Indonesian B737 runway overrun/crash

[Another Number]

http://www.abc.net.au/news/newsitems...4/s1886765.htm ("No evidence of argument"

was released shortly after

http://www.abc.net.au/news/newsitems...4/s1886734.htm ("Pilot argument could have led to Garuda crash: investigator"


Not up to the usual standard of the ABC!

[Magplug]

So my words are coming back to haunt me..... post #251

....was the Captain determined to press home the approach regardless because he did not want to lose face?
....This is a good talking point for F/O's.... What would you do if you were faced with such a situation?

How do you persuade a (perhaps) senior, well respected colleague away from
a course of action that you firmly believe may kill all of you?

If you are a Ryanair First Officer perhaps you have already given that a great deal of thought.... After all you were really lucky to get that job, even though you had to basically pay THEM to take you on after you had shelled out £70k+ on your training. As an FO sitting next to a Captain who has to squeeze in all those sectors into a maximum legal day to keep his job and earn the big bucks, your CRM powers of interpersonal persuasion to avert a disaster might just be lacking in one so young.

We lost a great deal in this industry when companies (particularly in Europe)stopped selecting their own cadets for sponsorship..... And as for Ryanair!

[Centaurus]

During the interview with the Indonesian chief investigator, the Australian TV reporter summed up by stating that: "In Indonesia, it is considered shameful for a pilot to go-around."

Sounds like she had been doing her homework as her statement certainly displayed disregard for political correctness.

[bomarc]

15,000 hours doesn't make you correct

2,000 hours doesn't make you wrong.


The sad thing is simply this. If you want good safe flying, you TRAIN everyone the same way. Demand following the operations rules and specifications and procedures.

hire people who are not the cheapest, but smart dedicated people. pay them well and demand the best from them.

the only shortcuts that ever work in flying: pick up the mic and say, "request direct" to ATC.


flying a fast approach to a short runway is a recipe for disaster.

and to the ryan copilots or any copilot, do what has to be done to prevent a crash, stay alive or whatever words you want to use. and know where the CVR circuit breaker is...pull it to preserve the truth.

any pilot must be prepared to lose his job if it means saving the lives of the people who depend upon you.

[theamrad]

Another Number: shame about the contradictory report titles – since it leaves us with doubt as to what the investigators really think. Does seem that the “absent-mindedness” remark is stated as a personal opinion though.

Marjono Siswosuwarno, says the call for a "go around" was too late to make any difference

Strange thing to say – but then we don’t know at what point the call was made – 500ft AGL, 50ft, or 1,000 feet of tarmac left to go?
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Magplug:

What would you do if you were faced with such a situation?

Mmmmmm? – In fairness, I can’t comment on Garuda, but I think anyone reasonable would have to say that in RA’s case it puts one hell of a barrier in the way of doing the ‘right thing’.

We lost a great deal in this industry when companies (particularly in Europe)stopped selecting their own cadets for sponsorship..... And as for Ryanair!

Well one way of looking at it – RA probably comes closest in the aviation world to pushing for ‘internships’ for cadets! With paying for your own training – it’s practically just a matter of terminology.
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Bomarc – of course I agree with what you’re saying.

Demand following the operations rules and specifications and procedures.

I think in Indonesia’s case – for anyone familiar with the course of events surrounding Adamair, you could be forgiven for thinking that government oversight is completely non-existent. I agree with one lawyer who specialises in the field of aviation who believes that “strong government oversight” is one of the four factors essential for ensuring safety in aviation. In Indonesia, there’s no great big stick being waved at airlines to ensure regulatory compliance (IMHO: the new rating system being nothing more than a crass PR exercise with no more purpose than ‘being seen to take action’). History has already taught us in Europe and the US, in a time when regulatory authority wasn’t as assertive as it is currently, there were only too many ‘airlines’ willing to bend rules (one or two currently still active, hint hint). The only incentive being how much they could bear in legal claims or loss in trade. So in general, without reference to Garuda in particular, when certain other operators in Indonesia face consequences varying from a little ‘bad press’ to none whatsoever – it shouldn’t be surprising that standards are not enforced rigidly WITHIN those airlines.

