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Our Airline (Nauru) seriously close shave during NDB approach

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Our Airline (Nauru) seriously close shave during NDB approach

Old 16th Mar 2018, 13:22
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Our Airline (Nauru) seriously close shave during NDB approach

https://www.atsb.gov.au/publications...r/ao-2015-066/
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Old 16th Mar 2018, 22:10
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Nearly wasn’t “ Their Airliner “ anymore if they had of slipped through one or two more cheese slices
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Old 16th Mar 2018, 22:40
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interesting to see the PIC was experiencing fatigue, yet there does not appear too much in the recommendations to improve the situation.

It appears that this is a problem throughout the world, ICAO have recently made FRM a requirement, yet many operators pay lip service to this. Crew in many operations are reluctant to call fatigued as they may be penalised by the company, loss of pay/sick days. The pilot body worldwide , IFALPA (?), really needs to start doing something about this, fatigue has caused many accidents and has the potential to cause many more.
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Old 17th Mar 2018, 12:10
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This occurrence highlights the importance of flight crews declaring any instances of acute fatigue and stress-inducing circumstances that may have an impact on their flying performance. Operators also need to remind flight crew of the importance of their decisions with regards to their fitness to fly.
A typical management style approach highlighting the fatigue onus being on the flight crew member (who is in the most difficult position to identify their level of fatigue) without any mention of work schedules/rostering/work practices which can contribute to said fatigue. It really is a joint responsibility but these days it seems crew are out on a limb all on their own these days when it comes to managing the 'f' word...
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Old 18th Mar 2018, 06:02
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Fatigue is an issue most airlines are reluctant to address. You have to look no further than the intense lobbying of a weak regulator by just about every operator in this country!

Then there’s the destination. Served only by a 1930’s era instrument approach! I mean is it such a stretch for a potential new carrier to insist on a minimum level of navaids? Or do they risk the entire operation because of an unacceptable number of holes in the cheese?

These are by no means isolated circumstances. One day when the unthinkable happens, will the investigation trace the real cause back to the source? Somehow I doubt it.
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Old 18th Mar 2018, 12:59
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https://www.avherald.com/h?article=495d5883&opt=0


More discussion from avherald.com
Much to learn from this incident. The DME was at the airport and if the crew had constantly checked DME versus altitude (320 feet of altitude for every one nm) from 10 miles out it would have been obvious that the stepped down profile as depicted on the chart was going to put the aircraft extremely low over the sea and at night. Commercial pressures would not have helped, either.
The ATSB report stated: "From the time the captain set the thrust toTOGA until the aircraft was stabilised on the missed approach path (at about 0905), the recorded aircraft pitch angle varied from -0.35° to +16°.
That is a significant pitch change, with the aircraft attitude at one stage below the horizon and within seconds of hitting the sea. This suggests the PF was probably chasing flight director indications and over-controlling while doing so.


If there is one thing positive to be learned from this incident, it is this: CASA must seriously consider including a lot more emphasis on manual raw data instrument flying competency during re-currency training and for each IPC. Otherwise, history will inevitably repeat itself.

Last edited by Judd; 18th Mar 2018 at 13:52.
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Old 18th Mar 2018, 17:00
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Only a matter of time for these porch monkeys flying old 737-300s out in the middle of the pacific not a place for this type aircraft, limited fuel two baby engines, limited or no alternate ( Island alternate fuel for holding to hope for the best ) it will not end well.
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Old 18th Mar 2018, 17:21
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Originally Posted by 4 Holer View Post
Only a matter of time for these porch monkeys flying old 737-300s out in the middle of the pacific not a place for this type aircraft, limited fuel two baby engines, limited or no alternate ( Island alternate fuel for holding to hope for the best ) it will not end well.
So, what is a "porch monkey" and how have you determined that the pilots were, in fact, "porch monkeys"?
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Old 18th Mar 2018, 17:36
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Originally Posted by Judd View Post
The DME was at the airport and if the crew had constantly checked DME versus altitude (320 feet of altitude for every one nm) from 10 miles out it would have been obvious that the stepped down profile as depicted on the chart was going to put the aircraft extremely low over the sea and at night.

