Report on 1999 B757 crash at Girona finally published
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Gerona Rpt Published
Here
http://www.mfom.es/ciaiac/publicacio..._texto_ENG.pdf
There for the grace etc.
Nasty night and lady luck on a sicky
http://www.mfom.es/ciaiac/publicacio..._texto_ENG.pdf
There for the grace etc.
Nasty night and lady luck on a sicky
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I'm actually reading over the report again right now, and the impression I'm getting is that the crew could have done some things slightly diferrent, but ultimately the MAIN factors seem to be the runway lights going out at the critical point where the PF is looking for visual cues(the lights came back on by emergency power within the 15second period required, but too late...), and the "sink rate" warning sounding over the last few rad alt callouts.
These comments I find too harsh, and I'm wondering if Joyce Tick has actually read the conclusions/findings of the investigation on the flight crew (page 88-would post them but can't seem to copy the text 
) or if he/she has made their own conclusions! especially as the report suggests that another (of the many) factors may have been the crew/airlines non-requirement to train go-around proceedures below minimums, the PF's apparent "shock" at the runway lights going out at that stage may have been reduced to some extent.
The sad thing is that the report says that if the nose landing gear support structure hadn't have displaced the control/thrust lever control cables in such way , the aircraft may have just come to an eventual stop on it's nose on the runway. The displacement of the thrust cables caused an increase in thrust, which literally powered the aircraft on into the actual events that occured thereafter. All in all, many factors from not only within the cockpit contributed to the incident, including bad luck!!!!! though it still amazes me to this day how there was no loss of life or very serious injury (at the time
), and I would hope that the crew can carry on their career with greater knowledge of such situations leading up to the event, I'm certainly not worried if I'm ever sat behind them if I was pax on their flight...
The crew screwed up big time - and there's little point in playing the "anyone else's fault but the pilot's" card here.
) or if he/she has made their own conclusions! especially as the report suggests that another (of the many) factors may have been the crew/airlines non-requirement to train go-around proceedures below minimums, the PF's apparent "shock" at the runway lights going out at that stage may have been reduced to some extent.The sad thing is that the report says that if the nose landing gear support structure hadn't have displaced the control/thrust lever control cables in such way , the aircraft may have just come to an eventual stop on it's nose on the runway. The displacement of the thrust cables caused an increase in thrust, which literally powered the aircraft on into the actual events that occured thereafter. All in all, many factors from not only within the cockpit contributed to the incident, including bad luck!!!!! though it still amazes me to this day how there was no loss of life or very serious injury (at the time
), and I would hope that the crew can carry on their career with greater knowledge of such situations leading up to the event, I'm certainly not worried if I'm ever sat behind them if I was pax on their flight...
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Simfly - In general terms I agree with you. Joyce Stick appears to have not fully read the report and as a consequence ends up quoting cliches and shooting from the hip. The main cause of the aircraft departing the runway was the left thrust lever cable run being displaced and running to high power and thus causing the aircraft to yaw right - otherwise it would have been a very heavy landing incident but repairable.
ATC bears a heavy responsibility in their management of the airfield lighting systems and subsequent reaction to the crash response.
Incidentally, both pilots have now retired.
The fatality was a supposedly terminally ill gentleman, the death of whom was not attributable to the accident.
To anyone who may be confused - Joyce Stick has removed his previous unnecessary comments to which several inputs have referred though his remarks have been paraphrased by others.
ATC bears a heavy responsibility in their management of the airfield lighting systems and subsequent reaction to the crash response.
Incidentally, both pilots have now retired.
The fatality was a supposedly terminally ill gentleman, the death of whom was not attributable to the accident.
To anyone who may be confused - Joyce Stick has removed his previous unnecessary comments to which several inputs have referred though his remarks have been paraphrased by others.
Last edited by willoman; 6th Sep 2004 at 17:13.
How common is it for an airline to employ FO's with 349 hours total and no ATPL, as was the case in this incident?
