ATSB Report on AirAsia X Gold Coast Approaches

[Kelly Slater]

Approach Plates are not drawn to scale, they are merely graphic illustrations. A quick look at the chart in question will verify this. Look at the length of the picture between the 5,7,8 and 10 DME steps. Obviously not a scale drawing. Not all of the discrepancy can be explained by the fact that the track in is converging on the runway centre line. As the vertical distances are not to scale, neither can the horizontal distances be to scale. It is a pictorial diagram only. Don't feel bad though, even the ATSB have used the words "scale" and "approach chart" in the same sentence in the past.

[Wally Mk2]

'MW' am not too sure what chart yr referring to here but the one the crew where using does have a dist/alt comparison so there's no excuse there for this crew not to be x checking on their way down the slope. Even if there wasn't it's pretty obvious that the side elevation of the App shows dist versus alt anyway in a pictorial format, easier for the human brain anyway.
Have I ever done an NPA with the DME behind me? Yep sure have. West Sale Vic NDB Y Rwy 27 in very crappy weather SP so it ain't rocket science.

These crews are meant to be trained professional pilots whom fly all over the world not to some hick outback town! You couldn't get it easier with this one. SL drome,straight in App (almost straight in & no teardrop req'd) & a 3x basic airmanship check was all that was needed to see if it looked okay. They cocked up pure & simple, there are no excuses here at all IMO & even though the chart may not be what we are used to seeing/using here in Oz it does have all the info req'd to conduct the App.

Wmk2

[waren9]

I'm looking for a T-VASIS, but with a TCH of 39', I want to be one dot high (in an A330). Simple.

Disagree with this.

The threshold for 32 is displaced roughly 450m. Flying on slope will mean an eye height crossing the start of the ashpalt of around 120'. Wheel crossing height is hardly an issue then, even for an A330.

Why risk landing long when the landing distance is given as 2042m after a long night flight?

[hongkongfooey]

Flown all over Asia and there is nothing particularly " gotcha " about that chart.
Why didn't they do what they usuall do and just hit " appr " then the a/c does it all for you .
RENNURPP, Air Asia have had many incidents including a runway over run in Malaysia, that you don't hear about in the sheltered workshop of Austraia.
Yes, I know we are all equal, and no race of pilots is better/worse that any others and we can all live side by side in peace and harmony, it's just that some countries pilots are more / less equal than others

[Capn Bloggs]

Originally Posted by Wally

These crews are meant to be trained professional pilots whom fly all over the world not to some hick outback town! You couldn't get it easier with this one. SL drome,straight in App (almost straight in & no teardrop req'd) & a 3x basic airmanship check was all that was needed to see if it looked okay. They cocked up pure & simple, there are no excuses here at all IMO & even though the chart may not be what we are used to seeing/using here in Oz it does have all the info req'd to conduct the App.

Wally, a tad simplistic there and a showing a lack of understanding on the real RPT world. To a large extent, these guys are a product of the system. I'll bet that they hardly ever do non-managed approaches. It's all well and good saying it should have been easy because that's all you do (or have done a lot in the past so it's ingrained) but put yourself in their shoes. For all we know, they may not even be allowed to keep current on the line by doing other than ILSs unless they don't have any other option. One in the SIM every so often: box ticked! Now prepared for a non-managed VOR in a strange place? System says "Yes!" Practically: nope.

Originally Posted by Fooey

Why didn't they do what they usuall do and just hit " appr " then the a/c does it all for you .

Did you read the report?

[Wally Mk2]

Well if you believe all that 'blogsey' & it's an excuse as yr implying then they have no place being in Australian Airspace!! I still stand by the fact that this particular App is dead easy & if they are having trouble with it then I hope I ain't there when the body count reaches 200+!


Wmk2

[ReverseFlight]

I think the presentation of the AirAsiaX chart of itself was not the problem. The real problem was that the presentation was being used by a flight crew who was not trained specifically for flying vertical profiles of NPAs incorporating intermediate segment MSAs.

