Report on 1999 B757 crash at Girona finally published
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Huh? Again
it would seem that the operating crew in question stuffed it up rather badly ...
Perhaps persuading yourself that it could not happen to you just represents a failure of imagination, rather than an affirmation of the skills you demonstrated in successfully getting yourself in and out of Girona on several occasions?
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You make a good point, atse, but then again the photo of the concerned aircraft off the side of the runway clearly showing the damage done, really says it all.
Yes, Girona has some of the same problems that many Spanish airports have...poor atc communication, rather nasty weather at times, high ground nearby, sub-standard lighting...but in the end it is the Commanders responsibility to factor all these in, and if the picture is not pretty, then immediate diversion becomes necessary.
If you don't have the fuel for same, due to poor planning in the beginning, or waiting too long to make that diversion decision, then the picture becomes very nasty indeed.
Many pilots (and especially, airlines) can learn valuable lessons from this very unfortunate accident.
Wonder if they will?
Yes, Girona has some of the same problems that many Spanish airports have...poor atc communication, rather nasty weather at times, high ground nearby, sub-standard lighting...but in the end it is the Commanders responsibility to factor all these in, and if the picture is not pretty, then immediate diversion becomes necessary.
If you don't have the fuel for same, due to poor planning in the beginning, or waiting too long to make that diversion decision, then the picture becomes very nasty indeed.
Many pilots (and especially, airlines) can learn valuable lessons from this very unfortunate accident.
Wonder if they will?
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The point I was making 411A is that the photo of the aircraft is a photo of an outcome, the end of a process. It is singularly inappropriate to judge culpability by the outcome. It may appear reasonable to do so, but it just ain't so. (You quickly end up in a position where the worse the outcome, the more the culpability ...).
Even in your response where you say I make a "good point" you quickly revert to the attribution of crew error with implicit backwards reasoning along the lines of:
- Bad things happened,
- The captain's responsibility is not to have bad things happen,
- Therefore, pilot error
Even in your response where you say I make a "good point" you quickly revert to the attribution of crew error with implicit backwards reasoning along the lines of:
- Bad things happened,
- The captain's responsibility is not to have bad things happen,
- Therefore, pilot error
Per Ardua ad Astraeus
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Still trying (with ´Big Tudor) manfully to try and drag this away from the vulture mentality into looking at Danny´s fatigue points.
Good idea in my book, and one of the things I started discouraging some years ago was the dialling-up of the ground frequency (if any) on finals, which could pre-condition the ´land´ mental picture. Leaving the radar frequency in place is better.
Can we now leave THIS crew alone - please, or are we all going to conduct our own ´accident investigation´ here over and over again?
A recommendation that go-around manoeuvres below decision height should be a mandatory part of recurrent training seems useful because it would help pilots override a "must land" mindset.
Can we now leave THIS crew alone - please, or are we all going to conduct our own ´accident investigation´ here over and over again?
411A :-
The report states:
1.17.1.9. Fuel Policy
The Operator's fuel policy objectives are as follows:
a) A sufficient quantity of fuel is carried for the intended flight with a safe margin for contingencies.
b) The range capability of the aircraft is fully exploited.
c) The uneconomic carriage of fuel is minimised.
If you were operating under this fuel policy how might it affect your daily decisions, year in year out, on how much extra fuel to carry?
The report states:
1.17.1.9. Fuel Policy
The Operator's fuel policy objectives are as follows:
a) A sufficient quantity of fuel is carried for the intended flight with a safe margin for contingencies.
b) The range capability of the aircraft is fully exploited.
c) The uneconomic carriage of fuel is minimised.
If you were operating under this fuel policy how might it affect your daily decisions, year in year out, on how much extra fuel to carry?
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I heard that there were 3 aircraft in the hold that night who were diversions from BCN (The nominated diversion for the Britannia flight).
Does that change your opinion about them commiting?
Does that change your opinion about them commiting?
I think we could go round in circles for ever on this one but a couple of comments:-
>a) A sufficient quantity of fuel is carried for the intended flight with a safe margin for contingencies.<
It is surely the aircraft commander who makes the decision to ensure a "safe margin".
>c) The uneconomic carriage of fuel is minimised.<
Emphasis on the word "uneconomic".
>If you were operating under this fuel policy how might it affect your daily decisions, year in year out, on how much extra fuel to carry? <
I hope that as an aicraft commander it would never influence my decision to carry any extra amount of fuel I deem necessary for safe flight. Further there must surely be other instructions in the fuel policy that the aicraft commander has the overriding authority as to how much fuel to depart with?
I cannot understand why various posters are being so defensive about this aspect. Surely it is a fact that more fuel should have been carried on this flight? Why dodge the issue? You only need to eliminate one of the holes in the cheese model to avoid an accident.
>a) A sufficient quantity of fuel is carried for the intended flight with a safe margin for contingencies.<
It is surely the aircraft commander who makes the decision to ensure a "safe margin".
>c) The uneconomic carriage of fuel is minimised.<
Emphasis on the word "uneconomic".
