Report on 1999 B757 crash at Girona finally published
Join Date: Dec 2003
Location: Dubai
Posts: 212
Likes: 0
Received 0 Likes
on
0 Posts
Dewly
The previous post of 411A exactly proves my point.
And having an opinion about certain things is Not always hindsight.
411A could keep his mouth shut but he doesn’t simply because he is a concerned natural be it a bit blunt.
But I prefer by far those who have a clear opinion than those that smile and put a knife in your back.
As I am almost sure 411A would defend any pilot against the management if in his opinion the guy was professionally correct.
And that is NOT the BRITISH way of doing things but it is very American.
To quote my chief pilot.
As a captain you are responsible for bringing the acft from A to B.
To do so you have an F/O and AFDS at your service, USE THEM AS EFFICIENTLY AS POSSIBLE and do not overload yourself by not delegating what can be delegated.
Certainly if you feel you are tired, try to be frech when needed and that means once below 300 ft.
13000 + , military and 3 Flag carriers
And yes, I landed last week with 5 tons fuel in the UK on a 737.
No questions were asked.
If you do not say it clearly then you are missing the point
And having an opinion about certain things is Not always hindsight.
411A could keep his mouth shut but he doesn’t simply because he is a concerned natural be it a bit blunt.
But I prefer by far those who have a clear opinion than those that smile and put a knife in your back.
As I am almost sure 411A would defend any pilot against the management if in his opinion the guy was professionally correct.
And that is NOT the BRITISH way of doing things but it is very American.
To quote my chief pilot.
As a captain you are responsible for bringing the acft from A to B.
To do so you have an F/O and AFDS at your service, USE THEM AS EFFICIENTLY AS POSSIBLE and do not overload yourself by not delegating what can be delegated.
Certainly if you feel you are tired, try to be frech when needed and that means once below 300 ft.
13000 + , military and 3 Flag carriers
And yes, I landed last week with 5 tons fuel in the UK on a 737.
No questions were asked.
Mach 3
Join Date: Aug 1998
Location: Stratosphere
Posts: 622
Likes: 0
Received 0 Likes
on
0 Posts
Out of interest, Appendix B of the report illustrates some radar images for the time period 2133 to 2153 on the night in question.
Correct me if I am wrong, but BCN looks wide open during that time period....
Are those radar images rainfall images?
I haven't actually seen the METARs and TAFs for the day in question as they aren't in the report. Has anyone?
If so maybe they could post them?
Correct me if I am wrong, but BCN looks wide open during that time period....
Are those radar images rainfall images?
I haven't actually seen the METARs and TAFs for the day in question as they aren't in the report. Has anyone?
If so maybe they could post them?
Join Date: Sep 1999
Posts: 541
Likes: 0
Received 0 Likes
on
0 Posts
Any crew can screw up.The last hundred years has surely taught us that much.More interesting than the actual error chain that night are the set of conditions that made that error chain possible,if not inevitable.
Something led that commander to load only 15 minutes of extra fuel when thunderstorms were forecast.Company pressure has already been rejected,so what was it?A genuine oversight?A belief that European weather is generally benign(which it is)?Was the co-pilot happy with the 15 minutes?Would he have dared speak up if he wasn't,considering his relatively junior status?The report's matter-of-fact statement that the crew "discussed" fuel requirements is frankly bizarre.Dispatch is not involved in the fuel decision in Europe as I understand it.It is fair to say that crews generally dislike sticking out like a sore thumb.Would dispatch involvement("Bad weather forecast in Gerona,we suggest an extra 45 mins,subject to your approval?")not give an automatic company seal of approval?
The fuel,or lack of it,dictated the mindset on that second approach,something which Bally Heck fails to recognize.The psychological benefit of carrying enough gas settles the mind,ensuring that judgement is never clouded by diminishing options.
Steep cockpit gradients do exist and can work.But there is a heavy burden on the Captain.Checks and balances from the right seat might be non-existent or inappropiate("1000 down" instead of "GO AROUND").Failure of the lights was unfortunate but must not be used as an excuse.Go-arounds can and often do involve main-gear touchdown.
Blaming dogbox design is a misnomer.If you dont crash the thing,the dogbox is just fine.
