Monarch & the Rock
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Pilot Pete,
The SRA to RW09 is carried out on a northerly track. The 90 degree turn towards the runway and the rock is only made after going visual.
Interestingly, there is no MDA, just a minimum cloud base of 1000'. A missed approach would normally commence at 1000' above the field, on a northerly heading, turning east after 1900'.
The SRA to RW09 is carried out on a northerly track. The 90 degree turn towards the runway and the rock is only made after going visual.
Interestingly, there is no MDA, just a minimum cloud base of 1000'. A missed approach would normally commence at 1000' above the field, on a northerly heading, turning east after 1900'.
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DH121
Thanks for that, my point being though that on approaches like this (I go to Samos regularly) you need a bit more thought and briefing because you aren't necessarily going to go around from the point you describe heading north!
Monarch Man's comments are as frank as mine, with some additional comments such as the fact that the GIB missed approach is also available in the FMC. I refrained from suggesting that as it wasn't mentioned in the AAIB report and I have not been to GIB, but if we want to learn something from this it is important to ask WHY did this situation develop, HOW did they get the missed approach so wrong and WHY did the crew stop operating effectively?
As there is no complete answer in the AAIB report one can only speculate.
1. Why did the situation develop? Possibly due to several previous benign arrivals into GIB as Monarch Man suggests. But the fact that you have to get specially checked out to go there and (presumably) an extensive airfield brief is enough to remind you each time you go there that it is somewhere to give extra consideration and respect to. The report says that there was a lack of a comprehensive brief prior to the approach. This could indeed lead to perhaps the plan not being fully complete in the mind of at least one of the flight crew. Having been somewhere lots of times before can lead to the temptation to underbrief.
2. How did they get the missed approach so wrong? I think they lost visual and elected to go around. The workload was high and an action error occurred, namely forgetting to press the TOGA switch. The unexpected had happened, they were late in the approach and the brain would have been thinking about rolling out onto final, searching and looking for the visual reference and the all of a sudden this was lost. Once the missed approach was actioned incorrectly I think this is what caused the loss of SA; thrust was manually increased and the nose was rising to the go around pitch attitude. The PNF was on the radio and then noticed no annunciation of G/A on the FMA. He called this to the PF which was not something that he would be ready for or expecting to hear. He pressed the TOGA switch and the flight directors popped back up. This distraction drew attention away from the MAP display which would have been showing that they were not lined up with the runway, not positioning towards the runway extended centreline or following the LNAV missed approach (if displayed on the map). A brief moment of confusion (we've all been there) and the prioritisation breaks down. After the G/A had been initiated, the G/A attitude selected, the flaps set for the G/A and the gear retracted the next priority would be to get onto the required track. This didn't occur and SA was lost with them heading towards the high ground.
3. Why did the crew stop operating effectively? Workload management I would suggest. Thorough brief perhaps missing and then the unexpected happened. The workload then goes up even more and the overload was not recognised (forgetting how to initiate the missed approach using the TOGA button), this leads to loss of SA in at least the PF, but by the sounds of the report the PNF too as nothing was said about the tracking. Then a radio call to say going around which was not the priority, followed by the PNF pointing out that G/A was not annumnciated. This was correct, but could possibly have become a distraction for the PF, taking his mind away from the tracking (MAP display) and onto the EADI. Pressing the TOGA switch then caused the flight directors to pop up and to show current ground track, which was not following the missed approach procedure. The flight directors are very powerful stimuli and it can be difficult to ignore them. I think this compounded the loss of SA. The PF was still turning when he thought he was in wings level flight, so he would have been diverging from the flight director commanded heading too. And during this high workload the PNF didn't mention anything about the lack of correct missed approach tracking. I suspect his SA was lost too in the confusion that was happening VERY quickly. Then the controller recognised the problem and told them to keep their turn going onto 180 degrees as the best way of avoiding terrain. Once the heading was selected to 180 degrees and HDG SEL taken the PNF obviously regained his SA and prompted the PF that the high terrain was on their left from his terrain display.
