Report on 1999 B757 crash at Girona finally published

[Yeovil]

Danny's observations about tiredness - third consecutive night flight are very apt.
Also readers should be aware that some big operators ( I don't know about Brit's ) but BA certainly put crews under a lot of pressure to take Cirrus ( flight plan fuel) .
The Cirrus may have as little as 6 mins contingency.Routes and diversion fuel figures are often @tight@ or simply unrealistic.
They publish league tables to highlight "offenders"... who are called in front of mgt for a roasting .
Unbelievable, but true.

[M.Mouse]

Also readers should be aware that some big operators ( I don't know about Brit's ) but BA certainly put crews under a lot of pressure to take Cirrus ( flight plan fuel). The Cirrus may have as little as 6 mins contingency.Routes and diversion fuel figures
are often @tight@ or simply unrealistic.

From conversations with colleagues when we see very low contingency figures we all seem to decide on a figure for ourselves.

They publish league tables to highlight "offenders"... who are called in front of mgt for a roasting.

That statement is inaccurate. Fuel tables are no longer published and most of us never read them anyway! The only people I am aware of being called in for a 'roasting' are those routinely carrying way more than everybody else. The 'roasting' is in fact a discussion. I would be happy to have such an interview because I believe I make considered fuel decisions.

Nobody has ever been disciplined, openly or otherwise, to my knowledge, for excess fuel carriage and believe me some of the now retired 'old school' routinely would carry vast quantities of excess fuel! One jumbo Captain in particular would always take 20 tonnes extra if he could physically get it on board!

[Waldo]

Returning to the subject of low houred first officers. I believe that some airlines are now employing first officers on B757 and other complex aircraft with the grand total of 160hrs training. Now that would have made interesting reading in the report!

[Shuttleworth]

M Mouse .

I know the league tables are there .... I saw them yesterday.

Maybe you are long haul? ... but Yeovil has a valid point.
There is pressure from BA SH mgt to carry Cirrus fuel . I could post the documents here , but it would degenerate into a slanging match. Lets stick with the Girona incident ....

[crackerjack]

A very sobering report. As someone with an interest, one of the things that interested me most was the skipper's decision to take the approach off the f/o who was pf. Shades of Kegworth indeed.

If a company like Brits - who 'pride' themselves on the quality of their training, don't trust their f/o's to fly non precision approaches in poor weather, what hope is there?

I was impressed by M.Mouse's posting regarding monitored approaches - any more ideas?

[Maxrev]

Hindsight is indeed a wonderful thing. What if they'd taken more fuel, what if the lights hadn't gone out, what if, what if...

The over-riding factor was the fuel state. Their options became limited by poor fuel planning in the first place. The rest was down to some poor airmanship and lady luck running out on them fast with the runway lights failing, and the subsequent damage to the systems after the bounce that caused them to accelerate off into the grass.

Lady luck did appear once again however though in the form of a lovely soft, wet field that prevented a fire.

This could happen to any of us on a bad day. These guys had made a couple of bad calls and it bit them on the ass big time. Next time you drop into a field on a crappy day with marginal fuel think how it might have been....

[NOT ORANGE]

Brittania have been flying around for years with minimum fuel always saying that they save 10 million or so over the space of a year by doing so.I was flying to BCN that night and had plenty of fuel for other options such as PMI,IBZ as I would consider that sensible thing to do.GRN is very close to BCN and not what you would consider a bolt hole on what was a sh...y night.You have to ask was it sensible to have one choice and that was to make an approach under a cb.

[acbus1]

Some observations re the thread as a whole.

Sponsored (in name if not in monetary terms) students graduate from schools such as Oxford and join airlines (using the term loosely in some cases) with a heck of a lot less than the figures given here. All of it on light aircraft and all but tiny fraction on single engine piston tiddlers.

The experience level of some f/o's is a disgrace. Stick em in a small turboprop for a couple of years, I say.



Anyway, was this a case of "pilot error" once again?

Or does anyone in the know want to tell us about pilot fatigue in this case?

Come on, it's an anonymous forum!


And would anyone like to confirm the Gestapo treatment of the Captain, without rest or recovery, immediately after the incident?