If they had been familiar with the plate, then intercepting at 2500' should have triggered the reminder they were intercepting below the normal height on the chart and therefore a later descent point would be required. Even if they were not familiar, for a sea level airport, they should have mentally worked out that for a 3 degree G/S, a 2500' intercept should occur at about 8 DME and not 10 DME.

I am aware of a least one Australian airline flying regularly into CG which frequently drills their flight crews to practice precisely this particular approach in the sim.

[Capt Claret]

In the late 90's when there was an exodus of Aussie crew to All Nippon, I think, word filtered back that crew were required to dive & drive to each step of a DME approach, as opposed to what seems to be the norm in Aus, of a constant descent profile.

I don't know this to be true but wonder if AirAsia requires the same of its crew?

[Capn Bloggs]

The real problem was that the presentation was being used by a flight crew who was not trained specifically for flying vertical profiles of NPAs incorporating intermediate segment MSAs.

If they had been familiar with the plate, then intercepting at 2500' should have triggered the reminder they were intercepting below the normal height on the chart and therefore a later descent point would be required. Even if they were not familiar, for a sea level airport, they should have mentally worked out that for a 3 degree G/S, a 2500' intercept should occur at about 8 DME and not 10 DME.

It's even simpler than that. All one needs to do is compare the current altitude with the profile on the chart for both the profile intercept DME and then the profile to fly. The Step limits are then irrelevant (a point that appears to be missed by the ATSB). Get on that profile and stay on it and all will be well.

The bad old days required looking at each step limit and working out how to avoid/skim it, without getting too high. Much to Ledsled's chagrin, I believe it was Australia that pioneered the DME/Altitude profile on NPA approach charts to permit a true CDA without VNAV.

There are other valuable lessons which have not been addressed in the report: why couldn't these guys get the FMS to do the approach (especially the second approach)? Being cut in, inside the IAF, by ATC? Did they know how to intercept an FMS leg midway down the approach? Did the FMS try to hold them up initially because it hadn't changed the active waypoint, and in desperation they took matters into their own hands?

I suspect that these incidents, combined with the rain, have influenced the decision to put in an ILS. Nothing like a couple of near prangs to blunt the pencils of the bean-counters.

[FlareArmed]

3000 at 20 DME for RWY32? Really?

Re-read as 20 miles to run to start slowing, and as per ATC clearance to 3000'.

The threshold for 32 is displaced roughly 450m. Flying on slope will mean an eye height crossing the start of the ashpalt of around 120'. Wheel crossing height is hardly an issue then, even for an A330.

Nice detail to consider – I missed the displaced THR on 32 (and re-reading, the TCH is 50' anyway). The kind of pick-up you can make having a cup of coffee in the cruise.

Not much 3xDME going on, by the looks of it.

It's pretty close: say 3 X DME +100 but I prefer planning an ROD, because it's simpler to execute. This approach is 3 degrees from 9.6 DME. I would anticipate that by 0.2 and descend at 5 X GS (rounded up). If the GS was 120 at 9.8 DME, I would dial-in 600 FPM (if no VNAV), or read the speed/ROD scale on the Jepp. The main thing I watch as PF is the ground-speed and adjust the ROD (without the joys of VNAV). In the old days, we had to dive and drive because we had no ground-speed and often no DME. It's a whole lot easier now.

My main point for the inexperienced or automation-reliant among us is – have a simple plan before you enter the 'battle zone' where things can go astray (ATC slam-dunking etc). If you have a plan, you can judge whether you are in a good or bad position when challenges arise. Energy management is the key.

As an airline training Captain, I saw plenty of examples of no planning and crap results on NPAs – that and circling approaches were the most demanding things we did. The best I saw was a pilot confused as all hell because he couldn't see the airport when getting visual on a DME arrival: 3 minutes of planning in the cruise would reveal the airport would be directly below (and out-of-sight) at the minima, requiring a 180-degree turn.

[A37575]

selected VOR apps are a very high workload app in a heavy jet.

