Jetstream Crash
Joined: Dec 1999
Posts: 144
Likes: 0
From: England
I have to agree, what a shocking chart. The obvious mistake to make is leaving IRK on your DME, not IIRK, but this would make you 600' (or so) high. Leaving MCM on when being vectored from the south and descending at 10.2 MCM is, as has been pointed out, miles worse.
I only did 600 hours in the JS32, but I saw this mistake (wrong DME selected on a 2 DME NPA) at least twice. But on our charts for this UK regional airport, we had a height table. And the two DME's had very different names. And we'd always put a NPA into the GPS, as a "backup".
After a very long 6 sector day, the kind of mistakes that I make are the "failing to remember to push one button on the nav equipment" type.
I really hope that if the "cause" of this accident is found to be the incorrect selection of navaids, then the outcry is not "pilot error", but "fatigue" or "15 hour days" or "6 sectors".
I am the master of making mistakes. I am at my most masterful after 6 sectors of practice.
What a tragedy.
I only did 600 hours in the JS32, but I saw this mistake (wrong DME selected on a 2 DME NPA) at least twice. But on our charts for this UK regional airport, we had a height table. And the two DME's had very different names. And we'd always put a NPA into the GPS, as a "backup".
After a very long 6 sector day, the kind of mistakes that I make are the "failing to remember to push one button on the nav equipment" type.
I really hope that if the "cause" of this accident is found to be the incorrect selection of navaids, then the outcry is not "pilot error", but "fatigue" or "15 hour days" or "6 sectors".
I am the master of making mistakes. I am at my most masterful after 6 sectors of practice.
What a tragedy.
Joined: Dec 2002
Posts: 2,776
Likes: 351
From: UK
Poor chart + bad weather + fatigue (human factors) = accident
Pure James Reason, and additionally the authorities are the mice.
If we can deduce high risk (threats to a safe operation) by chart analysis then why can’t the authority put defences in place? It would be appalling to blame a crew or operator for falling into a trap set by the safety regulator.
The NTSB recommended that all charts include a range/altitude table, but the FAA rejected the proposal and is not taking any action. (A-00-015, 27 Jan 2000, from Air Safety Week 11 Oct 04). The FAA believes that an additional chart would add clutter to the chart !!!! More like cluttered thinking.
Stu Bigzorst I read the chart as requiring DME IRK (114.6) to be used for the distances during the descent. Have I misread this (long time since I flew in the US), or have I misunderstood your post that indicates the use of I-IRK (111.5) for distance ?
Pure James Reason, and additionally the authorities are the mice.
If we can deduce high risk (threats to a safe operation) by chart analysis then why can’t the authority put defences in place? It would be appalling to blame a crew or operator for falling into a trap set by the safety regulator.
The NTSB recommended that all charts include a range/altitude table, but the FAA rejected the proposal and is not taking any action. (A-00-015, 27 Jan 2000, from Air Safety Week 11 Oct 04). The FAA believes that an additional chart would add clutter to the chart !!!! More like cluttered thinking.
Stu Bigzorst I read the chart as requiring DME IRK (114.6) to be used for the distances during the descent. Have I misread this (long time since I flew in the US), or have I misunderstood your post that indicates the use of I-IRK (111.5) for distance ?
Joined: Dec 1999
Posts: 144
Likes: 0
From: England
Safetypee,
QED! In so much as we are getting confused and we are not even flying...
I read the chart (and it is a while too since I flew in the US) as use the IRK initially for the arc and then the IIRK for distance when on the LOC. For a straight in, then yes it's straight to the IIRK. But if you were planning your descent from afar, I guess you may not be able to get the IIRK, so the IRK would give you a good TOD. Please feel free to correct me - I am regularly wrong! Much more likely to be the MCM/IIRK error though.
Good, safe, naming convention, don't you think?
Also, we must remember that 100 other things could cause this accident.
QED! In so much as we are getting confused and we are not even flying...
