ATR72 - Sea collision

[CAEBr]

Royal Air Maroc Express ATR72 managed to climb away after descending onto the Mediterranean during a botched approach. The GPWS had been turned off after working correctly and giving what were viewed by the crew as nuisance warnings.

Shades of PIA at Karachi ?

https://www.flightglobal.com/safety/atr-72-struck-sea-surface-after-crew-turned-off-ground-proximity-system/139264.article

[Hothighhungover]

The captain deserves to have his licence shredded. What an absolute cowboy.

[Maninthebar]

GPWS rather than GPS - was puzzled at how the sea might have changed location.

[Brakes...beer]

Strangely, not the first time a Royal Air Maroc ATR captain has overpowered the efforts of the first officer... RAM630 in 1994.

[Islandlad]

Getting their License from the Xerox and Brother School of Flying? :E

[Hot 'n' High]

From the article, "After the aircraft hit the water, the crew executed a belated go-around, telling the tower controllers that they were aborting the approach because of a bird-strike.". Bet the poor old Gull (or whatever it was) thought it was quite safe bobbing around on the oggin, even if it was under the FAP! :}

To be serious tho, for what was a miracle escape by the sounds of it, just how many of these sort of approaches are flown every day around the world (in pre-Covid days especially)? Me thinks these are probably far, far, far more common than we think given that both the down-route and up-route approaches to this location were flown in this manner even though they were both different procedures.

To completely re-paraphrase those excellent opening remarks by the Judge in the BBC sitcom "Porridge", is the following applicable? "...... You are an habitual criminal, who accepts flying dodgy approaches as an occupational norm, and presumably expects it will always work out OK every time in the same casual manner.".

And to how many more people does this apply across the world?

Makes you wonder........ :uhoh:

[Mach E Avelli]

It wouldn't matter where they photo-shopped their licences. Until they find a vaccine for stupidity these events will continue..

[MDS]

Mortifying.

Two impacts into the sea, while 3° nose down. Quite extraordinary there wasn't a complete structural failure.

Their first leg into Al Hoceima that day also resulted in descending to 60ft MSL without the runway in sight.

[fab777]

Having talked to someone who flew there for several years, I do not see anything unusual in their flying style. Going below minimas is just another day at the office in this outfit.

[Pugilistic Animus]

They were just practicing their ditching procedures which is a perishable skill. Nothing's wrong with that...jeez PPRuNe is so judgemental sometimes :}

[Jet Jockey A4]

They need to be fired immediately and even do some jail time for operating an aircraft in a dangerous matter while carrying passengers.

[Pugilistic Animus]

On the serious side...I agree, wholeheartedly pulling the GPWS while it's talking to you is one of the most reckless and careless things I have ever heard of!

[Momoe]

It's not shades of PIA320, it's more like Avianca 011, infamous "Shut up gringo" when the GPWS advised pull up.

Sacking them both isn't going to change the culture, CRM needs improving, both pilots putting in opposing inputs!
Very lucky to survive, however, IMO first officer does deserve some credit, if reporting is accurate, he clearly wasn't happy with the situation and without his intervention this would be a search and recovery thread.

[Pugilistic Animus]

I was being a hot head but the captain should have been sacked though that's way beyond any foolishness in a plane...I do agree a change in CRM or company culture seems necessary but the captain has to go!

[Pugilistic Animus]

That's nearly impossible in the information age... you can't hide it from the public. I wouldn't fly on that airline either not just the traveling public and I believe that my aeronautical knowledge is just a bit higher than most punters

This post was addressing a member's statement, which is now deleted... just in case my post seemed odd :)

[Pistonprop]

The first officer suggested, during this briefing, that the ground-proximity warning system should be turned off to avoid its being triggered again, and the captain agreed.

Beats me why the FO deserves any credit!

[blue up]

Alaska Airlines suffered a Fish Strike back in 1987. Maybe they could supply the relevant form.

https://bl og.alaskaair.com/alaska-airlines/flying-fish/

[safetypee]

Re '… viewed by the crew as nuisance warnings.'
There are no nuisance warnings with EGPWS / TAWS, only valid ones until you can prove otherwise at a safe height.
All terrain warnings must trigger an instant climb to above the safe altitude and then re-evaluate the situation.

Humans err more often than EGPWS.

Nuisance - false warnings can be investigated and rectified; engineering or procedure.
'Nuisance' - true warnings are usually buried.

https://www.flightglobal.com/complacency-disconnected-egpws-led-to-trigana-atr-crash/126596.article

[parkfell]

This event took place in July 2018 and further details can be found on AVHerald.com
Just what action the Regulator took is not known.
Perhaps “Culture” had a part to play....?