My understanding, from colleagues of his, is that under interrogation, he was asked if he was suffering from fatigue and was obliged to reply "No". To reply otherwise would have exposed him to reprimand for "flying when knowing himself to be fatigued" or such like. (The CAA cover themselves nicely with that little phrase, but how strange that it's no defence if you phone crewing and refuse to fly when you're within CAP........outside of BA, anyway).

[Jet A1]

Low houred F/O's - Big deal - BA have done it for years ! You guys obviously think you are infalable. Captains make misjudgements too even with 0000's of hours !

[Big Tudor]

Two very nice people and very experienced pilots. Men who I personally feel proud to call colleagues, albeit in a previous chapter of life. The were called upon to make some very serious decisions in a very high workload situation. They made the decisions they thought were right at the time, not knowing that circumstances would prevail to make it one, if not the, worst night of their lives. I'm sure they would be the first to admit that, with hindsight, they would have done things differently. They didn't, and have not only suffered the consequences of a major aircraft accident and subsequent inquiry, but are also suffering a 'Kangaroo Court' from the supposed professional aviation community. One wonders how many of the good ladies and gentleman on this BB have been in the same situation as these two, the difference being they have been fortunate enough to be able to analyse the situation from the comfort of their local pub over a quiet pint rather than a full accident inquiry. There but for the grace of God go we.

May I respectfully suggest that, rather than questioning the fuel loads and experience levels, we all draw as much experience as possible from this sad episode and draw it to a close. And while we are about it pray to whichever God we each believe in that such a situation will not happen again.

[Terror_is_firmer]

Here, Here. Thankfully no one (except the chap that passed a few days later) was killed in the accident.

[BOAC]

I would vote for Big T's post to be an excellent one on which to close this thread, or at least move on to discussions of the effects of accumulative sleep cycle disturbances.

As Big T says, what I or anyone else WOULD have done is pretty well irrelevant. This is a report on what HAPPENED to a crew and pax.

What IS relevant IMO is Danny's observation on the findings regarding 'fatigue' ('BAD' word) and extreme tiredness ('OK' word).

Anyone else agree?

[Tartan Giant]

I have read the report cover to cover, and I will start by saying it was a miracle there were no deaths or people crippled as a result of this accident. They were all very lucky that night. The muddy field/run-off area and the rain certainly was a fire suppressant – lucky.

I am sympathetic to the flight-deck crew at the sods-law sequence of events that culminated in the sad and dreadful accident. Those aviators left in the wake must learn from this accident.

Whilst 3 night flights might be legal, they play hell with your mental capacity even when the adrenalin is flowing and the “suits” and paperwork speak of more than minimum rest was taken.
On paper it looks good but hand on heart everyone, they are draining, even if you sleep well after the first two night flights.

Danny makes a good and valid point at the previous two night-flights these guys flew; a TCI (10.50 FDP) and that Turkey slog, 11 hrs FDP. Then this third launch into a very dirty night with CB’s where you don’t want them.

I mentioned luck, what was not lucky was the Commander’s choice of Ramp Fuel.
Taking such an small amount of extra fuel was not wise in my opinion, given the destination and ALL the alternates were forecast to suffer from thunderstorms.

There is the first lesson in commercial aviation – to hell with management pressures to take “minimum fuel” when you know the bets are against you.

I read about the fuel league tables – tear them up guys/managers. Penny pinching at the sharp end is completely futile. I think at the back of the Commander’s mind that night was that undeniable nagging doubt, “I have too little fuel to play with” – hence the mind changes about diverting. Taking, “an extra 15 minutes of holding fuel to allow for possible delays” does not cover it.

I have operated into GERONA many the time, and knowing there is no ATIS at least 120 ‘out’ and prior TOD one pilot talked to Gerona and got their “latest”. It would appear the “latest” weather was procured only about 50 miles from the overhead: “When within radio range of Girona at 21.14 hrs the crew requested the latest weather”. Eight minutes later they were O/H the VOR.

Another hellish bit of luck (airmanship) was the crew failing to notice the airbrakes were left “out” for 14 minutes ( 21.18 hrs until 21.32 hrs). It shows you the difficult and demanding task that was on their hands that night, and the lack of spare mental capacity available between them.
What did not help either was the Commander losing his VOR “plate” for R/W 02 (21.24) after he exercised his prerogative and became PF. A CRM question again? On passing, it is not clear to me if he managed to have his own “plate” for the ILS on 20 – perhaps I have missed that somewhere?

