AA Crash Jamaica
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see page 100
‘Pilots’ risk perception and risk management: their role in plan Continuation errors’.
‘Pilots’ risk perception and risk management: their role in plan Continuation errors’.
At our mob, we divert as necessary, do not need to give a reason, are never questioned by management for doing so, because...the company pays us to do our job, not makes excuses.
Just the facts.
Suits me just fine, thank you.
Agree that max reverse would probably not have helped them to stop.
However, this widespread encouragement of idle reverse in the name of fuel saving and the optimum heating of carbon brakes with one hard application is producing unintended consequences.
Unlike on older Aircraft where we trained to use the all stopping devices to their maximum potential as routine the 'relegation' of reverse thrust to a minor role can lead to an underestimation of it's importance when needed.
I have had to very assertively 'encourage' a few Pilots to get max reverse stuck in early when it's most effective on short / wet runways when it's really needed.
This is even after briefing the requirement prior to the approach. Can't blame them because it has ceased to be part of the normal 'muscle memory'
I do blame the 'negative training' that emphasises saving a few pounds of fuel and 'proper carbon brake heating' or even encouraging the irrational idea that you will 'damage the engines' by using more than idle reverse.
Sometimes 'moving forward' is a step back..
However, this widespread encouragement of idle reverse in the name of fuel saving and the optimum heating of carbon brakes with one hard application is producing unintended consequences.
Unlike on older Aircraft where we trained to use the all stopping devices to their maximum potential as routine the 'relegation' of reverse thrust to a minor role can lead to an underestimation of it's importance when needed.
I have had to very assertively 'encourage' a few Pilots to get max reverse stuck in early when it's most effective on short / wet runways when it's really needed.
This is even after briefing the requirement prior to the approach. Can't blame them because it has ceased to be part of the normal 'muscle memory'
I do blame the 'negative training' that emphasises saving a few pounds of fuel and 'proper carbon brake heating' or even encouraging the irrational idea that you will 'damage the engines' by using more than idle reverse.
Sometimes 'moving forward' is a step back..
Last edited by stilton; 9th Jan 2010 at 05:48.
Stilton;
From the ATSB Accident Report on the QANTAS B747-438 over-run accident at Bangkok, September, 1999, regarding use of reverse thrust, reduced landing flap and use of FOQA data:
Unlike on older Aircraft where we trained to use the all stopping devices to their maximum potential as routine the 'relegation' of reverse thrust to a minor role can lead to an underestimation of it's importance when needed.
I have had to very assertively 'encourage' a few Pilots to get max reverse stuck in early when it's most effective on short / wet runways when it's really needed.
This is even after briefing the requirement prior to the approach. Can't blame them because it has ceased to be part of the normal 'muscle memory'
I have had to very assertively 'encourage' a few Pilots to get max reverse stuck in early when it's most effective on short / wet runways when it's really needed.
This is even after briefing the requirement prior to the approach. Can't blame them because it has ceased to be part of the normal 'muscle memory'
The absolute rates of both QAR events listed in table 8 were low. However, statistical analysis indicated that there was a significant difference in the number of alerts for parameter 161 before and after the flaps 25/idle reverse procedures were introduced (December 1996). The exact reasons for the increase in parameter 161 alerts could not be determined. It is unlikely there was a general change in environmental conditions after December 1996 that resulted in a noticeable increase in the rate of alerts, and was then maintained at a higher level. However, due to the timing of the change, it is reasonable to conclude that the use of flaps 25 (rather than flaps 30) was one of the issues involved. Although the actual flap configuration used on each occasion could not be verified, it is reasonable to conclude, based on the information in section 1.7, that flaps 30 was used almost exclusively before December 1996 and flaps 25 was used predominantly after 6 December 1996. Regardless of the actual reasons for the increase in 161 alerts, the company’s monitoring of QAR data had not detected the increase. The company did not use QAR information to proactively monitor the possible influence of the flaps 25 procedure, and it had not systematically evaluated QAR data using formal statistical methods before the accident. Had it conducted such activities, the increased frequency of high-speed approaches would probably have been detected. The exact reasons for the increase could then have been investigated.
