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Lockhart River Coroners Findings (Merged)

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Old 31st Aug 2007, 06:17
  #61 (permalink)  
 
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It is very rare that I find myself on the opposite side of a debate from CC. However, that is the case on this occassion.

I have flown the YLHR GPSRNAV Appr in question on several occassions and do not see a problem with it or any other Ozzie GPSRNAV Appr.

BUT - I have a moving map on the GNS430 which make situational awareness much easier than older generatation approach capable GPS units.

I can see how a mistake could be made in relation to where you are on the descent, and I guess if if one flies the approach with the same disregard for the rules that appear to be evident in this case - the outcome is probably a forgone conclusion - eventually!

Dr

Last edited by ForkTailedDrKiller; 31st Aug 2007 at 07:54.
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Old 31st Aug 2007, 07:31
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On the aircraft I used to fly I had the benefit of map mode on the EHSI (being fed by a Trimble 2101) and the flight manual only allowed a GPSNPA to be flown in coupled mode - no hand flying even with flight director bars. It beats me how the guys fly the approach (on evidence quite successfully) with only the raw data 2101 presentation, and hand flying it at that. I'm afraid as I said before, I agree with CC, if only because of the work load involved, and the attention that is needed to "place" yourself in the correct segment of the approach. Easy with the map mode, but raw data? I suspect, but don't know if, this was one aspect which required our "coupled only" certification.

We are all entitled to our point of view, eg;

If you get your landings wrong the instructor doesn't sign you off for solo.
Quite right, and how many highly experienced aviators have found them selves sitting in the grass/over run/wreckage following a landing gone wrong wishing they could relive the previous five minutes. We all stuff it up at times, even the good Doctor, who didn't know whether it sucked or it blew (knows now but ), and that includes misreading/misunderstanding approach charts. Cargo 747 at KL for one. Or do some of you people never make mistakes - honest ones that is? Call me thick if you will, plenty of people do.
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Old 31st Aug 2007, 07:52
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"We all stuff it up at times, even the good Doctor, who didn't know whether it sucked or it blew (knows now but )"

.... but ignorance of "suck" or "blow" is unlikely to end one's life cycle!

ahhhhhh, well in an aviation sense anyway!

Dr
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Old 31st Aug 2007, 08:26
  #64 (permalink)  

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RR I am GPSNPA qualified and I do fly them...as published...but I have been instrument rated for over 20 years and have held Instrument C&Ting approvals, including Initial Issue captain/copilot and am very aware of the potential problems with the approach design...and have seen how innexperienced IFR pilots get confused.

The GPSNPA is an unreasonably complicated approach and what makes it so is the Foxtrot waypoint half way down finals. If the FAF waypoint was at say 9nm/2500agl and the MAP waypoint was, say, 2.0nm/600agl, or even 1.5nm/450agl ir would be VERY much more difficult to lose situational awareness and descend early.

It shouldn't need a high end moving map to safely fly a GPSNPA...It should be easy enough even with something like my KLN90b etc.

Whomever wrote into the TSO that a waypoint should be stuck where the foxtrot waypoint is clearly has next to no IFR experience. Then someone componded that by a less than simple waypoint naming protocol.

GPS is a highly accurate navigation system and it should have been reasonable to expect as simple as possible an approach to make best use of the technology...but we got something as complicated as possible...it's almost as if the same technogeeks that design Airbus aircraft wrote the GPSNPA TSO. GPSNPA are a human factors nightmare...just because most people manage to work around the inherant problems doesn't make them any less a problem.

There should be no more than 3 waypoints on a GPSNPA...IAF, FAF and MAF. The FAF waypoint should be up around 2400'agl and 8nm from the runway. If I was designing them there would be a dist/alt scale across the bottom WITH a 3x profile printed next to it that if followed would result in a safe constant descent to the MAP waypoint. The pilot could then load the approach read the chart profile and put the plate aside and merely fly the aircraft rather than constantly looking at the approach plate to check where he was in the approach...no distance counter marching down from 5nm to 0nm several times in the course of flying the approach. THAT is the potential confusion and it is potentially deadly....and it serves no usefull purpose.

I think it is HIGHLY likely that in the heat of the moment the co-pilot offered missleading advice on their position in the approach...however well intentioned. Had the approach been designed along the lines of every other approach with DME (of some description) then even if the copilot gave missleading advice the captain would instantly recognise it as such and discount it.