It makes a cracking read, verging on total disbelief when you first read it.
I had to read it again to get the full measure of just what happened.
CRM non existence.
The Captain conduct needs to be examined by the Trick Cyclists.
It brings into question whether he was mentally fit to fly.

Had this occurred in the UK, a prosecution would undoubtedly have occurred, and the Captain’s licence revoked.

A similar reckless conduct in the case R v. Robert Murgatroyd.
42 months at HMP [AAIB: G-BAKH]

A good read for all Junior Birdmen, CRM instructors & those who think ‘Culture’ is not a factor in aircraft accidents.

[zerograv]

The fact that the ATR is a High Wing design most likely saved the day.
Had it been a Low Wing aircraft, very likely there would be no going around from this contact with the water.

[swh]

Re '… viewed by the crew as nuisance warnings.'
There are no nuisance warnings with EGPWS


from avherald “Enroute at FL160 during the first sector the crew received a "TERRAIN" warning message on the EWD1 and an amber "TERRAIN FAULT" warning light. The warning indications disappeared after 6:38 minutes”

[DaveReidUK]

Final report (https://www.aviationcivile.gov.ma/wp-content/uploads/2020/04/Rapport-Final_CN-COH_09.07.2018.pdf)

[From a distance]

swh

Off course there has been nuisance GPWS warnings. Like any system it is prone to error or malfunction. But your first thought can’t be an ASSUMPTION of a GPWS error. Just like Fire warnings. You can’t assume it’s erroneous just because you don’t see fire or smell smoke.
Act on the warning, and only subsequently establish the veracity of the warning.

[slast]

For those interested an unofficial translation of the final report (which has so far only been published in French) can be seen at
2018 ATR72 struck water on app Al Hoceima Morocco | PicMA (http://www.picma.info/?q=content/2018-atr72-struck-water-app-al-hoceima-morocco)
This is a computer translation via Microsoft Translate and has not been edited or fully formatted. It does however provides more information than was available from sources noted here to date.
Other than for this item, PICMA.info has not been recently updated.

[Uplinker]

What the thunder is going on in aviation?

It wouldn't matter where they photo-shopped their licences. Until they find a vaccine for stupidity these events will continue..

This was way way more than stupidity. This was criminal negligence. Maybe even attempted manslaughter.

What happened to "There's something not right here. Let's go around and check what we are doing".

How are people like this allowed anywhere near an aircraft, let alone the cockpit of one?

[Hot 'n' High]

What the thunder is going on in aviation? ..................................... How are people like this allowed anywhere near an aircraft, let alone the cockpit of one?

My guess is that there are people like this all the way up the Management Tree in many, many airlines so they "hire/promote to personal Spec" (ie hire/promote people doing what they do themselves). In some cases, it's far more important who you know than what you know - re the Air India "Capt" who kept landing her A320 (I think) on its nose wheel. I've seen plenty of cases myself where promotions are "interesting" to say the least. Often, genuine professional ability counts for ziltch. Fortunately, such idiots have been away from the "coal face" - but even they can screw things up by, say, cutting staff levels at the coal face to meet an unrealistic savings target knowing that the next promotion will come from the saving they make tomorrow and that they'll be well gone by the time the operational chaos ensues a year down the line.

OK, so we are probably seeing a bit of a change in slightly less of the "gung ho" types in the cockpit - but these have been simply replaced by far more of the "cut-throat commercial pressure" types, maybe not even in a flying role but who sit looking at, say, fuel bills and budgets. "Captain Snodgrass has done 2 go-arounds in the last 6 days! What's he playing at?" types. Does it happen? Not seen it myself - but I'll not relieve you of any money by betting on a certainty that that sort of stuff happens! After all, the "fuel monitor"s bonus is linked to them shaving x% off the fuel bill this year and people doing go-arounds are not helping him/her towards that bonus!

We all make mistakes in the paddock - and hopefully learn from them. Some are even forced into mistakes due to things like punishing Rosters (or over-zealous fuel monitors) but, even then, we should know better and say "No!" - easier said than done I know. Then there are also a whole raft of people who probably operate, routinely, out on the Prairie day-in and day-out as that is quite usual for them and their peers. Been doing it for years. We only see what makes the accident statistics. We never even hear of the routine level-busts, non-stable approaches and general flying mayhem. That said, flying is still incredibly safe - just that there may be quite a few more pilots related to cats out there than we think - just they will not know when Life #9 is now in operation.