In mid-1999, two senior pilots expressed concern to the Manager B747-400 Training and some other managers that, in certain situations, some first officers did not appear to be considering flaps 30 and full reverse as intelligent options when conducting approach briefings. This issue was raised during the B747-400 training staff meeting in May 1999, and check-and-training staff were asked to ‘encourage and develop airmanship’ in this area. This instruction was recorded in the minutes of the meeting, which were available to all B747- 400 check-and-training personnel. However, during the investigation, a number of checkand- training personnel stated that they could not recall the issue being discussed.
Risk assessment of the flaps 25/idle reverse procedures
In a broad sense, Flight Operations Branch was aware that the risks associated with the flaps 25/idle reverse procedures needed to be considered in its evaluation of the proposal. The prime factors considered during the review process (see attachment H) were that flaps 25 was a certified flap setting, that the landing data did not include the use of reverse thrust, and that some other major airlines had adopted similar procedures. Some personnel considered that the decision to implement the new procedure would probably have not been any different had a formal risk assessment been conducted.
In attachment H, the conclusion is drawn that the informal risk assessment process used by the company in evaluating the flaps 25 and idle reverse proposals contained several
weaknesses. These included:
• There is no evidence that Qantas had sought Boeing’s opinion regarding the safety impact of the new procedures and their potential effect on carbon brake wear. Management personnel agreed that Boeing’s opinion on such issues would be useful, and that they would normally consider the manufacturer’s opinion before changing procedures. Boeing has since stated that it does not support the use of idle reverse thrust as a normal procedure as it increases landing distance. It has also stated that modified braking techniques alone would produce almost as much reduction in brake wear as the combined effect of the flaps 25/idle reverse procedures.
• Qantas examined the flaps 25/idle reverse procedures of two other operators as part of the project development process. This examination was incomplete and did not identify that the procedures used by these operators were more conservative than the proposed Qantas procedures, and had additional safeguards in place for operating on wateraffected runways (see airlines D and E in attachment I).
• The performance differences between idle and full reverse thrust, and between flaps 25
and flaps 30, were not fully examined. Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations.
• There is no evidence that a systematic attempt was made to identify all the situations for which flaps 30 and/or full reverse thrust would be more appropriate.
• The term ‘contaminated’ was used in the flaps 25 procedure but was not defined.
• There appears to have been no review of the human factors implications of the new procedures. For example, there appears to have been no consideration of the extent to which the use of flaps 25/idle reverse could become a skill-based habit (i.e. ‘ the norm’), and therefore might be used by crews when a more conservative configuration was required. As discussed in section 3.1.2, two senior personnel reported problems with the training of flaps 25/idle reverse procedures in mid-1999. However, there is no evidence that any followup action was obtained to assess the significance of this potential hazard.
Observations:
The Flight Operations Branch did not have in place a systematic process for assessing identified risks in its operations. The process of using expert judgement at a series of independent levels probably ensured that most problems associated with new procedures were identified, analysed and evaluated. The shortcomings in the development of the flaps 25/idle reverse procedures clearly indicated the limitations of relying on an informal process.
The approach outlined in AS 4360:1999 is highly desirable.
In a broad sense, Flight Operations Branch was aware that the risks associated with the flaps 25/idle reverse procedures needed to be considered in its evaluation of the proposal. The prime factors considered during the review process (see attachment H) were that flaps 25 was a certified flap setting, that the landing data did not include the use of reverse thrust, and that some other major airlines had adopted similar procedures. Some personnel considered that the decision to implement the new procedure would probably have not been any different had a formal risk assessment been conducted.
