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-   -   ATSB report on very low flying Thai Airways B777 at Melbourne. (https://www.pprune.org/australia-new-zealand-pacific/508526-atsb-report-very-low-flying-thai-airways-b777-melbourne.html)

clark y 22nd Feb 2013 19:04

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'?

Old Akro 22nd Feb 2013 23:06

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.

Capn Bloggs 23rd Feb 2013 00:45


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.
Agree. While not an ILS, the Cairns 33 LLZ is a classic example. A few years ago it was redone, but the DME remained at the other end. Very difficult to use the DME as a quick-check.


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.
For this Thai crew, was it? I doubt they use DAP. The 2009 NDB approach chart for that incident had 2 critical mile values missing: 7DME and 6 DME.

JammedStab 23rd Feb 2013 03:28


Originally Posted by Old Akro (Post 7709981)
I have 2 genuine questions.

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

Old Akro 23rd Feb 2013 07:19

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?

Capn Bloggs 23rd Feb 2013 08:13


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.

The minimum altitude for the segment inside 6.5 DME is indeed 760ft (corrected to 920 by the NOTAM).


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.
It's obvious to me that Akro was referring to the "approach" slope.


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.

Not a 777 pilot, but that's not how FLCH works, is it? The ATS comes to idle because this mode uses pitch to control speed. The ATS did/does not come to Idle to "maintain the target airspeed of 190KIAS". What actually would happen (in the A/T jets I've flown) is the A/T would have come to Idle (regardless of the speed) and the nose would have have come up to slow the aircraft down to 190KIAS, then the nose would have dropped (a lot) to maintain the speed.

DirectAnywhere 23rd Feb 2013 09:03

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!

JammedStab 23rd Feb 2013 09:27


Originally Posted by Capn Bloggs (Post 7710339)
The minimum altitude for the segment inside 6.5 DME is indeed 760ft (corrected to 920 by the NOTAM).


The poster stated that the aircraft was above minima because once inside 6.5 DME, they were above the published MDA as an argument to make it sound like they did not break any regulations. However, they had just arrived from a significant amount of time where they had been below minimum segement altitude.

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.

Old Akro 23rd Feb 2013 11:42

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.

Capn Bloggs 23rd Feb 2013 14:30


Originally Posted by DirectAnywhere
Bloggs,the link you've provided above is to the 16 incident.

I know. I posted it to show that the Thai chart in that earlier incident (a similar NPA) was missing two critical profile altitude checks. Was this also the case in the latest incident? If so, it removes a potential profile check that might have caused the FO to go "WTF!".


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!

Agree 100% with that.

DirectAnywhere 23rd Feb 2013 22:17

Ah, got ya. Ta.

JammedStab 23rd Feb 2013 23:14


Originally Posted by Old Akro (Post 7710603)
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.

If you compare the diagram(or table or chart) on page 17 with the diagram on page 3, it is quite easy to figure out what happened. There may be some minor discrepancies which is always annoying, but it is plainly clear that minimum altitudes were broken for a significant period of time. Most safety experts will tell you that a go-around should have been done prior to being called for by ATC after they discovered their error. Therefore whether they heard the ATC call clearly is irrelevant.

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.

Joker89 23rd Feb 2013 23:30

@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.

emeritus 24th Feb 2013 03:44

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

Lookleft 24th Feb 2013 08:59


It would therefore be reasonable to assume that Foreign Affairs would have a
large say in the final version of the ATSB report.
Not a reasonable assumption at all. DFAT would have neither the expertise or legal authority to have anything to do with the final report. They wouldn't even qualify as a DIP.


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.
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.

Kharon 25th Feb 2013 01:43

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.

FYSTI 25th Feb 2013 05:36


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.
Not only that, in the latest incident the crew were at Flap 1 the entire time, and in the 2007 incident, Flap 5 crossing BOL, then gear down flap 20 in level change.

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?

