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PoppaJo
12th Nov 2022, 04:12
The Australian Transport Safety Bureau (ATSB) is investigating two separate flight below minimum altitude occurrences 40 km south of Cairns Airport, Queensland. The first involved a Virgin Australia Boeing 737, registered VH-VUT, on 24 October, and the other a Qantas Boeing 737, registered VH-VZA, on 26 October 2022.

In both occurrences, the aircraft were following a standard arrival route (STAR), when they were inadvertently descended below the minimum safe altitude. On each occasion, air traffic control identified the aircraft's descent and alerted their flight crew. The flights in both cases were then completed without further incident.


This one certainly been kept quiet. Looks like similar behaviour in both, ie intercepting HENDO incorrectly instead of 6800. Having a quick look at the archives online, QF approaching HENDO from the east was visual at all times with the terrain, velocity certainly wasn't who came from the south in darkness and low cloud. Listening to that tape replay wasn't a pleasant experience in the VA case.

Mr_App
12th Nov 2022, 07:32
Starts at 10.00. Not pretty.
https://archive.liveatc.net/ybcs/YBCS-App-Dep-2-Oct-24-2022-1000Z.mp3

Duck Pilot
12th Nov 2022, 08:12
It's a pig of an approach with the arc and all the steps, particularly if you don't regularly fly it. Asked to do it in the sim last year as we had a bit of spare time left, we screwed it up and then the check captain in the back also had a go and screwed it up due to a FMS issue.

From the ATC recording, the 737 wasn't the only aircraft having issues with the approach.

megle2
12th Nov 2022, 09:17
In my world CS was the only ARC approach we used to fly. Are there many others in Aus

A320 Flyer
12th Nov 2022, 10:13
In my world CS was the only ARC approach we used to fly. Are there many others in Aus

Most of the RNP-AR approaches have radius to fix (arc) legs

aussieflyboy
12th Nov 2022, 10:25
What could have happened if CNS APP was TIBA

PoppaJo
12th Nov 2022, 11:12
What could have happened if CNS APP was TIBA
I recall it was for that whole week however a few hours post the Velocity approach and pre the QF.

What would have happened? Well it’s clear without someone watching VA would have got closer and closer. The report should give some insight into that and the path it was taking.

Duck Pilot
12th Nov 2022, 13:11
What's going to come out of this, zilch apart for the crews being called in for tea and biscuits and thrown in the dog house for a few weeks due to a ****ty designed approach that should be immediately redesigned and bought into the 21st century. Totally unsuitable in this day and age for a major aerodrome with high terrain around it and such a complicated bloody approach that was probably designed 40 years ago.

morno
12th Nov 2022, 17:20
What's going to come out of this, zilch apart for the crews being called in for tea and biscuits and thrown in the dog house for a few weeks due to a ****ty designed approach that should be immediately redesigned and bought into the 21st century. Totally unsuitable in this day and age for a major aerodrome with high terrain around it and such a complicated bloody approach that was probably designed 40 years ago.

RNP isn’t that old!

Lookleft
12th Nov 2022, 21:34
The coded part of the approach only starts late in the approach so you are relying on a managed descent most of the way down. Not perfect and not always accurate with the altitude constraints ( I am talking Airbus). I'm not sure how difficult it would be to adjust the databases to make the coded part of the approach start earlier. Before RNP approaches were designed for 33 the problem was always getting too high on the approach as you had to start configuring before HENDO which is 22 miles from the airport. A lot of pilots would think they still had time and space to start throwing gear and flap out.

No Idea Either
12th Nov 2022, 22:11
Let’s make sure we are all talking about the same thing here.