In attachment H, the conclusion is drawn that the informal risk assessment process used by the company in evaluating the flaps 25 and idle reverse proposals contained several
weaknesses. These included:
• There is no evidence that Qantas had sought Boeing’s opinion regarding the safety impact of the new procedures and their potential effect on carbon brake wear. Management personnel agreed that Boeing’s opinion on such issues would be useful, and that they would normally consider the manufacturer’s opinion before changing procedures. Boeing has since stated that it does not support the use of idle reverse thrust as a normal procedure as it increases landing distance. It has also stated that modified braking techniques alone would produce almost as much reduction in brake wear as the combined effect of the flaps 25/idle reverse procedures.
• Qantas examined the flaps 25/idle reverse procedures of two other operators as part of the project development process. This examination was incomplete and did not identify that the procedures used by these operators were more conservative than the proposed Qantas procedures, and had additional safeguards in place for operating on wateraffected runways (see airlines D and E in attachment I).
• The performance differences between idle and full reverse thrust, and between flaps 25
and flaps 30, were not fully examined. Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations.
• There is no evidence that a systematic attempt was made to identify all the situations for which flaps 30 and/or full reverse thrust would be more appropriate.
• The term ‘contaminated’ was used in the flaps 25 procedure but was not defined.
• There appears to have been no review of the human factors implications of the new procedures. For example, there appears to have been no consideration of the extent to which the use of flaps 25/idle reverse could become a skill-based habit (i.e. ‘ the norm’), and therefore might be used by crews when a more conservative configuration was required. As discussed in section 3.1.2, two senior personnel reported problems with the training of flaps 25/idle reverse procedures in mid-1999. However, there is no evidence that any followup action was obtained to assess the significance of this potential hazard.
Observations:
The Flight Operations Branch did not have in place a systematic process for assessing identified risks in its operations. The process of using expert judgement at a series of independent levels probably ensured that most problems associated with new procedures were identified, analysed and evaluated. The shortcomings in the development of the flaps 25/idle reverse procedures clearly indicated the limitations of relying on an informal process.
The approach outlined in AS 4360:1999 is highly desirable.
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Rwy 12 threshold elevation is 8'; rwy 30 is 17'. Of course, the threshold elevations by themselves don't describe any undulations along the length of the pavement.
I don't recall any NOTAMs concerning the PAPI servicability; I guess we'll find out soon enough
Tournament level proficiency with HUD does require practice. However, the GS reference line, the FPV and the airspeed deviation cue ("worm/nail" whatever you happen to call it) are pretty basic to HUD operation.
And if the 3.0-deg reference line is "sliding" toward the far end of the runway while a pilot is tunnel-visioned on keeping the FPV on the TDZ, the airspeed deviation cue will be very, very hard to miss.
On a normal HUD approach, pilots typically make corrections for tiniest airspeed deviations shown by the airspeed worm -- i.e., one knot IAS.
As other posters have noted, the fact that the initial touchdown occurred 4000+ from the threshold at Vref would seem to indicate that there was an abundance of energy back at the threshold -- too high, too fast or both.
Far from being a distraction, a HUD will vividly underscore the airplane's energy state referenced directly to the runway.
These pilots were hardly low-time or new to the B737.
It will be interesting to learn the rest of the story as the investigators complete their work.
If the pilot cannot see or perhaps comprehend where the touchdown zone is, nor perhaps see the PAPI (were they working / installed) then the HUD visual mode might be little more than a distraction. Technology is a wonderful thing, but most systems have limits, even pitfalls.
IMHO (and experience with HUD) it could be quite feasible that if the pilot was using HUD he was concentrating on maintaining a reasonable flight path in the turbulent tailwind conditions that he overlooked the GS reference ‘sliding’ down the runway well beyond a sensible touchdown point.
IMHO (and experience with HUD) it could be quite feasible that if the pilot was using HUD he was concentrating on maintaining a reasonable flight path in the turbulent tailwind conditions that he overlooked the GS reference ‘sliding’ down the runway well beyond a sensible touchdown point.
Tournament level proficiency with HUD does require practice. However, the GS reference line, the FPV and the airspeed deviation cue ("worm/nail" whatever you happen to call it) are pretty basic to HUD operation.