UnderneathTheRadar 25th Feb 2013 07:11

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

C441 25th Feb 2013 07:32

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.:eek:

Ollie Onion 25th Feb 2013 07:46

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.

Jack Ranga 25th Feb 2013 08:00

We are the best ATC in the world brutha :ok: just like you are the best pilots in the world ;)

Jack Ranga 25th Feb 2013 08:16

I've been doing a bit of research lately, on a project you see. If you think Australian ATC are restrictive, you are fiddling with your twinkies. Best to loosen your grip a little and have a look at the wider picture :ok:

Have the weather conditions @ Melbourne ever required an ILS approach as opposed to a VOR or GNSS for R34 or do you just want the option of autolanding with a Cat 3 because you haven't got the skills to visual onto 34?

Slag away as much as you want bruthas' but I thought we were in this game together? I have made the occasional mistake that has been picked up by pilots, the same as I've caught a couple of **** ups on the other side.

Perspective, perception. If the systems at fault here, change it. If the pilot cocked up, have a round table. Or report politically correct so that you never offend anyone, yeah, that'll work :ok:

DirectAnywhere 25th Feb 2013 08:47

Jack,

NPAs are a threat. They increase pilot workload significantly. I can fly them but I'd rather fly an ILS - much easier.

400 odd people down the back want my life as easy as possible so I can focus my attention as widely as possible - not just the approach.

SYD 16R G/P was out over the weekend. Frankly, it was a s$&tfight. No-one's fault, just greater seperation, a few missed approaches in crappy, windy weather and a NPA. Busy, threat rich environment. Ripe for errors and an incident along the lines of the one that we're discussing now.

Jack Ranga 25th Feb 2013 10:07

Direct, I appreciate that. :ok: I fly GNSS as well as ATC. I fly a GNSS better than I fly an ILS (:E). Point I'm making is: Pilots & ATC's slagging each other achieves NOTHING..........Our enemy's here are politically correct investigative bodies, shopping mall & car park operators masquerading as airport operators & politicians.

Next time you get on the PA & blame ATC for delays, have a think about what is really causing your delay. Question? Do you fellas have the balls to put over the PA:

'Ladies & Gentlemen, we strive to get you to your destination on time every time, unfortunately a traffic cap imposed by politicians, noise sharing & noise abatement legislation also imposed by politicians as well as airport operators who spend more money on retail development & car parks as opposed to runways has caused us to be late. Whilst we are sitting on the Tarmac for the next 15 minutes, waiting for a gate, feel free to turn on your mobiles & iPads, email your local (gutless) member of parliament & ask why?'

For the first dood that does this I will donate 5ung to your favourite charity & post the receipt on this forum:ok:

Whilst I'm mouthing off about delays the same can be said for the infrastructure you want :ok:

Wally Mk2 25th Feb 2013 11:09

Jack I often say due ATC restrictions at XXXX we shall be delayed Ldg now at xxxx, unfortunately this is beyond our control.
Obviously the gen public have no idea we have Draconian rules & regs with useless Pollies & greenies indirectly running our aviation infrastructure (what there is of it!)
No offense to the guys behind the Mic, they must be as frustrated as us airborne.



Wmk2

sheppey 25th Feb 2013 11:31


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.
Disagree on that blanket statement. The Australian rules when it comes to conducting instrument approaches are quite straight forward and in most cases accord with ICAO procedures with perhaps minor modifications to increase safety. if a foreign crew is unable to complete a normal instrument approach without all the drama associated with (for example), the Thai incidents, it is not the fault of those who design the procedures. The fault lies in the regulator of the country of origin for not ensuring their aircraft crews are competent in normal instrument approach procedures.

Cowboy flying (meaning careless, lazy and potentially dangerous) happens in airlines as well in other flying jobs. There have been many similar published incidents over the years by foreign operators into Australian airports. Ask any ATC controllers at the major international airports and I am sure the stories will flow although these never hit the media.