--------------------------------
Centaurus:

In Indonesia, it is considered shameful for a pilot to go-around

Not sure how fair her statement is in general – I think a couple of people here might argue against it in the case of Garuda.
-----------------------------------

In a general way, does it seem to anyone-else, that inspite of all the effort put into the development of, and training in CRM - it still seems to figure as an important factor in a good deal of incidents and accidents world-wide, in the last few years, during final approach/landing. Why is it that with the strict procedures for 'monitored approaches' (when part of an operators SOPS) communication between the crew members sometimes breaks down. What I mean in a general way is: is it a breakdown on the part of some individuals - or more along the lines of an inherent weakness in CRM versus individual perception during the final stages of approach, when other complications (e.g. shear, vis) are present - even with a well-trained and briefed crew?

[Centaurus]

In Indonesia, it is considered shameful for a pilot to go-around

Not so long ago while training a crew in the 737 simulator I cleared them for a straight-in visual approach from 20 miles on the localiser. Purpose of exercise to give crew practice at height/distance and speed control. Captain flying had 12,000 hours; the F/O 230 hours. Captain ripped in at 250 knots. The captain then forgot to ask for gear down and at 1300 ft with gear horn blaring with flaps blown back to 30 and no checks done, speed brake not armed and F/O was silently contemplating his navel. Not one single support call. At 800 ft captain casually calls for gear down. Speed Vref +40, sink high, throttles idle.
Passing 500 ft, gear not yet locked down, horn blaring, sink 1300 plus, throttles closed, the F/O calls "500 feet - stabilised..."
Froze the simulator and asked F/O to tell me the requirements of a stable approach. His reply was simple and concise. he said "I don't know - I just call 500 ft - stabilised". I asked the captain to explain his reasons for delaying gear and why did he not go around. Silence in the cockpit. No prize for telling which area the crew came from.

[realistic]

Question for the airline pilots.

I was under the impression if a pilot called "go around" it was procedure to abort and follow through with the go around?

Please correct me if I'am way off base here.

[theamrad]

Centaurus – if the details are correct – and I’ve no reason in particular to doubt you – the consequences are a little too on the horrific side for me to contemplate. I know it’s kind of a potentially sensitive/loaded question – considering the media are probably reading; from a RHETORICAL perspective – are we talking GA or OTHER? Personally, if the former – it would be extremely surprising to me – if SOME of the OTHERS – I honestly can’t say it would surprise me in the slightest.

But then seriously, in the case you describe – are we talking about ‘loss of face’ in the GA issue, or just a total haphazard attitude about the reasons for stabilised approach(indeed everything!)? Is it shame or ‘I’m planting this thing on the tarmac no matter what’?
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realistic - without giving you a complete lecture - the simple and safe version of the answer is normally/generally: yes. Although when and how it happens may differ due to type of approach and company SOP's etc. AT a certain altitude, there is a requirement for the approach to be stabilised - certain parameters must be within certain limits. If not stabilised, the pilot not flying calls for a go-around, if not already started by the pilot flying. That is, of course, how its MEANT to happen. At a slightly wider perspective - if either pilot is unhappy with the approach, or believes that a safe landing is in doubt, a go-around should be initiated.

[thecricket]

Theamrad,

You are a cynical one, aren't you? I bet you're one of those types who reckons he knows everything about how the media operates and yet has never remotely been involved in working in it.

I was the producer of the Sunday piece on Channel Nine where the Chief Indonesian investigator spoke exclusively about the cause of the crash.
The full story will run in about two weeks and will look at the broader Indonesian aviation industry. Please bear in mind, this is not Today Tonight. Sunday has earned a reputation over 26 years for journalistic excellence and avoiding sensationalism.