Anyone into counting cats? :confused: And, once you have done that for aircrew, you could start on ........ Engineering? ATC? Component suppliers? You know, at a personal level, it's far less stressful to look at the headline Safety figures rather than think too deeply about what contributes to those figures and, more importantly, what has nearly adjusted those figures but never been recorded (ie all the near-misses). How to solve it? Sheesh! Now there is a fortune to be made by the person who comes up with that "Holy Grail"!

[ATC Watcher]

Anyone into counting cats? https://www.pprune.org/images/smilies/confused.gif And, once you have done that for aircrew, you could start on ........ Engineering? ATC? Component suppliers? You know, at a personal level, it's far less stressful to look at the headline Safety figures rather than think too deeply about what contributes to those figures and, more importantly, what has nearly adjusted those figures but never been recorded (ie all the near-misses). How to solve it? Sheesh! Now there is a fortune to be made by the person who comes up with that "Holy Grail"!
Indeed but most of us here were raised and trained in a western culture and our manuals and rules designed originally with anglo-saxon rationale. We are judging those safety events on our western rational minds
Other Cultures often adapt those rules. Morocco is one of them .

Just finished to read the original (French report ) If you know a bit the country you can see some lines and remarks made by the BEAM are painting the reality .
The Domestic route network, local weather and lack of Nav infrastructure mean they have to "be flexible" as they say , but in this case we add the authority gradient , presence of a young female in the jumpseat, the relatively low experience FO being coached by an older CdB with lot of experience but on 737s.. where are using different routes and different airports .Perhaps the notion than an ATR can be flown like a light GA type., etc...The typical remark " we continue" (below minima) is heard all over the Southern Hemisphere , and even as North as in France until a few years ago ( e.g. Britair Brest CRJ100 /2003 ) Going below minima to have a look was probably done hundreds of time before by this CdB and it worked ... until now.
.
A remark from the flighglobal article. quoted above. The capt did not report a bird strike to ATC ( according the CVR) , a bit of extra sensationalism maybe , did not expect this from Flightglobal.:rolleyes:.

[A320LGW]

The GPWS faulted in the first sector, fair enough. Post landing, why didn't they have an engineer come and inspect it? They continued the day in IMC with the GPWS switched off? I have a sore head trying to process that. I haven't got the MEL out but I would be shocked if it says anything else about going with GPWS off in IMC other than 'NO'.

[MDS]

The GPWS faulted in the first sector, fair enough. Post landing, why didn't they have an engineer come and inspect it? They continued the day in IMC with the GPWS switched off? I have a sore head trying to process that. I haven't got the MEL out but I would be shocked if it says anything else about going with GPWS off in IMC other than 'NO'.

Doubtful they had an engineer at AHU as it's a tiny station.

It appeared to have an erroneous fault at FL160 during cruise however functioned correctly during the approach:

One minute later, the TAWS alarms "TERRAIN AHEAD PULL UP" and "AVOID" TERRAIN" are triggered when the aircraft is 1760m from the runway threshold and 60ft at radio altitude. The PF then performs a change of trim to be pitched, and restores power. The lowest point reached is 45ft radio altitude. The aircraft then proceeded up to a height of 108 feet and maintained until the view of the runway and then resumed a descent to land.

the co-pilot's suggestion to stop the GPWS to avoid alarms during descent and approach, as they believed that those issued by this system during the first stage were untimely.

This is the most shocking part. I don't see how it was 'untimely' when triggering at 60ft radio altitude almost 2km from the runway. It appears he wasn't concerned about the error during cruise, but rather the correct warning during a dangerous approach.

The whole thing is baffling.

[Pugilistic Animus]

The first officer suggested, during this briefing, that the ground-proximity warning system should be turned off to avoid its being triggered again, and the captain agreed.

Beats me why the FO deserves any credit!
​​​​​​I apologise I missed that part...yeah sack him too but I bet they won't

[alf5071h]

From the point of view that the crew were trying to do their best in the conditions, and attempting to manage the situation as they saw it. Trying to replicate that line of thought, there are aspects which are unclear or not understood after reading the report transcript (thanks Steve).

