ATSB report on very low flying Thai Airways B777 at Melbourne.
Having never flown the 777 and with respect to the initial pitch up, if the aircraft was in VNAV why did the aircraft wait until 3300' and then decide to climb up to 3400' (page 9). Is this normal or should the aircraft have levelled itself as it got to 3400'?
I have 2 genuine questions.
1. The ATSB are pretty good at placing different pieces of information in different places of reports (and even draft vs final versions). In this instance there is additional detail in Appendix B which notes that the crew initially responded copied (as opposed to repeating the instruction), followed by "maintaining 1200" followed by "inaudible". This seems to me to paint a picture that the crew didn't understand the instruction. What responsibility does this place on the controller to repeat the instruction?
In this instance, I only think it matters because of the severe criticism the ATSB is placing on the crew for not obeying an instruction for 50 seconds (which measures 47 seconds according to appendix B). To my logic, you either accept that the crew responded promptly to a command they acknowledged or you accept that there is a shared responsibility to clarify an unacknowledged command. What if the inaudible reply from the crew was " did not copy, say again?". To me if the report is going to criticize the crew it should make an attempt to understand if a) the controller did not speak clearly, b) there was other interfering or confusing radio traffic, c) the crew's English was inadequate d) the crew missed the call due to workload or e) the crew was simply belligerent.
Secondly - in part due to the delay in actioning the go around - at the time of the go around the aircraft was established on final, visual with PAPI in sight, above MDA and either on glideslope or close to it (because the ATSB publish time references and not distance measurements, its very hard to tell). My question is - after a 9 hour flight from BKK - which is the safer course: allowing the approach to continue or requiring a go-around?
Its clear that the crew were not on top of the non precision approach, but it seems to me that the greatest deviations occurred in the transition from the DME arc to the VOR approach before they were cleared for visual approach. At the time of the go-around it would seem that the crew was aware of their situation and had acted to correct the approach. Based on the ATSB report, I don't see any evidence that a safe successful landing would not have resulted from that approach. At the time of the go-around they had passed the Melbourne CBD on their right and were about over Flemington with Essendon airport at about 2 o'clock. There would have been heaps of visual reference.
1. The ATSB are pretty good at placing different pieces of information in different places of reports (and even draft vs final versions). In this instance there is additional detail in Appendix B which notes that the crew initially responded copied (as opposed to repeating the instruction), followed by "maintaining 1200" followed by "inaudible". This seems to me to paint a picture that the crew didn't understand the instruction. What responsibility does this place on the controller to repeat the instruction?
In this instance, I only think it matters because of the severe criticism the ATSB is placing on the crew for not obeying an instruction for 50 seconds (which measures 47 seconds according to appendix B). To my logic, you either accept that the crew responded promptly to a command they acknowledged or you accept that there is a shared responsibility to clarify an unacknowledged command. What if the inaudible reply from the crew was " did not copy, say again?". To me if the report is going to criticize the crew it should make an attempt to understand if a) the controller did not speak clearly, b) there was other interfering or confusing radio traffic, c) the crew's English was inadequate d) the crew missed the call due to workload or e) the crew was simply belligerent.
Secondly - in part due to the delay in actioning the go around - at the time of the go around the aircraft was established on final, visual with PAPI in sight, above MDA and either on glideslope or close to it (because the ATSB publish time references and not distance measurements, its very hard to tell). My question is - after a 9 hour flight from BKK - which is the safer course: allowing the approach to continue or requiring a go-around?
Its clear that the crew were not on top of the non precision approach, but it seems to me that the greatest deviations occurred in the transition from the DME arc to the VOR approach before they were cleared for visual approach. At the time of the go-around it would seem that the crew was aware of their situation and had acted to correct the approach. Based on the ATSB report, I don't see any evidence that a safe successful landing would not have resulted from that approach. At the time of the go-around they had passed the Melbourne CBD on their right and were about over Flemington with Essendon airport at about 2 o'clock. There would have been heaps of visual reference.
Australia certainly seems unusual to me in that they don't have co located DME's on all their ILS's and in some cases don't even have an ILS. That is not 'worlds best practice' or whatever they like to say.
