ATSB report on very low flying Thai Airways B777 at Melbourne.
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ATSB report on very low flying Thai Airways B777 at Melbourne.
The latest ATSB report is worth reading. It took nearly two years to produce. I recall media reports at the time where residents were startled to literally feel a low flying wide-body barely 500 feet above their houses.
Investigation: AO-2011-086 - Operational non-compliance involving Boeing 777, HS-TKD, 15 km south Melbourne Airport, Vic, 24 July 2011
To have a Thai Airways Boeing 777 so low on final at such a long way out during an attempt at Melbourne runway 34 VOR/DME approach is frightening. This is a basic instrument approach which any general aviation pilot could do without drama. It proves what most professional pilots already suspect and that is just because you fly a bloody great jet transport does not necessarily mean you are a good pilot. The above report included reference to another Thai Airways 777 which flew dangerously low on final while trying to fly the Melbourne 16 NDB. Nothing wrong with the automatics but something seriously amiss with the competency of both captains. Of course, that view does not appear in the official reports by ATSB.
Investigation: AO-2011-086 - Operational non-compliance involving Boeing 777, HS-TKD, 15 km south Melbourne Airport, Vic, 24 July 2011
To have a Thai Airways Boeing 777 so low on final at such a long way out during an attempt at Melbourne runway 34 VOR/DME approach is frightening. This is a basic instrument approach which any general aviation pilot could do without drama. It proves what most professional pilots already suspect and that is just because you fly a bloody great jet transport does not necessarily mean you are a good pilot. The above report included reference to another Thai Airways 777 which flew dangerously low on final while trying to fly the Melbourne 16 NDB. Nothing wrong with the automatics but something seriously amiss with the competency of both captains. Of course, that view does not appear in the official reports by ATSB.
The real question should be! Why does YMML not have ILS approaches on alp runways? Having flown longhaul you can go years without flying a VOR approach except the odd one in the sim. Is that an excuse... No, but surely OZ needs to start playing an active role in SAFETY and do all they can to provide the most robust approach systems at international airports! OOL also springs to mind.
I am not an expert by any means, but........
To borrow a phrase, reading this report reminds me of drowning to death in maple syrup.
Could I be forgiven for thinking that being a Thousand feet below minimum safe altitude for a particular point on an approach over a populated city is effing a critical incident?
To put that in context, the minimum safe altitude was 1950 ft and this genius got down to 984 ft, in other words 1000 ft below where he was supposed to be.
To put that another way, this aircraft was off altitude by FIFTY PERCENT!
...And the ATSB blandly reports:
This is a masterpeice of understatement. Tautological nonsense. "The aircraft was lower than required" - that should have read "The aircraft was lower than commanded because the pilot was unable to comply with the instructions of the tower." , given that the elevation at the point of lowest approach was about 130 ft, this bloke shoved a jet to within 850 feet of a Melbourne residential suburb with no safety action apart from "don't do it again"? Well I suppose the ATSB wouldn't want to be seen as anything like judgemental would it?
God help us all. The ATSB has been completely and utterly neutered.
To borrow a phrase, reading this report reminds me of drowning to death in maple syrup.
Could I be forgiven for thinking that being a Thousand feet below minimum safe altitude for a particular point on an approach over a populated city is effing a critical incident?
To put that in context, the minimum safe altitude was 1950 ft and this genius got down to 984 ft, in other words 1000 ft below where he was supposed to be.
To put that another way, this aircraft was off altitude by FIFTY PERCENT!
...And the ATSB blandly reports:
At 2019 Eastern Standard Time on 24 July 2011, a Thai Airways International
Boeing Company 777-3D7 aircraft, registered HS-TKD, was conducting a runway
34 VOR approach to Melbourne Airport, Victoria. During the approach, the tower
controller observed that the aircraft was lower than required and asked the flight
crew to check their altitude. The tower controller subsequently instructed the crew
to conduct a go-around. However, while the crew did arrest the aircraft’s descent,
there was a delay of about 50 seconds before they initiated the go-around and
commenced a climb to the required altitude.
Boeing Company 777-3D7 aircraft, registered HS-TKD, was conducting a runway
34 VOR approach to Melbourne Airport, Victoria. During the approach, the tower
controller observed that the aircraft was lower than required and asked the flight
crew to check their altitude. The tower controller subsequently instructed the crew
to conduct a go-around. However, while the crew did arrest the aircraft’s descent,
there was a delay of about 50 seconds before they initiated the go-around and
commenced a climb to the required altitude.
God help us all. The ATSB has been completely and utterly neutered.
Last edited by Sunfish; 21st Feb 2013 at 19:16.
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That little rant out of the way, I agree with the call for an ILS installation at every runway serving jet ops. Say what you like about skill levels, tired old guys make mistakes. Non-precision approaches are never as safe as an ILS...and the world is full of craters to prove it.
