page that you can't do it without the chart (which is why I said in the good old bad old days). My company very clearly introduced guidelines about fifteen years ago about what you could and could not do. In the dim and distant past I remember flying into a new airfield that was not in the database (although I did have the charts). As it was the inaugural flight we needed some common sense and an explicit authorisation from the chief pilot to avoid red faces all round. We then merrily flew self constructed NDB approaches for several days before someone managed to update the database. Fortunately it was good weather and I had an excellent copilot later one of our checkers. Reminds me of the old line 'be nice to your co-pilot one day he might be your checker'. In this case they seem to have rushed the preparation, the pilot flying had some finger trouble with the FMC and when it started to go wrong I would not be surprised if they were both heads down trying to work out what was wrong with the FMS and nobody was really flying the aircraft as it descended in vertical speed, before the GPWS saved the day.

[sycamore]

Should really have joined the hold for a lap or two to sort it out.....

[Philoctetes]

For such an error, both pilots should have had their IRs immediately suspended and made to pass another 'initial issue' flight again. The situation seems to have been saved by the terrain warning. What could have happened had that system been unavailable is beyond imagination.

[hec7or]

The Crew would be expected to pull the CVR CV immediately after shutting down (which renders the aircraft AOG until until a reset is authorised) and file an ASR as soon as practicable. Standard procedure in order to comply with EASA requirements would be for the airline to take both pilots off the line and then conduct a safety investigation followed by a training package appropriate to the event. I doubt very much that this crew operated the return sector and even if they did - if authorised by the Chief Pilot, they would not have flown again without a thorough debrief of the event, then a simulator check and a line check.

[Citybird]

If my memory serves me well, we weren't autorised/qualified/trained to perform RNAV approaches in Ryanair, back in early 2015.

[jmmoric]

On another note, they do bring up that the crew reported established on the final leg, eventhough they weren't.

Am I the only one who find that rather "normal", that you'd call "established" to ATC before you actually are... hence not really a problem in the current situation?

And technically, ATC would've seen it on his monitor, and discarded it for the same reason I just did. If I understand there actually is surveillance coverage, which is based on the MSAW alert the approach controller got. I really hope they fix the coordination issue with the MSAW alert, there was a reason it became mandatory to alert aircraft to MSAW many years ago.

And the French BEA to use english in their reports...

[SID PLATE]

For such an error, both pilots should have had their IRs immediately suspended and made to pass another 'initial issue' flight again. The situation seems to have been saved by the terrain warning. What could have happened had that system been unavailable is beyond imagination.


You seem to have a tenuous grasp of post incident protocols. Are you a pilot ?

[harryed]

Am I the only one who find that rather "normal", that you'd call "established" to ATC before you actually are... hence not really a problem in the current situation?


No, sadly plenty of your colleagues find it "normal", too. Sometimes I wonder whether you guys realise we can see you on the radar!

[Gizm0]

For such an error, both pilots should have had their IRs immediately suspended and made to pass another 'initial issue' flight again. The situation seems to have been saved by the terrain warning. What could have happened had that system been unavailable is beyond imagination.

Sir
That really is nonsense. You evidently don't understand how the professionals within the industry operate.

[FullWings]

I suppose some of the problems in flying a raw data approach when much/all of your day-to-day operation involves radar vectors to an ILS or some kind of PBN approach, are not that you can’t do it or don’t know how, it’s the difference in preparation, execution, familiarity and workload.

RNAV: Load approach into FMC(s), check, brief, set up MCP, altimetry, FMAs, RNP/ANP, progressive config, etc. Much button pressing and checking of automation which has deviation alerts but 99.9% of the time does it all pretty well.

Raw data: Brief, tune/ident navaid, procedural, timing, tracking, altitudes, full config, descent rates, more tracking, etc. Hands-on with the aeroplane - no alerts or warnings that you’re not doing it right until the EGPWS gets involved.

At first glance, they did bits out of both lists but omitted some of the more important items.

[Fursty Ferret]

No, sadly plenty of your colleagues find it "normal", too. Sometimes I wonder whether you guys realise we can see you on the radar!