My airline have a CRM Skills List, which was developed using one of the industry's leading lights on CRM together with our training department. The whole thing centres around WORKLOAD, with sub headings in that area of 'recognises high workload', 'takes or makes time', 'deals with overload and prioritises' and 'avoids distraction and distracting'. We use the list to debrief sim performances and line checks etc. It is a VERY USEFUL tool and I have worked through it with this scenario and it is very helpful.
Now I may be wildly wrong with my speculation about how it happened, but that's how I read the report and those are the lessons I have taken from it.
PP
Thanks for that, my point being though that on approaches like this (I go to Samos regularly) you need a bit more thought and briefing because you aren't necessarily going to go around from the point you describe heading north!
Monarch Man's comments are as frank as mine, with some additional comments such as the fact that the GIB missed approach is also available in the FMC. I refrained from suggesting that as it wasn't mentioned in the AAIB report and I have not been to GIB, but if we want to learn something from this it is important to ask WHY did this situation develop, HOW did they get the missed approach so wrong and WHY did the crew stop operating effectively?
As there is no complete answer in the AAIB report one can only speculate.
1. Why did the situation develop? Possibly due to several previous benign arrivals into GIB as Monarch Man suggests. But the fact that you have to get specially checked out to go there and (presumably) an extensive airfield brief is enough to remind you each time you go there that it is somewhere to give extra consideration and respect to. The report says that there was a lack of a comprehensive brief prior to the approach. This could indeed lead to perhaps the plan not being fully complete in the mind of at least one of the flight crew. Having been somewhere lots of times before can lead to the temptation to underbrief.
2. How did they get the missed approach so wrong? I think they lost visual and elected to go around. The workload was high and an action error occurred, namely forgetting to press the TOGA switch. The unexpected had happened, they were late in the approach and the brain would have been thinking about rolling out onto final, searching and looking for the visual reference and the all of a sudden this was lost. Once the missed approach was actioned incorrectly I think this is what caused the loss of SA; thrust was manually increased and the nose was rising to the go around pitch attitude. The PNF was on the radio and then noticed no annunciation of G/A on the FMA. He called this to the PF which was not something that he would be ready for or expecting to hear. He pressed the TOGA switch and the flight directors popped back up. This distraction drew attention away from the MAP display which would have been showing that they were not lined up with the runway, not positioning towards the runway extended centreline or following the LNAV missed approach (if displayed on the map). A brief moment of confusion (we've all been there) and the prioritisation breaks down. After the G/A had been initiated, the G/A attitude selected, the flaps set for the G/A and the gear retracted the next priority would be to get onto the required track. This didn't occur and SA was lost with them heading towards the high ground.
3. Why did the crew stop operating effectively? Workload management I would suggest. Thorough brief perhaps missing and then the unexpected happened. The workload then goes up even more and the overload was not recognised (forgetting how to initiate the missed approach using the TOGA button), this leads to loss of SA in at least the PF, but by the sounds of the report the PNF too as nothing was said about the tracking. Then a radio call to say going around which was not the priority, followed by the PNF pointing out that G/A was not annumnciated. This was correct, but could possibly have become a distraction for the PF, taking his mind away from the tracking (MAP display) and onto the EADI. Pressing the TOGA switch then caused the flight directors to pop up and to show current ground track, which was not following the missed approach procedure. The flight directors are very powerful stimuli and it can be difficult to ignore them. I think this compounded the loss of SA. The PF was still turning when he thought he was in wings level flight, so he would have been diverging from the flight director commanded heading too. And during this high workload the PNF didn't mention anything about the lack of correct missed approach tracking. I suspect his SA was lost too in the confusion that was happening VERY quickly. Then the controller recognised the problem and told them to keep their turn going onto 180 degrees as the best way of avoiding terrain. Once the heading was selected to 180 degrees and HDG SEL taken the PNF obviously regained his SA and prompted the PF that the high terrain was on their left from his terrain display.