A major airport without a full suite of precision approaches is like a country with two lane national highways. Oh wait....
A major airport without a full suite of precision approaches is like a country with two lane national highways. Oh wait....
When you live....
Thai
Putting aside precision vs non-precision approaches, it makes you wonder, with the frequency that Thai appear in ATSB reports for non-precision approaches into Melbourne, if thats a statistical blip or symptomatic of thier ability (or otherwise) anywhere in the world with a non-precision approach.
Not sure I'm game to fly Thai based on this and the previous NDB incident onto 16 about 4 years ago.
Not sure I'm game to fly Thai based on this and the previous NDB incident onto 16 about 4 years ago.
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I am not an expert by any means, but........
The report should have read
" Pilot struggles to regain control as Aircraft plunges within metres of school and suburbs, screaming passengers declared that they thought their days were over. ATSB police department have arrested the pilot and charged him with an offence under the plunging aircraft regulation."
Last edited by blackhand; 21st Feb 2013 at 20:51.
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Repeated incidents like this will see you get banned from operating in some countries, that is countries that take safety seriously. And it must be said Tids that if a safety agency has a list of these incidents on file & god forbid, 'you know what' happens. Maybe this is what's going to have to happen to get rid of these idiot, PC, incompent authorities?
Diverging:-)
Whilst such events as this one is of concern I am of the belief that humans are their worst own enemies when it comes to automation.
Mankind invented the lighter than air machine, essentially the aeroplane many many years ago now & has improved out of sight it's capabilities from the days where Wilbur & Orville stood there on Kill-Devil hills with a machine in it's infancy but mankind himself has not evolved one inch in some ways.
Sure we have advanced training via Sims etc, higher education abilities thru knowledge gained over the years & multiple bad mistakes in which to learn from but still we humans take a perfectly serviceable plane complete with hapless pax straight into the side of a hill!
Even though the human has almost been taken out of the equation here in the way of automation (pilot-less planes are already here & technically we are not really needed up at the pointy end other than redundancy) we still do what humans do best, make mistakes. You can make 100 airframes identical to perform exactly the same way every time but you will NOT make a 100 pilots do likewise, there in lies the "oil & water" interface that will never be bred or automated out.
Checklists, training, Psycho testing crap at interview level all the stuff that's meant to make the human the best he can amounts to little at the end of the day, the above 'process' weeds out a few but that's all.
CRM is a modern day "feel good" terminology & it's an industry in itself but whether it's making or going to make a noticeable impact on why humans make mistakes is arguable I believe. Back before they invented the hairy fairy CRM thingy Capt's of flying machines when faced with adversary would have enlisted the help of everything & everyone so save if nothing else his own butt so CRM has essentially been around well before it was dreamed up!
Australia has some pretty ordinary recorded events from our own pilots so Thia are not the only Airline under question here I believe.
The case in question here the 777 event is the perfect Eg of humans in action when man & machine are interfaced. The weather was fine, the crew where trained (well meant to be) the machine was one of the finest available but the human was/is the weakest link in the chain of events here as in any incident/accident.
I know I've looked back on some silly things I've done (especially in the Sim) & wondered why the hell did I do that when I know better?
The human mind, we know very little about it which shows every now & then & not just thru aviation either:-)
We can improve, we can be seen to be doing the right thing to reduce but we simply have to accept that incidents such as this one will continue to happen as long as mankind has the desire to fly:-)
Just some food for thought not meant to be anything else here:-)
Wmk2
Wmk2
Mankind invented the lighter than air machine, essentially the aeroplane many many years ago now & has improved out of sight it's capabilities from the days where Wilbur & Orville stood there on Kill-Devil hills with a machine in it's infancy but mankind himself has not evolved one inch in some ways.
Sure we have advanced training via Sims etc, higher education abilities thru knowledge gained over the years & multiple bad mistakes in which to learn from but still we humans take a perfectly serviceable plane complete with hapless pax straight into the side of a hill!
Even though the human has almost been taken out of the equation here in the way of automation (pilot-less planes are already here & technically we are not really needed up at the pointy end other than redundancy) we still do what humans do best, make mistakes. You can make 100 airframes identical to perform exactly the same way every time but you will NOT make a 100 pilots do likewise, there in lies the "oil & water" interface that will never be bred or automated out.
Checklists, training, Psycho testing crap at interview level all the stuff that's meant to make the human the best he can amounts to little at the end of the day, the above 'process' weeds out a few but that's all.
CRM is a modern day "feel good" terminology & it's an industry in itself but whether it's making or going to make a noticeable impact on why humans make mistakes is arguable I believe. Back before they invented the hairy fairy CRM thingy Capt's of flying machines when faced with adversary would have enlisted the help of everything & everyone so save if nothing else his own butt so CRM has essentially been around well before it was dreamed up!
