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Report on 1999 B757 crash at Girona finally published

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Report on 1999 B757 crash at Girona finally published

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Old 15th Sep 2004, 19:06
  #81 (permalink)  
 
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Well, was it Fuel, Weather, Fatigue, Cockpit Gradient, CRM, Planning or what?

Most accidents can be analysed from different perspectives and, depending upon that perspective (or hobby horse, or bias if you will) a version of events - and how those events could have been interrupted - can be easily re-created in retrospect. Those strongly holding to a particular point of view will invariably find suggestive evidence that just seems “obvious” to them.

The problem is that for each notion as to what factor was critical - e.g fuel, weather, fatigue, cockpit gradient, CRM, etc. - a version of events can be constructed which differs as to the crucial aspects. Working out which version is “correct” can rapidly become a fruitless exercise, since very notion of “correct” becomes part of the problem of analysing the events.

It is, just to take one example, clear that Tartan Giant is somewhat horrified by the fuel decision of the commander/crew. In the absence of knowing the outcome, or the commander’s reasons when he made the decision, the amount of fuel has to be considered sufficient (read that again carefully if you think it is nonsense. Otherwise you are forced to make the claim that the flight dispatch decision was itself demonstrably wrong, at the time of dispatch. I don’t think the evidence is there to make any such statement). The fuel carried may look insufficient IN RETROSPECT, given a particular perspective and the way events unfolded.

But how many times have pilots found themselves in situations that looked much worse, or better, than expected on arriving at destination? Consider it this way: if the crew had carried 45 minutes extra fuel, but arrived at the airfield 30 minutes earlier, held because of CB avoidance and then found themselves in an absolutely identical situation, would we now be hearing anything about fuel? I think not. I think the focus would be elsewhere. My point is that it is not the amount of fuel that is at issue here, but the reasonableness of the decisions made AT THE TIME THEY WERE MADE.

Surely the real point, so well outlined in the Flight Editorial, is that this was an ordinary flight that suddenly, and for various unpredictable reasons went awry. The big problem is that this was indeed an ordinary flight and the path to the dreadful outcome is only clear in retrospect. In my opinion we should be talking about why the Flight Editorial is so important, as well as it’s significant for all professional pilots.

If you think about this event in real time, as it unfolded for the crew concerned, I think there is a lot to be learned about how each of us might wish to approach analogous situations in the future. Surely that is the benefit of having a discussion about accidents?
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Old 15th Sep 2004, 19:31
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this was an ordinary flight that suddenly, and for various unpredictable reasons went awry
I quite agree. It could have been anyone of us up until the time the lights failed on short finals.

This is as close to being a pure accident as you can get. Rightly, blame was not apportioned.
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Old 15th Sep 2004, 20:37
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I was a bit perplexed by one part of the report which no-one seems to have picked up on. And which the investigators seem to have passed over.

However, at the time the autothrottle was disconnected a power correction had just been made to 1.51 EPR, a higher than usual approach setting (around 1.2 EPR)
Higher than usual approach setting is a bit of an understatement! It's not a million miles of take-off thrust. In several thousand hours of flying the 757, I have never seen an approach EPR much above 1.3!

The question begging to be answered is why did the autothrottle make this power change? Looking at the graphs, it lseems that the autothrottle was responding to a speed loss from around 152 knots to 127 knots over a period of around 12 seconds! Also considerably slower than the Vref of 141 knots! The ground speed at the same period went from 132 knots to 123 knots!

The report says that windshear and turbulence didn't significantly affect the performance of the aircraft.

It seems to me that that was one very big burst of windshear at a very low altitude (250ish radalt) A loss of 25 knots!!!

That the captain disconnected the autopilot and autothrottle with this high power setting (possibly because he was concerned by these changes?) left him with a very unstable situation.

Am I missing something here? That looks very much like low level windshear to me. And the occurence of that windshear seems to have destabilised the approach to such an extent that the subsequent hard landing(s) occurred.
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Old 16th Sep 2004, 00:10
  #84 (permalink)  
 
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A/T performance

Bally Heck,

I bow to your superior knowledge on the B757 and your observation about the EPR setting on the approach just prior to the Commander disconnecting the A/T.

My own limited observation on the A/T aspect was this:

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).
Your point about a,
very big burst of windshear
is not lost on me.

I'm still wondering why just after the OM the A/T was not responding very well to speed loss.
The last EPR setting was, as point out, quite a handfull.