DME x 300 works really well for a 3 degree approach on to this runway because of the combination of elevation and DME distance from the threshold.
It's published on the plate anyway.
It's published on the plate anyway.
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Sounds like you are trying to blame everyone else and at the same time misleading information.
On page one you said "nearly all the altitude reports are done against time, but the glideslope is defined by distance. A diligent report would have used distance so that the report was transparent someone reviewing it could plot it against the chart. The ATSB have denied us this ability."
Checkout the diagram on page 3. It shows what happened and where.
"a point missed by Sunfish and glossed over by the ATSB is that they were cleared for visual approach."
They were initially cleared for a VOR approach and this is when the error(s) happened. Later, after reporting the runway in sight, only then were they cleared for a visual approach.
"correct me if I'm wrong, but I'm pretty sure the command "cleared for visual approach" waives the approach altitude requirements and allows the pilot to descend at his / her discretion to make the landing."
Immediately prior to being cleared for the visual approach, the aircraft was on a VOR approach clearance at 1700 feet on a minimum altitude segment of 1959 feet.
As for the visual approach, the report says "The tower controller then cleared the aircraft for a visual approach, provided the aircraft was ‘... established on PAPI[5] and inside the circling area[6]’.
As the report states The captain recalled that, as the aircraft lined up on final approach, the PAPI was indicating ‘four reds’ and that they were ‘really low’
According to the pilots description (confirmed by the ATSB report) he an initiated recovery before the ATC alert.
Take a look at the so-called recovery in the Appendix that you refer to. It is not much of a recovery, it is a continued descent initially then a slow climb which is nowhere near as much of a recovery as a proper go-around.
It is entirely likely at the time of the instruction to go around, the aircraft was back on glideslope.
There is no glideslope on this approach and they had not returned to a 3 degree descent path toward the intended runway.
The MDA inside 6.5 mile is 760 ft, so the aircraft was ABOVE the published minima.
This is incorrect. Look at the diagrams. I think the difficulty is in your comprehending them.
I suspect that this is the only part where the aircraft breached the LSALT. It was above MDA when it was at 984 ft which is where the attention is focused
Check out the diagram on page 17. You are completely incorrect.
As for ATC, it sounds like they did an excellent job....
2018:31 Flight crew advise that they have the airfield in sight, then cleared for visual approach. Aircraft altitude 1,700 minimum altitude 1,950
2018:48 Aircraft’s autopilot disconnected. This is accoding to crew statement when they decided to recover to a higher altitude. Aircraft altitude1,300 Minimum altitude 1,950
2018:56 Flight crew told to ‘check altitude'. Aircraft altitude 1,100 Minimum altitude 1,950
2019:00 Flight crew instructed to go-around and to carry out missed approach runway 34. Crew responds ‘copied’ Aircraft Altitude 1,000
Minimum altitude 1,950
2019:26 Go-around instruction re-issued to flight crew, who respond that they are maintaining 1,200 ft. Aircraft altitude 1100 minimum altitude 1950
2019:35
Flight crew instructed to carry out a missed approach. The crew’s reply is inaudible
2019:47
The tower controller responds, ‘Negative, missed approach runway 34 climb to 4,000 ft’
Flight crew acknowledges that they are climbing to 4,000 ft
TOGA
I'm sorry you have trouble understanding the report
On page one you said "nearly all the altitude reports are done against time, but the glideslope is defined by distance. A diligent report would have used distance so that the report was transparent someone reviewing it could plot it against the chart. The ATSB have denied us this ability."
Checkout the diagram on page 3. It shows what happened and where.
"a point missed by Sunfish and glossed over by the ATSB is that they were cleared for visual approach."
They were initially cleared for a VOR approach and this is when the error(s) happened. Later, after reporting the runway in sight, only then were they cleared for a visual approach.
"correct me if I'm wrong, but I'm pretty sure the command "cleared for visual approach" waives the approach altitude requirements and allows the pilot to descend at his / her discretion to make the landing."
Immediately prior to being cleared for the visual approach, the aircraft was on a VOR approach clearance at 1700 feet on a minimum altitude segment of 1959 feet.