Fatigue might have played a role but there is less evidence for this.Loss of motor skills,induced by heavy reliance on automation day in day out,was not addressed either.The Captain was reported to be in a state of mental shock.Thats unfortunate because it takes but a second to check a -4.5 pitch attitude.Reliance on automatic height call-outs for flare is also an indication of automation over-reliance.This was addressed by the report but not in the correct context,I believe."I didnt flare because there were no call-outs"
Something led that commander to load only 15 minutes of extra fuel when thunderstorms were forecast.Company pressure has already been rejected,so what was it?A genuine oversight?A belief that European weather is generally benign(which it is)?Was the co-pilot happy with the 15 minutes?Would he have dared speak up if he wasn't,considering his relatively junior status?The report's matter-of-fact statement that the crew "discussed" fuel requirements is frankly bizarre.Dispatch is not involved in the fuel decision in Europe as I understand it.It is fair to say that crews generally dislike sticking out like a sore thumb.Would dispatch involvement("Bad weather forecast in Gerona,we suggest an extra 45 mins,subject to your approval?")not give an automatic company seal of approval?
The fuel,or lack of it,dictated the mindset on that second approach,something which Bally Heck fails to recognize.The psychological benefit of carrying enough gas settles the mind,ensuring that judgement is never clouded by diminishing options.
Steep cockpit gradients do exist and can work.But there is a heavy burden on the Captain.Checks and balances from the right seat might be non-existent or inappropiate("1000 down" instead of "GO AROUND").Failure of the lights was unfortunate but must not be used as an excuse.Go-arounds can and often do involve main-gear touchdown.
Blaming dogbox design is a misnomer.If you dont crash the thing,the dogbox is just fine.
Fatigue might have played a role but there is less evidence for this.Loss of motor skills,induced by heavy reliance on automation day in day out,was not addressed either.The Captain was reported to be in a state of mental shock.Thats unfortunate because it takes but a second to check a -4.5 pitch attitude.Reliance on automatic height call-outs for flare is also an indication of automation over-reliance.This was addressed by the report but not in the correct context,I believe."I didnt flare because there were no call-outs"
Join Date: Oct 1999
Location: United Kingdom
Posts: 398
Likes: 0
Received 0 Likes
on
0 Posts
An airspeed loss of 25 knots at around 250 ft RA caused a power change to 1.51 EPR. Nearly take off thrust! This caused a substantial pitch up to nearly 6 degrees. The autopilot was disengaged at about this point. Substantial forward elevator would be required to stop the nose up pitch particularly with the aircraft trimmed for the approach.
At this point it would be fair to say that the approach was unstable and a go-around should have been executed. Why it wasn't I can only guess, but possibly due to the combination of an unruly aircraft and loss of external visual cues, the captain was temporarily maxed out.
The rest is history.
If 411a doesn't suffer from fatigue on consecutive night flights, perhaps he is a vampire? Responding to his diatribe merely encourages him. I tend not to read his posts as they seldom add any value to the discussion. Their purpose seems to be deliberately vexatious and if you ignore him he goes away.
At this point it would be fair to say that the approach was unstable and a go-around should have been executed. Why it wasn't I can only guess, but possibly due to the combination of an unruly aircraft and loss of external visual cues, the captain was temporarily maxed out.
The rest is history.
If 411a doesn't suffer from fatigue on consecutive night flights, perhaps he is a vampire? Responding to his diatribe merely encourages him. I tend not to read his posts as they seldom add any value to the discussion. Their purpose seems to be deliberately vexatious and if you ignore him he goes away.
Join Date: Mar 2000
Location: Arizona USA
Posts: 8,571
Likes: 0
Received 0 Likes
on
0 Posts
Oh, I ain't going away, Bally Heck.
This accident is so egregious in its cause and effect, that if other crew can not actually learn from the mistakes that were made by the Commander, then European aviation is in a much worse state than I thought.
These companies cry out for proper licensed dispatchers to advise crews of problems, and recommend solutions.
The US FAA long ago required this, but European operators seem not to learn from the accidents that occur.
That they don't does NOT say much for their operating procedures.
Ha! JAA compliant....phooey.
If Captains can't (by themselves) uplift enough fuel on their own accord, they don't BELONG in the airline business.
What the hell is wrong with the 'thinking?' process in the UK with these few (or maybe more) Commanders?