Certainly the large power change would not be helpful nor contribute to a stable approach when needed most - but the loss of visual clues at the very same time added to this poor chaps problems; the application of near full down elevator fills in the story.

TG
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Old 16th Sep 2004, 04:15
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Quite so Tartan. I have no dispute with most of the findings. I just can't figure out how the report concludes that windshear was not a significant factor. The basis for this appears to be in 1.11.7 with some waffle about customer options for windshear alerts/warnings.

If a 25 knot airspeed loss to Vref minus 15 at 250 feet insn't significant, I don't know what is!

The effect of this large thrust change to 1.51 EPR would be a considerable nose up pitch which would require significant forward pressure on the column to counter. (typical take-off thrust on the 757 might be around 1.59 EPR) With the aircraft trimmed for the approach rather than take-off this sort of power setting must be close to the limit of elevator authority (educated speculation!)

The autothrottle on the 757 whilst well up to normal day to day operations, isn't particularly good at coping with gusts. It can only respond to speed changes after they occur, and is obviously incapable of anticipating them. The greater the speed change, the greater the correction the autothrottle will make.

I wonder how many people could cope with the workload of almost simultaneously having an aircraft lose 25 knots, trying to pitch upwards like a steeplechaser at Beechers Brook and losing all external visual reference?
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Old 16th Sep 2004, 04:42
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Lets face facts here...

The auto-throttle was not the cause of this accident.
Nor was any possible windshear.
Nor was it the relative inexperience of the First Officer.

And...fatigue is a complete red herring.
Med flights are not all that tiring, as I should know, as I've done a lot of 'em.

The very simple reason is the total lack of understanding by the operating Commander on insisting on taking min plog fuel (plus just a bit more) rather than the amount really necessary to achieve a reasonable expectation of reaching the nominated alternate.

In short, he painted himself right and properly into a corner, from which he had very few options available.

The guy is a clown, and simply does not belong in charge of a jet transport aircraft.

I fully expect the usual huffing and puffing, but the known facts speak for themselves...as does the wreckage off the runway.
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Old 16th Sep 2004, 06:11
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You'd be amazed (terrified?) to hear of the number of "proud" Captains who carry bare minimum fuel all the time in an outfit I'm familiar with, but could'nt possibly name. be my guest, stupidos!

I was once criticised on a line check for taking 45 mins extra holding fuel on a UK internal flight. CB activity was forecast for the entire destination and diversion area.

OK, I realise that on long flights, the MTOW may restrict extra fuel. I'm not 757 familiar. Anyone know if this was likely in the accident case?
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Old 16th Sep 2004, 06:24
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The flight plan indicates the required fuel load INCLUDING mandatory reserves to cover various eventualities like holding and diversion; and so the captain's decision to take flight plan + 15 minutes fuel is entirely legal and in keeping with both company and regulatory authority requirements in place at the time.

If those requirements are subsequently subject to review, I feel it is unreasonable to castigate the captain of this aircraft for shortcomings in the standard operating procedures that he was trained to follow.

As a secondary point, are we saying that if the Captain had more fuel, he would not have commenced the approach which led to the accident......? If he would have commenced the approach anyway regardless of fuel state, it possibly was a heaven-sent blessing given the subsequent turn of events that he didn't have more fuel on board. As well as fuel powering engines, it can also power nasty fireballs that kill people very quickly. Thankfully for all, this was avoided on this occasion.

Even with the benefit of hindsight, I don't think any of us can categorically say what would or would not have happened.
Continuing to argue on this one is not making any tangible contribution to safety as far as I can see.
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Old 16th Sep 2004, 07:51
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There are rules about the minimum fuel, these rules are established to avoid that people would even take less.

These rules are fine if operational conditions are the same as the model used to calculate the minimum required, hence no other factors, adversely affecting the flight are present.

Minimum fuel means that you would arrive (after shooting an approach at your destination) at alternate with only 30 min reserve CALCULATED and taking into account that there are no fuel indicator errors and all parameters used to do the math are correct. This is basic knowledge everybody is familiar with.

Minimum legal and SOP are two different things.

Fuel policy can only be integrated into company SOP if you have a policy that is very elaborate like for example the one from KLM. In other words, when all variables that could reasonably be taken into account are present in writing in the SOP.

If you take 15 min extra you are only 15 min away from landing with 30 min in your tanks in case you divert.

Under certain circumstances, 15 min is nothing.