A CRM question might be, why did he not hand back control to the F/O who had already briefed for an ILS on 20 and still had his “plates” available? The task sharing throughout the whole unfortunate affair fell very heavily on the Commander.

Taking a small amount extra over and above the “minimum fuel” might look good in an office to some desk-bound manager, but on a rotten wet night, flying into thunder storms (destination and all ALTS) is not a very good idea.

I don’t think the Gerona Air Traffic Controller was very helpful to this crew either. Taking 20 seconds to pass the Barcelona weather is poor service in my experience, and the further lapse (see 21.36:52 exchange).
The female ATCO on duty had only been doing the job for 3 months; and it sounds/reads as if she was acting alone in the tower that night as the report mentions no other ATC Officer and indeed no Supervisor. I say that because I recall the time (years ago) on a night flying into a major Spanish airport that the same voice came up on APPR/TWR/GND and on questioning if he was actually covering all ‘positions’ I was told “Affirmative”. My ASR was never answered! Much like the Electric Power Company never answered the questions about power outages at Gerona that night (that was a damnable disgrace).
It may well be that Gerona had ATC assistant/s available, but they did not have immediately to hand the latest wx’s one might expect on such a foul night. Perhaps that is why the female ATC Officer was on the phone so much, and the crew's request for weather to the North was never fulfilled.

With the greatest respect, it must be said the mental capacity of the Commander must have been reaching saturation point during the GA and then straight into a runway switch for the ILS on the other end, as his calls for Flap Up and then Flap One were only 8 seconds apart (21.38:14 and 22). Perhaps the low fuel state and the “insufficient fuel” FMC message got home. I can really feel for him.

I’m not familiar with the B757 “Landing Check List” but it crosses my mind reading the landing check-list after the OM is a bit late (OM at 21.44:20 – 43) and the intimation the Landing Check List was read at 21.44:56.
When one considers the weather, all the checks should be done and dusted nice and early to concentrate on the execution of a precision approach in crap wx.

I am also surprised that the A/T could not handle the speed sufficiently well in the relatively smoother conditions on the ILS such that the F/O called, “bug minus 10” after the OM and then again, “bug minus 5” and then the Power Levers were advanced – it is unclear from the report if that was by physical intervention by the Commander or the A/T system itself, as the report mentions the A/P and A/T being disconnected 4 seconds after that minus 5 speed call (21.46:58) and some 26 seconds after the Commander called, “Lights in sight” (21.46:32).

The situation got very desperate indeed some 12 seconds later when at 120’ AGL “near full nose down elevator” was applied. The sods law of those lights failing (?) and the loss of spatial awareness by the Commander shows how rapidly it can turn to absolute .

The Commander stating he, “did not see approach lighting or PAPI lights” calls into question whether these lights were actually turned on for him after the 02 approach !
The F/O did not see the Approach Lights or the PAPI’s either.
The inexperienced ATC Officer acting alone said she was, “absolutely sure” the lights were on.
I would contend, two pilots with 18,194 hours between them would not miss seeing a full set of Approach Lights (CL5B) in a black, miserable, rainy night.

The Commander said, “Lights in sight” at 21.46:32, some 26 seconds before he disconnected the A/P and A/T.
Sorry Gerona ATC, but it’s two against one, and you offer no other evidence those lights were on and serviceable.

There are many lessons to be learned; from the ramp fuel decision, to the low fuel state in severe weather, the minimum ATC support and handling (not to mention the late “rescue” services), CRM, and the body/mental stress of operating three long night flights in succession.
A hellish combination of misfortunes, hopefully never to be repeated.

We are all smart ar**s after the event.
One major item was the fuel carried. I do think the mental capacity would have been opened up if that huge worry was not with the Commander, and would have given him far more time and options up his sleeve. The pressures placed upon him were too many for my liking. I am very sorry it ended the way it did, but very relieved nobody was killed.

On Danny’s question: Does anyone else sense that there is some conflict between DERA concluding that the duties were not fatiguing and the two reports referenced to, one by NASA AMES Research (Principles and guidelines for duty and rest scheduling in commercial aviation) and one by Aviation Space and Environmental Medicine (Age, circadian rhythms and sleep loss in flight crew)?