And if the 3.0-deg reference line is "sliding" toward the far end of the runway while a pilot is tunnel-visioned on keeping the FPV on the TDZ, the airspeed deviation cue will be very, very hard to miss.
On a normal HUD approach, pilots typically make corrections for tiniest airspeed deviations shown by the airspeed worm -- i.e., one knot IAS.
As other posters have noted, the fact that the initial touchdown occurred 4000+ from the threshold at Vref would seem to indicate that there was an abundance of energy back at the threshold -- too high, too fast or both.
Far from being a distraction, a HUD will vividly underscore the airplane's energy state referenced directly to the runway.
These pilots were hardly low-time or new to the B737.
It will be interesting to learn the rest of the story as the investigators complete their work.
Last edited by Zeffy; 9th Jan 2010 at 13:49. Reason: grammar
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411A,
Do you train for circling approaches at your airline? If so what are the restrictions?
BS
Sorry, does not apoply to our operation, safetypee.
At our mob, we divert as necessary, do not need to give a reason, are never questioned by management for doing so, because...the company pays us to do our job, not makes excuses.
Just the facts.
Suits me just fine, thank you.
At our mob, we divert as necessary, do not need to give a reason, are never questioned by management for doing so, because...the company pays us to do our job, not makes excuses.
Just the facts.
Suits me just fine, thank you.
BS
Per Ardua ad Astraeus
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A plaintive (and oft repeated) plea to support Stilton in his views on reverse. It seems that this 'it's a waste of time'/'only wakes the Captain up' dangerous philosophy is really taking root. There are times when reverse is the ONLY retardation you may unfortunately find on a runway, and its use should always be thought about and encouraged where necessary - and to a standstill as per the drivers' handbook if required.
BOAC;
Slightly off-topic in one way, not in another, but in Canadian winters on contaminated runways one never "relaxed" reverse & braking just because the airplane was down to 60kts and there was lots of runway left.
The biggest surprises are often at the end of the runway when, at below 60 kts we often consider the landing "over", overconfidence in stopping ability has been misled by runway contamination, rubber deposits in rain, etc.
In precip, the first third of the runway is often "dusted off" or perhaps less contaminated due to use, the middle part a bit cleaner due to high-reverse use and the "non-operational" end where the surface was relatively undisturbed by aircraft and engine heat, (such as it was at -28C), was often far more slippery - one never knew.
The lesson of course is, the nature of the runway surface in winter always changes longitudinally and you are absolutely correct; sometimes the only means of stopping was reverse, even in one case I am aware of, coming into the gate in the last 50 ft. Blocked visibility due to blowing snow kicked up by the reverse used then became an issue.
It's never over until there is no more movement, forward or backwards!, period. Back to the thread.
There are times when reverse is the ONLY retardation you may unfortunately find on a runway, and its use should always be thought about and encouraged where necessary - and to a standstill as per the drivers' handbook if required.
The biggest surprises are often at the end of the runway when, at below 60 kts we often consider the landing "over", overconfidence in stopping ability has been misled by runway contamination, rubber deposits in rain, etc.
In precip, the first third of the runway is often "dusted off" or perhaps less contaminated due to use, the middle part a bit cleaner due to high-reverse use and the "non-operational" end where the surface was relatively undisturbed by aircraft and engine heat, (such as it was at -28C), was often far more slippery - one never knew.
The lesson of course is, the nature of the runway surface in winter always changes longitudinally and you are absolutely correct; sometimes the only means of stopping was reverse, even in one case I am aware of, coming into the gate in the last 50 ft. Blocked visibility due to blowing snow kicked up by the reverse used then became an issue.
It's never over until there is no more movement, forward or backwards!, period. Back to the thread.
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can someone with a keen computer post an image of the lighting of a runway showing the white, amber, green and red lights and how they tell a pilot what sort of runway is remaining...without touchdown zone lights
hey, did the airport have centerline lights?
hey, did the airport have centerline lights?
Last edited by protectthehornet; 9th Jan 2010 at 22:59.