Where I come from, you need 3000TT before you can even send in your CV and even then you'd be at the bottom of the pile.
I have read the report in full - please understand that I am not saying the inexperience of the FO contributed to the accident IN ANY WAY - just making an observation.
Where I come from, you need 3000TT before you can even send in your CV and even then you'd be at the bottom of the pile.
I have read the report in full - please understand that I am not saying the inexperience of the FO contributed to the accident IN ANY WAY - just making an observation.
Controversial, moi?
Page 6 and 7 states that the FO had a TT of 1,494 hours of which 1,145 were on type.
Where do you get 349 hours from?
Paragraph 2.3.2.3 on page 77 makes an interesting observation.
Where do you get 349 hours from?
Paragraph 2.3.2.3 on page 77 makes an interesting observation.
M.Mouse, at the time of the accident the FO had a TT of 1,494 with 1,145 of that of the 757, his only type rating according to the report. So, he must have come to BY with a TT of 349 hours.
I am just making the observation, without trying to make a point of it, that this was a very low time FO when he joined the company.
I am just making the observation, without trying to make a point of it, that this was a very low time FO when he joined the company.
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but for the grace of god,
a question though, does anyone have to justify the fuel load in brits ? with that weather it seems a bit short (15 mins) extra, and in a 757 10200kgs is a strange fuel load any way ?
a question though, does anyone have to justify the fuel load in brits ? with that weather it seems a bit short (15 mins) extra, and in a 757 10200kgs is a strange fuel load any way ?
Controversial, moi?
Buckshot,
I understand now.
In BA cadets were coming out of flying college under the JAR OPS rules and after considerable conversion training they were RHS of aircraft up to the B757s with circa 200 hours.
Very technically competent but the lack of experience was very obvious.
I understand now.
In BA cadets were coming out of flying college under the JAR OPS rules and after considerable conversion training they were RHS of aircraft up to the B757s with circa 200 hours.
Very technically competent but the lack of experience was very obvious.
I don't know how many of you have seen this photo?
http://www.airliners.net/open.file/327987/L/
They were very lucky the aircraft followed the track that it did. It is terrifying to imagine what would have happened if it had gone into the trees.
http://www.airliners.net/open.file/327987/L/
They were very lucky the aircraft followed the track that it did. It is terrifying to imagine what would have happened if it had gone into the trees.
Last edited by Groundloop; 6th Sep 2004 at 09:39.
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Toon,
10200KG was presumably the Block Fuel, minus the standard taxi figure for BAL B757's which is 200KG, obviously leaving 10T once off the runway. I agree, even as a non-flyer, that given the projected weather upon arrival that more fuel may have been prudent...20/20 hindsight is a great thing though isn't it?
M.Mouse,
Para 2.3.2.3 seems to contradict itself? It starts off apparently suggesting CRM may have been lacking at the time of the accident, but then states that even if the "monitored approach" working practice had been used, it may not have made any difference anyway?
I agree that a higher-houred pilot should have better experience of every situation, but it is a sweeping generalisation. I flew jumpseat (on a B757, coincidentally) with an FO on his third "live" sector recently, and I honestly cannot remember flying with a more "focussed" and proficient pilot (Particularly flying a last-minute change to a procedural approach at MAH! Certainly made me sit up and pay attention!)
PHX
10200KG was presumably the Block Fuel, minus the standard taxi figure for BAL B757's which is 200KG, obviously leaving 10T once off the runway. I agree, even as a non-flyer, that given the projected weather upon arrival that more fuel may have been prudent...20/20 hindsight is a great thing though isn't it?
M.Mouse,
Para 2.3.2.3 seems to contradict itself? It starts off apparently suggesting CRM may have been lacking at the time of the accident, but then states that even if the "monitored approach" working practice had been used, it may not have made any difference anyway?