Re inhibiting 'EGPWS' (TAWS - T2CAS), is there any guidance on deselecting the terrain feature. The terrain aspects require accurate navigation, which if not available, give a 'terrain fault' alert; this appears to be an automatic inhibition (button-light for info only). Alternatively are there any recommendations to press the button; either for the alert, or only to be used in other situations, e.g. QFE approach. The crew appears not to have understood the interaction of the fault alerting and inhibit functions, and misguidedly switched all functions off. Did the crews backgrounds involve EGPWS vice T2CAS, inappropriate knowledge of fault switching / inhibit procedures; TAWS was serviceable for all flights, one leg suffered GPS degrade.


What are the visual requirements for this type of approach; 'contact with the airport environment' or seeing the runway. Continuing the descent with the sea in sight could be permitted until some later point (visual descent point ?).

After visual contact, would both pilots fly 'heads-up' as indicated in the report, reducing the need to scan Rad Alt or check altitude with distance for the procedure. A 'visual' descent over the sea in poor visibility, without horizon for pitch reference is an opportunity to misjudge the true height above the surface.


Does the design of approach procedures still allow level flight after MDA - contrary to the principle of continuous descent, and / or have visual minima where it may not be possible to see the runway at MDA (cf Zurich NPA CFIT many years ago), further encouraging 'dive and drive'. Again what procedures were the crew familiar with based on previous employment / training.

[Hot 'n' High]

Indeed but most of us here were raised and trained in a western culture and our manuals and rules designed originally with anglo-saxon rationale. We are judging those safety events on our western rational minds
Other Cultures often adapt those rules. Morocco is one of them ........

Quite agreed ATC Watcher - and that's where this becomes a mare. As you yourself know, there has been much discussion in recent Threads, such as the PIA A320 crash Thread, as to how different cultural mind-sets subtly, or maybe not-so-subtly, drag certain areas of the world away from the so-called "western" standard you & I refer to - but where they end up is, to them, perfectly "normal" so, in that respect, who are we to judge.

Hell, we even have quite a bit of deviation within that "western" standard in the, erm, West - thinking of the recent ATP Thread and, as someone else mentioned, the "Barton Birdwatchers" saga - even though that was a light single with a PPL operating what was deemed a commercial flight https://www.cps.gov.uk/north-west/news/pilot-guilty-endangering-life-after-crashing-illegal-commercial-flight - or the Emiliano Sala crash which seems to have been masterminded by those who should be aware of what was expected of them and their pilot.

Where other cultures apply their norms to adapt the "western" standard, things inevitably happen differently. In many cases, such new norms (near-vertical gradients between the boss (Capt) and the lackey (P2)) have existed for 1000's of years so a few CRM courses is not going to change much when the whole of society operates on a fundamentally different basis. Therein lies my comment re the Holy Grail re finding a "one size fits all" solution.

No answers, just more questions I'm afraid!

[A320LGW]

Doubtful they had an engineer at AHU as it's a tiny station.

It appeared to have an erroneous fault at FL160 during cruise however functioned correctly during the approach:


This is the most shocking part. I don't see how it was 'untimely' when triggering at 60ft radio altitude almost 2km from the runway. It appears he wasn't concerned about the error during cruise, but rather the correct warning during a dangerous approach.

The whole thing is baffling.
This is what I am wondering, are they referring to 'untimely' as in the GPWS faulting and master caution appearing or untimely the fact it told them to pull up whilst they went full cowboy? The avherald is unclear of the specifics regarding this.

I want to know why a GPWS master caution went off before all the drama and if so did they attribute the warnings on final approach to that master caution they had previously encountered and therefore dismissed them? This could be significant as it indicates they saw absolutely nothing wrong with driving along at 100ft nearly 2km from the runway and in their minds meant there shouldn't have been any warnings, making them switch them off later on.

I have had this exact fault once and it was on the ground after push back. We taxied back onto the stand and the flight was subsequently cancelled. We had realised ourselves we couldn't go anywhere (MEL) and even the arrival of the engineers couldn't fix it. The fact they sought self diagnosis in this manner is incredible, not even a phone call back to Casablance? Most peculiar.

[A320LGW]

​​​​​​I apologise I missed that part...yeah sack him too but I bet they won't

For all we know the captain could be trying to pin this one on the FO to make himself look less bad, with a career at RAM he probably has all the contacts in the airline and CAA needed to do so.

[netpog]

Thanks to this IATA analysis, we're hearing about them. Unstable approaches are running at 3X the pre-pandemic rate.
What could explain this, other than stress?
www.flightglobal.com/safety/unstable-approach-rate-rose-sharply-as-air-transport-crisis-unfolded/139309.article

[ATC Watcher]

@A320LGW :
I want to know why a GPWS master caution went off before all the drama
It is explained in the final report. ( bad GPS)
For all we know the captain could be trying to pin this one on the FO to make himself look less bad
No chances with the conclusions of that report . Anyway the airline disciplinary part is long gone . this was a 2018 event remember.