Then we have the Hapag Lloyd A310 accident at VIE, FUEL quantity...AGAIN.
Steaming along, the Commander seemly oblivious to the fuel remaining, in spite of the First Officers concerns.
Hey there, big time Captains...maybe you should start to listen to the guys on the RH side, as they seem to be more concerned than YOU are.
Good grief!
PS: Just to add---
Of the many substitute flights I performed from the UK, MONARCH stands out head and shoulders above the rest, in their preflight briefing ability.
Professional guys, who would always recommend extra fuel if the conditions required same...and many times it did.
Other companies could actually learn from these excellent folks.
An old line company doing it right.
This accident is so egregious in its cause and effect, that if other crew can not actually learn from the mistakes that were made by the Commander, then European aviation is in a much worse state than I thought.
These companies cry out for proper licensed dispatchers to advise crews of problems, and recommend solutions.
The US FAA long ago required this, but European operators seem not to learn from the accidents that occur.
That they don't does NOT say much for their operating procedures.
Ha! JAA compliant....phooey.
If Captains can't (by themselves) uplift enough fuel on their own accord, they don't BELONG in the airline business.
What the hell is wrong with the 'thinking?' process in the UK with these few (or maybe more) Commanders?
Then we have the Hapag Lloyd A310 accident at VIE, FUEL quantity...AGAIN.
Steaming along, the Commander seemly oblivious to the fuel remaining, in spite of the First Officers concerns.
Hey there, big time Captains...maybe you should start to listen to the guys on the RH side, as they seem to be more concerned than YOU are.
Good grief!
PS: Just to add---
Of the many substitute flights I performed from the UK, MONARCH stands out head and shoulders above the rest, in their preflight briefing ability.
Professional guys, who would always recommend extra fuel if the conditions required same...and many times it did.
Other companies could actually learn from these excellent folks.
An old line company doing it right.
Last edited by 411A; 19th Sep 2004 at 23:51.
Psychophysiological entity
But what about the last few moments? I pose the question again. So much energy has gone into hacking at each other, so much into the tight fuel...we know he found himself up that dark corridor, but why could he not contain those last few seconds? A reference pitch, a survivable rate, the aircraft is a fabulous bit of kit, is it acceptable to wait for a cue for the ground to arrive?
Mach 3
Join Date: Aug 1998
Location: Stratosphere
Posts: 622
Likes: 0
Received 0 Likes
on
0 Posts
A/my simplistic analysis perhaps...
If you remove one causal event in the sequence of events that led to this accident, a different outcome would almost certainly have been guaranteed.
Fuel is a red-herring for me. I agree it would probably have been prudent to take a little more. There is nothing to suggest that even if G-BYAG had had block+10T onboard the same sequence of events would not have transpired.
The aircraft had fuel for LEBL. It would therefore appear reasonable to assume LFMP and LERS, albeit he'd be on vapour by the time he got there. In all cases, except perhaps LEBL, he'd have been <E @ ETA.
However, he could have committed himself to LEGE.
The outcome in the event of exercising any of these options is pure speculation.
The difference in attitude towards fuel policy between various posters reflects the difference in experience. Just a thought.
If you regularly operate full 735's on 1000NM sectors to/from hot performance restrictive fields, you will know that you are regularly up against RTOW limits. This precludes the carriage of alot extra.
You are then constantly weighing up how many bags to offload versus how much fuel to carry. The most I have been involved in offloading is 900KG out of LSGG purely to allow an equivalent extra uplift of fuel.
The point being that it must be the case that operational constraints allow some pilots less room for manoeuvre than others, whereupon the pressure they are under is greater than others.
IMHO though, the fuel state may have been contributory but not causal.
Neither is the fatigue issue causal. At best contributory. CAP371/FTL limitations ensure corporate culpability on this matter would probably be hard to prove. Even QinetiQ/NASA research brought to bear on the recent debate about FTL limitations has struggled to achieve credibility with the Commission. For all the wrong reasons perhaps...
It would appear that if fatigue is ever an issue, it is up to the individual concerned, bearing in mind the responsible nature of his job, to offload himself. If he doesn't, struggles through the duty, and has a CFIT inicident, then arguably he has only himself to blame with all the associated drastic consequences.