1. Cat I marginal or CAT II/III
2. Non Precision with a VIS that is lower than 6 x MDH
3. Significant WX

Then it is reasonable to assume that you may have to make a second shot. This has nothing to do with skill but only with luck.

15 min will not give you the chance to do that second shot.

Those that know what they are doing; cater for the cases were they may be unlucky.

Those that do not really know what they are doing need all the luck they can get.
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Old 16th Sep 2004, 09:22
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If you decide to carry the minimum legal fuel is OK, what is not good is not to be prepared to divert when you feel that your options are narrowing and the enviroment (weather) works against you.
And if you divert then better do it with plenty because you will not be the only one.

I do not want to be patronizing, but these things are know by everybody and that’s exactly why most pilots are amazed that the crew cornered themselves.

Whatever happened during these approaches is subsequent to the fact that the crew had put themselves under pressure because of fuel reasons. It must be very annoying to get those low fuel messages during an approach that needs all your attention.

I-FORD

I agree with you that if you are getting short, you man not even want to try a first shot at an approach. But that would mean you did not consider the possibility at dispatch stage otherwise you would have arrived with more anyway.
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Old 16th Sep 2004, 16:04
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In the States,standard extra fuel when thunderstorms are forecast is one hour and that includes a tempo observation.
Thunderstorms do,however,tend to be more spectacular stateside.
This thread is important and it should be allowed to run its course.I wonder how many UK pilots feel:
a)that their company encourage a minimum fuel policy to the extent that if they request extra,and it is subsequently proven to be unwarranted,that they will in some way be sanctioned?
b)that their chief pilot wears a corporate hat too often?A good CP dances to only one tune:"How can I best help my pilots to attain the safest operation possible?"He knows each and every pilot,their weaknesses,their strengths.And above all,trust is implicit.Its a managerial role,yes,but never a corporate one.Let the ops director try and bridge the gap between economics and safety.
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Old 16th Sep 2004, 17:00
  #92 (permalink)  

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Question....

What may one infer regards their companys attitude towards safety when a regular line pilot asks for more sim time, for no other reason than to become a better pilot, to practise responses to scenarios he has not otherwise seen before and is denied the request?

Is there a company out there that would accede to such a request?

The hegemony of political correctness is far-reaching.

Comment....

The simple argument that suggests the yardstick by which one is good at his job has a direct and unique correlation with one's experience is amusing.

For me, its the guys who get the job done whatever the TAF, and inspite of their experience, who determine the distinction between mediocrity and greatness.

I personally have learned from the report and thats all that counts.

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Old 16th Sep 2004, 17:09
  #93 (permalink)  
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Rananim,

Does the policy also extend to PROB30 and PROB40. I have often wondered whether there is a certain degree of apathy creeping in towards PROB30. It seems to be interpreted as the Met Man covering his rear end, just in case it happens.

I am not implying that the met report for that night contained any mention of PROB30 or PROB40.
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Old 16th Sep 2004, 17:44
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Somebody mentioned that there were two aircraft holding who had come from BCN which was the alternate for the BY flight. This must have greatly increased the "must land" mentality as with your alternate out as well your options are fading fast. The selection of BCN as an alternate was highly questionable given the fx. weather for all the airfields along the coast. I was flying in southern Spain that night and had Madrid fuel up my sleeve (ie. a lot of extra) plus enough to hold at our destination for 45 minutes before diverting. In the end we didn't need it but the weather was really bad all along the coastal area that night and knowing I had enough to divert well inland was a nice feeling. I can remember the details pretty clearly because I read about the BY accident the next morning over breakfast and like many here thanked my lucky stars it wasn't me. I took lots of extra that night but it's quite possible the implications of the forecast weather could have got past me and I would have departed with less fuel than we really needed which is maybe what happened to these guys. I am sure that had it dawned on them that their alternate and most of the other airfields in the area could all go down as well then they would have nominated another one.

It's very easy to scan through the weather pack at briefing without building up a picture of whats going on and what the implications of the information are and I must say that this accident plus a situation I got myself into at the start of my time in the left seat have made me much more carefull when looking at the weather, even on seemingly benign days.
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Old 16th Sep 2004, 18:08
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Quite amazing looking at some of these replies! Nowhere in section3.2 of the report (Causes) does it mention fuel or the First Officer's experience as being factors.

In my view most crews would have tried for the second approach, given the wind change, regardless of wheather they had 3 tonnes or 10 tonnes of fuel on board!