While I'm prepared to be corrected - for clearly you know far better than me - placing a post here asking to speak to pilots IS investigative journalism. It's called research and involves speaking to people who know more about aviation than I do. Public relations departments at big companies are very careful with what information they supply to the media - and therefore the public. Very often the truth can only be uncovered by asking those who actually work for the company in the field - off the record if necessary - about what's really going on. No pilot is being pestered by taking 20 seconds to read a request and then making up their own mind whether to respond.

Our investigation has never been destined to conclude that Garuda is making short-cuts in maintenance and training. It's called a "line of inquiry", a theory, if you like, and we can only prove or disprove that theory by asking questions. So far our inquiries seem to suggest safety at Garuda is pretty good.
We're still keen to speak to:
*any Aussie pilots who have landed at Yogyakarta (Is it a tough runway to land on? Why?)
*Former Garuda pilots. (Has Garuda been losing its best pilots to other airlines? Is pilot training being maintained to appropriate levels?)
We've already spoken to former employees of some of the budget Indonesian airlines.

We can only answer these questions if people speak to us so if you have any information that may help us better understand the story, please drop me a line at [email protected]

[Grongle]

Well said, theCricket. 29 years old, huh? I'm twice your age, but yesterday morning—I think it was—I was 29 too.

I'm not a pilot. I was an instructor of critical logic for a Canadian university. The "benefit of the doubt theory" I mentioned a page or so back was proposed by one of the most brilliant young Ph.D.s I've ever met.

Her acumen was so sharp that she would have been a formidable opponent —and yet, she suggested karate was the more appropriate field for "formidable opponents", and she introduced her philosophy textbook with the idea that we do better when we allow, by default, the possibility that the speaker intends the more intelligent or more credible of two possible meanings.

It's less sensational fun than a few of the more cynical people here might prefer, but it's not a bad exercise for those who are more interested in technical accuracy or the truth.

For example, at the moment, her technique would easily resolve the present Iran-UK standoff, without anyone losing any pride at all, in about—oh, 20 minutes or so. An easy win-win. No shame, no losers. Easy as pie.

I wasn't as bright as the girl I mention, but I tried my best to keep the faith of her advice. It is true that there have been bad journalists, bad aviators, and bad philosophers. Cynics, I've heard tell, are "fallen idealists"—and so I suppose if one retains his idealism, he does not do well as a cynic.

I congratulate you, theCricket, in being 29, in being a good writer, and very likely in being a good journalist. The main course I taught was deadly difficult. My somewhat uninformed, biased and prejudicial opinion, based on just a few words I read on the web that were written by a journalist, is that you would have passed that course with flying colours.

[llondel]

realistic:

I asked a similar question in another thread a while back and got some fascinatingly opposite responses. One was reassuring, exactly what you'd want (i.e. call of go-around from PNF and immediate initiaion of same), the other was that certain airlines had the approach that Centaurus described in the simulator.

I think the answer is to choose carefully with whom you fly, not all flight decks are equal.

At ground level, I am reminded of when I go driving in the US, I tell the passenger "don't assume I know what I'm doing" to encourage them to scream in terror if I'm about to turn left into oncoming traffic, in the hope that it'll warn me in time. (I only ever started to do that once...)

[theamrad]

Cricket and grongle – I might draw your attention to the title of the forum PPRUNE – Professional Pilots rumour network. Better still take a look at the forum rules – there is a specific area for people like you – non-professionals in the area of aviation.

I bet you're one of those types who reckons he knows everything about how the media operates and yet has never remotely been involved in working in it.

Not entirely true – but that doesn’t stop you from being PRESUMPTIOUS enough to suggest it. More to the point currently, I am exposed daily to it’s inaccuracies and general lack of ‘journalistic integrity’! Another Number’s post above being a classic example – my current personal favourite one being that “trains are steered”

Since the problem lies mainly with lack of government oversight, how are you proposing that your programme will bring about improvement for the INDONESIAN flying public?

We can only answer these questions if people speak to us

Who are you trying to answer for – the Australian public, who have a choice about whether or not they even go to Indonesia (moreover fly with an Indonesian airline)? Or the Indonesian public – some of whom have no choice but to use these operators?
You’re story may indeed be doing a service along the lines of a public duty from Australia’s viewpoint – but it will do nothing WITHIN Indonesia.