If the skipper himself says he wasn't fatigued, (Pg 7 of the report explicitly states this to be the case of both individuals concerned), lets consider that to be the case.
However, what seems to me to be causal in the event is the failure to GA when visual contact was lost. There was still 6 secs before touchdown to initiate a GA.
And this is an incident that reaffirms the sense in executing a GA in conditions where the visual reference is lost and reminds me not to be afraid to use TOGA. In fact, funnily enough, having reflected on this very matter last week, I almost did exactly that recently into EGFF in torrential rain.
But I'll have to keep remembering not to confuse TOGA with the A/T disconnect.
If you remove one causal event in the sequence of events that led to this accident, a different outcome would almost certainly have been guaranteed.
Fuel is a red-herring for me. I agree it would probably have been prudent to take a little more. There is nothing to suggest that even if G-BYAG had had block+10T onboard the same sequence of events would not have transpired.
The aircraft had fuel for LEBL. It would therefore appear reasonable to assume LFMP and LERS, albeit he'd be on vapour by the time he got there. In all cases, except perhaps LEBL, he'd have been <E @ ETA.
However, he could have committed himself to LEGE.
The outcome in the event of exercising any of these options is pure speculation.
The difference in attitude towards fuel policy between various posters reflects the difference in experience. Just a thought.
If you regularly operate full 735's on 1000NM sectors to/from hot performance restrictive fields, you will know that you are regularly up against RTOW limits. This precludes the carriage of alot extra.
You are then constantly weighing up how many bags to offload versus how much fuel to carry. The most I have been involved in offloading is 900KG out of LSGG purely to allow an equivalent extra uplift of fuel.
The point being that it must be the case that operational constraints allow some pilots less room for manoeuvre than others, whereupon the pressure they are under is greater than others.
IMHO though, the fuel state may have been contributory but not causal.
Neither is the fatigue issue causal. At best contributory. CAP371/FTL limitations ensure corporate culpability on this matter would probably be hard to prove. Even QinetiQ/NASA research brought to bear on the recent debate about FTL limitations has struggled to achieve credibility with the Commission. For all the wrong reasons perhaps...
It would appear that if fatigue is ever an issue, it is up to the individual concerned, bearing in mind the responsible nature of his job, to offload himself. If he doesn't, struggles through the duty, and has a CFIT inicident, then arguably he has only himself to blame with all the associated drastic consequences.
If the skipper himself says he wasn't fatigued, (Pg 7 of the report explicitly states this to be the case of both individuals concerned), lets consider that to be the case.
However, what seems to me to be causal in the event is the failure to GA when visual contact was lost. There was still 6 secs before touchdown to initiate a GA.
And this is an incident that reaffirms the sense in executing a GA in conditions where the visual reference is lost and reminds me not to be afraid to use TOGA. In fact, funnily enough, having reflected on this very matter last week, I almost did exactly that recently into EGFF in torrential rain.
But I'll have to keep remembering not to confuse TOGA with the A/T disconnect.
Last edited by SR71; 20th Sep 2004 at 12:36.
I don't know what's available in Europe, but here in North America, anybody with an internet connection, including dispatchers, can see radar for the entire United States plus the Southern part of Canada.
A dispatcher here who sees a flight with thin reserves headed into an area where CBs are blooming at destination and alternates within range will likely be diverting that flight to an airport in good weather where additional fuel can be taken on.
There is work under way to upload radar to the cockpit so that the crew can take advantage of national radar data: NASA Report
A dispatcher here who sees a flight with thin reserves headed into an area where CBs are blooming at destination and alternates within range will likely be diverting that flight to an airport in good weather where additional fuel can be taken on.
There is work under way to upload radar to the cockpit so that the crew can take advantage of national radar data: NASA Report
Join Date: Oct 1999
Location: United Kingdom
Posts: 398
Likes: 0
Received 0 Likes
on
0 Posts
Well done guys.
We are on a roll of thoughtfull comment instead off thoughtless blaming.
I wonder about the search and rescue thing quite a bit. It's hard to beleive that the airfield rescue services couldn't find the wreck! But I've been there and seen the wreckage after the event. Saw the aircraft sitting in a field, pretty well out of sight. Can't really blame the guys for not finding it more quickly. It seems they tried quite hard. Is this a result of airfield geography?