My airline have a CRM Skills List, which was developed using one of the industry's leading lights on CRM together with our training department. The whole thing centres around WORKLOAD, with sub headings in that area of 'recognises high workload', 'takes or makes time', 'deals with overload and prioritises' and 'avoids distraction and distracting'. We use the list to debrief sim performances and line checks etc. It is a VERY USEFUL tool and I have worked through it with this scenario and it is very helpful.
Now I may be wildly wrong with my speculation about how it happened, but that's how I read the report and those are the lessons I have taken from it.
PP
Just as a follow up to my previous post....
As far as I can gauge, there are a fair spread of opinions around the bases as to why/how this could have occured.
In my experience MON is an organisation with a weath of expertise, tech know how, and most importantly training ethos.
The lessons taken from this incident will be replayed, analyzed, disected, and poured through by our training departments for the next 10 years, with an emphasis on the error chain and CRM aspects of it.
I would also like to add at this point that MON as a general rule respects the fact that crews are human, and that we make mistakes, the company tends to train rather than apply punitive measures.
Like P Pete's employer, MON have an extensive and IMHO innovative CRM programme (although depending apon who you talk too, the opinions can vary a bit), we operate into and out of some fairly challenging places (GIB, Skiathos, Samos, INN, and a few more besides) with specific and well understood/reviewed procedures.
As I've said before, my personal opinion of the error chain is that this began in the weeks and months previous. I for one can hold my hand up to switching freq's close to the ground.
As far as I can gauge, there are a fair spread of opinions around the bases as to why/how this could have occured.
In my experience MON is an organisation with a weath of expertise, tech know how, and most importantly training ethos.
The lessons taken from this incident will be replayed, analyzed, disected, and poured through by our training departments for the next 10 years, with an emphasis on the error chain and CRM aspects of it.
I would also like to add at this point that MON as a general rule respects the fact that crews are human, and that we make mistakes, the company tends to train rather than apply punitive measures.
Like P Pete's employer, MON have an extensive and IMHO innovative CRM programme (although depending apon who you talk too, the opinions can vary a bit), we operate into and out of some fairly challenging places (GIB, Skiathos, Samos, INN, and a few more besides) with specific and well understood/reviewed procedures.
As I've said before, my personal opinion of the error chain is that this began in the weeks and months previous. I for one can hold my hand up to switching freq's close to the ground.
PP, DH121, MM, et al, the discussion continues to raise interesting points and questions.
Re “… the GIB missed approach is also available in the FMC.”
Is the FMC approved for flying the missed approach - LNAV? My logic would suggest that if it is then why isn’t the FMS used for the approach? Thus LNAV / GA not approved?
Is the FMC accurate enough to ensure no map shift (at GIB); as above, if so use it, but if not, then could a map display be a distraction – even a hazard – see the many incidents involving map shift. The report states that crew were verifying map accuracy prior to the approach.
“How did they get the missed approach so wrong?”
Previous posts described the procedure as a climb on North until 1900ft then turn on to East. In the incident the aircraft had passed the visual decision point ‘MDA’ – the assumed MAP for a GA procedure (?), and was already turning onto East. Thus the crew were faced with a GA from a location not on the missed approach track and well below the altitude requirement of the Easterly heading. So what is the procedure for the loss of visual contact on late final? Do operators assume that the aircraft will be visual to maintain runway hdg – a false assumption in this instance? Any conclusion that the ‘missed approach’ procedure was incorrectly flown could be based on a false premise as it appears that there is no procedure applicable from the location that the crew started from, i.e. a gap in the procedures?
“An action error occurred, namely forgetting to press the TOGA switch.”
