Citation 750 down in Egelsbach.
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(Egelsbach really is an airfield that one has to familiarise himself with _before_ flying there at night in marginal weather)
It seems that they just self-constructed an IFR approach where there was none, why otherwise would they have the AP engaged so close to the field and not hand-fly it
2 nm isnt that close to have the A/P engaged. The Report says the elevator input was up to 17° Nose up and the pitch changed wtihn 2 seconds from - 4 to +20°, now call me a pussy but I think that is really rapid change most likely not achievable with the AP ENGAGED. Either by TCS or brute force someone overpowered the A/P IMO.
They were most certainly NOT stabilized or ahead of their airplane. The whole approach was...well downright bad. Speed, situational awareness etc.
Last edited by His dudeness; 15th May 2012 at 13:53.
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Reading the preliminary BFU report puzzles me and makes me think: how could people like that be allowed to fly such a demanding airplane? How was the crew's performance during their latest recurrent trainings? Has nobody noticed anything before that accident?
Gear and landing flaps fully down, spoilers extended (?), power at 34%? The Citation X won't maintain level flight like this.
Why on earth being constantly below a 3 degree glideslope (and below the PAPI of 4,4 degrees) 4 miles from the runway, 500 ft above the ground, fully configured and with a rate of descent of 1,200 FPM?
It appears that they never overflew the point YANKEE ONE but rather intercepted the final course just before reaching the next point YANKEE TWO, losing altitude at a moderate rate at first. Can there still be any doubt about the concept of a stabilized approach?
Why going to this unfamiliar airfield, at night and in marginal weather in the first place? Maintaining VMC...
And then the crew's reaction to the EGWS alert, the last line of defence. Unbelievable.
Gear and landing flaps fully down, spoilers extended (?), power at 34%? The Citation X won't maintain level flight like this.
Why on earth being constantly below a 3 degree glideslope (and below the PAPI of 4,4 degrees) 4 miles from the runway, 500 ft above the ground, fully configured and with a rate of descent of 1,200 FPM?
It appears that they never overflew the point YANKEE ONE but rather intercepted the final course just before reaching the next point YANKEE TWO, losing altitude at a moderate rate at first. Can there still be any doubt about the concept of a stabilized approach?
Why going to this unfamiliar airfield, at night and in marginal weather in the first place? Maintaining VMC...
And then the crew's reaction to the EGWS alert, the last line of defence. Unbelievable.
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Jetopa - very well summed up.
Certainly not bashing non aoc ops, but without any real compliance monitoring of private ops like this one, the lines become fuzzy and it becomes very difficult to foresee any trends with crew performance / procedures / decision making etc...especially if the PIC is also the manager of the flight dept for the operation. An LPC once a year is not sufficient to establish all of these things.
It seems pretty clear that there were some seriously bad decisions made and that they were well outside of SOP's.
FNPL.
Certainly not bashing non aoc ops, but without any real compliance monitoring of private ops like this one, the lines become fuzzy and it becomes very difficult to foresee any trends with crew performance / procedures / decision making etc...especially if the PIC is also the manager of the flight dept for the operation. An LPC once a year is not sufficient to establish all of these things.
It seems pretty clear that there were some seriously bad decisions made and that they were well outside of SOP's.
FNPL.
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An LPC once a year is not sufficient to establish all of these things
If not, what is it going to establish? That you can fly an ILS? Surely irrelevant to this accident.
Following your logic, the Premier in Samedan couldn`t possibly have crashed AOC ops!)...unless that was a technical (no report out yet I think)
And who do you report to, that the bosses performance is below par?
Certainly not bashing non aoc ops
Last edited by His dudeness; 18th May 2012 at 06:43.
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HD - Accidents will happen, AOC and non AOC. The point I make is that with the right safegaurds in place, the risk is reduced.
Bottom line is that this accident would appear to have been totally avoidable. Trying to put a C-X into EDFE is madness anyway, but to try it in marginal weather...
This guy has paid with his life for those poor decisions, and taken others with him.