A few people seem to think that if an aircraft has lots of fuel on board, the approach won't become unstable below decision height and that somehow it will prevent the airfield lights from extinguishing in a thunderstorm. Perhaps this is a feature of Microsoft Flight Simulator?

If the aircraft had been carrying a few extra tonnes there is a greater chance that the tanks would have breached with horrific consequences.

If the aircraft had gone around from the second approach, there was sufficient fuel on board to take it to BCN.

The captain took more than legal minimum fuel, which in itself is normally quite fat, based on a great deal of experience. What he took was enough, although not fat. It did not bring the aircraft down.

Any chance of discussing the facts of the accident and the lessons to be learned from it rather than worrying the fuel policies and minimum hours requirements of various companies to death?
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Old 16th Sep 2004, 22:50
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Shinning thru clearly...

Wonder if Bally Heck is one of those who...steam along every flight with absolute minimum fuel, and feeling lucky doing so?

Those who ignore having adequate (for the anticipated weather) gravy will be caught out sooner or later.

Sad but true, as the concerned Commander found out.
Must be the Brit mentality.

Harsh you say? Have a count of the number of threads previously here on PPRuNe about just this idea. Arriving with min fuel, and then having the pucker factor so that ATC was bothered by those who think...don't confuse me with the facts, my mind is made up.
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Old 16th Sep 2004, 23:38
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Bally Heck,

Surely you can't be serious, the report clearly states that they were below min-fuel for diversion. I know that they would probably have made it to BCN but as you say they had sufficient fuel is just about as far from the truth as you can get. I would think that if more fuel was carried they/he (commander) wouldn't have been as commited to commence the second approach when they did.

I have to agree with 411A on this one, bloody silly thing to do flying into known adverse weather with only 15mins extra onboard..
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Old 17th Sep 2004, 02:10
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I Hope you will all forgive an intrusion from a non-pilot crew member. Having read the report, it strikes me that the dominant causal effect of the accident was the loss of visual on the landing lights, exacerbated by the uncommanded thrust increase from the shattered dogbox after impact. To an uninitiated person, fuel and F/O experience may have been contributory factors, but were not the dominant ones. As a Layman, I'm having problems understanding why you're apparently discussing the lesser contributory factors, rather than the major ones.

I'm very concerned that I may be commenting on matters that are outside my area of expertise, and do not wish to impinge on Flight Crew knowledge or experience. It;s just that when I read the report, it struck me as being a particularly malevolent combination of circumstances that combined against the crew, and little more. With hindsight, I expect most pilots would have handled things better, or at least differently. But that is with hindsight.

I have to confess that I work for the carrier involved, and the Captain had flown me on many sectors. He is a man I like and trust, to this day. I would be greatful if you could all avoid the predictable flaming on this subject. I am simply seeking an answer to a straightforward question, asked in good faith from a non pilot. Please, therefore, understand what may be a certain naivete about this post.
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Old 17th Sep 2004, 06:03
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'Dogs_ears_up', you are not asking silly questions. There is a culture amongst pilots of vigorous debate of the professional issues.

Yes, you are correct to say that if the electricity had not caused the lights to fail the Captain might have landed the aircraft safely.

The issue is that, if there had been more fuel on the aircraft, a landing at that time might have been averted.

Here we get into a real pickle. It is the Captains responsibility to carry extra fuel to cover eventualities. However, the airline is allowed to write a fuel policy which suggests that the carriage of extra fuel should be moderated.

This is the rub. In the UK, some airline management cultures put subtle pressure on Captains to carry minimum fuel.. Some do and some don't. It can depend how resilient you are to peer group pressure. It can also depend on whether you have ever been badly frightened.

I fall into the latter category and carry a lot of extra fuel for fog, strong winds and thunderstorms.

However, even if you carry lots of extra fuel you can still get caught out in extremis. The runway can become blocked or the lights can go out at night just as you are landing having used all the extra gas due to circumstances.

Perhaps we should practice fuel emergencies in the SIM. However, that might lead to pilots carrying more fuel all the time and then the bean counters would quietly suggest to the Board that they do something about it . . .
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Old 17th Sep 2004, 06:40
  #100 (permalink)  
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There has been little comment on the actual moment that the lights went out. Is there any clear data, even in the memory of the commander, of the decision to press on vs. go-around?

Intentional pushing on into absolute rain lashed blackness is not very likely, unless there was a compelling reason to do so. Even if he felt that the loss of lighting was containable, he may just have been unlucky enough to have a vicious weather induced increase in v/s .

Is there any evidence to show that the continued landing was intentional?
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