Virgin Australia Boeing 777 dirty dive at Melbourne 34

[Keg]

If approaches from SHEED were tripping the various QAR parameters then I suspect something would be done about it. The reality is that for most people that fly the visual from SHEED, it's a non event.

I've seen a couple of guys leave the automatics in after SHEED and disconnect when aligned with final. Have to say I'm not a big fan of it. Much prefer to disconnect and do it myself.

[judge.oversteer]

Huh?
What's the difference with this approach and the JFK 13L Canarsie approach? How on earth did we ever get on with the 13 IGS at Kai Tak??
Have to agree with you Keg.
JO.

[Centaurus]

How on earth did we ever get on with the 13 IGS at Kai Tak??
Have to agree with you Keg.

Actually that is a pertinent point. Having flown the Kai Tak 13 IGS approach many times in another life, it was nowhere as difficult as I was led to believe.
With a modicum of basic jet handling skills it was most enjoyable to hand fly the approach and gave one a great sense of satisfaction to complete the turn on to final without S turning.

I don't envy todays pilots where it seems to me they are forced into hanging on to the automatics to satisfy their company standard operating procedures. Then when they go click click and fly by hand because they enjoy flying the aeroplane rather than continue with button pushing until the last few hundred feet, they run the risk of tea and bikkies because big brother QAR is waiting to catch you.

It should be a seamless transition from automatic flight to manual flight providing the pilot has the confidence in his own ability to do so without scaring people

No one is saying after a long flight you should disengage the automatics at 15,000 ft just to get hand flying skills up. Time and time again we see sarcastic remarks on Pprune pages when someone dares to suggest they enjoy the pleasure and personal satisfaction of flying by hand.

What has happened in the last 30 years since automation became increasingly reliable and sophisticated, is that there are airline pilots secretly apprehensive of switching over from automatic flight to manual flight paths because they have got rusty and don't want to look a fool in front of the other pilot. They then rationalise by mumbling that autopilot flying is smoother and safer. And of course it is under certain circumstances.

A recent analysis of flight operations data (including normal flight operations, incidents, and accidents) identified an increase in manual handling errors. The Federal Aviation Administration (FAA) believes maintaining and improving the knowledge and skills for manual flight operations is necessary for safe flight operations

There are even Australian regional airlines mandating full use of automation from barely airborne to short final. And that is in CAVOK No wonder this breeds a pilot totally dependant on his automatic pilot and flight director. The cadet system does just that.

Apologies for thread drift.

[Keg]

Tony Kern made an interesting point at a safety seminar I was lucky enough to attend once.

He compared airline flying to target shooting and suggested that to be an airline pilot you need to be able to 'shoot' about an 84. He said if you consistently shot 85 but never higher than an 88 you may think you're ticking all the boxes…… until that one day where if you don't shoot a 93+, you're going to die in a plane wreck. If you've never tried to shoot 93+ previously, what are your chances of doing it when you suddenly need to?

From that day on I resolved to do as much hand flying and be as accurate as possible all the time when the conditions permitted. Sometimes that means that I'm auto coupled to 100' (or lower). Other times I'm disconnecting at FL150. Sometimes it means in the sim hand flying a 100m vis approach once the rest of the session is completed or engaging in various other things designed to improve my scan, handling ability, etc.

We've taken the love of automation WAY too far. Don't get me wrong, it's a great tool in the arsenal but if we neglect our own stick and rudder skills then the day we need THAT tool to survive we're not going to be able to use it properly.

[donkey123]

Funny thing is, you would expect the guys that chuck the automatics in at 500' and take them out at similar altitude the other end to be fairly 'current' when it comes to managing the automatics versus the guy that regularly hand flys to transition and on approach (when conditions permit).

In my experience that's not really case. I haven't flown the Victor approach to 34 for a couple of years, but in my observations the guys that regularly relied on the automatics were the same ones who started playing piano on the MCP once passed Sheed then quickly disconnected and battled with the machine all the way to touchdown. This is usually followed by some statement about that "bloody vnav" on the taxi in.

So it's a double edged sword, the guys that don't regularly practice hand flying seem to be the same guys that have to disconnect (unplanned) and hand fly after mismanaging the automatics on approach.

I guess it's kinda what keg was just saying, you need that currency one day when it all goes wrong.

[Anthill]

RWY 13 IGS was a fairly easy approach to fly: a LOC and G/S to take you to a pre-determined point at 700' and then SFL to guide you to a 60m wide RWY that had PAPI on both sides and an abundance of approach lights. I thank that the hype came from the fact that the approach meant operation in close proximity to buildings and a lot of journalistic beat-up in the travel press. The IGS was similar to the approach into NVVV. AS a further comparison, the similar IGS into Macau is tighter and less forgiving if you aren't tracking properly. Closer to home, I've seen more people stuff a visual approach to a 5nm final on RWY 16 at YMML than I have the RWY13 IGS.