As for the visual approach, the report says "The tower controller then cleared the aircraft for a visual approach, provided the aircraft was ‘... established on PAPI[5] and inside the circling area[6]’.
As the report states The captain recalled that, as the aircraft lined up on final approach, the PAPI was indicating ‘four reds’ and that they were ‘really low’
According to the pilots description (confirmed by the ATSB report) he an initiated recovery before the ATC alert.
Take a look at the so-called recovery in the Appendix that you refer to. It is not much of a recovery, it is a continued descent initially then a slow climb which is nowhere near as much of a recovery as a proper go-around.
It is entirely likely at the time of the instruction to go around, the aircraft was back on glideslope.
There is no glideslope on this approach and they had not returned to a 3 degree descent path toward the intended runway.
The MDA inside 6.5 mile is 760 ft, so the aircraft was ABOVE the published minima.
This is incorrect. Look at the diagrams. I think the difficulty is in your comprehending them.
I suspect that this is the only part where the aircraft breached the LSALT. It was above MDA when it was at 984 ft which is where the attention is focused
Check out the diagram on page 17. You are completely incorrect.
As for ATC, it sounds like they did an excellent job....
2018:31 Flight crew advise that they have the airfield in sight, then cleared for visual approach. Aircraft altitude 1,700 minimum altitude 1,950
2018:48 Aircraft’s autopilot disconnected. This is accoding to crew statement when they decided to recover to a higher altitude. Aircraft altitude1,300 Minimum altitude 1,950
2018:56 Flight crew told to ‘check altitude'. Aircraft altitude 1,100 Minimum altitude 1,950
2019:00 Flight crew instructed to go-around and to carry out missed approach runway 34. Crew responds ‘copied’ Aircraft Altitude 1,000
Minimum altitude 1,950
2019:26 Go-around instruction re-issued to flight crew, who respond that they are maintaining 1,200 ft. Aircraft altitude 1100 minimum altitude 1950
2019:35
Flight crew instructed to carry out a missed approach. The crew’s reply is inaudible
2019:47
The tower controller responds, ‘Negative, missed approach runway 34 climb to 4,000 ft’
Flight crew acknowledges that they are climbing to 4,000 ft
TOGA
I'm sorry you have trouble understanding the report
Last edited by JammedStab; 23rd Feb 2013 at 11:03.
Jammed Stab
If I see to criticise it is the sloppy ATSB report. I suspect that you are assuming I'm seeking to blame ATC, which is not my intention.
My page 13 is a page of text headed "Safety Action". My page 14 is blank. My page 15 has a copy of the VOR approach plate. By comparison, the 2007 report AO-2007-055 has a lovely diagram on p5. However the recent report AO-2011-086 has no similar diagram.
My understanding of cleared visual approach was imperfect and corected by previous posters. However, it has also been added that Australia and ICAO differ in the requirement to be within the circling area. So, an interesting discussion (which is absent from the ATSB report) is whether this might be a contributing factor.
You'll have to explain the MDA point to me. The approach plate on p15 has a shaded area at the 6.5 DME point that says MDA. The MDA for the VOR procedure is shown in the table as 760 ft. What did I get wrong?
Once again, the pdf report AO-2011-086 that I downloaded from the ATSB website has no diagram on p17. It has "Appendix B - Sequence of Events".
Do you have the same report copy as me?
One of the things I'm interested in is that on p2 the ATSB list the crews response to the initial command of "climb, go around"as "climbing". On p17 (appendix B) the table lists to crews response as "copied". Which is it? Why is the transcript quoted by the ATSB as different in two places of the same report?
If I see to criticise it is the sloppy ATSB report. I suspect that you are assuming I'm seeking to blame ATC, which is not my intention.
My page 13 is a page of text headed "Safety Action". My page 14 is blank. My page 15 has a copy of the VOR approach plate. By comparison, the 2007 report AO-2007-055 has a lovely diagram on p5. However the recent report AO-2011-086 has no similar diagram.
My understanding of cleared visual approach was imperfect and corected by previous posters. However, it has also been added that Australia and ICAO differ in the requirement to be within the circling area. So, an interesting discussion (which is absent from the ATSB report) is whether this might be a contributing factor.