My read of the report suggests (to me at least) that they had intentionally descended to the MDA as soon as possible (Vs a Continuous Descent Approach) If so, cross checking the distance and altitude wouldn't have proven anything because they knew they were below a CDA descent path.
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Old 18th Mar 2018, 20:34
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Originally Posted by A Squared View Post
My read of the report suggests (to me at least) that they had intentionally descended to the MDA as soon as possible (Vs a Continuous Descent Approach) If so, cross checking the distance and altitude wouldn't have proven anything because they knew they were below a CDA descent path.
I wonder what the Radio Altimeter was indicating ........ ?

Last edited by JPJP; 18th Mar 2018 at 20:47.
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Old 18th Mar 2018, 20:46
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Originally Posted by JPJP View Post
I wonder what the Radar Altimeter was indicating ........ ?
The report seems to indicate that the radar altimeter was reading anywhere from 130-140 ft lower than the barometric altimeter. It mentions them levelling off at 500 ft indicated with the Radalt indicating 368 ft, then later:
At 0903:19, the aircraft was at 4.31 DME, 480 ft indicated altitude and 340 ft radio altitude
and

The flight data recorder data showed that TOGA was
selected at 0903:47, at 448 ft indicated altitude, or 304 ft radio altitude (see Figure 3), and the aircraft was about 3.5 NM from the DME.
and

The aircraft was then at 384 ft indicated altitude, or 244 ft radio altitude
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Old 18th Mar 2018, 20:53
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3.5 miles from the DME on the field, at 300’ AGL. Shudder.
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Old 18th Mar 2018, 21:39
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I heard that the altimeters were never set to
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Old 18th Mar 2018, 21:43
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Sorry.Never set to QNH.This explains the very low radio altitude at times.If you have a look at flight safety site SKYBRARY.AERO you will find a section on go-around safety.Not only was the actual approach poorly flown, but the following G/A has many of the errors mentioned at Skybrary.This is a huge problem area in my opinion as an instructor.The all engines operating G/A is something that must get more practice during simulator training, not just the usual engine out exercise.
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Old 18th Mar 2018, 22:09
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4 Holer = NL - and he has an axe to grind.
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Old 18th Mar 2018, 22:18
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The all engine go around is far more likely to be faced (than the OEI GA) and due to the general lack of currency on it, far more likely to be stuffed up.
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Old 18th Mar 2018, 22:24
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Originally Posted by piratepete View Post
I heard that the altimeters were never set to QNH.
Yes, that's one of the facts from the report. They did not set altimeters to QNH descending through the transition level.
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Old 18th Mar 2018, 23:04
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Surely a latent threat (along with many others) here is that the transition altitude in this airspace is so ridiculously low. They passed over the NDB at 5000ft which meant they needed to set the altimeters moments before station passage. I imagine this would be the same for many non precision approaches which often start up around 5000ft.
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Old 19th Mar 2018, 00:18
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Surely one of the descent/approach/landing checklist items is "altimeters".The fact that this action was missed indicates some kind of serious issue in the cockpit, perhaps stress or fatigue, could be anything.My other observation would be to ask why pilots in this current age are still flying a dive and drive method.
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Old 19th Mar 2018, 01:08
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Only a matter of time for these porch monkeys flying in the middle of the pacific not a place for this type aircraft, limited fuel two baby engines, limited or no alternate ( Island alternate fuel for holding to hope for the best ) it will not end well.

Oh I don't know about that. That operator has been flying the 737-200 and now the 737 Classics all over the Western, Central and South Pacific since 1974 which is 44 years without an accident and crewed from the beginning by Australian pilots. Pretty good porch monkeys I would say, wouldn't you?
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