Air Niugini 737 overun at Guam
Join Date: Apr 2010
Location: Asia
Posts: 1,030
Likes: 0
Received 0 Likes
on
0 Posts
Disturbing footage indeed. Doesn’t say much about the other two sitting and saying nothing.
The old story of local skipper and expat pilot not wiling to challenge or call a missed approach? If they chose not to respond and end up like this well it’s on the skipper.
The old story of local skipper and expat pilot not wiling to challenge or call a missed approach? If they chose not to respond and end up like this well it’s on the skipper.
3.2 CAUSES[CONTRIBUTINGFACTORS]
The flight crew did not comply with Air Niugini Standard Operating Procedures Manual (SOPM) and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed.
The aircraft’s flight path became unstable with lateral over-controlling commencing shortly after auto- pilot disconnect at 625 ft (677 ft). From 546 ft (600 ft) the aircraft was flown in Instrument Meteorological Conditions (IMC) and the rate of descent significantly exceeded 1,000 feet/min in Instrument Meteorological Conditions (IMC) from 420 ft (477 ft).
The flight crew heard, but disregarded, 13 EGPWS aural alerts (Glideslope and Sink Rate), and flew a 4.5o average flight path (glideslope).
The pilots lost situational awareness and their attention was channelised or fixated on completing the landing.
The PIC did not execute the missed approach at the MAP despite: PAPI showing 3 whites just before entering IMC; the unstabilised approach; the glideslope indicator on the PFD showing a rapid glideslope deviation from half-dot low to 2-dots high within 9 seconds after passing the MDA; the excessive rate of descent; the EGPWS aural alerts: and the EGPWS visual PULL UP warning on the PFD.
The copilot (support/monitoring pilot) was ineffective and was oblivious to the rapidly unfolding unsafe situation.
It is likely that a continuous “WHOOP WHOOP PULL UP”70 hard aural warning, simultaneously with the visual display of PULL UP on the PFD (desirably a flashing visual display PULL UP on the PFD), could have been effective in alerting the crew of the imminent danger, prompting a pull up and execution of a missed approach, that may have prevented the accident.
3.3 OTHERFACTORS
This is used for safety deficiencies or concerns that are identified during the course of the investigation that while not causal to the accident, nevertheless should be addressed with the aim of accident prevention.
The investigation found a number of non-contributory safety deficiencies. These are addressed in Part 1 Factual and Part 4 Safety actions and recommendations.
3.4 USNTSBSTATEOFMANUFACTURECONCLUSIONS
The US National Transportation Safety Board’s Accredited Representative and Technical Advisers representing the State of Manufacture, had full access to the evidence, including all recorded data and the cockpit imagery (video), in accordance with Annex 13 international obligations.
The NTSB team provided their conclusions, which have been duly considered during the drafting of the Final Report.
With respect to the last paragraph of Section 3.1 above, the NTSB Team requested that the substance of their comments be appended to the Final Report, in accordance with Paragraph 6.3 of Annex 13, Standard.
The AIC agreed to publish the NTSB Team’s findings and conclusion, which states:
NTSB staff disagrees that an additional warning would have been effective in alerting the crew. The conclusions and the supporting information in the draft report effectively demonstrate that the pilots:
• Lost situational awareness.
• Disregarded 16 EGPWS alerts that had occurred in the 19 seconds preceding impact with
the water.
• Disregarded vertical guidance being displayed on the Primary Flight Display (PFD).
• Did not comply with the Air Niugini go-around policy after the first and subsequent EGPWS alerts.
• Did not comply with the Air Niugini go-around policy after the approach had become unstable with the descent rate exceeding 1000 feet per minute.
NTSB staff believes that the actions of the pilots to disregard the 16 EGPWS alerts and to not comply with Air Niugini policy clearly demonstrate that the crew was unresponsive to guidance that should have prompted a clear and decisive action to initiate a missed approach.
NTSB staff believes the disregard of the alerts, disregard of the PFD display guidance, and the continuation of an unstable approach demonstrate that any additional guidance, alert, or warning would be similarly disregarded by the flight crew and ineffective in preventing the accident.
The flight crew did not comply with Air Niugini Standard Operating Procedures Manual (SOPM) and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed.
The aircraft’s flight path became unstable with lateral over-controlling commencing shortly after auto- pilot disconnect at 625 ft (677 ft). From 546 ft (600 ft) the aircraft was flown in Instrument Meteorological Conditions (IMC) and the rate of descent significantly exceeded 1,000 feet/min in Instrument Meteorological Conditions (IMC) from 420 ft (477 ft).
The flight crew heard, but disregarded, 13 EGPWS aural alerts (Glideslope and Sink Rate), and flew a 4.5o average flight path (glideslope).
The pilots lost situational awareness and their attention was channelised or fixated on completing the landing.