The appropriate use of automatics as a risk mitigation tool is what is important. Why hand fly at FL370 when it is safer to use the autopilot? It's nice to hand fly an approach, but if you are tired and there are parallel RWY operations, isn't it safer to intercept the LOC with A/P?

During my career, I have flown SHEED in B737, B747, B767 and B777 aircraft. I've never had an issue with it. As for this particular incident, why there is so much discussion? So, what are the facts? A crew flew the approach with A/P connected, VNAV apparently commanded a higher rate of descent than the crew were happy with, the A/P was disconnected and the aeroplane landed safely without any stability parameters requiring a go-around being broken. The crew then self-reported a perceived safety issue.

Big Deal.

[waren9]

dead right mr anthill

still, its not yet got to 93 posts like the bne taxiway thread.

thats aussie aviation for ya tho'. an severe obsession with the trivial

[A37575]

why there is so much discussion? So, what are the facts?

Facts as read from ATSB:

after passing waypoint SHEED,4 the final waypoint in the STAR, the autopilot increased the rate of descent from about 700 feet per minute (fpm) to about 1,500 fpm. This was a greater rate than the crew were expecting. They discussed the anomalous descent and, expecting it to stabilise at the anticipated rate, they decided to monitor the aircraft’s rate of descent further.

Noting that the captain was concentrating on the information presented on the aircraft’s instruments, the first officer turned his attention outside of the cockpit to visually monitor the approach to the runway, which he had sighted to the right of the aircraft. The first officer noted that the approach to the runway visually appeared to be too low and alerted the captain, who agreed and attempted to reduce the rate of descent using the vertical speed mode of the automatic flight control system. After realising that this would not be effective, the captain disconnected the autopilot and took manual control of the aircraft. The aircraft was levelled off at about 700 ft above mean sea level (AMSL), or about 500 ft above ground level, and turned to the right to align with the runway.

The aircraft was flown level until the 3° approach glideslope was intercepted using the runway 34 precision approach path indicator (PAPI) and a normal approach and landing carried out.

No big deal someone remarked? Scarping in level flight at 500 ft agl until intercepting a three degree approach angle, isn't exactly a normal standard procedure for a wide-body is it?

thats aussie aviation for ya tho'. an severe obsession with the trivial

500 ft agl - that's trivial??

[Anthill]

Stabilisation height criteria for such an approach is 500' AAL. No stabilisation rules were broken. The crew put in a report.

So..??!

[hoss]

Intercepting PAPI from beneath, on a level segment, on the SHEED arrival.....priceless.

Might of ticked the boxes but I bet it was ugly!

[Lookleft]

Stabilisation height criteria for such an approach is 500' AAL. No stabilisation rules were broken. The crew put in a report.

I think even VA stabilized approach criteria might make reference to being on the correct approach path! Turning onto final on that approach you should be at least 1500'. Must have been interesting driving up the Calder that day to see a 777 fill your windscreen!

[spelling_nazi]

Originally Posted by Derfred

If you find yourself exceeding 2000 fpm after Sheed then I think a little chat with someone probably IS in order.

Not at all, the initial pitch over to regain path often demands a tad over 2000fpm . Only for a second or two but hardly unsafe

[Capn Bloggs]

Originally Posted by Lookleft

Stabilisation height criteria for such an approach is 500' AAL. No stabilisation rules were broken. The crew put in a report.

I think even VA stabilized approach criteria might make reference to being on the correct approach path!

So what is the point/altitude that you must be on-slope?

[Lookleft]

Turning final would be an appropriate place on an approach like that. You do bring up a good point though, if it is difficult to determine from the approach where the aircraft should be stabilized then the approach is flawed and should be replaced with one where it is possible to determine if you are going to meet the stabilized approach criteria. An RNP approach would take care of it (as long as it is not designed by ASA).

[Sarcs]

Three cheers to the VA crew job well done!

Given this incident has now led to two dedicated threads (Operational non-compliance involving a Boeing 777,VH-VPH, near Melbourne Airport)and numerous references in many others, I think full credit should be given to the crew for properly reporting this incident to the ATSB.

Here is the bare bones summary of the VA crew initial report (as listed in the ATSB weekly summary):

During the approach, the autopilot commanded a high rate of descent. The crew disconnected the autopilot and manually continued the approach. The investigation is continuing.