I agree that a higher-houred pilot should have better experience of every situation, but it is a sweeping generalisation. I flew jumpseat (on a B757, coincidentally) with an FO on his third "live" sector recently, and I honestly cannot remember flying with a more "focussed" and proficient pilot (Particularly flying a last-minute change to a procedural approach at MAH! Certainly made me sit up and pay attention!)
PHX
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Regarding the F/O's experience.... Over 1000 hours on type is still a good number. It's well over a year, and one would hope that after that sort of time, he would have been fairly proficient. Agreed there maybe sometimes unusual events which he may not have experienced, but couldn't that happen to anyone at almost any time in their flying career??
Controversial, moi?
Phoenix Son
Not wishing to start an interminable debate about the 'monitered approach' but given the unfortunate set of circumstances that prevailed it is my belief (I have around 15,000 hours experience) that it would have allowed the Captain to reduce his obviously considerable workload.
Similar in some respects to the actions of the Captain involved in British Midland Kegworth crash where the Captain also elected to fly the aeroplane while at the same time managing a very difficult situation.
It is BA policy, in circumstances where a situation develops requiring managarial oversight, that control of the aircraft is handed to the FO. He is competent to fly the aircraft as instructed, or required by a procedure, and it allows the Captain that all important space which is needed to maintain an overview and make decisions accordingly. We also employ the monitored approach as an SOP and in the circumstances of the Girona flight I know which procedure I would have preferred.
It was my first thought that the fuel carried was not overly generous for the forecast weather. 15 minutes extra is not a lot when one considers
There IS huge pressure from management in many companies not to carry excessive amounts of fuel.
Diversions create delays, costs and high workload. No doubt the wish to not divert lead to a strong desire to get in from the second approach. One has to ask the question if the aircraft was carrying another 30 mins of holding fuel would the crew have elected to make the approach when they did?
All personal opinion from the comfort of my study and I don't believe that a pilot alive does not feel for the situation that the crew found themselves in that fateful evening and it is a small mercy that the accident, bad as it was, did not turn into a massive tragedy.
A final comment. I don't doubt the competency of the FO you observed when jump seating and I have rarely flown with an FO who gives me reason to doubt that competency but there is a world of difference between competency and experience. Something not fully appreciated until having that experience! The 1500 hours of the flying that the BY FO had would have covered a huge variety of often demanding flying that the BY network provides.
Not wishing to start an interminable debate about the 'monitered approach' but given the unfortunate set of circumstances that prevailed it is my belief (I have around 15,000 hours experience) that it would have allowed the Captain to reduce his obviously considerable workload.
Similar in some respects to the actions of the Captain involved in British Midland Kegworth crash where the Captain also elected to fly the aeroplane while at the same time managing a very difficult situation.
It is BA policy, in circumstances where a situation develops requiring managarial oversight, that control of the aircraft is handed to the FO. He is competent to fly the aircraft as instructed, or required by a procedure, and it allows the Captain that all important space which is needed to maintain an overview and make decisions accordingly. We also employ the monitored approach as an SOP and in the circumstances of the Girona flight I know which procedure I would have preferred.
It was my first thought that the fuel carried was not overly generous for the forecast weather. 15 minutes extra is not a lot when one considers
TEMPO is used to describe changes which are expected to last for periods of 30 minutes or more but less than one hour in each instance, and which in aggregate are not expected to cover more than half the total period for which the TEMPO is indicated.
Diversions create delays, costs and high workload. No doubt the wish to not divert lead to a strong desire to get in from the second approach. One has to ask the question if the aircraft was carrying another 30 mins of holding fuel would the crew have elected to make the approach when they did?
All personal opinion from the comfort of my study and I don't believe that a pilot alive does not feel for the situation that the crew found themselves in that fateful evening and it is a small mercy that the accident, bad as it was, did not turn into a massive tragedy.
A final comment. I don't doubt the competency of the FO you observed when jump seating and I have rarely flown with an FO who gives me reason to doubt that competency but there is a world of difference between competency and experience. Something not fully appreciated until having that experience! The 1500 hours of the flying that the BY FO had would have covered a huge variety of often demanding flying that the BY network provides.