Grongle – maybe a few more posts which have ABSOLUTELY NOTHING to do with the thread may have a moderator step in to close the thread down. Since you seem not to have noticed – some of us are interested in discussion (detailed or otherwise) about THIS accident and Indonesia’s aviation woes.

Back to the discussion – and some relevancy

Llondel – I’m not familiar with what you’re saying about answers to the question – but I think it has come up here on PPRUNE in the past. It shouldn’t be all that surprising that there are different answers. What you intimate is quite true – there is a myriad of standards, both in terms of training and ability on a worldwide level (and sometimes WITHIN particular countries – which I think is a fair statement in Indonesia (GA versus Adamair?). The introduction of the new licensing system may (some say definitely will) increase the negative effects of the gradient between high hours captains and virtually ‘no-experience’ F/O’s. That implies that the potential for conflicting opinions (esp during approach to landing) is likely to rise, unfortunately.

Since, from your post, it suggests you’re not a pilot – I’ll try and summarise the potential problem as follows. For a low hours F/O with the obvious lower experience base, if he is unhappy with the approach, at some point he must decide if his more experienced captain (possibly very experienced) is acting reasonably in continuing the approach or heading towards danger. If he makes the call for a go-around – what does he do if the captain ignores him??????

[llondel]

theamrad:

I was referring to http://www.pprune.org/forums/showthr...=260549&page=3 posts 58-60, my question and the two contrasting responses.

I'm aware of the human factor issues from following discussions on here, plus general life experience of watching people attempting to point out to the "expert" that he's made a mistake. Perhaps a human psychology course should be part of pilot training, although those who need it most probably wouldn't be offered it.

The same issues come up in all walks of life, it's just that most times they don't have a smoking hole in the ground as a consequence.

[2b2]

Please bear in mind, this is not Today Tonight

or A Current Affair.

[theamrad]

Llondel - I see exactly what you mean - as far as the gradient going from east to west, it can still happen in surprising places - but the better the training - the less likely. There's been a few spats here over the years - a couple involving well known foreign carriers (not referring to RA, by the way) in which CRM breakdown and conflict between crew members were the major factors – fortunately only damage and no injuries. As already said by bomarc:

If you want good safe flying, you TRAIN everyone the same way. Demand following the operations rules and specifications and procedures.

And not just initial/qualifying training - but recurrent also.

As far as “loss of face” (for want of a better term) and CRM is concerned – someone else here on PPrune has already said the best place for egos is hung outside the cockpit before entering. They are of course correct.

Perhaps a human psychology course should be part of pilot training

Well, in a way, it already is an intimate part of CRM, in training and practice – especially from the point of view of it being the means to circumvent the negative aspects of psychology – when it is practised as intended. At the end of the day, CRM can be regarded as a tool which works well in theory, but in practice, I personally think it can have its vulnerabilities – like many other ‘tools’. Human factors studies have been an important part of aviation for quite some time – the problem is more a case of consistency in terms of geography. In some places it’s lack of financial commitment/availability to proper training/practice – in others it’s lack of will/motivation(whether political or otherwise).

[bomarc]

As journalists are frequently pounded by the members of this forum for innacurate reporting, I hope MORE journalists participate and weigh the opinions here.

We should welcome them with open arms...good pilots are unsung, unlucky pilots are in headlines all the time.

I hope journlists also ask telling questions about the governments who certify airlines, pilots, mechanics and the like.

THINGS were better in the past...MONEY has taken over as the prime directive, instead of safety.


Many years ago, the term "HIGH KEY" and "LOW KEY" were part of flying...as we funnel our way to the runway, if you were properly in both keys, the landing should be pretty good.

10 nautical miles from the runway at about 3000' is about right ( 3160 feet really, but lets give up something)


5 miles, 1500' or pretty near


cross the threshold at 50' ( really big planes, you know you will adjust) eye height. try to touchdown 1000' down the runway (again really big planes you know what to do).

above are three places to catch yourself....too high 10 miles out?, too high 5 miles out? too high crossing threshold? all are good places to make sure things are right or go around.