And here is where the ATSB investigation currently is at: AO-2013-130

The healthy debate that has so far occurred in both threads dealing with this incident just goes to show the value of learning from such occurrences when they are properly reported and in this case investigated.

Although the crew in this incident appear to have appropriately recovered the situation (automated dirty dive that could have had dire consequences otherwise ) there have been several recent incidents/accidents where the outcome, to say the least, has been less desirable.

sheppey mentions one of them:

Perhaps VA management and also ATSB could learn something useful about automation dependency by attending the USA conference on the Asiana 777 accident. See below.

NTSB Announces Investigative Hearing on Asiana Flight 214
Note: I would also suggest that there are a lot more stakeholders (other than VA management & the ATSB) that would benefit from attending the NTSB conference.

sheppey’s comment also highlights one of the chestnut safety issues that is troubling the worldwide aviation community and is being proactively tackled by the likes of the NTSB and the Flight Safety Foundation.

A bit of google research on the subject of Asiana Flight 214 and automation dependency brings up some interesting articles/references but surprisingly one of the most informative comes from a group of investigative journalists called the NBC Bay Area Investigative Unit: AnAutomation Trap for Pilots?

There is also another side effect of automation dependency and that is sudden and unexpected a/p disconnection (which amongst other things has got experts rethinking cockpit design):

Redesign for Sudden Autopilot Disconnection Needed, Say Flight Safety Experts

Flight safety experts studying recent high-profile plane crashes found sudden autopilot disconnection to be a design flaw that creates unnecessary emergencies by surprising pilots during critical, high-workload episodes.

"The sudden disengagement of autopilot is analogous to a pilot suddenly throwing up his or her hands and blurting to the copilot, 'Your Plane!'" says Eric E. Geiselman, lead author of a recently published two-article Ergonomics in Design series, "Flight Deck Automation: Invaluable Collaborator or Insidious Enabler" (July issue) and "A Call for Context-Aware Logic to Improve Safety" (October issue).

Eric E. Geiselman, along with coauthors Christopher M. Johnson, David R. Buck, and Timothy Patrick, have combined expertise as pilots, crew resource management instructors, and human factors researchers. They studied the 2009 Colgan Air crash in Buffalo, New York, and the 2009 Air France crash off the coast of Brazil with a focus on how humans and machines can best communicate on the flight deck.

The authors recommend that autopilot systems transfer controls following the same protocols crew members use -- with acknowledgment by the receiving pilot that he or she has assumed control. FAA regulations require a visual and auditory warning to occur following autopilot shutoff, but Geiselman et al. emphasize that such warning should occur before -- not after -- autopilot is disengaged.

Geiselman et al. report on many other design-level safety issues in these articles and offer prototypes featuring solutions that can be affordably implemented with available technology. They believe better design of automation technology on planes can prevent future accidents and that more pilot training shouldn't be the only solution pursued by the industry.

The other safety issue chestnut, that the VA 777 incident appears to be invoking debate on, is the parameters of a stabilised approach and when to initiate a go around. In light of Asiana Flight 214,amongst other similar incidents/accidents in recent years, the Flight Safety Foundation took the initiative to investigate what is regarded as the leading causal factor for runway excursions i.e. unstable approaches. The following is a FSF article on the subject which should help to liven up the debate: Failure to Mitigate

And a quote from that article to (hopefully) kick off some robust comments :

Example of a Go-Around Experience

1. At a point immediately above SAH, the pilot’s “gut,” or what we refer to as affective awareness, subtly signals him or her to confirm that the aircraft’s flight characteristics and profile are normal. In a near-instantaneous and seamless fashion, this might be followed by

2. A visual check, or what we refer to as a check to provide functional awareness, which would be made where the pilot’s expert knowledge and ability to understand the instruments plays a key role in confirming whether the cue from their gut was, in fact, correct. Simultaneously, there is …

3. An immediate and confirmatory statement from the pilot’s network of past experiences, or critical awareness, occurs, in which professional experience confirms the presence of a “normal” flight profile. Seconds later, however, imagine that in continuing its descent below SAH, the aircraft encounters significant turbulence with headwinds shifting to tailwinds and downdrafts altering VREF (reference landing speed) by +21 kt, accompanied by a vertical descent now greater than 1,100 fpm. Instantly, …

4. The pilot’s anticipatory awareness, the ability to see these threats, registers in harmony with the reactivated gut, expert instrument knowledge and experience — all awarenesses that are now signaling a non-normal event — and there arises an immediate need for a signal from...