Australia has some pretty ordinary recorded events from our own pilots so Thia are not the only Airline under question here I believe.
The case in question here the 777 event is the perfect Eg of humans in action when man & machine are interfaced. The weather was fine, the crew where trained (well meant to be) the machine was one of the finest available but the human was/is the weakest link in the chain of events here as in any incident/accident.
I know I've looked back on some silly things I've done (especially in the Sim) & wondered why the hell did I do that when I know better?
The human mind, we know very little about it which shows every now & then & not just thru aviation either:-)
We can improve, we can be seen to be doing the right thing to reduce but we simply have to accept that incidents such as this one will continue to happen as long as mankind has the desire to fly:-)
Just some food for thought not meant to be anything else here:-)
Wmk2
Wmk2
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I will abide by Tids request, however it is very difficult not to mention government agencies when it appears they themselves could be part of the problem or be a contributing factor. And what I mean by that is areas such as airspace, ground infrastructure, authority oversight, procedures, regulations and investigations are just a couple of those points.
Be that as it may, back to the airline in question...
Be that as it may, back to the airline in question...
Once again, the ATSB raises more questions than it answers. But you have to wonder that if it takes 18 months to issue a relatively straight forward report - how long does it take for a complex one.
The ATSB are pretty good at using units of measurement that confuse rather than illuminate. For instance, 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.
The ATSB are also a bit prone to using emotive language / distortion. I'm not sure that the delay to go-around was quite as it was represented. And of course there is no transcript of radio calls which once again denies independent review. Another favorite ATSB trick. Other international agencies not only publish the relevant transcript, but also publish any corrections - including those requested by the participants after they were given the opportunity to review it. Another thing the ATSB doesn't seem to do.
The aeroplane was too low. There is no getting around that and the captain did admit that, but a point missed by Sunfish and glossed over by the ATSB is that they were cleared for visual approach. The controllers comments of confirming that the aircraft was low by visual identification confirms that the conditions were visual. Others will 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. On that basis the pilot was guilty of poor airmanship, but not of breaching the approach procedure. It is entirely likely at the time of the instruction to go around, the aircraft was back on glideslope. According to the pilots description (confirmed by the ATSB report) he an initiated recovery before the ATC alert.
The ATSB listing of the sequence of events is not fully clear, but I would question whether the aircraft was as far below the glideslope as suggested. The report lists the minimum altitude that the aircraft reached, but is not clear where this was relative to the glideslope. It was inside the 6.5nm point at its lowest, so the comparison of 984 ft to 1950 ft is not valid. If the ATSB used distance from the aid rather than time, we could have a go at working it out. The MDA inside 6.5 mile is 760 ft, so the aircraft was ABOVE the published minima. Once again, the pilot was guilty of poor airmanship, but not necessarily in breach of the procedure.
It will require some work to try and reconstruct, but I suspect that the most serious breach may have been while the aircraft was flying the 11 DME arc and under ATC direction (ie before it was cleared for approach). 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 (and its easier to say it was the pilots fault exclusively).
The big question - which has already been raised - is why we don't have ILS on all runways. The crew was from Thailand. They may not be used to operating in third world countries like Australia that do not have the funds to invest in basic safety infrastructure. Has anyone noticed that the YWE VOR is still U/S? Together with the procedure having been removed from CWS - exactly where does one train for VOR approaches in Melbourne at the moment?
The other question I have is whether the controller should be expected to pick up a diversion from glideslope before it becomes such a large incident? Should the pilot expect a warning before being "waved off"the approach? This is a genuine question for the ATC among us and not a barbed comment.
The ATSB are pretty good at using units of measurement that confuse rather than illuminate. For instance, 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.
The ATSB are also a bit prone to using emotive language / distortion. I'm not sure that the delay to go-around was quite as it was represented. And of course there is no transcript of radio calls which once again denies independent review. Another favorite ATSB trick. Other international agencies not only publish the relevant transcript, but also publish any corrections - including those requested by the participants after they were given the opportunity to review it. Another thing the ATSB doesn't seem to do.
The aeroplane was too low. There is no getting around that and the captain did admit that, but a point missed by Sunfish and glossed over by the ATSB is that they were cleared for visual approach. The controllers comments of confirming that the aircraft was low by visual identification confirms that the conditions were visual. Others will 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. On that basis the pilot was guilty of poor airmanship, but not of breaching the approach procedure. It is entirely likely at the time of the instruction to go around, the aircraft was back on glideslope. According to the pilots description (confirmed by the ATSB report) he an initiated recovery before the ATC alert.