[parkfell]

For all we know the captain could be trying to pin this one on the FO to make himself look less bad, with a career at RAM he probably has all the contacts in the airline and CAA needed to do so.

The intriguing aspect is that we don’t know from the/any report what action was taken, if any, by the Regulator against the airline and that of the airline against the pilots.
The event was 2018. Captain “retired”, now aged 63.......and the FO..?

We know that the UK CAA took action against Emerald for two similar events on the same day at the IOM on the VOR/DME 08 approach.
The ATP crew with the recent dodgy crosswind landing at BHX are no longer employed ~ PPRuNe thread comment.

To have been a “fly on the wall” during the investigation interviews.......probably enough material for a complete CRMI conference.

[ATC Watcher]

Hot 'n' High: Thanks for the Barton Birdwatcher link. I had forgotten that one ..a copy of the Malibu Sala story .But those were amateurs trying to do like professionals. In this case, or the PIA Karachi one, we have professionals flying like amateurs.
Passing a safety audit in some places is just like teenagers preparing for an exam . make sure everything is OK on the day , learn by heart or write down somewhere accessible the answers to pass the test, and when it is done and the auditors.examiners are back home , go back as you were doing before.
I have been in so many places ( for ATC business) and watched and flew on so many of these" flexible " air operations. A good example , a small airline in a small poor Asian mountainous country operates Beech 1900s domestically for years , all VFR. Tourism grew and they bought a few ATRs 42 and 72s . They fly those VFR only , with a portable Garmin 196 screwed on the glare shield, just like the Beech were operated. It works..until now at least.
Similar situations in Africa and Latin america.
The world is much wider than FAA/EASA...

[parkfell]

Hot 'n' High

The difference here was that the two light aircraft crashes were rogue British PPLs carrying out commercial flights.

The ATR ‘stone skimming’ event was carried out on a commercial flight by pilots holding professional licences and duly authorised to operate the flight.

Culture played a significant part in all three events ~ a blatant disregard for the rules and regulations.

The PPL holders knew what they were doing was illegal and didn’t give a toss, with the PA46 pilot & passenger dead.

The ATR event was “pony express” mentality (by the Captain) which nearly ended in disaster.
I had thought about mentioning the “Swiss Cheese” model. However, the mince had consumed all that cheese, before it appeared on the table !

The Trick Cyclists would have a field day.

[safetypee]

From the number of posts concluding 'blame and train' or prosecute individuals there should be greater concern about the effectiveness of HF training, what is taught, remembered, how applied. The opinions are without justifying evidence, only based on outcome - valueless; should all adverse outcomes suffer the same critique and action - who judges.
We learn little from this approach, apart from the frailty of human behaviour and inability to identify the limits of performance (the posters suffer the same weakness, particularly with hindsight).

In addition, there is an apparent lack of technical knowledge about the aircraft, operation, situation, the context.
Mea culpa; but with a little research, a pilots guide for TAWS re post #31 https://www.pprune.org/10838174-post31.html - Terrain inhibit (one function) vs TAWS Inhibit (all functions) can be viewed @ http://uaecis.com/files/T2CAS/T2CAS%20Pilots%20Guide%20Rev4.pdf 2008, see sections 9-10.

Example of inappropriate use in incident 8 in the ICAO link in https://www.pprune.org/10834718-post5.html

Also, if the earlier Terrain Fault annunciation was due to GPS, this was for info only; except checking GPS might have identified an aspect which would suggested not using GPS for navigation or the approach.

What might we learn from this accident;- how do we learn from what we don't know.
Ask questions, seek answers; never assume, nor allocate blame unless we were there.

[Herod]

There's a lot of talk about the fancy electronics, but....does no-one look at altimeters (baro and rad) anymore?

[EDLB]

A non precision approach in zero VIS pushing down until you hit anything with a passenger load in your back asks for a criminal investigation.
They had a lot of luck to survive this.

[Hot 'n' High]

Hi ATC Watcher and parkfell, on first inspection, I totally see your point! :ok: However, the way I see it, in both cases, there is more to it than 2 PPLs going "rogue". Yes, we are not talking BA, Easy or anyone else - but there was more to these two than first meets the eye. There was a far more "professional" perspective to both events - which is why I brought them up as examples of "Western" rule-breaking.