AOC or not, these type of operations should be well supported by an active and competent flight ops department, so the guy at the pointy end can concentrate on what pilots do best - flying the aircraft. Under AOC there would be line training, which is designed to pick up on and rectify any sub standard problems any given crew member might demonstrate. For the life of me I can't imagine why anyone who gets in these rather fast, complex aircraft, beit pilot or pax, wouldn't want to ensure safe and robust operations.
This isn't a pissing contest between AOC and private, simply common sense to raise the safety bar all round. I get the impression that you think you are above all of these initatives, which is a real shame for you and your pax if that is the case. We never stop learning.
Trying to cut down human error as a factor in accidents is surely a good thing?
Blah blah blah - If it is the opinion of the non PT community as a whole that this scenario is somehow acceptable, and just a bit of bad luck old chap - - - then yes I certainly am bashing it. With responsibility come accountability.
Bottom line is that this accident would appear to have been totally avoidable. Trying to put a C-X into EDFE is madness anyway, but to try it in marginal weather...
This guy has paid with his life for those poor decisions, and taken others with him. AOC or not, these type of operations should be well supported by an active and competent flight ops department, so the guy at the pointy end can concentrate on what pilots do best - flying the aircraft. Under AOC there would be line training, which is designed to pick up on and rectify any sub standard problems any given crew member might demonstrate. For the life of me I can't imagine why anyone who gets in these rather fast, complex aircraft, beit pilot or pax, wouldn't want to ensure safe and robust operations.
This isn't a pissing contest between AOC and private, simply common sense to raise the safety bar all round. I get the impression that you think you are above all of these initatives, which is a real shame for you and your pax if that is the case. We never stop learning.
Trying to cut down human error as a factor in accidents is surely a good thing?
Blah blah blah - If it is the opinion of the non PT community as a whole that this scenario is somehow acceptable, and just a bit of bad luck old chap - - - then yes I certainly am bashing it. With responsibility come accountability.
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According to the FPG, it would have required 3360ft at MLM, and 2980ft at 28.000lbs (3180lbs below MLM), at 25000 2710ft. Even the 2.5 Knots of tailwind should have been bearable...LDA 27 3824ft, 09 4592ft.
I´m the first to admit that have made, do make and will continue to make mistakes. Anyone telling you different is either a liar or not in aviation.
But - I have been a commercial air taxi dude for 16 years and I´m in corporate for over 5 years now - what I`ve witnessed mostly in the air taxi aka AOC (pre and post JAR/EU-ops experience) world is, that apart from raising the levels of paper filled in, little has changed to the better.
From what I have witnessed - and I was CRE / CRI in three different AOC operations - that is simply not true. Good pilots are often the ones to say 'no' and are exactly what the companies don´t want.
When a lot of pilots can´t do things that were considered normal knowledge in the 70s, 80s and 90s then we need to ask us two questions:
1) whats wrong with the way we train and check pilots? (when exactly did you do a VFR part for an LPC or OPC in a shiny jet? All we do (cause its right there in the form to be filled in as an mandatory item) is V1 cuts and the like, which statistically is an almost non event)
2) should we forbid anything but ILS to ILS because we don´t want to train our pilots properly (think MPL as an example)?
I had written a lengthy reply, but my computer has 'eaten' that one and I don´t have the desire to re-write everything I put down before... so:
yes, I object more regulation. These guys were from the safest aviation system there is, the US/FAA. Obviously they either simply slipped through the gates or they had a very, very bad day. The report says nothing about how long they have been up, whether the PIC was on a business meeting before the flight, how long the crew took to prepare themselves ( I honestly think they did not at all). These are very important factors IMO.
OTOH having the airplane in an AOC like structure (management) might have gotten them a slot in EDDF, but if not I don´t see how the outcome would have been a different one if the cockpit crew does not prepare itself for a nonstandard, close to the minima flight/landing.