You'll have to explain the MDA point to me. The approach plate on p15 has a shaded area at the 6.5 DME point that says MDA. The MDA for the VOR procedure is shown in the table as 760 ft. What did I get wrong?
Once again, the pdf report AO-2011-086 that I downloaded from the ATSB website has no diagram on p17. It has "Appendix B - Sequence of Events".
Do you have the same report copy as me?
One of the things I'm interested in is that on p2 the ATSB list the crews response to the initial command of "climb, go around"as "climbing". On p17 (appendix B) the table lists to crews response as "copied". Which is it? Why is the transcript quoted by the ATSB as different in two places of the same report?
Originally Posted by Jammed Stab
The MDA inside 6.5 mile is 760 ft, so the aircraft was ABOVE the published minima.
This is incorrect. Look at the diagrams. I think the difficulty is in your comprehending them.
This is incorrect. Look at the diagrams. I think the difficulty is in your comprehending them.
It is entirely likely at the time of the instruction to go around, the aircraft was back on glideslope.
There is no glideslope on this approach and they had not returned to a 3 degree descent path toward the intended runway.
There is no glideslope on this approach and they had not returned to a 3 degree descent path toward the intended runway.
Originally Posted by ATSB Factual Info page 1
the flight crew changed the MCP target altitude to 970 ft, selected FLCH mode and the aircraft commenced descent. To maintain the target airspeed of 190 kts, the autothrottle reduced engine thrust to flight idle.
Bloggs,the link you've provided above is to the 16 incident. I'm not sure what the Jepp plate looked like in the 34 incident. There is a DAP plate reproduced here.
http://www.atsb.gov.au/media/4080756...-086_final.pdf
The ATSB also really needs to include the data as it's presented to the pilots ie. if they're Jepp users please include the appropriate Jepp plate!
http://www.atsb.gov.au/media/4080756...-086_final.pdf
The ATSB also really needs to include the data as it's presented to the pilots ie. if they're Jepp users please include the appropriate Jepp plate!
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Just because the minimima inside 6.5 DME is 760 feet doesn't mean that the aircraft was above minima as he stated, it was not earlier in the approach.
However, I could have worded it more clearly in my proof that he was incorrect. Thanks.
In an earlier reply I mentioned page 13....It should have said page 3.
Last edited by JammedStab; 23rd Feb 2013 at 11:04.
JammedStab
You've addressed the p13 issue, but what about your reference to a diagram on p17?
Also, the diag on p3 does not have any (flown) altitude references whatsover, so it does not give any illustration to the issue at all. The diagram also conflicts with para 3 of page 2 which says that the minimum altitude of 984 ft was reached at 6.4nm. The diagram shows this point as before the 6.5nm point.
I agree that the crew was sloppy and contravened the procedure. But my point is that it was some time before the go around instruction. As far as I can see at the time of the go -around instruction the aircraft was legal.
I also question whether or not the crew heard or understood the first go-around instruction. This question is heightened by the ATSB reports use of 2 contradictory references to the crews radio response to the go-around. In my opinion, this is enough to raise questions about the voracity of the report. If the crew did not hear or understand the initial go-around command, then the ATSB's criticism of the crew not obeying the go-around instruction is not valid.
You've addressed the p13 issue, but what about your reference to a diagram on p17?
Also, the diag on p3 does not have any (flown) altitude references whatsover, so it does not give any illustration to the issue at all. The diagram also conflicts with para 3 of page 2 which says that the minimum altitude of 984 ft was reached at 6.4nm. The diagram shows this point as before the 6.5nm point.
I agree that the crew was sloppy and contravened the procedure. But my point is that it was some time before the go around instruction. As far as I can see at the time of the go -around instruction the aircraft was legal.
I also question whether or not the crew heard or understood the first go-around instruction. This question is heightened by the ATSB reports use of 2 contradictory references to the crews radio response to the go-around. In my opinion, this is enough to raise questions about the voracity of the report. If the crew did not hear or understand the initial go-around command, then the ATSB's criticism of the crew not obeying the go-around instruction is not valid.
