Monarch & the Rock

[DH121]

it was just a question of faith as to whether the climb gradient was going to be steeper than the slope of the west face of the Rock

The aircraft did not actually overfly any high ground. Read the report.

[radarman]

DH121. I have read the report, cos it's my evidence that's in it! You're quite right though - thanks to Rolls Royce responding to a boot-full of wellie, and a timely turn, the aircraft did not actually fly over any high ground (That's according to the QAR trace, but not according to one of my colleagues who saw it overfly his house some way up the Rock) However, I suggest you study the topography and contours of the Rock. These are not evident from the map in the report. You will then be able to see that a flight path half a mile further east could have resulted in disaster. I repeat, at the time it was a question of faith etc etc. Adrenalin is brown, and it smells like sh*t.
Any replies to my question about when crews notify ATC of a go-round?

[DH121]

Radarman - I don't disagree and I am familiar with The Rock. I just wish some people posting on here would stick to the facts, rather than being sensationalist, like The Sun.

We call "going around" ASAP, subject to cockpit workload. All being well, as soon as gear retraction has been initiated.

[Earthmover]

Radarman you raise a good point about when to inform ATC of a go-around. I've always taught (for many years actually) get the aeroplane going up, configured and in the correct mode before contacting the Tower ... with a new lad/ess in the RHS one can end up doing all this ones-self if ATC come back with any complex instructions or non-standard missed approach procs (I know that's unlikely in our ATC system because you tell us in advance usually, but elsewhere I've had really complex stuff issued during the initial climb off the G/A.)

But you've caused me to think again about this ... especially where terrain is a factor. Hmmm.

[Pilot Pete]

Originally Posted by Earthmover

But you've caused me to think again about this ... especially where terrain is a factor. Hmmm.

I don't know why you should 'think again'...it is better to get the aircraft correctly following the standard missed approach, in the correct configuration than to not complete that correctly with one pilot talking on the radio....

The standard missed approach will provide the requisite terrain clearance if flown properly.

What you are talking about is a 'double failure', where you don't fly the standard missed approach, don't configure the aircraft correctly and end up with ATC 'interrupting' this with a timely intervention and change from the standard missed approach, as in the case with G-MONE. If you look at the root cause of the problem it was the incorrect initiation/ following of the missed approach which required the intervention of the controller. If the crew had actioned the missed approach correctly and then flown the procedure accurately there would have been no need for the ATC intervention, hence your idea of 'thinking again' would not be required.

Aviate, Navigate, Communicate. If they had initiated the missed approach correctly (Aviated), then followed the standard missed approach accurately (Navigated) and then told ATC what they were doing (Communicated) then this report would not be being discussed here. Or at least that is what I have learnt from reading this report.

PP

[Earthmover]

I said I'd think about it again. Note the 'hmmm' ... I thought it a valid subject to review and analyse to see if my teaching is reasonable. I was pleased Radarman raised the subject. Thanks.

[Blighty Pilot]

What you are talking about is a 'double failure', where you don't fly the standard missed approach, don't configure the aircraft correctly and end up with ATC 'interrupting' this with a timely intervention and change from the standard missed approach, as in the case with G-MONE.

Who said the aircraft was configured incorrectly???
Who's to say if ATC had not interupted the pilots carrying out thier standard proceedures they would rectified the problem as opposed to having the "aviating" and "navigating" inturupted.
I am also lead to believe that the radar wasn't actually working correctly and the returns were intermittant at the final approach stage of the arrival.
Easy to judge when you don't have all the facts or you take what The Sun prints as fact!!

[chandlers dad]

Originally Posted by GreatCircle

Here is the email address of the Sun's moron who wrote the article: -

[email protected]

I am about to email the dear chap/chapess and tell him/her/it my thoughts on his/her/its amazing piece of journalistic analysis.

Best make it words of one syllable or less, so he/she/it understands it.

Anyone else up for sending a note ?

Please make sure that you send a copy to his editor as well. This way the editor knows what trash the writer is putting out. Maybe it will be vetted a bit better next time.