Yes the copilot in this case was not qualified to actively participate in the approach...but human nature suggests a captain would be more likely to try and keep a 2 crew interaction going in the most high workload part of the sector...most pilots in this situation would consider it good CRM...it is not a hugh stretch to suggest the captain had developed some degree of trust in the young man and thought he was more than capable of reading the chart and recognising the waypoint names well enough to be of help.

We'll of course never know for sure but is it more or less likely that this is what happened or that the captain just decided on the spur of the moment that a dirty dive to VMC was called for in an area he knew to have terrain considerations?

I just do not accept that the captain, whatever his perceived professional faults, was that stupid...suicidal or confused?

It is easy to say that if the FO was qualified to fly the approach the accident may not have happened...equally it is reasonable to suggest innexperience may have caused him to be similarly confused and still misslead the captain with well intentioned but deadly advice.

Had the approach been designed with proper Human Factors taken into account there is MUCH less likelyhood ANYONE would have been confused and if ONE person was it is MUCH less likely the other would have been too and flown into the ground as a result.

The design of these approaches is a hole in the cheese that DOES NOT NEED TO EXIST.

In my view this is a design fault that is even more a potential trap for single pilot operations...it shouldn't need FTDK's high end moving map to fly safely.

Interestingly Air Niugini BANNED non EFIS (big moving map nav display) aircraft from flying these approaches...I say again BANNED them.

Why?

Because Air Niugini pilots spend their entire working lives in and around terrain, bad weather and truly crap ATC and the check and training system has been teaching profiles and demanding a very high standard of situational awareness for DECADES...they have never had a CFIT even though the PX operation suffers EVERY SINGLE RISK factor for CFIT...all in spades.
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Old 31st Aug 2007, 08:35
  #65 (permalink)  

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It is of course equally possible that the captain became confused about his exact position with no input from the FO at all...same result for the same reasons.

These approaches are a human factors **** up.
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Old 31st Aug 2007, 11:44
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"It is very rare that I find myself on the opposite side of a debate from CC. However, that is the case on this occassion."

Naah! On second thoughts I take it all back. Just had another look at RNAV Rwy 12 YLHR - maybe it is a crap approach made relatively easy in terms of situational awareness by the use of a moving map display.

I always fly them like an Localiser Appr and set the aircraft as I would to fly a 3 degree glidepath from the indicated top of descent point. Why is that not LHRWF rather than 1.7 nm from LHRWF?

In the case of YLHR I gotta work a bit at getting down in the BE35 cause its 3.49 degrees not the usual 3 degrees.

Why in this Appr is it 5 nm from LHRWI to LHRWF and then 7 nm from LHRWF to LHRWM?

Dr
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Old 31st Aug 2007, 14:10
  #67 (permalink)  
 
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I am still learning this. In most all NPA in Australia that I have looked at, Why isn't there a waypoint AT the point where the descent begins? I checked OS NPA and they ALWAYS seem to have a fix or waypoint at the beginning of the descent.

Except for ILS and LLZ approaches we always begin a descent AFTER passing an aid. Why is a NPA different? Is there a reason for it to be this way?
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Old 31st Aug 2007, 15:05
  #68 (permalink)  

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As I have not flown the approach in question I went and pulled up the plate on AsA's website (nice feature btw) and had a quick peruse...and I gotta say I have rarely seen a more boobytrapped approach.

GPSNPA have their faults generally speaking but this particular approach is virtually unflyable as published.

1/. To have any chance maintaining the published profile(s) you're descending at 400'/nm..at 120KIAS that is 800'/min just for starters. You'd need to fly the entire approach FULLY configured in something like a Metro to have any chance.

2/. If the weather is right on the minima you're to too high to land straight in. At 3nm the profile is 1375'....that is 475' higher than you would be on a normal approach. Even in my Bonanza with gear down and full flap I would need 700'/min all the way to touchdown or >1000'/min down to <500' and then something approaching a normal RoD after that....and I don't fly ANY approach configured that way...well I used to fly the Kathmandu VOR/DME Rwy 02 configured except for final landing flap....from memory the profile for that approach was 400'/nm too but you arrived at a usable MAP and a 10000' runway.

At 2nm/1040' you're still 440' high...no possibility of landing on 12 and you're also 350' below the circling minima.