The PIC did not execute the missed approach at the MAP despite: PAPI showing 3 whites just before entering IMC; the unstabilised approach; the glideslope indicator on the PFD showing a rapid glideslope deviation from half-dot low to 2-dots high within 9 seconds after passing the MDA; the excessive rate of descent; the EGPWS aural alerts: and the EGPWS visual PULL UP warning on the PFD.
The copilot (support/monitoring pilot) was ineffective and was oblivious to the rapidly unfolding unsafe situation.
It is likely that a continuous “WHOOP WHOOP PULL UP”70 hard aural warning, simultaneously with the visual display of PULL UP on the PFD (desirably a flashing visual display PULL UP on the PFD), could have been effective in alerting the crew of the imminent danger, prompting a pull up and execution of a missed approach, that may have prevented the accident.
3.3 OTHERFACTORS
This is used for safety deficiencies or concerns that are identified during the course of the investigation that while not causal to the accident, nevertheless should be addressed with the aim of accident prevention.
The investigation found a number of non-contributory safety deficiencies. These are addressed in Part 1 Factual and Part 4 Safety actions and recommendations.
3.4 USNTSBSTATEOFMANUFACTURECONCLUSIONS
The US National Transportation Safety Board’s Accredited Representative and Technical Advisers representing the State of Manufacture, had full access to the evidence, including all recorded data and the cockpit imagery (video), in accordance with Annex 13 international obligations.
The NTSB team provided their conclusions, which have been duly considered during the drafting of the Final Report.
With respect to the last paragraph of Section 3.1 above, the NTSB Team requested that the substance of their comments be appended to the Final Report, in accordance with Paragraph 6.3 of Annex 13, Standard.
The AIC agreed to publish the NTSB Team’s findings and conclusion, which states:
NTSB staff disagrees that an additional warning would have been effective in alerting the crew. The conclusions and the supporting information in the draft report effectively demonstrate that the pilots:
• Lost situational awareness.
• Disregarded 16 EGPWS alerts that had occurred in the 19 seconds preceding impact with
the water.
• Disregarded vertical guidance being displayed on the Primary Flight Display (PFD).
• Did not comply with the Air Niugini go-around policy after the first and subsequent EGPWS alerts.
• Did not comply with the Air Niugini go-around policy after the approach had become unstable with the descent rate exceeding 1000 feet per minute.
NTSB staff believes that the actions of the pilots to disregard the 16 EGPWS alerts and to not comply with Air Niugini policy clearly demonstrate that the crew was unresponsive to guidance that should have prompted a clear and decisive action to initiate a missed approach.
NTSB staff believes the disregard of the alerts, disregard of the PFD display guidance, and the continuation of an unstable approach demonstrate that any additional guidance, alert, or warning would be similarly disregarded by the flight crew and ineffective in preventing the accident.
I'm surprised the captain still kept his job.
You can deliberately not comply with SOP, crash and kill, and still keep your job. Everyone's job is safe now.
More evidence of the culture at the airline, which lead to an accident like this.
The fact they also ignored so many EGPWS warnings on a previous sector is also evidence of the culture there, once again another contributing factor.
Seems like this is the normal thing.
You can deliberately not comply with SOP, crash and kill, and still keep your job. Everyone's job is safe now.
More evidence of the culture at the airline, which lead to an accident like this.
The fact they also ignored so many EGPWS warnings on a previous sector is also evidence of the culture there, once again another contributing factor.
Seems like this is the normal thing.
Last edited by John Citizen; 18th Jul 2019 at 10:24.
Yes very experienced at deliberately not following procedures and ignoring EGPWS warnings.
No doubt they always got away with it the past.
No doubt they always got away with it the past.
Last edited by John Citizen; 18th Jul 2019 at 12:04.
Probably a lesson for the children of the Magenta Line,
This is exactly what happens when adults don't follow the magenta line. (As children can't do this and never do this)
The copilot was blamed for failing to take control from the captain when it was obvious the aircraft flight path was seriously unstable. The wording being:
Quote: The copilot was completely unaware of the hazardous situation unfolding and did not challenge the PIC and attempt to take control of the aircraft from the PIC and execute a go-around, in accordance with company instructions that require taking over when an unsafe condition exists. Unquote.
Conveniently, there were no directions in the FCOM exactly how the copilot physically snatches control from a captain who doubtless would strongly object to his subordinate wrestling the controls from him and in attempting to do so, compound the already dangerous situation.
If, as the report suggests, the captain was already "fixated" on getting in, one can only imagine the utter confusion if the copilot attempts to wrestle the controls away from the captain. Make no mistake, the captain would not meekly relinquish the controls just to keep the copilot happy.