They screwed that one up royally. ("Speed checks, Flaps to 5" 35 knots ABOVE the limit for Flaps 5 shows the stress level. E in the FMS instead of Y1 & 2, the totally unstable approach, the handling of the TCAS alert -> they were way behind their airplane and not prepared at all, IMO)
I get the impression that you think you are above all of these initatives
But - I have been a commercial air taxi dude for 16 years and I´m in corporate for over 5 years now - what I`ve witnessed mostly in the air taxi aka AOC (pre and post JAR/EU-ops experience) world is, that apart from raising the levels of paper filled in, little has changed to the better.
Under AOC there would be line training, which is designed to pick up on and rectify any sub standard problems any given crew member might demonstrate
When a lot of pilots can´t do things that were considered normal knowledge in the 70s, 80s and 90s then we need to ask us two questions:
1) whats wrong with the way we train and check pilots? (when exactly did you do a VFR part for an LPC or OPC in a shiny jet? All we do (cause its right there in the form to be filled in as an mandatory item) is V1 cuts and the like, which statistically is an almost non event)
2) should we forbid anything but ILS to ILS because we don´t want to train our pilots properly (think MPL as an example)?
I had written a lengthy reply, but my computer has 'eaten' that one and I don´t have the desire to re-write everything I put down before... so:
yes, I object more regulation. These guys were from the safest aviation system there is, the US/FAA. Obviously they either simply slipped through the gates or they had a very, very bad day. The report says nothing about how long they have been up, whether the PIC was on a business meeting before the flight, how long the crew took to prepare themselves ( I honestly think they did not at all). These are very important factors IMO.
OTOH having the airplane in an AOC like structure (management) might have gotten them a slot in EDDF, but if not I don´t see how the outcome would have been a different one if the cockpit crew does not prepare itself for a nonstandard, close to the minima flight/landing.
They screwed that one up royally. ("Speed checks, Flaps to 5" 35 knots ABOVE the limit for Flaps 5 shows the stress level. E in the FMS instead of Y1 & 2, the totally unstable approach, the handling of the TCAS alert -> they were way behind their airplane and not prepared at all, IMO)
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Much had been posted about the behaviour of the pilots, not all was correct.
VFE (flaps 5°) is 250 KIAS - they were set at 245 KCAS
But for me there is another perspective to the accident. That is the information that has been made available via AIP to those planning to fly to EDFE, which has been proven to be irritating and a bit chaotic.
The recommendations are quite revealing:
Since all of the above should be absolutely standard and no-brainer, I see it as a major exposure of incompetency that the officials were not able to adhere to worldwide standards without being reminded.
If you have a look at the approach charts yourself (partly scanned in the report) you might agree that they are quite cluttered with irrelevant information. Four pages of bureaucratic non-sense (e. g. repeating the depicted VFR traffic pattern in words - in case you cannot read a map) do not contain a hint that could have saved lifes again. But you are reminded to keep your transponder on and to "report overflying the compulsory reporting points". (sic!) But you do not find the hint for the 4,4° glideslope in the lengthy description of the approach. You find it in the Aerodrome Chart - if you are looking there for approach info, that is.
Egelsbach AIP is for me a perfect example for non-priorisation of information. It's printed in the map (not in the several pages text part) that "Take-offs and landings by students without instructor are not allowed." But NOT that the terrain is higher east of the field.
The last fatal accident occurred 2,5 years before in a KingAir 90, they impacted only 50 meters away. The maps weren't amended with any terrain warning.
Flaps to 5" 35 knots ABOVE the limit for Flaps 5
But for me there is another perspective to the accident. That is the information that has been made available via AIP to those planning to fly to EDFE, which has been proven to be irritating and a bit chaotic.
The recommendations are quite revealing:
Recommendation: 12/2012
The Darmstadt Regional Council, in cooperation and coordination with the competent air traffic control agency and the Federal Supervisory Office for ATC (Bundesaufsichtsamt für Flugsicherung, BAF) the procedures for conducting flight under visual flight rules (VFR) to and from the airport Frankfurt-Egelsbach. The description of the procedure should be simple, understandable and free of contradictions and should be published in the AIP.
This also applies to VFR charts.