Regarding RM of "Barton Birdwatcher" infamy, a quick scan of Companies House show him as a Director of the ex-Comed Aviation Limited, SICs for Scheduled Air Transport and for Non-scheduled Air Transport from 1982 until 2018. There's even a Comed thread on PPRuNe tho dealing with Flight Training. Comed also had a Bandeirante based at Blackpool (G-ONEW) - as well as a load of other stuff (something like 11 aircraft) again, the subject of another PPRuNe Thread - https://www.pprune.org/spectators-balcony-spotters-corner/37093-comed-blackpool.html. Indeed, back in about 2001, Comed Aviation Limited flew scheduled daily flights to Belfast, Dublin and the Isle of Man until Comed went bust - https://www.lancashiretelegraph.co.uk/news/5911948.aviation-boss-grounded/ ! And there's also Fly Bpl, yet another PPRuNe Thread - https://www.pprune.org/private-flying/519678-fly-bpl-beginning-end.html! As you can see, this guy was not your average PPL cashing in on the unsuspecting "twitchers".

Re the Sala accident, the extensive PPRuNe Thread on that accident ( https://www.pprune.org/accidents-close-calls/617514-cardiff-city-footballer-feared-missing-after-aircraft-disappeared-near-channel-island.html?highlight=sala ) is there and there is much discussion as to who organised what and in what capacity. In that case, DI was simply the pilot in a wider web of commercial intrigue which saw him "hired(?)" to fly the aircraft by 3rd parties (unclear exactly who did what, when and where - that's all gone a bit quiet). Anyway, those with time to spare can browse all 107 pages of that one. One health warning before you do, there's this blithering idiot called H 'n' H who appears frequently in the Sala Thread!!!! :cool: You have been warned!!!!! :ok:

But, you are both correct, both pilots were PPL-holders. Best I blither off

[parkfell]

H n H

As someone who was born and bred in Cumbria, and learnt to fly at Carlisle in 1972, I became aware of RM and have “followed” his career.
It was common knowledge that he would stick his head well above the parapet often coming to the attention of Air Safety Enforcement (CAA).
A certain TEFLON effect?
That effect failed post COMED with the HMG banning him as a company director.
During his interview with Manchester’s finest, he claimed his crash landing was similar to ‘Sully on the Hudson’ and perhaps a film will eventually be made.

He was unaware that the CAA were the other side of the one way glass.
The subsequent court case and AAIB report on G-BAKH is a matter of public record.

As for the Sala accident, this matter is still active and I shall treat it as sub judice.
The relationship between Cardiff FC and one Mr Henderson, who it is alleged would fly their personnel and on this alleged occasion acted as ‘agent’ for the fateful flight ~ one of the many aspects under investigation.

[A320LGW]

I agree that there is often too much finger pointing and "hang'em high" mob type culture with a lot of incidences, but this incident may actually deserve it. I fully accept every single one of us makes mistakes. We can forget a call due to distraction or fatigue, we can misjudge the effect of a tailwind in a descent and end up a bit high on final etc etc, incidents resulting from these types of human errors are beneficial to us all, because they can so easily happen and can catch us despite our best efforts. We read them and learn from them. My personal motto with incidences is I am far from perfect, so who am I to criticise?

However, there is a fine line between the above and deliberately deciding to go below minimums as this crew did. I accept others across the globe may have different 'styles' let's say, but at the end of the day this was an ATR, there are manuals clearly defining how this aircraft must be operated and it is up to the crew to adhere to those SOPs as best as they can. In this instance they made a conscious decision to flout these SOPs - to the detriment of the safety of the innocents sat down the back who naturally trust the pilots up front.

To bring an aircraft down to 50ft over the sea at 2km from the RWY, with pax on board, against all known SOPs is gross negligence, negligence because they knew what they were doing was wrong but neglected to care and did it anyway.

It is hard to gain any beneficial lessons from this incident because it is so far removed from how (I hope) most of us on here operate that it's difficult to draw any useful conclusions that we can apply to our own flying. I am rated on type, this has little to do with the type though. Switching off the GPWS, setting -1,200fpm at 400ft, flying along at 100ft over the sea etc requires no knowledge of the type to see it's wrong. The only thing maybe type related would be the fault given, but the MEL says it is a NO GO, I don't know what or who else they consulted before switching it off but it is misguided and in all fairness we don't need the MEL to tell us it is not allowed to fly into IMC with a faulty/switched off GPWS (if indeed it was faulty). Anyway I shouldn't think the MEL of any other type says you can fly in IMC with the GPWS switched off.