IIRC the RNP approaches into CS from the south are AR approaches, only available to VA, JQ and QF due to advanced aircraft FMS upgrades, extra pilot training/checking and recurrency in the sim. There are no ‘bog standard’ older style GNSS/RNAV straight in approaches from the south. The RNP AR’s due to much lower RNP values and the ability to follow multiple curved flight paths (at the lower RNP values) have paths that weave around obstacles such hills and also avoid settlements for NAP. These approaches are constructed from multiple ‘Radius to Fix’ turns (arcs) hence the use of the term ‘arc’. But I believe that the references above to the ‘arc’ from some posters is the DME arc whereby the ‘arc’ is followed around a single DME value, such as the 24 mile arc, to intercept the final approach LOC through a waypoint, in this case HENDO, the whole procedure to the runway following the arc, FAC and step down procedures as you go. If flown manually, or even with basic autopilot functions, in actual IMC these approaches are a **** fight, as many have identified and I agree having done it many times.

But (correct me if I’m wrong) the problem with the VA and QF incidents is that when the crews were programming the FMC with the arrival STAR and the RNP AR approach, they didn’t select HENDO as a STAR transition. If you do not do this then it doesn’t enter the crossing height at HENDO as 6800A, it just calculates the constant descent path between the previous and next waypoints, leaving you too low at HENDO, hence the ATC warnings. This also happened a few times about 10 years ago when this approach was first introduced and my company went to great pains to reinforce the need for the transition selection for the obvious reason of terrain avoidance.

So, yes, the approaches to RWY33CS, no matter how you actually fly them, are pretty ****ty. If flown in basic modes you’ve gotta be aware of where you are and what’s around\underneath you. If flown in more advanced modes then in has to be entered and checked in the FMC, then monitored throughout to ensure correct compliance with the design approach. BUT having said all that, if there’s hills there, then the RNP AR should be constructed/coded correctly to avoid this situation……I agree, code it for 6800A regardless. But (not saying this was actually what happened) all they had to do was push another button and it would have been all good. Not being critical here just factual (I have no first hand knowledge of the actual events or the circumstances leading up to them)…..I’ve had my fair share of stuff ups as well so not throwing stones.

Not sure they would have got closer and closer, the AR’s do recognise a below path situation and will level off to correct it when the next segment path angle comes into the equation. But, like I said don’t know the specifics, if both crews had grossly incorrect QNH set then the aircraft will fly the entire approach at the incorrect altitude (10 hpa high QNH means 300ft low on path:uhoh:) and all the indications such as crossing heights on your altimeter match the charted heights but you are actually 300 foot lower in space though.

so hope this helps anyone trying to wrap their head around it. But I think we all agree the arrivals could be better designed.

megle2
12th Nov 2022, 23:33
Correct No Idea, I was referring to the DME arc

SHSS
13th Nov 2022, 13:02
Let’s make sure we are all talking about the same thing here.

IIRC the RNP approaches into CS from the south are AR approaches, only available to VA, JQ and QF due to advanced aircraft FMS upgrades, extra pilot training/checking and recurrency in the sim. There are no ‘bog standard’ older style GNSS/RNAV straight in approaches from the south. The RNP AR’s due to much lower RNP values and the ability to follow multiple curved flight paths (at the lower RNP values) have paths that weave around obstacles such hills and also avoid settlements for NAP. These approaches are constructed from multiple ‘Radius to Fix’ turns (arcs) hence the use of the term ‘arc’. But I believe that the references above to the ‘arc’ from some posters is the DME arc whereby the ‘arc’ is followed around a single DME value, such as the 24 mile arc, to intercept the final approach LOC through a waypoint, in this case HENDO, the whole procedure to the runway following the arc, FAC and step down procedures as you go. If flown manually, or even with basic autopilot functions, in actual IMC these approaches are a **** fight, as many have identified and I agree having done it many times.

But (correct me if I’m wrong) the problem with the VA and QF incidents is that when the crews were programming the FMC with the arrival STAR and the RNP AR approach, they didn’t select HENDO as a STAR transition. If you do not do this then it doesn’t enter the crossing height at HENDO as 6800A, it just calculates the constant descent path between the previous and next waypoints, leaving you too low at HENDO, hence the ATC warnings. This also happened a few times about 10 years ago when this approach was first introduced and my company went to great pains to reinforce the need for the transition selection for the obvious reason of terrain avoidance.