>If you were operating under this fuel policy how might it affect your daily decisions, year in year out, on how much extra fuel to carry? <
I hope that as an aicraft commander it would never influence my decision to carry any extra amount of fuel I deem necessary for safe flight. Further there must surely be other instructions in the fuel policy that the aicraft commander has the overriding authority as to how much fuel to depart with?
I cannot understand why various posters are being so defensive about this aspect. Surely it is a fact that more fuel should have been carried on this flight? Why dodge the issue? You only need to eliminate one of the holes in the cheese model to avoid an accident.
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Accidents are caused by a chain of events that were able to happen because some defences failed. Mentioning a specific defence (ie. crew experience, CRM, fuel etc..) is not meant to single out a cause, it's just to poit to were defences failet to meet their objective.
By law it's so easy, the commander shall...... So it's all his/her responsibility nowhere however does JAR-OPS say that the company must make shure commanders take their responsibilities. Worse even in many occasions the company consider a pilot who is willing to take a risk (read breake a rule) a better pilot because it helps the company to acieve their goal which is making money.
Detailed discussions into the amound of fuel required is in my opinion bs. we should discuss how to deal with commercial pressure, and how to regain captains authotity because that is were the risk starts.
Troubles
By law it's so easy, the commander shall...... So it's all his/her responsibility nowhere however does JAR-OPS say that the company must make shure commanders take their responsibilities. Worse even in many occasions the company consider a pilot who is willing to take a risk (read breake a rule) a better pilot because it helps the company to acieve their goal which is making money.
Detailed discussions into the amound of fuel required is in my opinion bs. we should discuss how to deal with commercial pressure, and how to regain captains authotity because that is were the risk starts.
Troubles
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I worked for an airline that had a set of, I think it was six, corporate objectives. The first was that "the company should operate to standards of safety that tolerate neither accident or incident". It is obvious commonsense that if there is only one corporate objective in an airline it would have to be about safety.
Once you have established such an objective all sorts of things flow from it if is going to be achieved. The Captain's authority over the preparation for the flight and the management of the flight are just two examples.
I am not going to pass any judgment about the Girona crash because all the issues would appear to be in the accident report. But I would like to see the corporate objectives for the business as a whole. I was told some years ago by a senior director in the Thomson organisation that thre role of Britannia was very clear. It was to be the mass trassport system for Thomson Holidays.
Some years later I was headhunted to run a shipping business. I did not get the job and I was given some feedback on why. It was apparently because I answered one of the questions at the interview in the wrong way. I was aked what I would do on my first morning there. I answered that in addition to meeting the key people who would be reporting to me I would need to study the accident handling procedures so that I would know what I was required to do if there was any incident or accident on my first day there. I was told in the feedback that I should have talked about profit instead.
I wonder just how many airlines would have a similar view.
Once you have established such an objective all sorts of things flow from it if is going to be achieved. The Captain's authority over the preparation for the flight and the management of the flight are just two examples.
I am not going to pass any judgment about the Girona crash because all the issues would appear to be in the accident report. But I would like to see the corporate objectives for the business as a whole. I was told some years ago by a senior director in the Thomson organisation that thre role of Britannia was very clear. It was to be the mass trassport system for Thomson Holidays.
Some years later I was headhunted to run a shipping business. I did not get the job and I was given some feedback on why. It was apparently because I answered one of the questions at the interview in the wrong way. I was aked what I would do on my first morning there. I answered that in addition to meeting the key people who would be reporting to me I would need to study the accident handling procedures so that I would know what I was required to do if there was any incident or accident on my first day there. I was told in the feedback that I should have talked about profit instead.
I wonder just how many airlines would have a similar view.
Alba Gu Brath
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BOAC
It would appear that your are striving in vain. It seems strange that the fatigue aspect of the incident is being overlooked by the majority of posters, especially since there have been numerous threads on this BB recently about his very subject, some quite voiciferous. We appear to be concentrating on how much fuel the commander chose to carry and how much more we would have uplifted in the circumstances. Did fatigue play a part in the commanders decision on fuel, one wonders? If the commander had uplifted more fuel would the outcome have been any different?
There are plenty of scary comments about flying when fatigued, but what about the implications of planning when fatigued? It is said that familiarity breeds contempt, what happens when familiarity is coupled with fatigue, especially when reading met briefings prior to a flight. What do you think when you read an all too familiar TAF for an airfield of TEMPO VRB20 TSRA OVC500? Do you take in what the TAF is telling you or is it pushed to one side with an confident look and a "Been there in worse" thought?
It would appear that your are striving in vain. It seems strange that the fatigue aspect of the incident is being overlooked by the majority of posters, especially since there have been numerous threads on this BB recently about his very subject, some quite voiciferous. We appear to be concentrating on how much fuel the commander chose to carry and how much more we would have uplifted in the circumstances. Did fatigue play a part in the commanders decision on fuel, one wonders? If the commander had uplifted more fuel would the outcome have been any different?