The Darmstadt Regional Council, in cooperation and coordination with the competent air traffic control agency and the Federal Supervisory Office for ATC (Bundesaufsichtsamt für Flugsicherung, BAF) the procedures for conducting flight under visual flight rules (VFR) to and from the airport Frankfurt-Egelsbach. The description of the procedure should be simple, understandable and free of contradictions and should be published in the AIP.
This also applies to VFR charts.
Recommendation: 14/2012
In the VFR charts of Frankfurt-Egelsbach it should be made obvious that the descent angle of 4.4° during final approach is mandatory due to the obstacle situation. The wooded hills east of the square
should be presented as an obstacle in the charts.
In the VFR charts of Frankfurt-Egelsbach it should be made obvious that the descent angle of 4.4° during final approach is mandatory due to the obstacle situation. The wooded hills east of the square
should be presented as an obstacle in the charts.
Egelsbach AIP is for me a perfect example for non-priorisation of information. It's printed in the map (not in the several pages text part) that "Take-offs and landings by students without instructor are not allowed." But NOT that the terrain is higher east of the field.
The last fatal accident occurred 2,5 years before in a KingAir 90, they impacted only 50 meters away. The maps weren't amended with any terrain warning.
Last edited by TripleBravo; 19th May 2012 at 20:07.
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@TripleBravo: Good points.
By the way, the interim report is also available in English:
http://www.bfu-web.de/cln_030/nn_223...tin2012-03.pdf
By the way, the interim report is also available in English:
http://www.bfu-web.de/cln_030/nn_223...tin2012-03.pdf
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Two years ago we were tasked to fly to dusseldorf then egglesbach. During a three hour layover in dusseldorf I took a look at the charts for egglesbach to prepare for our arrival in what were likely to be marginal conditions.
The charts were a confusing mess and so full of contradictions that I decided to visit the CAA office to get a copy of the AIP. The two gentlemen i met were at first very helpful but were not able to find anything. They then offered me help with the charts we had printed from egglesbach web site. They too were confused by what they read. Two pilots and two German CAA employees sat on the ground couldn't figure out half of what was going to be required of us later in the day at a time when we would be scrabbling around barely 1000 ft agl, and at 200 kts.
We decided to land elsewhere.
The charts were a confusing mess and so full of contradictions that I decided to visit the CAA office to get a copy of the AIP. The two gentlemen i met were at first very helpful but were not able to find anything. They then offered me help with the charts we had printed from egglesbach web site. They too were confused by what they read. Two pilots and two German CAA employees sat on the ground couldn't figure out half of what was going to be required of us later in the day at a time when we would be scrabbling around barely 1000 ft agl, and at 200 kts.
We decided to land elsewhere.
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I have taught biz owners how to fly their jets for some time. A common component is an ego that translates 'if he can do it, I can do it'...which tends to serve them well in business, but if I land their jet with ease on a short runway, then I later learned that's like planting a flag on Everest, now they want to rush up the hill to do what I did.
Combine that with my attitude that 'you can do it, I'll teach you'...can get some guys in trouble.. WHEN I AM NOT THERE.
More often then not, biz owners just don't have the experience flying around year after year experiencing what pro pilots see...they have the money to buy the plane, they get signed off, now they think they are as good as the rest of us that do this for a living.
Make the condition at night, some wind, marginal visibility, add in the fact that they don't have short field experience, so instead of knowing to plant it on the numbers, or doing a go around, they run it down the runway a third like they were taught, 20 knots fast...the plane floats, anti lock brakes come on...they throw the buckets out when they aren't planted, so now they have 500 ft of runway left at 100 knots, committed and they don't have rubber on the ground. They can't stop, they can't go around.
Few pilots honestly have critical flight operation (CFO) experience where they HAVE to fly the aircraft to it's performance limitations, and sometimes beyond...they are working in the margins of how they were taught and the runway or conditions that day won't allow it, they have to push their abilities and aircraft to get the job done, and most guys have never done that, so they can get themselves in trouble.