I remember one of the first space shuttle landings, the commander called, "high key" over hawaii for a landing in california. (of course he couldn't go around)


Air Garuda probably needs better training, better pilots and more resources...I won't fly them...but I don't need to go where they go.


And to the sim instructor and 500' stablized call...I have seen the same thing...speaking the words without understanding the concepts...it all harkens to poor training and SOP's etc.


AND poor hiring practices...Oh for the days when you actually had to be a sharp pilot to get a job anywhere.

[alf5071h]

There are several viewpoints in this thread; in particular the industry’s understanding of the worldwide safety record and the travelling public’s view of aviation safety, both of which are intertwined with media views.
We operate in a highly reliable and safe industry. Furthermore, most operators/countries are dedicated to continuous improvement; therefore the impact of a major accident on us is often greater than in a less safe environment – marine ferries come to mind.

We can learn from differing viewpoints when considering the human issues; from aviation the human factors, and from the public/media, expectation of safety vs reality and the social pressures that can be applied albeit unwittingly.

This accident appears to have ingredients for an organisational error, an aspect associated with ‘culture’ as discussed by J Reason ‘Achieving a safe culture: theory and practice’. Yet as with most accidents there is also the ‘unsafe act’.

Humans suffer error; recent views of this, at least in aviation, include the importance of acknowledging this characteristic and provisioning defence based on the avoidance of the error provoking situations and behaviours, identifying errors, and / or mitigating the resultant. A safety tool in this is the duality provided by the two-crew concept of monitoring and alerting. The process has to accommodate differing standards in ability, experience, and the effects of culture.

The human remains the weakest point. We teach pilots the importance of having a shared mental model, but how do we ensure that it is the correct mental model, i.e. both pilots can suffer the same error in perceiving the situation. Duality relies on detecting a difference in the situation from a given norm; rules, limits, SOPs and experience; these are functions of education, training, and of course the organisation - ‘culture’.
How does the monitoring pilot intervene? PACE provides a view of ‘the co-pilot’s dilemma’, but what if the pilot flying has a different and stronger perspective of the situation – unlikely if the rules, training, etc are in place. This weakness has received much attention. However what if the pilot flying was so engrossed with his/her view of the situation and in attempting to rectify it – high workload, s/he cannot ‘hear’ (receive) any intervening call? My experience suggest that there are situations where verbal communication fails, thus other attention mechanisms are required – a tap on the glareshield a ‘poke in the shoulder’, alternatives used well before the need to consider the monitoring pilot taking control which can introduce greater hazards.
Often problems late in the approach stem from a much earlier degradation in situation awareness; even basic experience can identify high speed/altitude or late checks at the approach fix or ‘gate’. Again early intervention is required – or at least a question about the intentions of the pilot flying – the need for a good briefing.

On top of these issues there are those of individual behaviour and attitudes – personality, which can be shaped by fatigue, health, and personal environment.
Humans experience emotion. Shame – (loss of face) is “uncomfortable and usually involves feelings of fear, awkwardness or uncertainty. … triggered by the anticipation of your reputation being damaged”. New Scientist 23 Dec 06. A significant factor in ‘damaging your reputation’ by discontinuing an approach is peer pressure, not only within your professional culture, but also the wider industry, your management, ATC, and of course the public. All viewpoints (aviation, public and media) have a role to play in this issue – it’s OK to Go Around – it’s normal, it’s part of the way of life; humans - flight crews are not perfect, and more often, it is the surrounding organizational aspects or the situation that leads to the ‘error’ and not the crew.
Hopefully our industry recognises these deficiencies and strives for improvement; this takes time, particularly with training and standardisation. It may take up to two years to implement and check the effectiveness of some safety changes, perhaps longer for ‘cultural’ or behavioural aspects.

The industry requires public support in these efforts; we require understanding and consideration without unwarranted pressures stemming from apparent failures – accidents; particularly avoiding those opinions formed with hindsight. See For those condemned to live in the future.