Jack Ranga 25th Feb 2013 11:31

Wal.........THEY ARE NOT ATC RESTRICTIONS :cool: They are restrictions imposed by the above considerations as well as weather. Let ATC go flat knacker & see what happens to your movement rates ;)

You blokes pushing that easy bullish!t PA let's the above wankas off the hook, punters blaming ATC! C'mon Wal, $500 bills, will you do it? If not, why not? It's an internal PA, not subject to any communications law......

Old Akro 25th Feb 2013 13:37

Jack

I don't think anyone is having a go at ATC. A number (including me) are having a fair crack at the system that you work within, but certainly have not meant to criticise the controller.

I had dinner with an overseas based 747 captain on Saturday night. He says the only time he flies a NPA is in the SIM or when he comes to Australia. While the points about pilots should have the skill is correct, the plain fact is that many foreign pilots coming here are simply not fluent in them. He also says that the FCS of glass cockpit 747's don't deal as well the transition to NPA as the 747 classic (for reasons I don't understand). Whether or not this translates to the 777, I don't know. But its an interesting question. His comments make me wonder if modern digital FCS are optimised for NPA approaches.

My suspicion is that the problems with the approach started in the LH turn from the 11 DME arc to the VOR 346 radial, then developed.

The second point is that while the DME Arc entry VOR approach may be a good valid procedure, why should we not move with technology and strive to have systems that benchmark with other international airports in the region? Australia used to lead the world in aviation technology. Now countries that we label as third world have better, more modern infrastructure.

My beef is that the ATSB report has been used to criticise the airline flag carrier of one of our major trading partners (#7 from memory). Yet this report would fail as an undergraduate report. I count 9 discrepancies between the schedule of events in appendix B and the body copy. When I try and derive a groundspeed to fill in missing DME blanks, I get numbers that vary from 120 kts to 600 kts. There is something not quite right about the published event chronology. The crew was criticised for not reacting to the go-around instruction, but when you compile a full list of radio calls (must add the body copy reported calls to Appendix B) then it really looks like they did not hear / did not understand the first call. The report does not give this impression, but I think there was a combined total of 10 radio transmissions regarding the go-around. An initial instruction with either the response "Copied" or "Climbing"(depending on which part of the report you read), then a 35 sec break, then a further 4 transmissions & responses between 2012:26 & 2019:47. One of my only real questions of the controller, is why in the face of no positive reply of a go-around let alone the correct phraseology, did he wait 35 sec to re-issue the instruction? If we are going to criticise the crew for not affirming a command, isn't there some shared responsibility? Just asking.

If the crew was under the expectation of ICAO rules (whether rightly or wrongly), then they were operating legitimately (albeit with sloppy airmanship) from the point at which they were cleared for visual approach. At the point of actual go-around they were inside the circling area and were therefore OK according to both Australian & ICAO standards. This difference to ICAO is not mentioned in the ATSB report at all. I read the Jepp manual looking for the Australian requirement to be within the circling area and I don't think its at all clear in the Jepp document. I don't think you can blame them for not being clear.

The point at which it is unequivocal that they had breached the LSALT was during the LH turn from the DME arc to the VOR radial. This was up to 30 sec before they were cleared for visual approach and a full minute before the first go-around instruction.

This report does not mention any history of altitude infringements to RWY 34, but the active report AO 2012-120 into a US registered B747 cites that there have been 5 altitude infringements to RWY 34 in 2011/12. So, it looks like there might be a bit of an issue.

Tiger airways report (AO 2011-070) of June 2011 (vs Thai in July 2011) was another altitude infringement issue (RWY 27). It pointed to a discrepancy in operational data between the published charts and that in the flight management system. This was not considered in the recent Thai investigation. 2 incidents, a month apart, same airport, both with involvement of the FCS. It would seem to me that it should have been on the list to consider.