[Pilot Pete]

Originally Posted by Blighty Pilot

Easy to judge when you don't have all the facts or you take what The Sun prints as fact!!

When you read the report it says that the TOGA button was not pressed until after G/A thrust was applied and that therefore the crew did not follow the correct go around procedure. By then pressing the TOGA button after initiating a turn and a climb the flight directors popped up and gave them current ground track, which was taking them towards the high terrain. I would consider this to be an incorrect configuration of the available systems for the phase of flight.

Who's to say if ATC had not interupted the pilots carrying out thier standard proceedures they would rectified the problem as opposed to having the "aviating" and "navigating" inturupted.

And who's to say that they wouldn't have had a CFIT if ATC hadn't interrupted them? Look at the ground track shown in the report. Are you trying to say they were flying the missed approach correctly, or were about to correct their 'off track' flight? This is what the report said

When visual contact was lost, the crew were required to carry out the missed approach procedure. The aircraft was now right of the centre-line and turning right, although the commander thought that he was maintaining a constant heading.

They were following the flight director which was taking them towards the high terrain and not over the runway following the correct missed approach track. It also states

Without CVR and FDR information, it was not possible to determine the exact timings and actions of the crew. Nevertheless, it was apparent that the crew had not maintained continual visual contact with the runway and then did not comply fully with the go-around procedures.

Thirty seconds after the aircraft commenced the turn, the engine thrust increased for the ‘Go‑Around’. At this point G-MONE was descending through 650 ft at 134 kt, with a bank angle of 8º to the right and turning through a heading of 077ºM. The aircraft descended a further 100 ft to 550 ft before it entered a climb. It then achieved a climb rate of about 3,000 ft/min whilst turning onto a heading of 140ºM. It remained on this heading for 12 seconds before turning left onto a heading of 134ºM for a further 12 seconds, followed by a turn to the right onto a heading of 180ºM. As G-MONE turned onto the heading of 180ºM, it was overland and climbing through 2,100 ft.

Note the amount of time they were on track 140 degrees and then 134 degrees. Total time 24 seconds heading towards high terrain. I don't think they were aware that they were heading towards the high terrain, because if they were they would not have stayed heading towards it for 24 seconds. They believed they were following the missed approach, but because of loss of situation awareness and incorrect initiation of the go around they were not.

My personal opinion is that the controller prevented the last hole in the swiss cheese lining up by telling the crew to turn onto 180 degrees when he saw them heading towards the high terrain and not following the missed approach correctly. So we can all 'judge' for ourselves based on the facts as produced in the AAIB report. If you can draw another conclusion then it would be interesting to hear it so that we can all learn from this incident, because at the moment I stand by my last post as being what I have learnt from it.

PP

[ChristiaanJ]

"They were following the flight director which was taking them towards the high terrain and not over the runway following the correct missed approach track."

Don't we have a potential problem here somewhere? Next time ATC may have a bit more of a radar problem, or the GA may be on one engine after a bird strike....

This reminds me of a well-known book read years ago about a CFIT in the States, due to a sustained turn, which upset the gyro compass system. Can't instantly remember author or title, but maybe someone does? The story stuck in my mind because somebody battled for years to clear the pilot from the "pilot error" verdict.

[Blighty Pilot]

Standard calls:
GO AROUND FLAP 20
POSITIVE CLIMB - GEAR UP
I hear it was at this point that ATC contacted the aircraft as the pilots were mid flow of SOP's - The next call would have been:
HDG SELECT/LNAV
BLAH BLAH BLAH
I agree with you entierly PP we should all learn form peoples experiences but you do seem to be placing a lot of blame on the crew and not considering the poor lighting at GIB, the weather conditions on said night nor the apparantly dodgy radar.

[alf5071h]

I suggest care is required in any analysis of this event. There are several inconsistencies, which is why my earlier post expressed disappointment in the AAIB’s report. However, I note that they are confined by ICAO Annex 13 to ‘the facts’ which might prevent helpful human factors speculation such as ‘we considered … … but here was insufficient information’. Also, there was a lack of technical information – no CVR/FDR, but I doubt that the all-important FD command information would be shown anyway.