3/. You'd need something like 4nm vis to be able to see the landing environment.. Much rain and you just won't...even if you can vaguely make out the landing threshold through light rain on the windscreen you will need best part of 1000'/min all the way to roundout to make it.

Can anybody say "stabilised approach?"

Airlines demote/sack people for flying as per above.

If I was the CP of a multi crew turbine RPT operation my crews would be banned from flying the runway approach in IMC, period.

It would be;

1/. Captains only approach,
2/. Flown to the circling minima only,
3/. Company profile based on arriving at the circling minima at 2nm..that's 3xdist+800'....all the way from tip over...that keeps you well above all limiting steps, gives a shallower descent flown configured for circling and gives you 1 min level to the MAP to assess the circling area.
4/. If visual over the runway and assured of maintaining visual reference circle left descending to be 1000' established on downwind and a normal 'min weather' circuit from there.

Nice and calm and above all controlled.

Captains route training would be 5 trips (2 at night) with a minimum of three such approaches flown to simulated minimas (minimum 1 at night) (real if the weather is such) under the care and feeding of a training captain and two such approaches flown as recurrent ICUS every 6 mths. FO route training would involve supporting a training captain as he flies the circling approach to simulated minimas 5 times (2 at night).

Any captain reported attempting to fly the runway approach in anger would be busted back to FO for 12mths without even 4 seconds worth of discussion on the matter.

The rwy approach to 30 is no better

There is just NO other way, in my view, to fly that approach with weather anywhere near minimas.

Edited to get my > and < around the right way.

OBD...VERY good question...and the answer is NO.

Last edited by Chimbu chuckles; 31st Aug 2007 at 15:29.
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Old 31st Aug 2007, 20:28
  #69 (permalink)  
 
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CC - I have never flown YLHR RNAV Rwy 12 to minima. I think the lowest I have broken out is about 1600' at around 4 nm from the threshold, and of course there is plenty of runway length available to get a Bonanza down anyway.

I have flown the NDB to the circling minima and circled onto 12 - by day.

Dr
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Old 31st Aug 2007, 23:58
  #70 (permalink)  
 
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Flown the Metro for many years. Flown the approach. I agree with CC.

It is a booby trapped approach.

Of interest or this may come as no surprise to some particularly former Eastland Air pilots

http://www.pprune.org/forums/showthread.php?t=289980
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Old 1st Sep 2007, 00:06
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As I have not flown the approach in question I went and pulled up the plate on AsA's website (nice feature btw) and had a quick peruse...and I gotta say I have rarely seen a more boobytrapped approach.

What a load of crap. What boobytraps?

GPSNPA have their faults generally speaking but this particular approach is virtually unflyable as published.

Rubbish, it is flown regularly. Transair only crashed ONCE and did this approach lots of time. CASA flew it recently and reported it as FLYABLE and meeting the criteria.

RAAF conducted an independent check of the approach and it meets the criteria. See the coroner's report.

1/. To have any chance maintaining the published profile(s) you're descending at 400'/nm..at 120KIAS that is 800'/min just for starters. You'd need to fly the entire approach FULLY configured in something like a Metro to have any chance.

Read the profile. 3.5 degrees APCH PATH. Well within Descent Gradient criteria.

2/. If the weather is right on the minima you're to too high to land straight in. At 3nm the profile is 1375'....that is 475' higher than you would be on a normal approach. Even in my Bonanza with gear down and full flap I would need 700'/min all the way to touchdown or >1000'/min down to <500' and then something approaching a normal RoD after that....and I don't fly ANY approach configured that way...well I used to fly the Kathmandu VOR/DME Rwy 02 configured except for final landing flap....from memory the profile for that approach was 400'/nm too but you arrived at a usable MAP and a 10000' runway.

At 2nm/1040' you're still 440' high...no possibility of landing on 12 and you're also 350' below the circling minima.


Who says you have to be able to land from the Missed Approach Point? It is purely a point, if at which you are not visual with your landing environment, you CONDUCT THE PUBLISHED MISSED APPROACH.

If you understand where you will be at the bottom of the approach, before you start it, then there are no surprises. DO YOUR APPROACH PLANNING PROPERLY.

3/. You'd need something like 4nm vis to be able to see the landing environment.. Much rain and you just won't...even if you can vaguely make out the landing threshold through light rain on the windscreen you will need best part of 1000'/min all the way to roundout to make it.