There is no denying that this was a pretty bad approach, but using the crew as whipping boys doesn't help explore how to improve the situation.

We should debate whether all runways should have ILS
We should debate if we should bring the cleared visual approach requirements into line with ICAO
We should debate whether a redesign of the VOR approach would make it easier for foreign crews
We should debate whether the RWY 27 ILS might be an option for longhaul foreign crews with light crosswind (about 10 kts on the night).

The ATSB report does not mention if this flight had relief crew. The BKK - MEL flight runs about eight and a half hours to nine and a quarter hours, which I understand is borderline for a relief crewmember. I understand some airlines do, some don't. It would seem to me that fatigue should probably have been discussed in the ATSB report as well. I have no idea how to weigh up the risks of landing from a non stabilised approach vs a go-around at night at the end of a 9 hour flight, but it would be an interesting discussion.

clark y 25th Feb 2013 15:42

Well said.

A couple of other things missing from the report- the crews total and recent experience. We don't know their nationalities. A copy of the chart actually used (not the AIP)and the FMS coding would have been nice (the fleet I fly has had about 3 different versions for the 34 VOR).

joker89, thanks, I asked about the pitch up at 3300' because this is where the captain state he thought he had a problem with the VNAV. This is where the use of LVLCH started.
Jack r, I have gone around off the 34VOR due low cloud. Never even saw the ground. Though it was very quick forming and bit lower than thought.

Clark y

Derfred 26th Feb 2013 03:41

Jack, I have done two go arounds in succession on VOR34, not visual due visibility in rain. Got in on the third approach declaring min fuel. The forecast for the day was 9999 SCT035 -SHRA.

Jack Ranga 26th Feb 2013 06:31

Looks like an ILS is needed on R34?

Lookleft 26th Feb 2013 07:32

An ILS on 34 would be great as would CATIIIB approaches at all capital cities. The obvious question is who would pay for it. The airlines won't as they don't think the small number of days it would be used is worth the expense. The gummint won't as they would consider that its not a vital piece of national infrastructure. Airservices won't as they would consider that the airlines should pay. Who's left? Would pilots put their hands in their pockets and pay for it?

So it comes back to playing with the cards you are dealt. If you fly in Oz, for better or for worse, you have to know how to deal with an NPA.

The worst way to deal with an NPA is to set the minima and push FLCH or OPEN DESC depending on your chariots manufacturer. This is fundamental stuff and not nice to know when you do your training. Thai Airways and any other airline who have pilots who don't understand the functions of these "buttons" need to look at their syllabus of training.

Centaurus 26th Feb 2013 10:02


NPAs are a threat. They increase pilot workload significantly
It is all relative. Thousands of pilots flew NPA's usually by hand in the years leading to the introduction of glass cockpit instrumentation and ever increasing sophistication of automatics. The wartime GCA (radar equivalent to ILS) took good flying skills because they were flown manually raw data. The term "work-load" had not been invented then. Pilots were airmen - with all that implies. With the ever increasing sophistication and reliability of today's automatics, work load has been steadily reduced to often a state of boredom.

Suddenly people bleat about the 'work-load" of flying a bog standard NPA. They are forced to elevate their cockpit activity and either press a few more automatic buttons or God forbid, actually grip the joy-stick or control wheel and fly by hand (following a compliant flight director and autothrottles of course). The pulse rate goes up caused by the increase in "work-load"

They even complain about increase in "workload" even though the automatic pilot system is doing all the work!!:eek::eek:

Old Akro 26th Feb 2013 10:28

Centaurus.

I agree. But I still think real aeroplanes have tailwheels.

Jack Ranga 26th Feb 2013 12:02

So an ILS on R34 is not needed?

Keg 26th Feb 2013 12:31

Handy? Yes. Needed? Too many more incidents like this then perhaps yes. Really needed? No. Within 3-5 years everyone will be doing straight in RNAV approaches to altitudes that will be close to ILS minima so it won't be an issue.