If there had been a fire, it would have been obvious. Thankfully there wasn't.
How many more airfields could host this type of incident without being able to respond?
How can we make this better?
We are on a roll of thoughtfull comment instead off thoughtless blaming.
I wonder about the search and rescue thing quite a bit. It's hard to beleive that the airfield rescue services couldn't find the wreck! But I've been there and seen the wreckage after the event. Saw the aircraft sitting in a field, pretty well out of sight. Can't really blame the guys for not finding it more quickly. It seems they tried quite hard. Is this a result of airfield geography?
If there had been a fire, it would have been obvious. Thankfully there wasn't.
How many more airfields could host this type of incident without being able to respond?
How can we make this better?
Bally Heck,
Don't know if you've seen the aerial photo of where the aircraft finally stopped (it was posted here on one of the earlier pages). After losing contact with the aircraft ATC could only suppose it had crashed, but where, if they couldn't see anything from the tower themselves (sorry, she)? It could have been miles away, and who was to suppose it had threaded that needle between the wall of trees into the adjacent field? Imagine if that one passenger hadn't sprinted through the mud, over culvert, etc and alerted the fire brigade - how long might it all have taken?
I'm sure you could think of more than a few dozen airports around the world where, under similar circumstances, the accident site wouldn't be found for quite some time. Memory's a bit blurry but it tells me evenn the Staines Trident accident site took some time to locate.
How to make things better? Well one thing that occurs to me is that when ships go down in oceans, their EPIRBs go off and say "I'm here, Help". When aircraft go down, they just disaappear from radar screens at x altitude. I wonder why, with the the technology available right now, an aircraft can't transmit it's position continuously, linked into the radar image. It may disappear from radar but "there it is, in the field just across the runway".
Don't know if you've seen the aerial photo of where the aircraft finally stopped (it was posted here on one of the earlier pages). After losing contact with the aircraft ATC could only suppose it had crashed, but where, if they couldn't see anything from the tower themselves (sorry, she)? It could have been miles away, and who was to suppose it had threaded that needle between the wall of trees into the adjacent field? Imagine if that one passenger hadn't sprinted through the mud, over culvert, etc and alerted the fire brigade - how long might it all have taken?
I'm sure you could think of more than a few dozen airports around the world where, under similar circumstances, the accident site wouldn't be found for quite some time. Memory's a bit blurry but it tells me evenn the Staines Trident accident site took some time to locate.
How to make things better? Well one thing that occurs to me is that when ships go down in oceans, their EPIRBs go off and say "I'm here, Help". When aircraft go down, they just disaappear from radar screens at x altitude. I wonder why, with the the technology available right now, an aircraft can't transmit it's position continuously, linked into the radar image. It may disappear from radar but "there it is, in the field just across the runway".
Psychophysiological entity
Just a sad moment of reflection on the Staines. A road traffic cop told me that the real problem that they had getting to the Trident, was the mass of people that had stopped to look.
Back to the present. It sounds as though that lone soul running over rough terrain was a bit of a hero.
Back to the present. It sounds as though that lone soul running over rough terrain was a bit of a hero.
Join Date: Oct 2003
Location: n/a
Posts: 1,425
Likes: 0
Received 0 Likes
on
0 Posts
their EPIRBs go off
Many aircraft have automatic ELTs based on a deccellaration switch, a nice heavy landing sets them off. However as airports and fire vehicles can not track on them you would need a chopper or fixed wing. And the accuracy is not that great.
However there are enhanced vision systems for fire trucks. obviously they are expensive and it comes down to cost versus lives saved.
In this case 200+ lives would nicely pay for one or two.
Its derived from tank night driving systems, consisting of FLIR and Low light cameras and a DGPS map position.
However on the night in question the amount of rain (44L/M2 in 30 mins) may have neutralised even this kit.
http://www.galaxyscientific.com/areas/navigati/air3.htm
http://www.massport.com/logan/about_publi_massp.html
Join Date: Mar 2000
Location: Arizona USA
Posts: 8,571
Likes: 0
Received 0 Likes
on
0 Posts
Reality 101
Does anyone really believe that any airport authority in Spain or Portugal (and indeed we can include most any airport on the Med) has any intension whatsoever in providing emergency services beyond what the absolute minimum requirements are?