Putting a ten on a 4600 ft field requires critical airspeed control, hitting the numbers, generally with a very low stabilized approach, at speeds that are on the slow side of normal, everything is 'done' on downwind, all that has to be done is hitting the numbers and stopping the aircraft. The danger is getting to low on the approach side, or landing to far down, to fast, buckets out on the other end.
So bottom line, these guys weren't up to the task, and the passengers paid for it.
Combine that with my attitude that 'you can do it, I'll teach you'...can get some guys in trouble.. WHEN I AM NOT THERE.
More often then not, biz owners just don't have the experience flying around year after year experiencing what pro pilots see...they have the money to buy the plane, they get signed off, now they think they are as good as the rest of us that do this for a living.
Make the condition at night, some wind, marginal visibility, add in the fact that they don't have short field experience, so instead of knowing to plant it on the numbers, or doing a go around, they run it down the runway a third like they were taught, 20 knots fast...the plane floats, anti lock brakes come on...they throw the buckets out when they aren't planted, so now they have 500 ft of runway left at 100 knots, committed and they don't have rubber on the ground. They can't stop, they can't go around.
Few pilots honestly have critical flight operation (CFO) experience where they HAVE to fly the aircraft to it's performance limitations, and sometimes beyond...they are working in the margins of how they were taught and the runway or conditions that day won't allow it, they have to push their abilities and aircraft to get the job done, and most guys have never done that, so they can get themselves in trouble.
Putting a ten on a 4600 ft field requires critical airspeed control, hitting the numbers, generally with a very low stabilized approach, at speeds that are on the slow side of normal, everything is 'done' on downwind, all that has to be done is hitting the numbers and stopping the aircraft. The danger is getting to low on the approach side, or landing to far down, to fast, buckets out on the other end.
So bottom line, these guys weren't up to the task, and the passengers paid for it.
Silleypeoples,
I have not flown with a lot of owners, however your description of real life experiences and perception of realities seems very correct.. Anyone can go out and fly and make things happen - on the rare yearly occasions things are ever so slightly different from the ordinary and thats were a professional pilot with experience in his belt sees what lies ahead - as opposed to an less experience pilot - and makes crucial and life saving decisions (diversion, early established, on the numbers speed approach etc. etc.). Owners or less experienced "co-pilots/captains" may think they've got what it takes - it's only human. When you say NO as a pilot - thats when you realize you have come a long way - not when you say YES!
Silleypeoples, thanks for a very valid contribution!
I have not flown with a lot of owners, however your description of real life experiences and perception of realities seems very correct.. Anyone can go out and fly and make things happen - on the rare yearly occasions things are ever so slightly different from the ordinary and thats were a professional pilot with experience in his belt sees what lies ahead - as opposed to an less experience pilot - and makes crucial and life saving decisions (diversion, early established, on the numbers speed approach etc. etc.). Owners or less experienced "co-pilots/captains" may think they've got what it takes - it's only human. When you say NO as a pilot - thats when you realize you have come a long way - not when you say YES!
Silleypeoples, thanks for a very valid contribution!
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Thanks Kitekruncher for the translation....I appreciate it. I landed a CE560XL there last year in daylight and VERY VFR conditions. Obviously in an Excel, no problem. I personally would NOT attempt a night landing UNLESS it was TRULY CAVOK there.
I think the talk about runway lengths, IFR into VFR is off the mark.
The case where an aircraft can impact reletively flat ground with the engines at flight idle, speedbrakes out etc indicates very poor situational awarenes. Who was watching the shop when they went below the MDA. Even the most inexperianced night VFR student has this hammered into them. Monitor distance, altitude and flight path.
Btw, 1400m shouldnt be a problem for a C750. They put 737-800s into snow covered runways that are 1500m long at Midway.
The case where an aircraft can impact reletively flat ground with the engines at flight idle, speedbrakes out etc indicates very poor situational awarenes. Who was watching the shop when they went below the MDA. Even the most inexperianced night VFR student has this hammered into them. Monitor distance, altitude and flight path.
Btw, 1400m shouldnt be a problem for a C750. They put 737-800s into snow covered runways that are 1500m long at Midway.