PEI_3721 26th Feb 2013 13:31

Some similarities with some of the incidents in Celebrating TAWS ‘Saves’: But lessons still to be learnt.

Perhaps there is a need to revise the chart so that altitude is above distance in the ‘altitude/distance’ table, i.e altitude is the most important variable. At least pilots should think that way irrespective of the chart.

Twin Beech 26th Feb 2013 14:51

Twin Beeches have tailwheels. Castering tailwheels.
 
Fellas: there is no doubt that hairy-chested airmen can fly the pants off anything, conventional gear or not. An NDB is pure luxury, accustomed as we all are to audible range let-downs. I think that the "A" quadrant is germane here, as the "N" is reserved for the adjacent North Melbourne community.

That foolishness aside, a non-ILS approach to a major destination runway is unforgivable. To speculate that a foreign crew might be fatigued after an intercontinental flight is to parse the obvious. Why try to justify an obviously, clearly inadequate approach? An easy, vectored ILS is what long haul heavy crew ( and passengers, too, if they had a clue) expect. To provide, and require otherwise, is to compromise safety in its most basic form.

All readers of this post not current widebody captains who have seen more dawns than they care to remember need not respond with tales of daring-do. We were all young once, but now we have real jobs. Flying to real, fair-dinkum airports chock full of ILS approaches to every runway. While tired. And no holding, either, Jack.

Twin Beech. C-17 compass, tailwheel, carb heat, bfo, dit-dah, dah-dit. A cone of silence without Maxwell Smart, or the Chief. But with Agent 99 for sure.

Jack Ranga 26th Feb 2013 20:19

So an ILS is required on R34?

Old Akro 26th Feb 2013 21:06

Jack

The real answer to this question would lie in a review of the incidents of altitude infringements on RWY 34. The search function on the ATSB website is completely inadequate for anyone external to do this research. With the current state of the ATSB, I doubt you'll ever get the full information required for a proper decision. However, with only an hour or so's work I turned up with 6 instances in the last year or so.

Considering the Thai flight, they could have easily landed with a mild cross wind on RWY 27 with ILS. I presume (note: presume because the ATSB did not consider this) that the aircraft was directed to RWY 34 for ATC operational reasons and not aircraft or weather requirements. Some degree of understanding about this would help inform the assessment.

I fly twins not jets. This approach would be pretty easy in the twin. However, my 747 captain mate says it is not as simple in a widebody jet and even less simple in a glass cockpit wide body jet. Something to do with the flight control system that I don't understand. It seems to me that the most critical group of flights on this approach are therefore foreign long haul, glass cockpit widebody jets (none of whom are participating in this discussion). How welcoming do we want to be to overseas guests?

My understanding (which is imperfect) is that GPS has not made nearly the inroads to airlines that it has to GA. I understand that where it is used in airlines it typically feeds into the INS system to update it, rather than being used as a standalone system. I think it will be many years before we see airliners using GPS RNAV approaches. And unless Australia gets WAAS it may be never.

The truth is that we have under funded aviation infrastructure for years. In Australia we get by because we have better weather than most of the world, lower traffic densities, possibly better pilots and better controllers :) . There comes a time when we just have to do whats right. Surely at least Sydney & Melbourne should be at a similar standard to Singapore, Hong Kong, Bangkok, Heathrow, Los Angeles, Frankfurt, etc.

The maritime industry gets new lighthouses, marine GPS WAAS, channel dredging, port upgrades and other infrastructure without industry funding. The trucking industry gets free use of roads, B-double assembly areas, emergency repose (police, ambulance, etc) without any significant industry contribution. Its only aviation where we get hung about about user pays. And before someone mentions Dick Smith - it started in the seventies with Frank Crean.

The rest of the world is investing in WAAS, ADSB-in traffic, radio weather, autoland and we're trying figure out if we should fully adopt ILS.


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