While companies have SOP's requiring the PM to warn the PF of an unstable situation, there is no advice of the step by step procedure for wrestling the controls away from the PF. And wrestle it would be.
During previous Pprune discussions on this very subject, there was a suggestion that the most expeditious method of forcing a go-around was for a PM to call "Go around - gear coming up" and select gear up without delay. It is doubtful if a PF (assuming the captain) will deliberately land wheels up just to make a point. The captain would have no choice but to go-around; which after all was the point of the exercise. That way there would be no confusion of who has control.
The report also stated: Quote: The Air Niugini Simulator training and checking policies and procedures did not require training and testing in the practical application of the challenge and response requirement for the monitoring pilot to take control of the aircraft if a challenge to an unsafe situation, including EGPWS aural alerts went unresolved. Unquote.
That is not surprising. . During simulator training exercises this correspondent has yet to see the situation where a PM (captain or copilot) suddenly decides an approach by the other pilot has become dangerous and unilaterally takes over control to correct the situation. Normally it is not a regulatory box ticking exercise. Such an action is prone to confusion since pilots are not given dual instruction in the simulator on how to physically take control (apart from an incapacitation) from a PF who doesn't expect it to happen. One would think a Regulator would demand that competency be demonstrated in such an event. Challenge and response words are fine initial warnings but actions speak louder than words. The report's criticism could apply to most operators involved with airline pilot training.
Quote: The copilot was completely unaware of the hazardous situation unfolding and did not challenge the PIC and attempt to take control of the aircraft from the PIC and execute a go-around, in accordance with company instructions that require taking over when an unsafe condition exists. Unquote.
Conveniently, there were no directions in the FCOM exactly how the copilot physically snatches control from a captain who doubtless would strongly object to his subordinate wrestling the controls from him and in attempting to do so, compound the already dangerous situation.
If, as the report suggests, the captain was already "fixated" on getting in, one can only imagine the utter confusion if the copilot attempts to wrestle the controls away from the captain. Make no mistake, the captain would not meekly relinquish the controls just to keep the copilot happy.
While companies have SOP's requiring the PM to warn the PF of an unstable situation, there is no advice of the step by step procedure for wrestling the controls away from the PF. And wrestle it would be.
During previous Pprune discussions on this very subject, there was a suggestion that the most expeditious method of forcing a go-around was for a PM to call "Go around - gear coming up" and select gear up without delay. It is doubtful if a PF (assuming the captain) will deliberately land wheels up just to make a point. The captain would have no choice but to go-around; which after all was the point of the exercise. That way there would be no confusion of who has control.
The report also stated: Quote: The Air Niugini Simulator training and checking policies and procedures did not require training and testing in the practical application of the challenge and response requirement for the monitoring pilot to take control of the aircraft if a challenge to an unsafe situation, including EGPWS aural alerts went unresolved. Unquote.
That is not surprising. . During simulator training exercises this correspondent has yet to see the situation where a PM (captain or copilot) suddenly decides an approach by the other pilot has become dangerous and unilaterally takes over control to correct the situation. Normally it is not a regulatory box ticking exercise. Such an action is prone to confusion since pilots are not given dual instruction in the simulator on how to physically take control (apart from an incapacitation) from a PF who doesn't expect it to happen. One would think a Regulator would demand that competency be demonstrated in such an event. Challenge and response words are fine initial warnings but actions speak louder than words. The report's criticism could apply to most operators involved with airline pilot training.
It’s hard to imagine this kind of flight deck culture from NZ or Aus but I have witnessed it in the recent past and it is alive and well in some parts of the world.
Is it true that the Captain kept his job? If so that is pretty disturbing. I think he would have done well to stay out of jail. He failed his passengers and crew by not complying with the rules and regulations his licence required of him. I understand that he was part of a broader failed company culture but at the end of the day if you take the pay cheque you take most of the responsibility. There was nothing stopping him from going around, he even mentioned they had lots of fuel.
The report seems to suggest that they got sufficient rest prior to the duty but then mentions a letter that suggests that they were rostered illegally and didn’t get sufficient rest......does anyone know which is correct and why the report is contradictory?
Is it true that the Captain kept his job? If so that is pretty disturbing. I think he would have done well to stay out of jail. He failed his passengers and crew by not complying with the rules and regulations his licence required of him. I understand that he was part of a broader failed company culture but at the end of the day if you take the pay cheque you take most of the responsibility. There was nothing stopping him from going around, he even mentioned they had lots of fuel.
The report seems to suggest that they got sufficient rest prior to the duty but then mentions a letter that suggests that they were rostered illegally and didn’t get sufficient rest......does anyone know which is correct and why the report is contradictory?
As per the other thread on go-arounds, I wonder if the FO had of called one in this case, whether the Capt would have gone around or used their authority to continue.