Usually this only happens on an ILS after being cleared to establish on the localiser only. Often with precise vectoring the localiser and GS capture occur simultaneously, so it's actually a bit of a PITA for everyone if we're forced to level off on the localiser because we couldn't get an established call in because of a busy frequency. You can also guarantee that the "cleared ILS" instruction usually includes a speed reduction, which is nigh on impossible when capturing from above.

On a non-precision calling established a tiny bit earlier (ie as the turn starts) just frees up capacity for the whole descent / timing / monitoring stuff.

[hec7or]

On a non-precision calling established a tiny bit earlier (ie as the turn starts) just frees up capacity for the whole descent / timing / monitoring stuff.

You are only established when within 5 degrees of the published FAT, - PANS Ops.

UK airspace vertical division between Class D/G requires you to be cleared to descend on the ILSGP by Approach due to the possibility of uncontrolled VFR traffic below the platform altitude and within 10nm from the THR. In Europe the rules are different in Class C airspace where you may be cleared for the approach from the IAF.

[Locked door]

If a crew called established before being within +-5° during an LPC it would trigger a repeat if I was examining with a discussion about CFIT thrown in for good measure. Likewise if they deviated from +-5° during the approach and continued while not being visual, or went below any hard minimum altitude.

If a crew obeys the rules in the sim and then breaks them on the line, they’re asking for trouble in an environment where a repeat / retest isn’t an option.

[hec7or]

If a crew called established before being within +-5° during an LPC it would trigger a repeat if I was examining with a discussion about CFIT thrown in for good measure.

With respect, descending before being established is a repeat/fail, - simply reporting established before actually being established is a debrief point. Airline SOPs are not written to supply this degree of detail as it is assumed that the basics are covered before the initial IR by the Flight Training Establishment before a pilot joins the airline.

A fact of life nowadays is that the volume of knowledge required to assimilate the airline SOPs and the complexity of the aircraft type rating tends to displace the basics in the pilot's personal database. (head)

[Icelanta]

If a crew called established before being within +-5° during an LPC it would trigger a repeat if I was examining with a discussion about CFIT thrown in for good measure. Likewise if they deviated from +-5° during the approach and continued while not being visual, or went below any hard minimum altitude.

If a crew obeys the rules in the sim and then breaks them on the line, they’re asking for trouble in an environment where a repeat / retest isn’t an option.

You are completely out of your mind to fail someone for calling established a bit early. It is a debriefing point, nothing more.

[Phantom Driver]

You are completely out of your mind to fail someone for calling established a bit early. It is a debriefing point, nothing more.

Unfortunately , it sometimes needs a fail , rather than a debrief to concentrate minds .There are some areas in the profession where lazy practice is definitely not acceptable. Discipline is paramount .

When I did my initial CAA IR ( many many years ago on a Piper Aztec ) , this would have been a re-fly for that segment , just like failing to call " check for ice ! " every 5 minutes . No questions asked . And then, apart from anything else , money alone ( re-booking the aircraft for another test ) meant it was not an option . Discipline .

[Rt Hon Jim Hacker MP]

If a crew called established before being within +-5° during an LPC it would trigger a repeat if I was examining with a discussion about CFIT thrown in for good measure. Likewise if they deviated from +-5° during the approach and continued while not being visual, or went below any hard minimum altitude.

If a crew obeys the rules in the sim and then breaks them on the line, they’re asking for trouble in an environment where a repeat / retest isn’t an option.

I'm just interested as a fellow TRE. PF flies the NDB within all the tolerances but the PM calls "established" at +/- 6 degrees. Whilst a repeat is at the discretion of the examiner, we are also encouraged by DOC24 to avoid nit picking. Personally, I wouldn't even mention it. It's trivia.

We had a TRE that seemed to be on a bit of a crusade in my outfit. Lots of sickness from candidates on their LPC/OPC days with this guy. Duly noted by management and the CAA FOI.

My two cents.

[A320LGW]

If a crew called established before being within +-5° during an LPC it would trigger a repeat if I was examining with a discussion about CFIT thrown in for good measure. Likewise if they deviated from +-5° during the approach and continued while not being visual, or went below any hard minimum altitude.

If a crew obeys the rules in the sim and then breaks them on the line, they’re asking for trouble in an environment where a repeat / retest isn’t an option.