The ATSB listing of the sequence of events is not fully clear, but I would question whether the aircraft was as far below the glideslope as suggested. The report lists the minimum altitude that the aircraft reached, but is not clear where this was relative to the glideslope. It was inside the 6.5nm point at its lowest, so the comparison of 984 ft to 1950 ft is not valid. If the ATSB used distance from the aid rather than time, we could have a go at working it out. The MDA inside 6.5 mile is 760 ft, so the aircraft was ABOVE the published minima. Once again, the pilot was guilty of poor airmanship, but not necessarily in breach of the procedure.
It will require some work to try and reconstruct, but I suspect that the most serious breach may have been while the aircraft was flying the 11 DME arc and under ATC direction (ie before it was cleared for approach). 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 (and its easier to say it was the pilots fault exclusively).
The big question - which has already been raised - is why we don't have ILS on all runways. The crew was from Thailand. They may not be used to operating in third world countries like Australia that do not have the funds to invest in basic safety infrastructure. Has anyone noticed that the YWE VOR is still U/S? Together with the procedure having been removed from CWS - exactly where does one train for VOR approaches in Melbourne at the moment?
The other question I have is whether the controller should be expected to pick up a diversion from glideslope before it becomes such a large incident? Should the pilot expect a warning before being "waved off"the approach? This is a genuine question for the ATC among us and not a barbed comment.
Wondering where the pilot derived the 970' which was set in the MCP?
It's not a number which would make sense under my SoPs, does anyone know how it may have been calculated?
It's not a number which would make sense under my SoPs, does anyone know how it may have been calculated?
And 50 seconds to action the go around instruction. That alone should have them denied access to to Australian airports.
In the body copy (not under the go-around sun head) its pretty clear that the pilot initially mis-understood the ATC instruction. At the time of the go-around instruction the aircraft had recovered altitude and was probably at glideslope (hard to tell the way the ATSB present data). I think the ATSB claim of 50 seconds delay is mischievous. I suspect they have taken the time from the ATC first keying the mic to a response in altitude change (ie including engine spool-up time). The report states that the controller issues a second instruction after 35 sec. If it was so critical, why did the controller wait 35 sec for a second call? I question if the pilot heard the first call as an altitude warning and only acted on the second call. If we had a transcript, we could make our own judgements, but we do not. The Mojave Bankstown ATSB report has discrepancies between the draft and final reports which raises questions about whether the ATSB change transcripts to suit the report.
If the second call was the only one the pilot heard as an instruction, then his response time was under 15 seconds, which doesn't deserve the vitriol of the ATSB report.
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The handling of the approach sounds incompetent, but what part of the 'Go Around' instruction did they not understand,that it took 50 secs to comply.
Last edited by sheppey; 21st Feb 2013 at 23:56.
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Akro, in Australia an ATC is guilty until proven innocent & when the ATC is found innocent he is still guilty.
If an ATC sees something that 'doesn't seem right' regardless of whether a pilot is doing the right thing/wrong thing they are obliged to check.
If an ATC sees something that 'doesn't seem right' regardless of whether a pilot is doing the right thing/wrong thing they are obliged to check.
Wondering where the pilot derived the 970' which was set in the MCP?
The minimum descent altitude (MDA) for the approach was 760 ft. However, a Notice to Airmen (NOTAM) current at the time raised the MDA to 920 ft because of crane operations beneath the approach path. The operator advised that ‘the pilots added approximately 50 feet to the MDA due to [a] CANPA [constant angle non-precision approach] requirement’.
ATC, its workload, clarity and wording of the call are all absent from the report. Thailand uses 5 letter registrations (like Australia). Were there any aircraft in the Melb TCA with similar sounding 3 letter call signs? Did the mic clip one of the call sign letters which led to confusion on the part of the captain?
These are valid issues that may or may not have contributed that the ATSB should have considered, but are absent from the report.
With the lack of clarity of the ATSB report, I'm prepared to give the pilot some benefit of the doubt and argue that his response time may have been 15 seconds, not the 50 seconds that is emotively used in the ATSB report.
If there was any hint of confusion about the calls, then both sides of the coin need to be examined, not just the PIC.
I think that it is indefensible that the ATSB do not append transcripts to their reports as is common in other countries.
I think this is a case study of another sub standard ATSB report.
These are valid issues that may or may not have contributed that the ATSB should have considered, but are absent from the report.
With the lack of clarity of the ATSB report, I'm prepared to give the pilot some benefit of the doubt and argue that his response time may have been 15 seconds, not the 50 seconds that is emotively used in the ATSB report.
If there was any hint of confusion about the calls, then both sides of the coin need to be examined, not just the PIC.
I think that it is indefensible that the ATSB do not append transcripts to their reports as is common in other countries.
I think this is a case study of another sub standard ATSB report.