So, yes, the approaches to RWY33CS, no matter how you actually fly them, are pretty ****ty. If flown in basic modes you’ve gotta be aware of where you are and what’s around\underneath you. If flown in more advanced modes then in has to be entered and checked in the FMC, then monitored throughout to ensure correct compliance with the design approach. BUT having said all that, if there’s hills there, then the RNP AR should be constructed/coded correctly to avoid this situation……I agree, code it for 6800A regardless. But (not saying this was actually what happened) all they had to do was push another button and it would have been all good. Not being critical here just factual (I have no first hand knowledge of the actual events or the circumstances leading up to them)…..I’ve had my fair share of stuff ups as well so not throwing stones.

Not sure they would have got closer and closer, the AR’s do recognise a below path situation and will level off to correct it when the next segment path angle comes into the equation. But, like I said don’t know the specifics, if both crews had grossly incorrect QNH set then the aircraft will fly the entire approach at the incorrect altitude (10 hpa high QNH means 300ft low on path:uhoh:) and all the indications such as crossing heights on your altimeter match the charted heights but you are actually 300 foot lower in space though.

so hope this helps anyone trying to wrap their head around it. But I think we all agree the arrivals could be better designed.
The selection of the transition it would seem is the issue. I recall similar issues quite a while ago. Would the issue be resolved by the STAR requiring 6800A at Hendo?

mates rates
13th Nov 2022, 23:51
What is going on in the training departments here?As trainers move on and are replaced with the new breed,this sort of training information,to use the HENDO transition when selecting this approach is essential.RW 32 at CNS is not used that often,so it needs to be part of the on going SIM program so people are reminded of the problem.

morno
14th Nov 2022, 00:12
What is going on in the training departments here?As trainers move on and are replaced with the new breed,this sort of training information,to use the HENDO transition when selecting this approach is essential.RW 32 at CNS is not used that often,so it needs to be part of the on going SIM program so people are reminded of the problem.

2 events from 2 different airlines doesn’t spell out problems with training departments to me. It spells out bad design, or, just bad luck. How many times in the past has this occurred?

If they put every approach that doesn’t get used very often but could potentially be problematic, into every sim, there’d never be time for anything else.

Mach E Avelli
14th Nov 2022, 01:31
2 events from 2 different airlines doesn’t spell out problems with training departments to me. It spells out bad design, or, just bad luck. How many times in the past has this occurred?

If they put every approach that doesn’t get used very often but could potentially be problematic, into every sim, there’d never be time for anything else.

However, if we stopped wasting valuable sim time on familiar stuff (long-winded briefings, engine starts, taxying, SIDs & STARS at home base, ILS approaches etc) and reduced the amount of time spent on things we should be able to handle (rejected take-offs or engine failures), maybe we could devote more time to the tricky things more likely to be encountered. Some of the recurrent training and check matrixes I have seen seem to be there to give an impression all eventualities are being covered, without consideration for probabilities and relative risk. Often run from the pilots' home airport or over a familiar route. Pointless box ticking.
Note I said LESS time, not NO time on RTO's & engine failures, but realistically if these were visited once every two years it should be enough. More aircraft have probably crashed due to mismanaged approaches than mismanaged systems failures.

non_state_actor
14th Nov 2022, 03:32
However, if we stopped wasting valuable sim time on familiar stuff (long-winded briefings, engine starts, taxying, SIDs & STARS at home base, ILS approaches etc) and reduced the amount of time spent on things we should be able to handle (rejected take-offs or engine failures), maybe we could devote more time to the tricky things more likely to be encountered. Some of the recurrent training and check matrixes I have seen seem to be there to give an impression all eventualities are being covered, without consideration for probabilities and relative risk. Often run from the pilots' home airport or over a familiar route. Pointless box ticking.
Note I said LESS time, not NO time on RTO's & engine failures, but realistically if these were visited once every two years it should be enough. More aircraft have probably crashed due to mismanaged approaches than mismanaged systems failures.