An essential element of training and procedures is that they minimise the crew exposure to situations where a single (foreseeable) error can hazard the flight. The operational requirements in JAR-OPS / FCL might assume that any crew would be capable of flying a GA without FD – power, pitch, roll, hdg. A related assumption might be that leaving the FD displayed during a visual approach is not distracting – the assumption being that pilots are taught to ‘look-through’ the FD to the attitude display. I suspect that these might be false assumptions, if so who tells the JAA?
I do not like the term ‘loss of situation awareness’; it suggest that some ‘thing’ can be lost or gained. Most, even the best CRM instructors struggle to define the operational content of the situation and the practical circumstances for loss or gain.
In the incident the crew’s situation awareness was sufficiently accurate to fly the approach and for them to determine the need for a GA. Thereafter their awareness either did not match the actual situation or it was insufficient for them to comprehend the need for a change of action (the commander did not perceive that he was turning – his situation was ‘falsely’ wings level).
How would a commander incorporate a GA SOP into situation assessment (before choosing a course of action) where there is no SOP applicable to the perceived geographic situation? Not that there can be an SOP for every possible circumstance, but there should be some guidance for all of those foreseeable situations – a risk assessment task for company management.
Many pilots discount the threat of illusions. Hopefully most will have experienced some form of turning illusion during instrument training – at a safe altitude with an instructor, and learn to counter it. However, experiencing an illusion in operation, in low visibility, and at low altitude could be very disturbing. In addition both pilots could suffer a turning illusion at the same time, and furthermore if there is significant head movement then there could be a risk of a Coriolis (turning) illusion – dizziness / tumbling.
A recent paper on EGPWS warnings (FSF Safety Seminar Athens) reported illusion as a contribution to approach incidents; one example of a black hole illusion during the approach resulted in a ‘heavy’ being at 125ft at 1.5 nm still descending (FAF Aviation Safety World July 2006).
It appears that there are many contributions to this incident which may have been ‘assumed’, and even more in what this discussion has covered. Perhaps this identifies an important issue in human factors safety – beware of assumptions.
Re “… the GIB missed approach is also available in the FMC.”
Is the FMC approved for flying the missed approach - LNAV? My logic would suggest that if it is then why isn’t the FMS used for the approach? Thus LNAV / GA not approved?
Is the FMC accurate enough to ensure no map shift (at GIB); as above, if so use it, but if not, then could a map display be a distraction – even a hazard – see the many incidents involving map shift. The report states that crew were verifying map accuracy prior to the approach.
“How did they get the missed approach so wrong?”
Previous posts described the procedure as a climb on North until 1900ft then turn on to East. In the incident the aircraft had passed the visual decision point ‘MDA’ – the assumed MAP for a GA procedure (?), and was already turning onto East. Thus the crew were faced with a GA from a location not on the missed approach track and well below the altitude requirement of the Easterly heading. So what is the procedure for the loss of visual contact on late final? Do operators assume that the aircraft will be visual to maintain runway hdg – a false assumption in this instance? Any conclusion that the ‘missed approach’ procedure was incorrectly flown could be based on a false premise as it appears that there is no procedure applicable from the location that the crew started from, i.e. a gap in the procedures?
“An action error occurred, namely forgetting to press the TOGA switch.”
An essential element of training and procedures is that they minimise the crew exposure to situations where a single (foreseeable) error can hazard the flight. The operational requirements in JAR-OPS / FCL might assume that any crew would be capable of flying a GA without FD – power, pitch, roll, hdg. A related assumption might be that leaving the FD displayed during a visual approach is not distracting – the assumption being that pilots are taught to ‘look-through’ the FD to the attitude display. I suspect that these might be false assumptions, if so who tells the JAA?
I do not like the term ‘loss of situation awareness’; it suggest that some ‘thing’ can be lost or gained. Most, even the best CRM instructors struggle to define the operational content of the situation and the practical circumstances for loss or gain.
In the incident the crew’s situation awareness was sufficiently accurate to fly the approach and for them to determine the need for a GA. Thereafter their awareness either did not match the actual situation or it was insufficient for them to comprehend the need for a change of action (the commander did not perceive that he was turning – his situation was ‘falsely’ wings level).