The media has an important role; the facts must be reported, but these are rarely available with meaningful accuracy in the immediate aftermath of an accident – just when public emotion is high. Thus much of the reporting and discussion is circumstantial. However this can be of value to both industry and the public in providing some understanding, but this requires good background and supporting explanation – human factors – human nature – social climate. Provided that these are given in parallel with speculative reporting (or Pprune comment) then we really can learn lessons for improving safety. All of us have a role in providing the much need education and understanding in these areas.

The re-invention of human error
The new view on error and performance
Punishing People or Learning from Failure?
Diagnosing vulnerable system syndrome
Culture, threat and error; assessing system safety
Building on the three cultures of aviation
Systems safety in the wake of the Cave Creek disaster
Managing threats and errors during approach and landing
FSF ALAR
Aviation Safety network

[vwreggie]

here in aus when a go around occurs on the line it is not uncommon for the captain to receive a phone call from the fleet manager to BE THANKED for making that decision! You never fail a simulator ride for conducting a missed approach either. For sure an informal discussion may occur to decipher what preceded the go around but only after acknowledgement of the correctness and safety first choice TO CARRY OUT A GO AROUND. It's a training culture.

[theamrad]

Bomarc - as far as the first part of your post is concerned - count me out - In this particular case - the media, whether Indonesian or not, is not going to force government action where it matters - IN INDONESIA. As for things closer to my neck of the woods during my temporary 'exile' - no amount of 'investigative' reports or spectacular exposes have made a blind bit of difference in the case of RA - or indeed (more importantly) even dented the enthusiasm of the public for flying with them! In fact, the last one I saw was more concernced about the condition of seats etc, as opposed to the real safety of flight issues.

Air Garuda probably needs better training, better pilots and more resources

Possibly - but they are by far at the top of the pyramid in Indonesia - what all of them really need is a firm 'boot' from a government which cares about the safety of its own public - rather than PR excersises (the rating system) designed to fend off embarrassment or attention. Would the rating system have appeared if Australian officials hadn't been onboard, with the resultant increased interest from outside Indonesia? Personally, regrettably, I think NOT.

AND poor hiring practices...Oh for the days when you actually had to be a sharp pilot to get a job anywhere.

Isn't that the way with everything now? At least whenever companies can get away with it without consequence. The new licensing arrangements (where they are implemented) are going to make it a hell of a lot worse - as I'm sure you already know - it's been mentioned on PPruNe already.
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alf5071h - that's quite an impressive examination. Just to mirror some of your comments in relation to what this accident shares with the others in Indonesia:

Latent conditions arising mainly in the managerial sphere. Latent conditions are present in the system long before the event and are most likely bred by decision-makers, regulators, designers and other people and organisations far removed from the event;

wider industry, your management, ATC, and of course the public

We can see the public perception about GA's from a recent thread here on PPrune - and it's probably disconcerting to most pilots. But then, it's pilot responsibility to ensure safety - and if that means a GA is in order - then to hell with their perceptions. Naturally, it would be better if they understood!

It looks like it will be another while before we know WHY no GA happened(as in the motivation for continuing a 'hot' approach in the case of GA200). So an answer to the question of whether it was 'shame' or 'bravado' is going to have to wait for the moment.
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For sure an informal discussion may occur to decipher what preceded the go around

That would be the ideal situation - where many are fortunate to be. But then there are the examples of companies which publicly state their training and practice is GA-positive - but pilots have to submit written reports whenever a GA results - often in the environment of finger-waving. Of course, we all know what should happen if a F/O calls for GA - or indeed only corrections from parameters if above 500ft AGL VMC, but there are many F/O's who have a seriously justifiable reason to doubt their 'career indemnity' if they push the issue. And, unfortunately, they're not always in airlines operating in 'far off places'. Without the support of managment - CRM and GA's begin to loose their significance - and the potential for disaster increases.

[bomarc]

craig

good for you guys...safety begins with corporate culture and example...better a good go around than a bad landing.