Originally Posted by DirectAnywhere
Bloggs,the link you've provided above is to the 16 incident.
Originally Posted by DA
The ATSB also really needs to include the data as it's presented to the pilots ie. if they're Jepp users please include the appropriate Jepp plate!
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JammedStab
Also, the diag on p3 does not have any (flown) altitude references whatsover, so it does not give any illustration to the issue at all. The diagram also conflicts with para 3 of page 2 which says that the minimum altitude of 984 ft was reached at 6.4nm. The diagram shows this point as before the 6.5nm point.
I agree that the crew was sloppy and contravened the procedure. But my point is that it was some time before the go around instruction. As far as I can see at the time of the go -around instruction the aircraft was legal.
I also question whether or not the crew heard or understood the first go-around instruction. This question is heightened by the ATSB reports use of 2 contradictory references to the crews radio response to the go-around. In my opinion, this is enough to raise questions about the voracity of the report. If the crew did not hear or understand the initial go-around command, then the ATSB's criticism of the crew not obeying the go-around instruction is not valid.
Also, the diag on p3 does not have any (flown) altitude references whatsover, so it does not give any illustration to the issue at all. The diagram also conflicts with para 3 of page 2 which says that the minimum altitude of 984 ft was reached at 6.4nm. The diagram shows this point as before the 6.5nm point.
I agree that the crew was sloppy and contravened the procedure. But my point is that it was some time before the go around instruction. As far as I can see at the time of the go -around instruction the aircraft was legal.
I also question whether or not the crew heard or understood the first go-around instruction. This question is heightened by the ATSB reports use of 2 contradictory references to the crews radio response to the go-around. In my opinion, this is enough to raise questions about the voracity of the report. If the crew did not hear or understand the initial go-around command, then the ATSB's criticism of the crew not obeying the go-around instruction is not valid.
Whether the crew did hear ATC properly or not I cannot confirm but we can always bring up endless possibilities. What if there instruments were erronous, what if there was a temporary medical issue unknown to the crew, what if......
Bottom line.....it appears ATC did an excellent job.
Therefore mostly pilot error in this case but it would help to have an ILS at a busy airport. Slightly sloppy report likely due to administration errors.
@clark y
I don't read it as the aircraft climbed, I think they mean pitched up to perhaps maintain level or reduce vertical speed to capture path from below.
As they were cleared to decend 2000 then VOR 34 the pilot quite correctly wanted to keep descending. The problem came when instead of continuing to 2000 and commencing a 3deg path from there they set the altitude to the minima resulting in a unrestricted idle decent. Giving the aircraft no chance to get back on profile.
Terrible use of automation and display of mode awareness in my opinion.
Edit: this has nothing to do with a visual approach. The pilot made incorrect selections on the FCP and there appears to be little awareness of where the aeroplane was and how it got there.
I don't read it as the aircraft climbed, I think they mean pitched up to perhaps maintain level or reduce vertical speed to capture path from below.
As they were cleared to decend 2000 then VOR 34 the pilot quite correctly wanted to keep descending. The problem came when instead of continuing to 2000 and commencing a 3deg path from there they set the altitude to the minima resulting in a unrestricted idle decent. Giving the aircraft no chance to get back on profile.
Terrible use of automation and display of mode awareness in my opinion.
Edit: this has nothing to do with a visual approach. The pilot made incorrect selections on the FCP and there appears to be little awareness of where the aeroplane was and how it got there.
Last edited by Joker89; 24th Feb 2013 at 02:59.
Years ago, a friend high up in ATC told me that any incidents involving foreign reg a/c went through Foreign Affairs.
This was in response to a query as to the outcome of a foreign a/c commenced t/o after the clearance had been cancelled.
His reply was that the 225 would have been torn up and binned by or on instructions of Foreign Affairs.
It would therefore be reasonable to assume that Foreign Affairs would have a large say in the final version of the ATSB report.
Emeritus
This was in response to a query as to the outcome of a foreign a/c commenced t/o after the clearance had been cancelled.
His reply was that the 225 would have been torn up and binned by or on instructions of Foreign Affairs.