FO “Nah your honour - I didn’t call for a go-around ‘coz he wouldn’t have done it anyway” �� - good luck with that one in the Coroners Court.
Similar poor flying ability by a senior management local captain a few years back when approaching to land at Port Vila. Same aircraft type but different company though. On short final Runway 11 localizer approach in rain and cloud, aircraft reaches MDA and copilot calls" Minima not visual go-around." Captain starts the go-around pitching up and applying GA thrust but doesn't call "Flap 15" The copilot selects Flaps 15 after fraction of delay waiting for captain's call. Suddenly the runway became visual in rain and captain cancels GA and bunts over to land. The copilot was astonished and caught unawares. By now the flaps had just arrived at Flap 15 but captain determined to land and touches down heavily with Flap still at 15. Heavy braking followed and the 737 stopped at end. The was a close shave hushed up by the company.
All the Human Factors lectures, Notices to Pilots and Power Point presentations in the world, warning of the risks associated with unstable approaches, often go in one ear and out the other with certain types of pilots. They might know the rules but the dangerous ones often act on impulse.
All the Human Factors lectures, Notices to Pilots and Power Point presentations in the world, warning of the risks associated with unstable approaches, often go in one ear and out the other with certain types of pilots. They might know the rules but the dangerous ones often act on impulse.
Join Date: Dec 2006
Location: australia
Posts: 916
Likes: 0
Received 0 Likes
on
0 Posts
Suppose always could be - if the PIC perceived a greater threat to safety of the flight by doing the go around.
Birds on finals but by doing go around flying into a greater concentration was an example provided on a previous thread.
Maks sense.
Birds on finals but by doing go around flying into a greater concentration was an example provided on a previous thread.
Maks sense.
Appalling report
I hope these guys never fly again. That is the most appalling report I have ever read. Six Sink Rate, seven Glideslipe warnings and two Pull Up warnings and they ignored them and talked over them. "The crew had experienced these before and considered them nuisance alerts"- astonishing!! At 300 feet they were descending at 1530 fpm. They continued past the missed approach point and entered IMC. Just unbelievable. Same crew, previous day flew below the glide and got 28 Glideslope alerts and ignored them. Speechless.
I hope these guys never fly again. That is the most appalling report I have ever read. Six Sink Rate, seven Glideslipe warnings and two Pull Up warnings and they ignored them and talked over them. "The crew had experienced these before and considered them nuisance alerts"- astonishing!! At 300 feet they were descending at 1530 fpm. They continued past the missed approach point and entered IMC. Just unbelievable. Same crew, previous day flew below the glide and got 28 Glideslope alerts and ignored them. Speechless.
We all can read the report 1000 times and make our own judgements of what the crew done wrong, right and everything in between, however we need to be cognisant of the fact that the crew were a cog in a wheel that wasn’t perfect and certainly still is not. Sack the crew, remove their licenses and all the rest of it, is that going to do anything positive? While CASA PNG are at it why not cancel ANG’s AOC and all their other approvals as well just to be fair!
For anyone who has had anything to do with aviation in PNG, we all know how the boundaries are pushed on occasions as most of us who have been around the traps up there for a while have done it ourselves many times. If any long time PNG pilot can’t admit to pushing the limits and probably going beyond the limits with regards to the hard rules specifically in relation to the interpretation of weather conditions, they are complete liars - FACT!
Who needs to take ownership of the findings that have come out in the report? Certainly Air Niugini and the regulator in PNG, however everyone else who is involved in the industry, either directly or indirectly is also responsible as the report highlights that there are systemic failures with the industry in PNG.
Being an ex Air Niugini Dash 8 Captain and still being indirectly involved within the aviation industry in PNG, I certainly will continue to use Air Niugini as a fare paying passenger and I believe it’s important that we all as an industry learn from this accident without appropriating blame to any individual or organisation. Air Niugini is safe as any other airline in the world.
Cheers - PLUGGA
For anyone who has had anything to do with aviation in PNG, we all know how the boundaries are pushed on occasions as most of us who have been around the traps up there for a while have done it ourselves many times. If any long time PNG pilot can’t admit to pushing the limits and probably going beyond the limits with regards to the hard rules specifically in relation to the interpretation of weather conditions, they are complete liars - FACT!
Who needs to take ownership of the findings that have come out in the report? Certainly Air Niugini and the regulator in PNG, however everyone else who is involved in the industry, either directly or indirectly is also responsible as the report highlights that there are systemic failures with the industry in PNG.
Being an ex Air Niugini Dash 8 Captain and still being indirectly involved within the aviation industry in PNG, I certainly will continue to use Air Niugini as a fare paying passenger and I believe it’s important that we all as an industry learn from this accident without appropriating blame to any individual or organisation. Air Niugini is safe as any other airline in the world.
Cheers - PLUGGA