We can extend this to ATC as well.
These folks want your tourist Dollar, Euro etc.
What, upgrade emergency and ATC facilities? Whatever for?
We can extend this to ATC as well.
These folks want your tourist Dollar, Euro etc.
What, upgrade emergency and ATC facilities? Whatever for?
Join Date: Mar 2000
Location: Between The Black Swan & The Swettenham Arms
Age: 69
Posts: 90
Likes: 0
Received 0 Likes
on
0 Posts
And yes, I landed last week with 5 tons fuel in the UK on a 737.
You can still crash with this amount of gas.
Too many posters have a fixation that the ramp fuel decision was the one & only cause of this accident. With the benefit of hindsight, we can all see that more fuel would have been advantageous, but no-one - NO-ONE - can categorically state that in this circumstance, the fateful approach would not have be made at exactly the same time, with exactly the some conditions. The only difference would be that AG crashed with more fuel on board.
Re-read the report; it is 100 or so pages long, produced by experts from Spain, the UK & the US. Experts who are professional tin kickers and do this for a living.
At the end, there are 10 recommendations:
1 refering to the operator's fuel policy,
1 refering to go around training,
1 refering to met svcs,
3 refering to airfield & facilities &
4 refering to airframe construction/certification.
Blaming dogbox design is a misnomer.If you dont crash the thing,the dogbox is just fine.
I've learned something from this accident:
There, but for the grace of God, go I.
I-FORD
"(2) ....like letting the copilot fly the plane until OM or FAF...."
I liked your posting but I would suggest that the above be modified to
"....like letting the copilot fly the plane until minimums...".
Let's face it, they usually do it better than we do!
"(2) ....like letting the copilot fly the plane until OM or FAF...."
I liked your posting but I would suggest that the above be modified to
"....like letting the copilot fly the plane until minimums...".
Let's face it, they usually do it better than we do!
Daysleeper,
Agree, there are a fair number of false alarms; nothing on a ship is idiot-proof. On the other hand a few lives have been saved. The technology is fairly straghtforward though and I can't imagine it hasn't been considered; making blending it into proprietary radar technology obligatory may be something else.
Re the links you posted, the view through the firetruck's windscreen at 400' was great! Sounds a bit expensive.
411A, re your last comment: pretty much the same in Wichita as in Girona; a national or supra-national authority says it has to happen and, eventually, it does or it's blacklisted and rendered inoperative by the relevant authority - which might even be Homeland Security. Whether Girona or Aeropuertos Espanoles (if that's the national authority name) want to spend the money is immaterial; if they want your tourist dollar or euro that's the way it has to be.
Rivets, you're right. Arrived on a BEA Trident same time, picked up a rental car and got stuck in traffic, resented being labelled ghoul by H Wilson.
Agree, there are a fair number of false alarms; nothing on a ship is idiot-proof. On the other hand a few lives have been saved. The technology is fairly straghtforward though and I can't imagine it hasn't been considered; making blending it into proprietary radar technology obligatory may be something else.
Re the links you posted, the view through the firetruck's windscreen at 400' was great! Sounds a bit expensive.
411A, re your last comment: pretty much the same in Wichita as in Girona; a national or supra-national authority says it has to happen and, eventually, it does or it's blacklisted and rendered inoperative by the relevant authority - which might even be Homeland Security. Whether Girona or Aeropuertos Espanoles (if that's the national authority name) want to spend the money is immaterial; if they want your tourist dollar or euro that's the way it has to be.
Rivets, you're right. Arrived on a BEA Trident same time, picked up a rental car and got stuck in traffic, resented being labelled ghoul by H Wilson.
Join Date: Oct 2004
Location: Canada
Posts: 52
Likes: 0
Received 0 Likes
on
0 Posts
Gerona.
Now that this topic has gone quite and the dust settled, lets look (with the benefit of hindsight), at what we have learned.
From the alarm clock going that day (for both crew members), what would you have done differently?
List your points in the order of importance ... one airline has already set this as a project for their winter refresher course!
From the alarm clock going that day (for both crew members), what would you have done differently?
List your points in the order of importance ... one airline has already set this as a project for their winter refresher course!