How would a commander incorporate a GA SOP into situation assessment (before choosing a course of action) where there is no SOP applicable to the perceived geographic situation? Not that there can be an SOP for every possible circumstance, but there should be some guidance for all of those foreseeable situations – a risk assessment task for company management.
Many pilots discount the threat of illusions. Hopefully most will have experienced some form of turning illusion during instrument training – at a safe altitude with an instructor, and learn to counter it. However, experiencing an illusion in operation, in low visibility, and at low altitude could be very disturbing. In addition both pilots could suffer a turning illusion at the same time, and furthermore if there is significant head movement then there could be a risk of a Coriolis (turning) illusion – dizziness / tumbling.
A recent paper on EGPWS warnings (FSF Safety Seminar Athens) reported illusion as a contribution to approach incidents; one example of a black hole illusion during the approach resulted in a ‘heavy’ being at 125ft at 1.5 nm still descending (FAF Aviation Safety World July 2006).
It appears that there are many contributions to this incident which may have been ‘assumed’, and even more in what this discussion has covered. Perhaps this identifies an important issue in human factors safety – beware of assumptions.
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Drop me off miles from the runway...
Please forgive the slight digression (another man's hijacking?), but doesn't this incident brightly illuminate the hazards of "IFR drop-offs at a point in space" approach procedures? -- i.e., those with circling-only minima and very high HAA's/HAT's, those with lengthy visual segments, etc.
Irrespective of the cause (crew error, scud, precip, etc.) -- initiating a missed approach from a point beyond the MAP and/or below MDA/DA is fraught with risks.
RNP_RNAV procedures have the potential to greatly reduce risk at locations like LXGB. For example, note that two procedures at another challenging airport not only provide continuous vertical guidance and vastly improved operating minima, they also offer positive course guidance throughout the missed approach segment.
http://www.aip.net.nz/pdf/NZQN_45.3_45.4.pdf
Obviously, RF (Radius to Fix) legs provide the procedure designer enormous flexibility.
Procedures like the NZQN RNAV imply the need for GPS-updating of the FMS in addition to FD logic that sustains LNAV-coupling in the event of a GA selection. Dropping to TRK, HDG or ROLL HOLD won't do a satisfactory job of keeping the airplane in the middle of the fairway, especially when the DA point occurs in a turn.
Irrespective of the cause (crew error, scud, precip, etc.) -- initiating a missed approach from a point beyond the MAP and/or below MDA/DA is fraught with risks.
RNP_RNAV procedures have the potential to greatly reduce risk at locations like LXGB. For example, note that two procedures at another challenging airport not only provide continuous vertical guidance and vastly improved operating minima, they also offer positive course guidance throughout the missed approach segment.
http://www.aip.net.nz/pdf/NZQN_45.3_45.4.pdf
Obviously, RF (Radius to Fix) legs provide the procedure designer enormous flexibility.
Procedures like the NZQN RNAV imply the need for GPS-updating of the FMS in addition to FD logic that sustains LNAV-coupling in the event of a GA selection. Dropping to TRK, HDG or ROLL HOLD won't do a satisfactory job of keeping the airplane in the middle of the fairway, especially when the DA point occurs in a turn.
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One other thing worth pointing out is that if the Spanish allowed flights inbound/outbound from GIB to use their airspace that is in close proximity (ie around Algeciras/La Linea) then this incident probably wouldn't have occurred. It is only recently that they started allowing diversions to Spanish airports.
Similar airspace politics contributed to the Crossair RJ crash at Zurich a few years ago.
Politics compromising flight safety.
Similar airspace politics contributed to the Crossair RJ crash at Zurich a few years ago.
Politics compromising flight safety.
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Originally Posted by Cuillin
Politics compromising flight safety.
Having acknowledged that ugly little facet, the characteristics of RNP RNAV procedures would frequently permit accommodation of the political/environmental/ATC requirements without having to resort to risky NPA's with long visual segments, landings with tailwinds, landings with difficult x-wind components, etc.