This is ridiculous apart from perhaps the altitude bit, I will accept no argument about 'standards' because the rest has nothing to do with standards or safety nor does it have any actual relevance, it comes across more as a bit of willy waving by you to tell the truth.

Thankfully in my outfit they are more focused on the big picture stuff rather than focusing on reasons to fail you.

[FlightDetent]

Thankfully in my outfit they are more focused on the big picture stuff rather than focusing on reasons to fail you. And hence the decline continues, by our own folk cherry picking which rules they like to be subjected to and which not.

Perhaps for the altitude bit? Brrr.

[sonicbum]

Unfortunately , it sometimes needs a fail , rather than a debrief to concentrate minds .There are some areas in the profession where lazy practice is definitely not acceptable. Discipline is paramount .


Agree with Your statements except for the initial part : "it sometimes needs a fail" means nothing. As a TRE You can't just fail people depending on how You wake up in the morning or whether You think they just need a lesson because the do not show enough discipline ; it's just not the way it works, at least in EASA land.
To fail/retest a crew You must have observed an unacceptable reduction in safety level at any stage of the flight, and it must be observed and described in details, otherwise the crew will (rightfully) appeal.

[sonicbum]

I'm just interested as a fellow TRE. PF flies the NDB within all the tolerances but the PM calls "established" at +/- 6 degrees. Whilst a repeat is at the discretion of the examiner, we are also encouraged by DOC24 to avoid nit picking. Personally, I wouldn't even mention it. It's trivia.

We had a TRE that seemed to be on a bit of a crusade in my outfit. Lots of sickness from candidates on their LPC/OPC days with this guy. Duly noted by management and the CAA FOI.

My two cents.

The problem is that a huge amount of TREs still erroneously think that they have been given the sheriff badge and are entitled to do as they please, when it is completely not the case.
When conducting Initial TRE AOC during my career I have witnessed in many occasions a lack of knowledge on OM-D and EASA training bulletins and that is exactly the moment I understand they are not (yet) suitable for the position despite a total knowledge of FCOMS/OM-A and so on.

[172_driver]

Has anyone ever passed a NDB appr as I can assure you you will be out of +/- 5 deg as you approach the beacon? The geometry doesn't lie ;)

If we're nit picking, I mean

[Uplinker]

I think the "established" point has two elements.

One is for ATC sequencing, the other for safe descent:

It is not unknown to called established as the ILS pointer moves across, because if one has armed ILS capture, modern airliners will very rarely not capture, assuming correct speed and config for that phase of flight. And it helps ATC sequencing if they know you are within a gnat's crotchet of being there rather than them having to move planes around in the sequence. Would ATC agree?. I would say "becoming established" to indicate this. Likewise, if we were intercepting an NDB track, I might call established if I could see that the trend was reliable - we might be +- 6° but by the time I had finished the radio call, we would be within +- 5° for example.

The second point is being actually legally established for the purposes of descent, which must obviously be within the published limits, otherwise, CFIT or terrain issues could occur.

I am sure that most TREs would use their sensible discretion on this.

[ATC Watcher]

I think the "established" point has two elements.

One is for ATC sequencing, the other for safe descent:

.
:)
From my long passed Approach days , "reporting established" for a Controller main function is that it automatically means the aircraft is on its own navigation .In a radar environment you stop vectoring it to intercept the LOC , and transfer it to TWR ( or keep it in LVP ) Responsibility for terrain is transferred to the pilot.
As to sequencing, In busy airports maybe , but we have better ways to sequence aircraft . As an aside in Bergerac they have 2 or 3 commercials ops per day only ..

[BizJetJock]

Interesting discusssion, I would put completely the opposite emphahsis on my debrief to an LPC candidate; if you have been cleared for the approach (ILS or other), then all R/T calls are merely courtesy to help the controller keep his SA. They are totally secondary to the task of flying the correct profile and as such can wait until workload permits. Radar to the ILS this is usually as it happens, but in a procedural environment crews need to prioritise taking into accoutn their level of currency.
Particulalry relevant at the moment, I have done a lot more procedural stuff than normal recently as ATC units are short staffed. In addition to a sudden revivial in LPC/OPCs in the aircraft as we are unable to get crews to the sim. Interesting times!

[A320LGW]

And hence the decline continues, by our own folk cherry picking which rules they like to be subjected to and which not.