There are plenty of scary comments about flying when fatigued, but what about the implications of planning when fatigued? It is said that familiarity breeds contempt, what happens when familiarity is coupled with fatigue, especially when reading met briefings prior to a flight. What do you think when you read an all too familiar TAF for an airfield of TEMPO VRB20 TSRA OVC500? Do you take in what the TAF is telling you or is it pushed to one side with an confident look and a "Been there in worse" thought?
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I don't think anyone has mentioned the one conclusion that was, I believe, the cause of this becoming an accident rather than just a landing incident.
This is the poor construction of the dog box, which caused thrust to be applied leading to the aircraft departing the clearway. The conclusion was that if the dog box construction was more robust the aircraft would have come to rest within the airport perimeter with little further damage to the aircraft. This is not the first time that this has happened to a B757 yet Boeing do not seem to have any thoughts on rectification of this problem.
This is the poor construction of the dog box, which caused thrust to be applied leading to the aircraft departing the clearway. The conclusion was that if the dog box construction was more robust the aircraft would have come to rest within the airport perimeter with little further damage to the aircraft. This is not the first time that this has happened to a B757 yet Boeing do not seem to have any thoughts on rectification of this problem.
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The conclusion in 2.2.2.3 that the cockpit gradient didnt play a role in the crash is frankly suspect.By advocating the use of a monitored approach(a procedure designed to combat adverse cockpit gradient) in its recommendations,the report seems to be contradicting itself.
Disappointingly,the report didnt discuss what role the first officer had in the decision to take only 15 minutes extra fuel.Also no broader discussion on the general fuel policy adopted by the company.Did an in-house fuel league table exist whereby pilots compete for brownie points?What effect did the fuel status have on the captain's decision NOT to go-around when it was mandatory to do so.
Disappointingly,the report didnt discuss what role the first officer had in the decision to take only 15 minutes extra fuel.Also no broader discussion on the general fuel policy adopted by the company.Did an in-house fuel league table exist whereby pilots compete for brownie points?What effect did the fuel status have on the captain's decision NOT to go-around when it was mandatory to do so.
It will be a big day for passenger aviation in Europe when there is a hull loss + widespread death at any well known airline. If the subsequent report blames fatigue - even obliquely - there will be hell to pay. The whole health and safety mafia will feel mandated to get into aviation and fatigue is their easiest and most powerful entry point.
Doctors, lorry drivers, train and tube operators, Air Trafficers; all are required by law to work fewer hours with more rest than the pilots of airliners. The logic and the media impetus from mass funerals will be overwhelming.
Which leaves one frustrated that the authorities do not prempt and prevent the whole sorry scenario. Lets face it - the industry is overdue for another big one in Europe after many close calls.
Cheers
WWW
Doctors, lorry drivers, train and tube operators, Air Trafficers; all are required by law to work fewer hours with more rest than the pilots of airliners. The logic and the media impetus from mass funerals will be overwhelming.
Which leaves one frustrated that the authorities do not prempt and prevent the whole sorry scenario. Lets face it - the industry is overdue for another big one in Europe after many close calls.
Cheers
WWW
Last edited by Wee Weasley Welshman; 16th Sep 2004 at 14:15.
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You cannot be serious!
I have been following the thread closely, from the outset, and measuring the replies without further comment since my own.
However, I do feel the need to ask readers what they feel about the one insert by WWW - and I add this:
WWW
You cannot be serious - surely!?
Are you telling readers, that YOU would take only 15 minutes extra fuel had you been the Commander of that flight?
I wonder how many readers with real airline Command experience would support your veiw of that RAMP fuel decision?
The "poor facilities" you mention - are you talking about NAV aids, or those engaged after the sad event.
I'm glad you engaged your imagination on this one; for I hope never to fly with you in the LHS if you opt and contend it reasonable to carry such fuel loads in those conditions.
Seems the lessons about WX and options have been lost on some F/O's.
TG
However, I do feel the need to ask readers what they feel about the one insert by WWW - and I add this:
WWW
I don't think the fuel uplift was unreasonable.
Are you telling readers, that YOU would take only 15 minutes extra fuel had you been the Commander of that flight?
I wonder how many readers with real airline Command experience would support your veiw of that RAMP fuel decision?
The "poor facilities" you mention - are you talking about NAV aids, or those engaged after the sad event.
I'm glad you engaged your imagination on this one; for I hope never to fly with you in the LHS if you opt and contend it reasonable to carry such fuel loads in those conditions.
Seems the lessons about WX and options have been lost on some F/O's.
TG
With MY reputation?
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was the fuel uplift a contribution to the accident?????
"REC 31/04 - It is recommended that the Operator should review its Flight Planning and Clearance Procedures in order to take into consideration probable meteorlogical conditions at the destination and alternate airports, including thunderstorms"
PHX
The SIDS, STARS, likely routings, winds aloft, estimated weight vs reality, all these things we know not. The Skipper may have thought himself likely to have quite a bit more than 15mins.
Pointless speculation really.
Cheers
WWW
Pointless speculation really.
Cheers
WWW
Last edited by Wee Weasley Welshman; 16th Sep 2004 at 14:11.