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Do you train for circling approaches at your airline? If so what are the restrictions?
We not only train for circling approaches, we do circling approaches, at night, if necessary, at the lowest charted minima (600 agl) for our type (category D, large heavy jet).
No problems encountered, to date.
And, no problems expected.
Why, you might ask?
Because...we train our pilots to proficiency and I see to it that this is accomplished.
No excuses.
We're oldtimers here..and we know how to do the job.
We also fly the Lockheed L1011...an old time airliner that is second to none for CATIII ops, when needed
Ahhhh, Lockheed
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Call me an old fart , or a cantankerous old fart. . . but whenever I have landed in places where it said "reverse thrust only allowed for safety reasons" I have always used detent 2 (or 3 if I was a little pissed off that day) When the guy on the right said why ? simple I said, for the safety of my licence . . . and yours.
After what the Greeks did to the Swissair crew in Athens, can you believe they had the cheek to put this sh1t on a Jepp? for Athens
Give it large, pull those handles back any time you want to hear that comforting sound, the sound of your licence being protected.
F#CK the accountants
F#CK the @ssholes in Civil Aviation (of whatever country)
Vive le Commandant/ Vive le revolution
Be feckin serious guys, back to basics, back to 1960, this is a big piece of tin, going very fast, and YOU Captain ! need to stop it before you are in the Boonies, for Christs sake man, forget all this do goody good ecological /save 50kg of fuel **** . . . pull da fookin levahs- push da pedals & stop da fookin aircraft. Jeezus is it really so hard ? ? You a pilot? or a dumb-asss systems operator.
I really think gentlemen, we are sometimes guilty of getting hung up on details, and thereby losing sight of the big picture. . . best not to , really!
Get back to basic basic basics, land the fecker (somewhere sensible on the RW) and get it stopped somewhere that you can subsequently taxi it to a stand, christ, nothing changed this last 50 yrs, did it ? ?
After what the Greeks did to the Swissair crew in Athens, can you believe they had the cheek to put this sh1t on a Jepp? for Athens
Give it large, pull those handles back any time you want to hear that comforting sound, the sound of your licence being protected.
F#CK the accountants
F#CK the @ssholes in Civil Aviation (of whatever country)
Vive le Commandant/ Vive le revolution
Be feckin serious guys, back to basics, back to 1960, this is a big piece of tin, going very fast, and YOU Captain ! need to stop it before you are in the Boonies, for Christs sake man, forget all this do goody good ecological /save 50kg of fuel **** . . . pull da fookin levahs- push da pedals & stop da fookin aircraft. Jeezus is it really so hard ? ? You a pilot? or a dumb-asss systems operator.
I really think gentlemen, we are sometimes guilty of getting hung up on details, and thereby losing sight of the big picture. . . best not to , really!
Get back to basic basic basics, land the fecker (somewhere sensible on the RW) and get it stopped somewhere that you can subsequently taxi it to a stand, christ, nothing changed this last 50 yrs, did it ? ?
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Call me an old fart , or a cantankerous old fart. . . but whenever I have landed in places where it said "reverse thrust only allowed for safety reasons" I have always used detent 2 (or 3 if I was a little pissed off that day) When the guy on the right said why ? simple I said, for the safety of my licence . . . and yours.
After what the Greeks did to the Swissair crew in Athens, can you believe they had the cheek to put this sh1t on a Jepp? for Athens
Give it large, pull those handles back any time you want to hear that comforting sound, the sound of your licence being protected.
F#CK the accountants
F#CK the @ssholes in Civil Aviation (of whatever country)
Vive le Commandant/ Vive le revolution
Be feckin serious guys, back to basics, back to 1960, this is a big piece of tin, going very fast, and YOU Captain ! need to stop it before you are in the Boonies, for Christs sake man, forget all this do goody good ecological /save 50kg of fuel **** . . . pull da fookin levahs- push da pedals & stop da fookin aircraft. Jeezus is it really so hard ? ? You a pilot? or a dumb-asss systems operator.