100% agree with that. However CASA needs to get the memo and then want to change.

morno
14th Nov 2022, 04:01
However, if we stopped wasting valuable sim time on familiar stuff (long-winded briefings, engine starts, taxying, SIDs & STARS at home base, ILS approaches etc) and reduced the amount of time spent on things we should be able to handle (rejected take-offs or engine failures), maybe we could devote more time to the tricky things more likely to be encountered. Some of the recurrent training and check matrixes I have seen seem to be there to give an impression all eventualities are being covered, without consideration for probabilities and relative risk. Often run from the pilots' home airport or over a familiar route. Pointless box ticking.
Note I said LESS time, not NO time on RTO's & engine failures, but realistically if these were visited once every two years it should be enough. More aircraft have probably crashed due to mismanaged approaches than mismanaged systems failures.

I don’t disagree with you. And this is where Evidence Based Training will hopefully cut that down. But a simple thing such as inputting or selecting data from an FMS, shouldn’t be an approach specific thing, so why do we need to practice them. An internal memo saying “hey dickheads, do it properly and then check the data” should be sufficient for this. And if events continue to occur, maybe then look at the systems (including procedures) or the design (approach, FMS entry process). But wasting time flying an approach in the sim, when the process could be the problem, is not the answer.

maggot
14th Nov 2022, 08:21
What is going on in the training departments here?As trainers move on and are replaced with the new breed,this sort of training information,to use the HENDO transition when selecting this approach is essential.RW 32 at CNS is not used that often,so it needs to be part of the on going SIM program so people are reminded of the problem.

The coincidences aren't directly training related imo considering how many RNPs are shot every day of the week.

Also the prior rnp selection issues at CNS were on the other rwy iirc
looking at the star charts compared to others we're used to for AR stuff, the CNS charts seem to be presented differently and HENDO on the RNP chart is a little subtle, as a transition, compared to others.
​​​​​​
That's where I'd be looking at for contributing factors.

​​​​​​

Dusty332
14th Nov 2022, 08:27
I have to agree with NIE above but add the following. Having been involved with Managed (Airbus) VOR/DME, NDB, GPS, RNP and RNP AR since inception, it is absolutely imperative that the coding of the FMS is checked intimately against the AIP of the country. In the early days there were massive errors in the coding resulting in the aircraft in auto flight descending abruptly, or not descending or levelling off during the approach. RNP AR has improved database coding , but there are still occasional errors. An airline is required to have a form of database checking, however it is certainly in the Airbus SOP that the PIlots are required to check the database coding against the chart before commencing the approach and ensuring it complies with the ATC Clearance and the charted approach. In my experience pilots often accept the FMS database as correct without checking. “After all the aircraft flew it OK last month”.

Capn Bloggs
14th Nov 2022, 10:33
But a simple thing such as inputting or selecting data from an FMS, shouldn’t be an approach specific thing, so why do we need to practice them. An internal memo saying “hey dickheads, do it properly and then check the data” should be sufficient for this. And if events continue to occur, maybe then look at the systems (including procedures) or the design (approach, FMS entry process). But wasting time flying an approach in the sim, when the process could be the problem, is not the answer.
Agree.

However:
and reduced the amount of time spent on things we should be able to handle (rejected take-offs or engine failures)
Disagree. These are the two things we can't practice on the line and bear no resemblance to normal ops. In my experience, they are also the things most stuffed-up in the sim (and GAs). We don't need sim time to make sure we know how to insert an IAF in an approach string.

mates rates
15th Nov 2022, 00:17
It’s the continuity of knowledge that needs to be passed on.Some pilots employed by the airlines have never been to Cairns before they joined,so they have no knowledge of the terrain,let alone the 32 approach.Then you have the 35 CBR terrain.Remember the QF terrain incident a few years ago?The DME arrival into LST from SYD is another example.There would be other examples and they need to be part of a cyclical program,not practiced EVERY sim.There are too many “children of the magenta” out there.The FMC is only as good as it is fed and CHECKED.