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Is this the same MON 757 Gibraltar event I recall a thread on here a wee while back when a contributor claimed he was a pilot sitting in the back of the plane? Other contributors doubted his credentials. I recall reading about the lights of various Spanish towns visible at various points in the flight - or was that another MON/GIB event (or "non-event")?
Rgds, Neil
Rgds, Neil
Train the way you fly... Fly the way you train.
RNP RNAV Procedures are great and GNS approaches are coming. However we have to work with what we have..and therein lies the problem. Round dials and NDB approaches concentrated the mind wonderfully. We now have glass everything and we let the magic fly us. 
Back to basics chaps. Every go-round is annunciated.."Go-round TOGA". Said every time ,done every time. PRESS the BUTTON. Now at least we have our FD pointing where it should. BUT. And this is a hugh BUT... its dumb. Pitch up and wings level is all it knows. We have to follow a routine. Again every time and the same way every time. Flaps, positive rate, gear, Missed approach altitude. NOW make your FD smart. Give it a roll and pitch mode mode. Heading and V/S (or FLCH). Now at the very least you are climbing to a safe altitude and you have control of your heading. Now turn the d#mn thing yourself or if you can't live without FMS, verify the missed approach has sequenced and arm LNAV. Works every time and more to the point, since you've done it a thousand times in the sim it's a non event. And before you start firing I've done my share of missed approaches for real and they really aren't a big deal.
Back to basics chaps. Every go-round is annunciated.."Go-round TOGA". Said every time ,done every time. PRESS the BUTTON. Now at least we have our FD pointing where it should. BUT. And this is a hugh BUT... its dumb. Pitch up and wings level is all it knows. We have to follow a routine. Again every time and the same way every time. Flaps, positive rate, gear, Missed approach altitude. NOW make your FD smart. Give it a roll and pitch mode mode. Heading and V/S (or FLCH). Now at the very least you are climbing to a safe altitude and you have control of your heading. Now turn the d#mn thing yourself or if you can't live without FMS, verify the missed approach has sequenced and arm LNAV. Works every time and more to the point, since you've done it a thousand times in the sim it's a non event. And before you start firing I've done my share of missed approaches for real and they really aren't a big deal.
Is this the same MON 757 Gibraltar event I recall a thread on here a wee while back when a contributor claimed he was a pilot sitting in the back of the plane? Other contributors doubted his credentials. I recall reading about the lights of various Spanish towns visible at various points in the flight - or was that another MON/GIB event (or "non-event")?
Rgds, Neil
Rgds, Neil
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If only we were all as good as flown-it. sounds like he never makes mistakes!
Seems to have spent a lot of time in the sim though?
Now lets try that one again shall we ace!
Seems to have spent a lot of time in the sim though?
Now lets try that one again shall we ace!
No one has followed up on the issue that the location of the point at which the approach was discontinued was not on the missed approach path. Furthermore, there does not appear to be any approved procedure for loss of visual reference after commencing the turn and continuing the descent below the ‘visual commit point’.
Perhaps we should consider the crews mental workload / puzzlement in this situation; is the GA wings level straight ahead, or is a turn back onto North allowable/safe. In either event, there might be considerations of obstacle clearance (or over flying national boundaries).
This might represent the classic case of a situation where there is no SOP – the crew has to solve the problem of what to do there and then; unfortunately being ‘there’ is not conducive to continued safety and ‘then’ requires immediate action.
Perhaps we should consider the crews mental workload / puzzlement in this situation; is the GA wings level straight ahead, or is a turn back onto North allowable/safe. In either event, there might be considerations of obstacle clearance (or over flying national boundaries).
This might represent the classic case of a situation where there is no SOP – the crew has to solve the problem of what to do there and then; unfortunately being ‘there’ is not conducive to continued safety and ‘then’ requires immediate action.