[lederhosen]

I am not entirely convinced that the captain did know what he was doing. According to the report he had just under 200 hours on type, so in most European airlines would have been barely out of line training. The co-pilot was also low time but significantly more experienced on the ATR than the captain. They may (if my French is up to scratch) have switched off the GPWS due to poor system knowledge and nuisance warnings earlier rather than simply a desire to bust minimums. It would be interesting to know the captain's previous history and why he switched to the ATR at age sixty. Given the focus on dubious qualifications and Parker pen hours following the Pakistan crash it is reasonable to be sceptical, particularly given how close they got to crashing. The overconfidence displayed however is all the more remarkable give the pilot's low experience and the technical failure, if we are being charitable about why they switched off the GPWS.

[Uplinker]

Can I just confirm what we think actually happened? I have tried to read the machine translation of the report but it is not easy going and I might have got confused.

I think they were flying a VOR/DME approach and saw nothing at minima, so they went down to a lower minima? They still saw nothing so selected V/S down of more than 1000' per minute and eventually hit the sea a couple of km out?

On the VOR/DME approach plate there must be a table of altitudes versus DMEs for cross checking? Does anyone have a copy of the plate available?

Thanks

[A320LGW]

They may (if my French is up to scratch) have switched off the GPWS due to poor system knowledge and nuisance warnings earlier rather than simply a desire to bust minimums.

I did consider this, but then again, that doesn't answer for the fact they did go below minimums. This is obviously a rule that applies from a C172 to an A380, you don't go below minimums without visual reference. We aren't even talking about a cheeky delayed 'looking out' ... ..... 'visual', in fact what they did to was quite extraordinary. I see this and the GPWS confusion as 2 entirely separate issues, one does not simply lead to the other.

[alf5071h]

A320LGW, et al; recent posts.
re 'you don't go below minimums without visual reference.'

My earlier post #13, asked if operational procedures would allow the crew to continue the approach with the sea in sight at MDA; check ICAO approach procedures, charted procedures, operators specific procedures (local authority).

If the crew's understanding was that contact with 'the airport environ' (or similar wording used in some documents) was allowed, then they could continue the approach having the sea in sight. But would this be a continuous descent approach - encouraged for safety, and better enabled by GPS; or would the aircraft have to fly level until the runway was seen - where the aircraft would have to fly a steep (unstable) approach. (Catch 22)

The inappropriate conclusion of 'deliberate' might reflect ambiguity in rules or guidance; what are operators allowed to do, what interpretations are made, or what happens in real operations. (Work as done vs work as imagined; viewpoint - crew, operator, regulator, investigator, Pprune Pundits)

Thus the crew - from their point of view, may have been able to continue the descent, but with additional risk from increased workload - maintain visual and accurately checking the vertical path, and awareness of height illusion when flying over a horizonless seascape. (Risk mitigation, but from whom; crew first or last, operator, regulator, industry, … point of view)

[lederhosen]

My interpretation of the report is that the captain (non flying) was pushing the nose down (without saying I have control) while the co-pilot was pulling the other way. The captain appears to have lost situational awareness, was not monitoring the instruments and was interfering with the controls in an extremely unhelpful and inappropriate manner. They were over the sea so the mindset would appear to have been that there were unlikely to be any obstacles, while disregarding the fact that it might well be difficult to judge height over the water visually, particularly at a high rate of descent. There was the thread about the Westjet 737 which got very low over the sea and of course those about the Air Niugini and the Lionair 737s that actually did crash on similar non precision approaches. So this is by no means an isolated incident.

[janrein]

A remark from the flighglobal article. quoted above. The capt did not report a bird strike to ATC ( according the CVR) , a bit of extra sensationalism maybe , did not expect this from Flightglobal.images/smilies2/icon_rolleyes.gif.

According to the CVR transcript in Annex 2 indeed not, however elsewhere in the main body of the report ...

Page 30 under "La Troisième Etape (TNG-AHU)" does mention a birdstrike in connection with the go-around call (4th bullet from bottom), which afterwards in a phonecall had been "precised" by the commander by stating the water had been hit before initiating the go-around (last bullet on same page).

For completeness and to be fair to Flightglobal.

[Uplinker]

..........that it might well be difficult to judge height over the water visually, particularly at a high rate of descent.............

............awareness of height illusion when flying over a horizonless seascape.......