If the workload is too high with the use of automatics, then surely it would be better to reduce the workload by switching off the automatic pilot and fly manually? It shouldn't be that hard for an experienced heavy jet captain.

[hongkongfooey]

Bloggsy, no I didn't read the report, do not have that much spare time on my hands.
Bottom line, if you want 199 fares gold coast-KL you are going to get (generally) 2000hr guys in the left seat and 200hr guys in the right, so I guess it's all " risk management "
BTW, OOL is not by a long shot the only place in SE Asia where you would have to do an NPA.

[Marcellus Wallace]

Excerpt from the ATSB report:
Additional information

Similar occurrences – other operators
The Australian Transport Safety Bureau reviewed notification data that had been collected between
July 2003 and July 2011 for similar occurrences involving high capacity aircraft. That review identified 21 additional reported occurrences of aircraft descending below the relevant segment minimum safe altitude while conducting an instrument approach in IMC. Six of those occurrences involved foreign-registered aircraft and the remaining 15 involved aircraft that were Australian registered. That data had not been normalised for the number of approaches being flown.

Yes, they screwed up big time but they were not the only ones.

[Capn Bloggs]

Originally Posted by Marcellus

Yes, they screwed up big time but they were not the only ones.

Hang on. That's the same as saying NSW is 100 times more dangerous on the roads than TAS because they had 100 times more deaths. The ATSB, by it's own admission, says as much in the report: That data had not been normalised for the number of approaches being flown., as you quoted.

Ex A380 Driver, that Lido chart is the least user-friendly of all of them. No info/profile outside 7.1DME/2200ft. They were cleared to 2500ft.

[smiling monkey]

Yes, they screwed up big time but they were not the only ones.

Yeah, and Tiger was shutdown by CASA for a few months for doing it a couple of times. What about the others?

[sheppey]

Actually no - It s much harder to fly an NPA manually.

Is that for just the A380 or does it apply to all jet transports? Why is flying an NPA manually, harder?

[4dogs]

why is it harder?

cos you have to touch the controls and stop being a spectator!!!

Stay Alive,

[Marcellus Wallace]

Hang on. That's the same as saying NSW is 100 times more dangerous on the roads than TAS because they had 100 times more deaths. The ATSB, by it's own admission, says as much in the report: That data had not been normalised for the number of approaches being flown., as you quoted.


I was just pointing out that they screwed up big time, but this type of mistake is not exclusive to AAX/pilots from that part of the world - as others seem to believe so.

Have a read of the UK AAIB report #5/2007 on G-MEDG into Khartoum 11 March 2005. Pretty scary.

Flight Safety Foundation ALAR acknowledges that NPA are a threat and the crew should be aware of this and take extra precautions. Working out your distance to touchdown in relation to the DME available is a good start to improve your situational awareness.

RNAV STARs leading to RNAV Approaches are a pretty cheap fix - but still need to be flown correctly.

Yes the LIDO chart doesn't give a profile beyond 7.1nm - a look at the difference in altitude between 6 DME and 7 DME yields 320 feet - add that to the altitude of 2200feet at 7.1 DME and you have 2520 feet - better than nothing - so start descent at 8.1DME or 8.3 DME according to your SOP for inertia etc. Were they prepared for this or as you alluded to attempting the managed approach without the blue arrow and panicked?

We are all here to learn from each other and hopefully not make the same mistake.

Damn lucky they didn't hit anything. No GPWS with the gear hanging out either.

I believe the airplane was fitted with EGPWS and terrain warnings would have been issued had they been below the Terrain Clearance Floor - provided YBCG was in the database - still no excuse to be at such a low altitude so far out.

[CaptCloudbuster]

Because the Human Brain is a single channel computer which can quickly (and insidiously) run out of R.A.M.

[sheppey]

Because the Human Brain is a single channel computer which can quickly (and insidiously) run out of R.A.M.

Amusing but unconvincing reply. With the thousands of single pilot IFR charters day and night operating in Australia, then if the human brain is that bad (run out of RAM), there would be crashes everywhere.