The required vis is 5.0KM due to the high MDA required by the terrain environment.

If the vis is forecast or reported at less than 5KM you are not allowed to do the approach. REF AIP.

Can anybody say "stabilised approach?"

If you fly the published APCH PATH you will have a STABILISED APPROACH all the way to 50ft above the threshold.

That is what all the CFIT studies have advocated and why AsA design the procedures that way.

It is steep but within the criteria.

Airlines demote/sack people for flying as per above.

If I was the CP of a multi crew turbine RPT operation my crews would be banned from flying the runway approach in IMC, period.

It would be;

1/. Captains only approach,
2/. Flown to the circling minima only,
3/. Company profile based on arriving at the circling minima at 2nm..that's 3xdist+800'....all the way from tip over...that keeps you well above all limiting steps, gives a shallower descent flown configured for circling and gives you 1 min level to the MAP to assess the circling area.
4/. If visual over the runway and assured of maintaining visual reference circle left descending to be 1000' established on downwind and a normal 'min weather' circuit from there.

Nice and calm and above all controlled.

Captains route training would be 5 trips (2 at night) with a minimum of three such approaches flown to simulated minimas (minimum 1 at night) (real if the weather is such) under the care and feeding of a training captain and two such approaches flown as recurrent ICUS every 6 mths. FO route training would involve supporting a training captain as he flies the circling approach to simulated minimas 5 times (2 at night).

Any captain reported attempting to fly the runway approach in anger would be busted back to FO for 12mths without even 4 seconds worth of discussion on the matter.

The rwy approach to 30 is no better

There is just NO other way, in my view, to fly that approach with weather anywhere near minimas.


Circling Approaches in near minima conditions increase the possibility of CFITs.

Several major airlines do not allow their crews to conduct circling approaches in some weather conditions.

Your attitude shows that you will say anything to have a go at the authorities but will not directly approach them. Your attitude is also not the way that many other RESPECTED operators allow their crews to operate.

Put your concerns to CASA and stop corrupting the minds of those on PPRUNE with your crap about RNAV (GNSS) approaches.

Fly the published approach after a thorough brief and you will not be putting the lives of yourself and your passengers in jeopardy.
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Old 1st Sep 2007, 00:13
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OZBUSDRIVER says:

"I am still learning this. In most all NPA in Australia that I have looked at, Why isn't there a waypoint AT the point where the descent begins? I checked OS NPA and they ALWAYS seem to have a fix or waypoint at the beginning of the descent."

I am yet to see a descent fix for any approach at 120nm from the airfield.

If you are cruising at FL390 that is about where you start descent. If you are a decent captain, and ATC don't stuff you around at low level, then you should be able to continue descent into the approach.

"Except for ILS and LLZ approaches we always begin a descent AFTER passing an aid. Why is a NPA different? Is there a reason for it to be this way?"

Maybe it is because the RNAV(GNSS) NPA does not have NAVAIDS!!!!!

A VOR approach from straight in does not commence at a NAVAID.

There is no reason for NPAs to be any other way.
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Old 1st Sep 2007, 00:15
  #73 (permalink)  
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Looking through the ATSB reports today and found this incident. This happened on the 29 May 2007 in a B300. Incident No: 200703363

Quote "During a runway 12 RNAV approach to Lockhart River in IMC, the aircraft's EGPWS activated a momentary terrain warning. The crew carried out a missed approach and elected to carry out the approach again. During the second approach, at the same position as in the first approach, the EGPWS activated momentarily before returning to normal. The crew established visual reference and landed safely.
The investigation is continuing."
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Old 1st Sep 2007, 05:17
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ROARING RIMAU, Thats not what I meant. TOPD is an arbitary point dependant on your own aircraft's performance Yes? I am talking about the PUBLISHED approach. At this point you must be at X speed and Z height and commence the descent at Y rate to arrive at the MAP with this much vis and threshold or environs visual to continue the approach or go missed. NDB and VOR procedures have you passing the aid to then commence a procedure. A fixed point to do a specific thing. I feel an NPA still requires a point where the descent commences. IAF or FAF, whatever!

I understand that positioning over an aid places you within the protected zone down to the MDA. A precision approach gives a glideslope so doesn't require a point to begin the descent, or does it? You have to have a knowledge of the height you must be at to intercept that glideslope without being too high or too low. Vectoring gives me an intercept from below the glideslope so I wait until I intercept to begin approach.