Re “the controller prevented the last hole in the swiss cheese”, perhaps some people overlooked EGPWS and particularly that the crew had selected the terrain display for the approach – a valuable safety aid.

Many commentators fall into the trap of allowing hindsight to (inadvertently) lead to blame – “therefore the crew did not follow the correct go around procedure”.
Our safety interests require an understanding of the incident so we might learn from it; to do that we have to consider all of the issues that made sense to the crew at that time and in the unfolding situation that they perceived.

Beware of assuming too much “They were following the flight director …” we don’t know that, the information shows that the GA selection was late, but even so the ground track shows a continuing turn – see my previous post.
Was the crew behavior consistent with “ … loss of situation awareness … “, again we cannot judge as whatever the crew perceived apparently made sense to them at that time – the commander did not appreciate that he was turning.

These are just are some of the factors which could lead to an explanation of human error, but the error is only definable after the fact (by our hindsight), the crew had no prior intent of making an error and we must not judge them on error, only speculate on how we might do better in the future.

Thus, a lesson for us all could be to remember that we can all make mistakes; i.e. attempting to multitask at an inappropriate time during the approach, ‘delaying’ the GA button due to the surprise of a GA, and being susceptible to turning illusions.

ATC played an important part in this incident, but most procedures and GA routings will ensure safety even with engine and comms failure; as stated - Aviate, Navigate, Communicate – but don’t attempt to multitask even these golden rules at critical times.

For Ppruners background reading see Punishing People or Learning from Failure by Sidney Dekker.

[Pilot Pete]

Originally Posted by Blighty Pilot

I agree with you entierly PP we should all learn form peoples experiences but you do seem to be placing a lot of blame on the crew and not considering the poor lighting at GIB, the weather conditions on said night nor the apparantly dodgy radar.

I accept that the written word can come across in a manner different to the spoken word. I am not trying to apportion blame, just trying to read what happened.

From the moment that the decision to G/A was correctly taken (loss of visual reference), the crew should be back on instruments. Poor lighting may have caused them to lose visual reference, but didn't contribute to the badly executed go-around. The weather conditions similarly. And the dodgy radar? Well, again I cannot see that it had a bearing on them not following the standard missed approach accurately, other than the possible 'interruption' from ATC to get them to turn away from the high terrain.

We are all trained to Aviate, Navigate, Communicate from a very early stage in our training and this incident re-enforces that for me.

Re “the controller prevented the last hole in the swiss cheese”, perhaps some people overlooked EGPWS and particularly that the crew had selected the terrain display for the approach – a valuable safety aid.

The report mentions that the F/O pointed out the terrain on their left once they were heading 180 degrees, not mention of any comment before then, like they were heading towards it.

Many commentators fall into the trap of allowing hindsight to (inadvertently) lead to blame – “therefore the crew did not follow the correct go around procedure”.

It's not blame, it's stated fact. The PF didn't press the TOGA switch until after applying manual TOGA power and then didn't follow the standard missed approach.

Beware of assuming too much “They were following the flight director …” we don’t know that

Conceded, we don't know that.

Was the crew behavior consistent with “ … loss of situation awareness … “, again we cannot judge as whatever the crew perceived apparently made sense to them at that time – the commander did not appreciate that he was turning.

If the PF perceived he was not turning, but he actually was, towards high terrain, I would call that loss of situational awareness. Am I missing something here? I ask honestly, not sarcastically.

the crew had no prior intent of making an error and we must not judge them on error, only speculate on how we might do better in the future.

Completely agree, like IU said at the start, my wording was not meant to be BLAME, merely statement of fact and a personal interpretation of the events in an attempt to learn from this, which as stated, I have.