Capn Bloggs
15th Nov 2022, 00:40
It’s the continuity of knowledge that needs to be passed on.Some pilots employed by the airlines have never been to Cairns before they joined,so they have no knowledge of the terrain,let alone the 32 approach.Then you have the 35 CBR terrain.Remember the QF terrain incident a few years ago?The DME arrival into LST from SYD is another example.There would be other examples and they need to be part of a cyclical program,not practiced EVERY sim.There are too many “children of the magenta” out there.The FMC is only as good as it is fed and CHECKED.
Decent companies have a decent route manual that describes all these little gotchas; a quick read before you go (route qualification) is all that should be necessary. Modern aviation shouldn't rely on "the continuity of knowledge that needs to be passed on".

Mach E Avelli
15th Nov 2022, 06:31
It’s the continuity of knowledge that needs to be passed on.Some pilots employed by the airlines have never been to Cairns before they joined,so they have no knowledge of the terrain,let alone the 32 approach.Then you have the 35 CBR terrain.Remember the QF terrain incident a few years ago?The DME arrival into LST from SYD is another example.There would be other examples and they need to be part of a cyclical program,not practiced EVERY sim.There are too many “children of the magenta” out there.The FMC is only as good as it is fed and CHECKED.

Indeed. If the children of the magenta were occasionally required to fly a few gnarly 2D approaches the old way, situational awareness would be raised. Maybe they would eventually get ahead of the FMS when using it, instead of blindly following a mile behind it, trusting its electronic brain to keep them safe. Do any sim sessions include spurious navigation data, short of obvious total systems failures?
I have actually seen pilots program the FMS to fly a visual circuit on a clear day. It's not surprising that situational awareness is disappearing.

Lead Balloon
15th Nov 2022, 06:38
But surely these kinds of risks are identified and dealt with in each operator’s SMS and resulting procedures. Is it really the case that a pilot without any first-hand experience of these kinds of - I’ll use the word ‘quirky’ - approaches is ‘let loose’ on them without specific briefing/training on those ‘quirks’? How can that happen in 21st century in country with the number of rules Australia has?

josephfeatherweight
15th Nov 2022, 07:31
Decent companies have a decent route manual that describes all these little gotchas; a quick read before you go (route qualification) is all that should be necessary. Modern aviation shouldn't rely on "the continuity of knowledge that needs to be passed on".
Modern approaches shouldn't have "gotchas".

Lookleft
16th Nov 2022, 00:25
Decent companies have a decent route manual that describes all these little gotchas; a quick read before you go (route qualification) is all that should be necessary. Modern aviation shouldn't rely on "the continuity of knowledge that needs to be passed on".

Define decent Bloggsy? I dont disagree with you but as an example the outfit I fly for has no mention of the RNP approaches into CNS but still refers to the 33 LOC. Most new Captains who have to do a physical entry into CNS for their training will do it onto 15. I don't know the composition of the crews involved in the incidents but if they had recently been upgraded from WB in the case of QF or had recently returned to flying in the case of VA then the continuity of knowledge that is still an important part of flying into those ports was probably missing.

In the absence of that knowledge then this statement is even more important "The FMC is only as good as it is fed and CHECKED". If the crews did not put in the transition on an RNP approach then where is the cockpit discipline?

The 33 RNP should be coded much earlier than it is but doing a selected or managed descent to that point and actively monitoring the approach should keep you out of trouble. There is a reason that RNP approaches has a requirement for all those cross checks before the approach and during the approach. Unfortunately it is often treated like an ILS and once on a vertical profile it is almost considered to be set and forget. As has been mentioned, an incorrect QNH puts you on a highway to the danger zone. Personally I would rather do an ILS than an RNP. Townsville 01 is a case in point.

Eclan
16th Nov 2022, 00:49
The first rule of FMC usage is GIGO.