5. Task-empirical awareness, the pilot’s expert knowledge of the safe operational envelope limits of the aircraft. Imagine further that this expert knowledge confirms that although the aircraft is now unstable, it still remains within the safe operational envelope. However, before concluding that parameters are now safe or unsafe, manageable or unmanageable, this developing event requires immediate input from another awareness competency …

6. Compensatory awareness, or the ability to understand how to compensate correctly for non-normal events, occurs by referencing through functional awareness whether the aircraft and the instruments will direct the flight state back to a normal condition if acted upon. Whether the answer, not yet fully formed but informed by critical awareness, is likely to be “yes,” “no” or uncertain, imagine that the pilot is also simultaneously receiving …

7. Through relational awareness — the pilots’ knowledge of how they use their relationships to protect safety — input from a crewmember that re-enlivens a memory trace of a prior verbal signal, based on a conversation and agreement earlier in the approach initiated by the pilot monitoring, that a go-around might be necessary should the aircraft become unstable at or below SAH, which …

8. Informs and motivates the pilot to engage hierarchical awareness, or the individual’s expert knowledge of operational procedures under specific operational conditions, so as to confirm their ability to safely fly a go-around if necessary. Finally, with the pilot-in-command and other crew rapidly coming to a common assessment of, and agreement about, the risks inherent in continuing with the unstable situation that faces them, in comparison with the inherent risks of any go-around maneuver, and...

9. Confident that their company would support a decision to initiate a go-around, and in an expression of their environmental awareness concerning the wider organizational reward structures surrounding support for safety, the pilot flying puts all of these elements of awareness together to judge that the risks confronting the flight crew are not fully manageable, and so decides to call for a go-around.

Some more articles from FSF on this safety issue: The Rare Go-Around & Why Do We Forgo the Go-Around?

Fill your boots...and IMO three cheers to the VA crew!

[A37575]

Informs and motivates the pilot to engage hierarchical awareness, or the individual’s expert knowledge of operational procedures under specific operational conditions]

A thoughtful and most pertinent observation. That said, and I agree with the post, I often wonder if the 250 hour overseas cadet pilots now commonly occupying the second in command position in the 737, 777, A330 and other jet transports can possibly have all those attributes listed. After all, those qualifications only come with been there-done that, experience.

[Berealgetreal]

That approach is fun on a clear day when well fed and rested. In other circumstances it can be a handful.

[Potsie Weber]

The latent failure in this incident was the SOP of the company to change the RW34 altitude to 380'. It is as simple as that. This was the root cause of the incident.

Who the hell derived an SOP to complicate a quite simple visual maneuver by adding 50' to the RW34 waypoint in the FMC to produce a more accurate VNAV path for a "VISUAL" procedure?

On a visual procedure do you really need to have an accurate VNAV path to within 50' over the threshold?

How this SOP to alter the FMC altitude was derived, approved and implemented by flight ops management is what needs investigating.

This incident has very little to do with the operating crew.

The crew were following utterly ridiculous policy and resultingly made a simple error by putting the 380' at the runway extension waypoint instead of the threshold. An obvious potential threat with such a flawed and unnecessary SOP.

To me this potentially indicates an immature organisational structure within flight operations management where policy is implemented with little understanding or review of the potential adverse outcomes of seemingly innocuous standard operating procedures implementation.

[UnderneathTheRadar]

C'mon Potsie - tell us what you really think.... :-)

[maui]

Potsie

If this is an SOP, it must be published somewhere. It would be helpful if you could advise where such publication lurks, cos I am stuffed if I have seen it.

If it is not published in a controlled document, it is not an SOP. On that basis "caveat emptor" would be appropriate.

This is a relatively straight forward VISUAL procedure. The STAR finishes at SHEED and the charts used by this crew indicate a visual segment from that point. Why o why do we continue to complicate our job by fiddling with boxes, when a good old mk 1 eyeball is what is required.

In days of old, (before it was called SHEED and before 250 below 10) this approach was regularly flown at up to 300 clean at the 26 EN threshold, then stabilised at 500. And that is before we had glass and stabilised criteria. It was even done by F/O's and graduate cadets, (horror).

That is not to suggest that we can indulge in that style of operation in today's environment, nor should we. It does however suggest that this approach is not overly difficult for a crew that is on top of their game.

If the weather is crappy, don't do the SHEED, it's a VISUAL approach. If you are tired and not feeling up to it, don't do the SHEED, have ago at one of the less stressful options. If you choose to do SHEED (if your company will let you), don't complicate it with unecessary procedures, and above all look out the friggin window, it's a visual approach.
If you think it is beyond you when well rested and in visual conditions, look for another line of work. It aint rocket science!

These comments are not directed at the crew of this particular flight as I have little knowledge of who what when or why. These comments are directed at the mish mash of pious drivel appearing in the thread, many of whose contributors clearly have issues, real or imagined.

Feels better

M