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Without wishing to get into any dispute, or indeed to be accused of hindsight, I do think 15 minutes extra in TS conditions is a bit tight. Especially when all the alternates (indeed the whole region) seemed to be having the same weather. I guess you could say the skipper was carrying enough to hold and allow a single cell to clear the field...15 minutes might do it...but all the same I personally would like more. Maybe they had weight/range probs? I'm not familiar with the type.
As to the crews competence, I may be reading it wrong but I thought the F/Os input sounded OK. He seemed to make all the required callouts (e.g spotting the 1000fpm descent and calling it). Given his low time I expect there was (even with the best will in the world) quite a steep cockpit gradient.
Incidentally, do Aussie rules require an extra 1hr holding fuel when CBs are forecast? Heard so somewhere.
As to the crews competence, I may be reading it wrong but I thought the F/Os input sounded OK. He seemed to make all the required callouts (e.g spotting the 1000fpm descent and calling it). Given his low time I expect there was (even with the best will in the world) quite a steep cockpit gradient.
Incidentally, do Aussie rules require an extra 1hr holding fuel when CBs are forecast? Heard so somewhere.
If the destination is tempoing (= change of up to one hour) thunderstorms then perhaps carry an extra one hours holding. If, in addition, the alternate is also tempoing the same then best find another alternate with better weather!
Flying around in such weather without a lot of extra fuel puts crews under enormous pressure and, I believe, this accident is an example of what can happen. The crew and, in particular, the captain have all my sympathies and it was fortuitous that all initially came away more or less unscathed.
I have yet to read the full transcipt of the accident report but I feel that operating close to minimum fuel reserves was a major factor in this accident and in the circumstances the crew were fortunate in carrying out a "controlled" arrival at an airport rather than running out of fuel downwind.
Flying around in such weather without a lot of extra fuel puts crews under enormous pressure and, I believe, this accident is an example of what can happen. The crew and, in particular, the captain have all my sympathies and it was fortuitous that all initially came away more or less unscathed.
I have yet to read the full transcipt of the accident report but I feel that operating close to minimum fuel reserves was a major factor in this accident and in the circumstances the crew were fortunate in carrying out a "controlled" arrival at an airport rather than running out of fuel downwind.
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M.Mouse,
I agree with your comments re. the difference between competency and experience - Like I said, hindsight is a wonderful thing, I don't envy the situation the crew found themselves in at all. I don't fly, you do, and I think we both feel the same about these guys,
And sometimes, that pressure adds to the situation, which may well be the case here.
PHX
I agree with your comments re. the difference between competency and experience - Like I said, hindsight is a wonderful thing, I don't envy the situation the crew found themselves in at all. I don't fly, you do, and I think we both feel the same about these guys,
There IS huge pressure from management in many companies not to carry excessive amounts of fuel.
PHX
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We appear to be descending into the usual PPRuNe scenario of 'expert' analysis by people whose only experience of piloting a B757, never mind any other heavy jet or even any aircraft, is anecdotal, to say the least. Mixing that with an uncanny ability to interpret a brief synopsis of the accident and come up with conclusions that have been thoroughly examined in the report, only goes to show that they are either unable to read the whole thing or are somehow gifted with divine insight that warrants them a permanent job with the AAIB should their services be required. 
Please, can we limit the discussion to facts that we, the people who fly these jets and operate into the airports, can learn from. There is no need for the 'schadenfreude' attitude of some posters (although I see some comments have since been removed) together with the 'green eyed monster' questioning by wannabes who are unable to comprehend that 1,145 hours on type with this operator represent about two years of operational experience into some very demanding airports and weather scenarios. Gaining successful employment on this type of equipment is not that uncommon in this business.