In the olden days, after the Earth had cooled but before the introduction of something which chipped away a little more at the need to think and which is called a "STAR", we would at some point prior to TopD examine the charts and determine the most limiting of the CTA steps (which protect against terrain) and plan a descent accordingly based on a 3X + [factor] angle to the limiting step. This was simple to do and kept us all out of trouble. The people who taught these techniques to the newer pilots had been doing the job for years and worked their way up through the airline. Pilots I fly with today look at this sort of thing the same way my dog looks at the TV. They used to call that concept "Experience" and in the olden days it was considered valuable, if intangible, by CEOs and managers who could see the wood for the trees but this is no longer so and we've watched certain airlines emerge staffed by inexperienced pilots eager to climb the scrotem pole and CEOs focused on share prices and dividends and woke agendas and gender quotas and so now with STARs and magenta lines to follow people scratch their heads and wonder how this sort of terrain event can happen.

43Inches
16th Nov 2022, 01:08
Don't know how others think about it, but my first though of Cairns is problematic terrain everywhere. So that sets my train of thoughts as to cross checking descent steps and procedures. Same as Canberra, Albury or Launy, and a few other places with unusual terrain and steps. It's nice to rely on ATC to give you descent altitudes (in this case ATC only cleared them to 6800 and then via the RNP so had no adverse affect), but I'm always conscious of the spot heights and such into these areas and have a floor in my mind where I will question a cleared alt if it seems too low. It doesn't help that MVAs are not published, so hard to gather what the minimum vector altitude is, but I reckon it won't be anywhere near 500 ft agl of terrain.

PS just listened to the radio of the VA incident, well done to that controller, spotted alerted and hurried them up back to altitude all well communicated. Probably avoided GPWS getting involved.

It's times like these I get reminded why we readback inane things like "descend via star". Oops, forgot to read the STAR/Approach chart properly and identify the limitations, ATC forgot to tell me to!

FJ44
16th Nov 2022, 09:55
Starts at 10.00. Not pretty.
https://archive.liveatc.net/ybcs/YBCS-App-Dep-2-Oct-24-2022-1000Z.mp3

What was going on that night? Must have been the full moon...

In that 30 min clip there are three aircraft struggle with the approach.
Rex sound like they go through the centreline and do some manoeuvring to get back to it,
The VA go-around,
and then Border Force have some difficulty also with a "FMS issue"


Sounds like that controller earned his keep that shift.

Capt Fathom
16th Nov 2022, 10:46
What ever happened to reading and following the approach chart? When you went somewhere for the first time, that’s all you had.
Maybe this was a case of familiarity. Been here before, load the FMS and watch it happen.
If this was done as a raw data approach, it would be done perfectly.

maggot
16th Nov 2022, 21:06
What ever happened to reading and following the approach chart? When you went somewhere for the first time, that’s all you had.
Maybe this was a case of familiarity. Been here before, load the FMS and watch it happen.
If this was done as a raw data approach, it would be done perfectly.

If you select the approach without the transition it presents in the FMS as the correct routing, in which lays this trap.

Lookleft
16th Nov 2022, 21:57
If you select the approach without the transition then the crew are not doing their job properly. Both pilots not cross checking the STAR in the FMC then briefing it correctly is not a trap, its poor flying.

turbantime
16th Nov 2022, 22:25
This thread started off well by not pointing fingers at crew but rather discussing the threats around Cairns and approach transitions. But as usual, the armchair experts chime in beating their chests proclaiming how they are superior because they would not let it happen to them. What is it with you types? Just can’t keep it in your pants huh?

Lookleft
16th Nov 2022, 22:58
No one is pointing the finger at anyone idiot. Just a response to the statement that not putting the transition in on an RNP approach into Cairns is a trap. Its not a trap just poor airmanship. As yet we don't know what the 2 crews did. It could actually be a problem with the 737 database. Given your lack of any constructive discussion then I can imagine you sitting in your armchair yelling at the keyboard.

neville_nobody
16th Nov 2022, 23:09
No one is pointing the finger at anyone idiot. Just a response to the statement that not putting the transition in on an RNP approach into Cairns is a trap. Its not a trap just poor airmanship. As yet we don't know what the 2 crews did. It could actually be a problem with the 737 database.