I really think gentlemen, we are sometimes guilty of getting hung up on details, and thereby losing sight of the big picture. . . best not to , really!
Get back to basic basic basics, land the fecker (somewhere sensible on the RW) and get it stopped somewhere that you can subsequently taxi it to a stand, christ, nothing changed this last 50 yrs, did it ? ?
After what the Greeks did to the Swissair crew in Athens, can you believe they had the cheek to put this sh1t on a Jepp? for Athens
Give it large, pull those handles back any time you want to hear that comforting sound, the sound of your licence being protected.
F#CK the accountants
F#CK the @ssholes in Civil Aviation (of whatever country)
Vive le Commandant/ Vive le revolution
Be feckin serious guys, back to basics, back to 1960, this is a big piece of tin, going very fast, and YOU Captain ! need to stop it before you are in the Boonies, for Christs sake man, forget all this do goody good ecological /save 50kg of fuel **** . . . pull da fookin levahs- push da pedals & stop da fookin aircraft. Jeezus is it really so hard ? ? You a pilot? or a dumb-asss systems operator.
I really think gentlemen, we are sometimes guilty of getting hung up on details, and thereby losing sight of the big picture. . . best not to , really!
Get back to basic basic basics, land the fecker (somewhere sensible on the RW) and get it stopped somewhere that you can subsequently taxi it to a stand, christ, nothing changed this last 50 yrs, did it ? ?
For the record, we use MAX reverse on every landing with our Lockheed airplane, no matter what.
Why?
Standard procedure...with the possible exception of Geneva, conditions permitting, of course.
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Good vs. Good enough
we have become a society of pilots in which good enough is routine.
and 411a reminded me of something important...train to proficiency instead of training to be good enough to pass a check ride.
.who wants to be an average pilot? I never wanted to be average...well above was minimum in my mind.
And in the sim...you should hold reverse on every critical situation until you are going backward!
and 411a reminded me of something important...train to proficiency instead of training to be good enough to pass a check ride.
.who wants to be an average pilot? I never wanted to be average...well above was minimum in my mind.
And in the sim...you should hold reverse on every critical situation until you are going backward!
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No mention of African continent air carriers below
I've come to the conclusion that American Airlines pilots surely have been
unfairly demonized after reading the replies thus far in this thread.
Normally, unless we're talking about a few Eastern European or several South American airlines for example, most come to the crews defense early on with British Airways often being the exception.
People love to pick on those BA guys for some odd reason.
unfairly demonized after reading the replies thus far in this thread.
Normally, unless we're talking about a few Eastern European or several South American airlines for example, most come to the crews defense early on with British Airways often being the exception.
People love to pick on those BA guys for some odd reason.
captplaystation and PJ2 - how true!
The manufacturer fitted landing flaps (ie full), Autobrakes (backed up by manual brakes) and Reverse Thrust for a reason - to stop the b****y a/c on the paved surface!
The manufacturer fitted landing flaps (ie full), Autobrakes (backed up by manual brakes) and Reverse Thrust for a reason - to stop the b****y a/c on the paved surface!
Penko, a good question and am happy to take it! Am sure you know the answer to the question. Of course not! Everything landing needs to be careful assessed in terms of flap setting, autobrake level, reverse thrust etc.
However, as playstation so eloquently implied, the emphasis on idle reverse, lower flap settings etc for reasons of "economy" and "environment" is tending to cloud our responsibilities as professional pilots of operating safely, methinks, especially (dare I say it) with the "new" generation of pilots, for whom I have to say I have the utmost respect.
There's nothing too economic about an overrun and it probably won't help the environment either.
However, as playstation so eloquently implied, the emphasis on idle reverse, lower flap settings etc for reasons of "economy" and "environment" is tending to cloud our responsibilities as professional pilots of operating safely, methinks, especially (dare I say it) with the "new" generation of pilots, for whom I have to say I have the utmost respect.
There's nothing too economic about an overrun and it probably won't help the environment either.