NPA plate has you flying along at a height above the LSA for the sector then you must chose your own descent point to arrive at the FAF at the stipulated height in approach config. Wouldn't it be easier to have this point stipulated so as you fly the last sector before this point you have configured yourself for approach you have leveled off at the correct altitude to start the procedure You pass the point and start descent for the approach
. Wouldn't this be easier than trying to judge the point yourself?

EDIT-I am learning this so please be gentle

Last edited by OZBUSDRIVER; 1st Sep 2007 at 05:44.
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Old 1st Sep 2007, 08:49
  #75 (permalink)  
 
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Jusiceseeker, welcome. I had no direc connection with this accident althought a couple of indirrect ones. I would welcome any input you may have.

I do believe Chimbu Chuckles has rasied very valid points and in particular the possible input of the F/O which I had not considered in such a way. Did any investigation reports explore that possibility?

Cheers

J
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Old 1st Sep 2007, 09:08
  #76 (permalink)  

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Rimau the approach plate is here.

http://www.airservices.gov.au/public...HRGN01-101.pdf

The descent profile keeps you approx 500 higher than what would be considered nominal all the way down. I never suggested you should be able to land straight in from the MAP...that is clearly impossible in this case, and many others, but even if you got visual at 3nm or 3.6 you would be too high to make a landing on 12 without excessive sink rates on short final.

Looking at the plate I would suggest about the only way to land straight in is if you got visual back around 5nm, where you would be 2100' (still 600' higher than a 'normal' approach profile), and then visually ducked under the profile...terrain permitting of course...which it seems it maybe doesn't.

If the cloudbase was 1600' you would get visual at 3.6nm...500' higher than a nominal altitude for a straight in approach.

If the cloudbase is at the circling minima, 1390', you will see nothing until 3nm...where you will be 490' high on approach for a straight in.

If the cloudbase is at the straight in minima you will see nothing until it is FAR too late to land straight in and you will be 350' below the circling minima.

If you turned final at 3 or 4nm in a Metro on a cloudless blue day 500' high would you,

a/. stuff the nose down and land or,
b/. Go around?

This is the classic non stabilised approach and this IAL procedure sets you up for it right from the get go...hence it is boobytrapped.

If you cannot land off a straight in using normal rates of descent and manouvers then you are limited to the circling manouver. To suggest a gentle circling manouver from overhead the landing threshold is more dangerous than poking the nose down to salvage a landing from 500' higher than nominal beggers belief...you clearly have not flown many circling approaches, I have flown 100s.

I don't give a flying fig who has flown this approach in sunny, calm conditions and pronounced it wonderfull...get them out there when the weather is on the minima in low cloud and rain and ask them again.

As to my 'constant' attacks on the regulator or this IAL procedure?

Believe me I have told them to their face...usually the answer has been "Well Chuck yes, you're right, but...."

Classic groupthink...google the term if you're unfamiliar.
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Old 1st Sep 2007, 09:59
  #77 (permalink)  

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And Rimau wonders why I have no patience with the 'regulator'. It is because I have been watching this sort of **** happen for nearly 28 years.

I was a CP once under CASA...our FOI colluded with a non flying manager to have me replaced with a yes man who then went on to condone illegal operations...never again
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Old 1st Sep 2007, 10:12
  #78 (permalink)  
 
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The F/Os father was also a company director. Read into that what you will.
I do not recall this being announced anywhere before? Maybe I missed this if it has been announced.

Add this to the other points about paying for dodgy endo's, and CC's possible scenario of passing wrong data to the captain, and maybe thats where the holes in the cheese lined up?

Yes the Captain was acting like a cowboy, and even doing this approach, regardless of a possible error given to him, he still should not have been, but add the above up and the F/O may well have been more responsible than we think.

Was this young chap, (one of the indirect connections via my daughter at school) possibly doing a job he should not just coz daddy had bought him a job? Long bow to draw I know but has this been discussed.

CC, Justiceseeker what do you think? I am punching above my weight here, but on the surface could this be the case?

J
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Old 1st Sep 2007, 12:54
  #79 (permalink)  
 
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"Jeppesen has since reprinted its LHR approach chart with coloured contours!!!!! "

and man do those dark brown bits get your attention and help to keep you focussed when you fly that approach!

Dr
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