It is a trap when there are two transitions and one isn’t mentioned in the clearance.

maggot
16th Nov 2022, 23:43
...and charted differently/poorly to elsewhere we fly them
just another hole in the cheese that you never have I guess lookleft.

turbantime
16th Nov 2022, 23:59
No one is pointing the finger at anyone idiot. Just a response to the statement that not putting the transition in on an RNP approach into Cairns is a trap. Its not a trap just poor airmanship. As yet we don't know what the 2 crews did. It could actually be a problem with the 737 database. Given your lack of any constructive discussion then I can imagine you sitting in your armchair yelling at the keyboard.
Yeah, nah. I fly the type so am fully aware of the aforementioned failure to select both transitions on the STAR and Approach.
As for the idiot comment and accusing me of yelling at keyboard…pot…kettle…black…

Lookleft
17th Nov 2022, 08:17
I fly the type so am fully aware of the aforementioned failure to select both transitions on the STAR and Approach.

So now we move on from the juvenile to the substantive. So when you state that you are fully aware of the failure to select both transitions on the STAR and the Approach are you referring to your own error or that of one of the crews involved? If it is your error then maybe some rational dialogue as to why you didn't put the transition in would be helpful to others. If you are talking about the thread incident why do you think the crew did not put the transition in?

​​​​​​​and charted differently/poorly to elsewhere we fly them
just another hole in the cheese that you never have I guess lookleft.

The first time I flew the 33 RNP Y I was surprised as to the point where the approach was coded. In that instance I did a selected descent to the coded part using the LOC profile as a guide. The next time I managed the descent and monitored the contraints like a hawk. An approach onto 33 has always required greater attention and planning than most other approaches even before the advent of RNP. I will restate the obvious. If you don't select the transition even though its part of the clearance readback then you are not doing your job properly. You don't need to be ace of the base or beyond Reason just do the job. If the crew(s) did not select the transition in the FMC then the question is why?

turbantime
17th Nov 2022, 09:55
The answer seems pretty obvious to me, they made an error, hopefully one we can all learn off. Internal comms were sent re this incident to ensure no one else falls into the same trap (of failing to select both the STAR and approach transitions).

It’s great to see that you hold your airmanship in such high regard. For the rest of us mere mortals, we like to learn from other’s mistakes so that we don’t make them ourselves.

Lookleft
17th Nov 2022, 10:49
Internal comms were sent re this incident to ensure no one else falls into the same trap (of failing to select both the STAR and approach transitions).

This seems to be where we started. Its not a trap if it is a requirement to read back the transition as part of the clearance and then not insert it into the FMC then not cross checking it. An error would be for one pilot to omit the selection. In TEM parlance an error led to a UAS. Not a trap but a failure of procedures and proper monitoring. I will let you work out where a UAS leads if you even understand the term.

​​​​​​​It’s great to see that you hold your airmanship in such high regard.

Not really, just an example of taking the threat seriously. It doesn't take superior airmanship but it does take a modicum of attention to what will kill you if you don't pay attention to your environment.

maggot
18th Nov 2022, 07:07
.........

Xhorst
19th Nov 2022, 04:53
This seems to be where we started. Its not a trap if it is a requirement to read back the transition as part of the clearance and then not insert it into the FMC then not cross checking it.

I'm pretty sure the Hendo Transition is not provided as part or the clearance, so nor is it read back by the crew. Working out that it needs to be selected is up to the crew. It is not always obvious, so yes, in a critical terrain environment such as this, it's a trap.

neville_nobody
20th Nov 2022, 07:14
I'm pretty sure the Hendo Transition is not provided as part or the clearance, so nor is it read back by the crew. Working out that it needs to be selected is up to the crew. It is not always obvious, so yes, in a critical terrain environment such as this, it's a trap.

Yes this is the issue. The transition you read back is the STAR transition. You just have to know to put the approach transition and the STAR transition in the FMC and I don't believe it is uniform across the country.