What I find slightly disturbing about the report are the references to fatigue and tiredness which are mentioned briefly but ignored in the conclusions. I know what I feel like on a third consecutive night duty. Add marginal, severe weather for a non-precision approach and I certainly wouldn't have envied this crew and what they had to deal with.
Section 2.3.1 specifically raises the points that whilst the crew did not think tiredness or fatigue were factors in the accident, considering that this was their third consecutive night flight, an analysis of their schedules carried out by DERA concluded that cumulative fatigue did not appear to be an issue but short term fatigue was a 'possibility' even though the recovery periods 'appeared' to be adequate. Even more interesting, I thought, was the reference to the previous two nights duty (Cardiff to Tenerife and Cardiff to Bodrum {and back}) exceeded the NASA and European Scientists 'recommended' 10 hour limit for duties starting or finishing between 0200 and 0600 local time.
In other areas of industry, studies have shown that the accident rate for shift workers increases on consecutive working nights. Also, scientific studies show that the change to being active in daytime rather than night, especially as you grow older, leads to difficulties in adapting to time changes as a result of the shortening of circadian rhythms. In the case of the commander, the report states specifically that "he was within the risk spectrum and on his third consecutive night of duty and it is therefore probable that he had suffered an accumulative loss of sleep."
And that's it from the report with regard to fatigue and tiredness. 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)? Considering that DERA had a hand in recommending the rostering practices as some sort of 'balance' between managements & beancounters desire to get their pound of flesh from pilots and the pilots desire to work as much as possible during daylight rather than through the night, their conclusion that 'recovery periods' appeared to be 'adequate' seems rather feeble.
Please, can we limit the discussion to facts that we, the people who fly these jets and operate into the airports, can learn from. There is no need for the 'schadenfreude' attitude of some posters (although I see some comments have since been removed) together with the 'green eyed monster' questioning by wannabes who are unable to comprehend that 1,145 hours on type with this operator represent about two years of operational experience into some very demanding airports and weather scenarios. Gaining successful employment on this type of equipment is not that uncommon in this business.
What I find slightly disturbing about the report are the references to fatigue and tiredness which are mentioned briefly but ignored in the conclusions. I know what I feel like on a third consecutive night duty. Add marginal, severe weather for a non-precision approach and I certainly wouldn't have envied this crew and what they had to deal with.
Section 2.3.1 specifically raises the points that whilst the crew did not think tiredness or fatigue were factors in the accident, considering that this was their third consecutive night flight, an analysis of their schedules carried out by DERA concluded that cumulative fatigue did not appear to be an issue but short term fatigue was a 'possibility' even though the recovery periods 'appeared' to be adequate. Even more interesting, I thought, was the reference to the previous two nights duty (Cardiff to Tenerife and Cardiff to Bodrum {and back}) exceeded the NASA and European Scientists 'recommended' 10 hour limit for duties starting or finishing between 0200 and 0600 local time.
In other areas of industry, studies have shown that the accident rate for shift workers increases on consecutive working nights. Also, scientific studies show that the change to being active in daytime rather than night, especially as you grow older, leads to difficulties in adapting to time changes as a result of the shortening of circadian rhythms. In the case of the commander, the report states specifically that "he was within the risk spectrum and on his third consecutive night of duty and it is therefore probable that he had suffered an accumulative loss of sleep."
And that's it from the report with regard to fatigue and tiredness. 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)? Considering that DERA had a hand in recommending the rostering practices as some sort of 'balance' between managements & beancounters desire to get their pound of flesh from pilots and the pilots desire to work as much as possible during daylight rather than through the night, their conclusion that 'recovery periods' appeared to be 'adequate' seems rather feeble.
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phoenix, i have over 6000 hrs on 757/767's, not as many as the captain concerned granted, but just goes to show that we can all make mistakes, as soon as i see thunderstorms on the taf i think nothing about putting on 2 tons extra (1750kgs is 30 mins holding at 1500ft) , maybe more if its night ! but hindsight is a wonderfull thing.