I read the chart (and it is a while too since I flew in the US) as use the IRK initially for the arc and then the IIRK for distance when on the LOC. For a straight in, then yes it's straight to the IIRK. But if you were planning your descent from afar, I guess you may not be able to get the IIRK, so the IRK would give you a good TOD. Please feel free to correct me - I am regularly wrong! Much more likely to be the MCM/IIRK error though.
Good, safe, naming convention, don't you think?
Also, we must remember that 100 other things could cause this accident.
Joined: Oct 2004
Posts: 223
Likes: 0
From: Los Angeles
To answer boxmover's question, the vast majority of civilian pilots in the US use Jepps.
I checked out the Kirksville plate yesterday and found it far easier to read than the NOS plate shown here.
One possibility is that considering that the pilot reported the field in sight shortly before impact and the MDA is 356 ft and can be reached quite easily 2 to 3 miles out from the threshold using a non precision descent rate, is that the pilot had visual and then commenced a visual descent at 300 ft/nm in "Black hole" conditions which would have impacted the ground 1 or 2 miles short of the threshold.
I checked out the Kirksville plate yesterday and found it far easier to read than the NOS plate shown here.
One possibility is that considering that the pilot reported the field in sight shortly before impact and the MDA is 356 ft and can be reached quite easily 2 to 3 miles out from the threshold using a non precision descent rate, is that the pilot had visual and then commenced a visual descent at 300 ft/nm in "Black hole" conditions which would have impacted the ground 1 or 2 miles short of the threshold.
Everything is under control.
Joined: Jul 2001
Posts: 437
Likes: 0
From: Washington, D.C.
Investigators: Pilot error caused crash
"Pilot errors caused the deadly crash of a commuter airliner in northeast Missouri in 2004, and the crew's nonstop joking and expletive-laden banter in the cockpit didn't help, federal investigators said Tuesday. The two-man crew and 11 of 13 passengers were killed when Corporate Airlines Flight 5966 crashed on Oct. 19, 2004. It was the country's deadliest civilian air crash that year."
http://www.wjla.com/news/stories/0106/296856.html
http://www.wjla.com/news/stories/0106/296856.html
Joined: Jun 2005
Posts: 954
Likes: 5
From: USA
The article was very interesting. Here is the summary of the final NTSB report. Full version should be out soon.
http://www.ntsb.gov/publictn/2006/AAR0601.htm
One of the reccomendations to the FAA is a bit disconcerting though:
Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatigue-related information similar to that being developed by the Department of Transportation Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects. (A-06-XX)
I have not yet read the DoT fatigue information mentioned above, so I cannot yet comment on it. But to suggest that providing training to pilots will somehow abate the effects of this kind of fatigue seems ludicrous. Makes more sense to suggest stimulants in place of rest! What NTSB should suggest is sensible duty rules that consider the findings of objective scientific research. New rules have been discussed with industry groups and the FAA in commitee for at least two years now. Individuals in the FAA are quietly saying not to expect the new rules to be settled upon and adopted anytime soon. There's a suprise! Maybe they want to get these new rules just right. $$ Meanwhile, at least the coffee is free. Think I'll have another cup.
Westhawk
http://www.ntsb.gov/publictn/2006/AAR0601.htm
One of the reccomendations to the FAA is a bit disconcerting though:
Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatigue-related information similar to that being developed by the Department of Transportation Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects. (A-06-XX)
I have not yet read the DoT fatigue information mentioned above, so I cannot yet comment on it. But to suggest that providing training to pilots will somehow abate the effects of this kind of fatigue seems ludicrous. Makes more sense to suggest stimulants in place of rest! What NTSB should suggest is sensible duty rules that consider the findings of objective scientific research. New rules have been discussed with industry groups and the FAA in commitee for at least two years now. Individuals in the FAA are quietly saying not to expect the new rules to be settled upon and adopted anytime soon. There's a suprise! Maybe they want to get these new rules just right. $$ Meanwhile, at least the coffee is free. Think I'll have another cup.
Westhawk