I don't know about other pilots, but when I fly visually, I still refer to my flight instruments: Thrust, speed, altitude, Rad Alt, V/S, and pitch - and gear and flap status, as well as looking out the window.

Does the ATR not have a Rad Alt? I am sure it has at least two altimeters.


Regarding the bird strike, please check my schoolboy French, but I think bird is "oiseau", and water is "eau". Could this have been a mis translation or a misheard word?. "We have hit the water" might have been heard or written as "we have hit the bird"?

[A320LGW]

It certainly does, the ATR has all the bells and whistles, except for autothrottle!

[slast]

alf5071h

In nearly all these types of events (and unfortunately a lot of the comments) there seems to be a basic ignorance of the meaning of instrument approach minimums, required visual reference, and what is needed to continue below DH or MDA.

ICAO Annex 6 is what governs the minima and they are based on a very specific requirement. Whatever the visibility, if you have not been able to confirm the aircraft's position and velocity in relation to the desired flight path from the external cues BEFORE you reach DH/MDA, you must go around. If you don't adhere to that, every aspect of the underlying safety assumptions is undermined.

[parkfell]

It certainly does, the ATR has all the bells and whistles, except for autothrottle!

1. They (Captain essentially) blatantly and recklessly disregarded what any sensible crew would do.

2. Once below DA, the Workload went significantly UP, and the Situational Awareness plummeted.
Failed to appreciate the Rad Alt, and for that manner the Altimeters.

3. They would both have got one hell of a fright when sea contact was made.
Just what the CCM and the passengers thought, and what they were eventually told or learnt sometime later has not been disclosed.

4 Had any Brits been on board then the Daily Mail / Sun would have been hot on the trail.

Still hard to believe such an event occurred.

[alf5071h]

Thanks Steve, #54
I agree with all of your points; however its the unusual regulation or its interpretation that might lead us astray, e.g.

"10. other visual references specified in the operations manual."

AMC1 CAT.OP.MPA.305(e) - Commencement and continuation of approach,
https://www.easa.europa.eu/sites/default/files/dfu/Consolidated%20unofficial%20AMC-GM_Annex%20IV%20Part-CAT%20March%202018.pdf page 157 / 158

And within that, weak knowledge within the regulatory authorities - your ' a basic ignorance of the meaning of instrument approach minimums, required visual reference, and what is needed to continue below DH or MDA.'

It has not been established which particular regulation the operator was using, nor the interpretation of this or any rules from previous employment, however misguided that might be.
Even so, flight over featureless sea with minimum horizon has significant risk.

[Herod]

When I flew the C 130 for Her Majesty, our minimum height over the sea was 250'. That was set on the rad alt, and a warning light came on if the reading was below that. Three crew facing forward. The captain flew it, with the co-pilot and engineer's eyes glued to the rad alt. Any deviation below 250' would elicit an immediate "height" call. What this crew did was outside limits and dangerous, but if you are going to do it, set the rad alt at say 150' (which should clear any fishing boats) and have the PM glued to that instrument. I don't think they used it at all; nor the DME.

[Joe_K]

Regarding the bird strike, please check my schoolboy French, but I think bird is "oiseau", and water is "eau". Could this have been a mis translation or a misheard word?. "We have hit the water" might have been heard or written as "we have hit the bird"?

On the bottom of page 30 it says "Le CDB confirme avoir fait part de cet événement, par «Air Safety Report» et par téléphone, au management de RAM EXPRESS en tant qu’impact d’oiseau, mais qu’il a rappelé ensuite pour préciser que «l’eau aurait été touchée avant la remise des gaz».

Which translates to: the PIC confirms that he has informed the management of RAM Express of the event as a bird strike, via Air Safety Report and via telephone, but that he later phoned back to clarify that the water had been contacted before the go-around.

[steamchicken]

The inquiry doesn't seem to have picked up on an interesting detail. They make the obvious CRM point that the cross-cockpit gradient was steep, with the Captain on 13,487 hours and the F/O on 1,063. They don't say anything about the fact that there was also a steep cross-cockpit gradient in the other direction with regard to hours on-type - the F/O had 815 hours on the ATR-72, over 4 times as many as the Captain, who had 193 (and some more on the ATR-42 30 years earlier). The combination of a Captain with lots of experience in general, but not much on the specific aircraft, and an F/O with little experience in general but much more on the specific type, sounds about as bad as it could be.

[ehwatezedoing]

Joe_K

More "Would/Could have been contacted" Than "Had been contacted before the go-around"

Sounds like a bad face covering attempt.