Perhaps for the altitude bit? Brrr.

If these words make you feel special, then good on you :ok:

Meanwhile the rest of us will keep flying practically. Not busting altitude limitations and maintaining big picture situation awareness at all times.

As a matter of interest I don't think I have ever called ATC as being 'established' until actually established on the LOC course (CDI needle centered is my mental cue) or fully established LOC and GS. I have no fears of failing for calling 'established' when 5.3 degrees off the inbound course because for me it isn't habit (whereas for you it would clearly lead to a climax)

Whoever said that people need to be failed to concentrate on something need to have a word with your selection department if that's the type of pilot being hired. I speak for every colleague I've been in the sim with when I say a notebook of the debrief is always kept and used for personal review. To suggest you need to fail someone for them to learn something is an insult to our profession and intelligence.

[IcePack]

Surly the rt call is irrelevant but if you descend when > 5deg off track that is a no no.

[hec7or]

Absolutely, but perhaps if this crew had been looking for the ADF pointer to line up with the FAT and used all this as the prompt for the callout, then they may have realised they were pointing in the wrong direction.

[FlightDetent]

A320LGW You may want to read the post that you originally opposed again.

#92 Said "Unfortunately, sometimes" he may need to fail the crew for flying outside limits. Not that he habitually comes to the sim seeking the soft spots to stab them in the back.

#88 had spelt three points to retake the exercise:
- i) calling ATC with a report which is not true
- ii) continuing an approach outside the tracking limits in IMC
-iii) busting a hard altitude limit.

By your own words, i) and ii) are ridiculous and iii) is perhaps understandable. So spade was called.

Happy to see now that altitude keeping is actually the primary focus in your big picture, welcome to the team.

Here's my original message in different wording: Un-focusing from the minutae and as we frame the "big picture" is not risk-free. Once you zoom out even further, it becomes visible that in the long run some lines may get blurred beyond recognizable as we pardon the irrelevant slips over and over again with increasing tolerance. If this is allowed to happen systematically we're not only scoring own goals but bribing the referee to lose. Moreover, there's no lack of evidence that normal human nature puts us on a tilted pitch before the game opens.

[A320LGW]

I termed it 'ridiculous' to fail somebody for calling established if not exactly within 5 degrees, that is to say if somebody called at 5.2 degrees they would fail their LPC and need to repeat. I stand by this definition of the matter. Let's say there was another task that needed completing and the pilot decided they'd call established ASAP to tend to the other task (whilst being able to get a move on with ATC and switched to tower etc) rather than tend to it and forget the 'established' call entirely, what then? Flying is obviously not black and white and there is a lot more to be considered.

Regarding the altitude, you are playing semantics and you know well.

About your final paragraph, I do not disagree nor did I say we are to do away with SOPs in favour of simply flying from A to B hoping it goes well. I mean to say that once the operation is safe and SOPs are adhered to within reason then nitpicking serves the benefit of neither the pilots nor the safety of the operation. Where do we stop? somebody calling 'acceleration altitude' as they eye the altimeter pass 1,280' instead of the millisecond it displays 1,300'? This is the stuff I really dislike seeing and is a pain. What exactly do we learn from this type of stuff? I go to my LPC looking to learn as well as demonstrate competency. If you remove the learning aspect and replace it with nitpicking then we have well and truly lost it.

[FlightDetent]

Again, happy to hear #94 was mis-worded. Guilty as charged for only reading what it says, not what you actually meant. It must be those communication filters from the CRM class. Nothing new learned, but still worth going through as a refresher.

Besides, we lost the plot of the thread. I always understood the Ryanair bunch to be doing a stellar job with regards to training and standards. Given their experience-demographic, daily roster patterns, network airports and a few others, there is hard evidence of a well-run ship by the lack of incident reports over the years.

And they are no strangers to NPAs, hence the report comes as a surprise with the disregard of vertical awareness that it describes. Getting lost laterally is not that hard to do once the crew paint themselves in the corner, chart sheets start flying around the deck with everything upside down or on the reverse side, and fast slippery fingers cause the FMC do draw mandala circles on the ND. But vertical modes need to stay sacred under all circumstances.

The only difference from ITF148 https://aviation-safety.net/database/record.php?id=19920120-0 could be the GPWS fitted, God's grace.