Thus, a lesson for us all could be to remember that we can all make mistakes

You bet and I certainly have.

attempting to multitask at an inappropriate time during the approach

Another good learning point, but I wouldn't say you were blaming them! See, it's hard to try to point out these things without sounding like you are attaching blame after the event!

PP

[gbh]

Anyone know what is the published missed approach procedure for GIB?

[DH121]

Of course, the published missed approach assumes the aircraft is on a northerly heading. Having gone visual, this aircraft was heading east. I'm not surprised that they attampted to maintain runway heading, in this case. I'm also not surprised that the turn was inadvetantly maintained, in their half visual, half instrument situation. I think this incident was waiting to happen and I expect it'll happen again.

I think it's wrong to try to blame the controller - he appears to have done an excellent job. Having said that, I've sometimes thought that you get too much talking from GIB ATC. You're the only aeroplane for 50 miles, but they still cause a workload for you. I'm talking more about RAF controllers than the current NATS ones, I think.

[DH121]

Anyone know what is the published missed approach procedure for GIB?

It's in the AAIB report. See above for a link.

[Two's in]

Surely the most obvious "situational awareness" issue here is that they were approaching to a runway equipped with less than optimal navigational aids, and one that also has a very significant piece of rock co-located a few hundred feet south of the runway edge. The company SOP's required previous experience of the field, indicative of the perceived skill levels required to safely operate here, so the assumption is that the situational awareness level and the 'what if' scenarios would have been at the forefront of your mind before starting the approach. Not criticism, just an observation. The further events progress before breaking the chain, the harder it is to affect the course of action.

[Pilot Pete]

The published missed approach from the AAIB report is as follows:

‘Continue in radar pattern as directed climbing to 3,900’ (3885’). When over the upwind end of the runway, or passing 1,900’ (1,885’) in IMC, climb on runway heading.’

Of course, the published missed approach assumes the aircraft is on a northerly heading.

Don't know where you get this from, it doesn't say that anywhere. It depends when you go around as to where you will be heading, this is why airports like this require a more indepth brief. You must brief the contingency for a go-around after becoming visual and possibly in a turn to final as well as before then and once on final approach. I've not flown there or got the chart to hand, but it would appear that after going visual and turning towards final approach, if you go around you need to head towards the final approach track, then the runway, then fly on the runway track.

I'm not surprised that they attampted to maintain runway heading, in this case.

Correct, they should have been.

I'm also not surprised that the turn was inadvetantly maintained, in their half visual, half instrument situation.

Well, I would say that once they lost visual contact and decided to go around they were full instrument, not half and half. Remember, if you have the map display selected on the EHSI (and the report states)

The aircraft was being flown on autopilot with the autothrottles engaged and each pilot had ‘Map’ displayed on his horizontal situation indicator (HSI).

then you should have the runway and extended centreline (at least) if you have selected the landing runway from the DEP/ARR page in the FMC. This can assist visually to get onto the correct track.

Two's in makes a very astute comment in my opinion.

PP

[Monarch Man]

First a personal opinion from someone that knows both the flightcrew involved, they screwed the pooch (not intended to point the finger, as there but for the grace of god..potentially theres goes I!)

Now some observations.

Yes SA was lost, why? I would suggest that this is difficult to assess, as is at what point SA was lost. In any case there is simply no excuse for what took place..only consequences.
The mechanics of the approach are demanding, even on a good day, it is however well within the capabilities of an average pilot.
The missed approach (an often practiced sim exercise) is something that is rarely carried out in anger (in relative terms).

then you should have the runway and extended centreline (at least) if you have selected the landing runway from the DEP/ARR page in the FMC. This can assist visually to get onto the correct track.

This is the key IMHO, not only for SA, but also for the PNF who should have noted any track divergence, and by the fact that the published missed approach also appears on the EHSI as part of the GIB approach function.

This chain of errors IMHO have their beginings in the many uneventful GIB approaches completed by both pilots in the past few years.

[Itswindyout]

MM good post

That sums it up for me....

I actually carried out my first for real missed approach in anger this month, (at LTN in VFR).

Not bad for 30 years of flying.

Windy