It would therefore be reasonable to assume that Foreign Affairs would have a large say in the final version of the ATSB report.
Emeritus
It would therefore be reasonable to assume that Foreign Affairs would have a
large say in the final version of the ATSB report.
large say in the final version of the ATSB report.
The problem came when instead of continuing to 2000 and commencing a 3deg path from there they set the altitude to the minima resulting in a unrestricted idle decent. Giving the aircraft no chance to get back on profile.
Terrible
use of automation and display of mode awareness in my opinion.
Terrible
use of automation and display of mode awareness in my opinion.
Last edited by Lookleft; 24th Feb 2013 at 09:04.
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Just a stray thought; there have been a few of this incident type in Australia, wondering if other NAA 'closer' to the ICAO rule set have the same problems? Perhaps they just have more ILS than we do; but it would be interesting to see how many incidents, not so unique countries, have with night visual approach. No bullets please, just idle curiosity. Tanx.
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Exactly. Read the report of the similar incident in 2007. The crew set the minima for a NPA, selected FLCH and then watched passively as it dived for the level set in the MCP. This seems to be an issue that should be addressed by the airline through training.
The ATSB make absolutely no mention of the configuration (the word "flap" appears exactly once in the 2011 (AO-2011-086) final report) and no analysis of consequences for Non Precision approaches in either the 2007 or 2011 reports. I thought as an industry we were moving to being fully configured for straight in NPA's by the 3 degree descent point for CFIT mitigation. Not a hint of analysis.
Both reports contain lots of word, pretty pictures and complicated diagrams that would impress non-pilots. Yet it appears to add very little toward making safer, as witnessed by the fact the same operator had almost identical outcome in substantially similar circumstances at the same aerodrome only four years later.
What was learnt from either report?
Last edited by FYSTI; 25th Feb 2013 at 05:36.
When you live....
I thought I'd posted a question but now can't find it.
Can someone explain why, after being cleared for the 34VOR, a subsequent Visual Approach clearance is needed? What benefit is obtained by using the visual approach? Spacing?
Also, why was a visual approach being offered given the forecast was for 8km vis in rain? The report said the captain lost sight of the field at one point.
Thanks
Can someone explain why, after being cleared for the 34VOR, a subsequent Visual Approach clearance is needed? What benefit is obtained by using the visual approach? Spacing?
Also, why was a visual approach being offered given the forecast was for 8km vis in rain? The report said the captain lost sight of the field at one point.
Thanks
If they struggle to conduct a VOR to rwy34 with everything apparently working, I would not like to be onboard if they have to conduct an approach with multiple failures or perhaps even with an engine inop.
Problem is C441 that in most 'big' airlines overseas NPA's don't significantly feature in the training regime. Most if not all emergency scenarios in the simulator end with an ILS approach to a 3500m runway, couple that with the 'unique' australian rules and it is no wonder these incidents keep occurring. Take the visual approach rules for instance, normally when cleared for a visual approach overseas all it means is that you have the runway in sight, you are then free to manouvre the aircraft as you see fit whether it be day or night, no such thing as you must maintain msa until the circling area etc etc. Certainly no CTA steps to contend with. The crew in this instance totally screwed the pooch, and it is not good to admit that some pilots flying these aircraft are not capable of flying a managed NPA but in reality we are seeing increasing evidence of that. OZ is a uniquely challenging environment for foreign crews, the sad part is that it isn't due to weather, terrain or any other environmental issues, it is down to the crap rules, procedures and lack of proper infrastructure.
When I first joined a longhaul fleet for a major legacy carrier in Europe I asked a Captain what his favorite and least favorite trips were. Without hesitation he said Australia for both. Favourite because it is a cracking country to visit, least favourite because of the Aerad (Jepp) differences section, poor ATC and total lack of well equipped airports.
When I first joined a longhaul fleet for a major legacy carrier in Europe I asked a Captain what his favorite and least favorite trips were. Without hesitation he said Australia for both. Favourite because it is a cracking country to visit, least favourite because of the Aerad (Jepp) differences section, poor ATC and total lack of well equipped airports.