There is conflict there. Even though 1993 might not be that long ago, things have changed.
http://human-factors.arc.nasa.gov/zt...-age.circ.html

http://human-factors.arc.nasa.gov/zt...d.g.intro.html

TG

[phoenix son]

Waldo,

Sorry if it seems like we are going in circles here, but whilst I wholeheartedly agree that the more experienced a pilot is (or anyone in any job for that matter), the more capable they are likely to be when it comes to dealing with out-of-the ordinary, that doesn't automatically mean that a low-houred F/O makes a bad pilot. Sure, they have lots to learn, but they've also spent the last couple of years getting to that RHS where they are now sitting, not an easy job in anyone's mind.

PHX

[Final 3 Greens]

To add to Danny's examples, the insidious nature of tiredness also impacts the efficient execution of project plans.

If you analyse the error rates of teams working long hours/weekends/overtime against norms for teams working 9-5 hours, the results are quite clear.

It truly is a human factor in aviation.

[DingerX]

Always interesting to read the conclusions reports like this come up with:
A) Sure it's 2-1 that the approach lighting or PAPI lights were not on, but the report uses separate"In sight" and "Contact" calls, along with the ATC's claim that she was dead certain, to conclude that it was "probable" they were on. A more believable conclusion would be that the state of such lights was "undetermined".

B) While the report makes numerous recommendations for changes in practice and regulations, such as suggesting requiring training for initiating a GA below decision height, its only comment on the power failure is that the 11-second interval during which the lights were off -- long enough to make 2 of the 5 contributory factors in the report, and, after the crash, to cause the ATC to lose sight of the crashing aircraft -- is that 11 seconds is well within the 15 seconds mandated by the ICAO. Come to think of it, there were several power failures, including a non-functioning crash alarm, but these failures of primary safety systems appear to be treated as acceptable since they comply with regulations.
I mean sure, you can train crews to deal with losing the runway lighting 7 seconds before touchdown, just as you can train crews to deal with losing an engine on TO; but it's also effective to get manufacturers and maintenance to minimize the possibility of engine failure in the first place. Is it too much to ask that airport operators ensure their primary safety systems function in adverse weather, when ATCs, emergency services and crews are likely to be task-saturated? Or maybe suggest that 15 seconds is more than enough time for an aircraft to crash unseen by those on the ground?

l mean sure, airfields are big places, and locating an accident in severely reduced visibility is difficult, and should (as experience shows) be a part of the training received by emergency crews. But would it be helpful to have a source of power that was working? Would that have reduced significantly the 40 minutes or so between the incident and the arrival of the emergency services at the site?
Okay, sure, I'm nuts, and most places in the world can't afford such an infrastructure, especially if the airfield in question handles primarily seasonal charters. Is there any harm in asking?
(unless, of course, there was pressure on the investigation not to cost the Spanish government any money)

[NoSig Break]

I have heard that the pilots based in CWL were at their wits end and knackered after a hellish summer. I think that the report fails to give adequate weight to the issue of fatigue.

Both the pilots no longer fly. Very sad story indeed.

P.S I have flown into GRO at night in the rain and the whole approach lighting system was turned off, very gash ATC.

[Backtrack]

No Sig Break:

Capt is retired & drawing his pension. FO is still with BAL (probably not far off command). Hope this eases the sorrow.

[NoSig Break]

Backtrack old chap,

It is not quite that simple.

I know for a fact that the FO has hung up his spurs. He feels like a tremendous weight has been removed from his shoulders. I wish him all the very best in his new endeavours.

As for the Skipper, he went on PHI and subsequently retired, never managing to fly the line after the accident.

I hope, in time, they can get over the whole affair.

[Backtrack]

NoSIg Break,

Yes I am old & I am a chap, but please don't patronise me, especially when you don't have all the facts.

"I know for a fact that the FO has hung up his spurs." (your quote).

Can you then explain to me why his name still appears on the seniority list?

As for the capt, what I previously stated still holds true - he is drawing a BAL pilot's pension.

It would be wrong of me - and you - to put any more concerning the current position of these two pilots. However, I stand by my previous post.