Indonesian B737 runway overrun/crash
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PK-KAR,
I agree about the issue of speed of response. The video seems to give a pretty clear idea of the response time, at least as far as response on the ‘field is concerned. I can’t remember the layout of access gates to off field at Yogya from when I was there. Given the apparent response time ‘on field’, the crash site ‘off field’(rice field with tegalan), the criticism by media and others always seemed a little unfair if not invalid. I recall an incident here a few years ago, where civil fire engines needed to gain access to the airfield through an access gate, which, by chance, was only a couple of hundred yards from the incident. The local fire crews turned up at the gate, as indicated by emergency planning directions, but the gate couldn’t be opened……….involving travelling back down a public road to another gate about half a mile away. The unlockable gate would have been the crucial one for the evacuation of injured if the incident hadn’t had a favourable outcome!
This all seems to mirror the criticism flung at the cabin crew, some of which was thrown only hours after the crash.
The issue of ‘stopway’, is a little bit of a distraction for us and the media, I think. I recognise that this would be an obvious point to include from the investigators’ perspective and could/should be part of the contributory factors. Of course there is a technical breach of regulations concerning requirements. I agree, between the road and stopway consideration, it most likely was a major factor in the severity of the crash. But from a pilot decision making perspective, with (I assume) Yogya being a regular destination for an experienced GA captain – I would regard the lack of ‘stopway’ as being an intrinsic part of landing there. But then I have always regarded the stopway as being critical in terms of takeoff calculations(when operating in the limiting extreme for the most part) and not an ‘assumption’ or ‘given’ for the landing (baulked or messed up) case – in terms of ‘LDA’ and no (or small) stopway declared on charts. I understand “familiarity breeding contempt” in a lot of circumstances, but, as you’ve previously described Yogya’s peculiarities – this would seem a strange place to ‘get sloppy’.
From another perspective. I’m curious to consider the Min ICAO requirement and what you think about the following:
I’m curious to get an indication of speed when she left the tarmac. Should then be able to make a reasonable ‘guesstimation‘ of the difference the min’ run-off requirement would have made. If we assume the same geography – position of road, rice field(tegalan and embankment) – the effect of the extra 30m min requirement as displacing the entire runway or just the initial contact point. Considering the energy at the tarmac end-point (as you observed earlier from lack of damage on road divider, embankment – enough energy to ‘float’ that gap – 70, 80 kts or a lot more ????) – would it really have made much of a difference?..........I could see that putting us into a “more direct” conflict with that embankment! – maybe even more serious consequences?
I think the critical understanding will come along if and when the full FDR data is available.
I’m focusing on the min requirement, because 260m sounds really nice – but Indonesia doesn’t have a monopoly on having airports than don’t or can’t meet the recommendation.
From the flap/speedbrake info – without going into the area of good airmanship and energy management. Since it seems he was determined to ‘give it a try’ after the first F/O intervention – another question arises as to why he never used speedbrakes (albeit from 2500’, speed 272kts, for example
) – I believe on type -400 with AD’s, etc, legally they would have been available up to flap 15 and down to 500’ in vmc.
------------------------------------
Markf – how do you know what the report says – unless you have a copy?....you’re not…………. by any chance……… a journalist???
Funny that for a first post here you’ve singled me out for personal attention ‘in the third person’
, despite the obvious fact that others indicate the SMH’s attempts at ‘trying to accurately dissect events’ are a BIT short of the mark with statements like: “nearly double normal landing speed”
– You won’t, of course, mind me returning the favour.
no – I’m not poking fun, sorry you think it’s meant as a joke!
It’s a full frontal attack on journalistic quality – I’m giving my opinion on their lack of journalistic integrity – in common with SOME other elements of media coverage on this accident. If you, or anyone else want to debate/discuss the factual issues about the crash, I genuinely welcome it. Conversely, if you, or anyone else, don’t like criticism of media coverage – tough 
!
‘to each his own’ – I think you’ll be of the opinion that I’ve done a hell of a lot worse, if you read the entire thread. If you’re happy with media performance on this one, others, or indeed in general, then I’m pleased for you. Sorry I can’t/won’t agree with you. Maybe IF they have the report – they SHOULD report accurately what it contains and they SHOULDN’T be editorialising it, or adding a ‘cause/blame’ section on, or stating fictional remarks like “pilot's claims of a massive down draught” as fact?
Yeah…………. But the SMH doesn’t leave it at that!
Possibly the aircraft itself was to blame by not having the ‘goddam’ courtesy to come to rest in a more convenient place – amazing how often this happens…. by the way – this is a criticism of media presentation on the matter – not of the report itself! I could be really obnoxious here with a statement along the lines of: 'every rice field should be fitted with an internal access road prior to any possible event……..just in case'. I’m not quite sure where this leaves ‘adamair lost contact’, Air India over the Atlantic, etc. At the end of the day, this, like any other preliminary or final report is purely written from a ‘presentation of facts’ point of view – NOT OF BLAME. An important distinction which most here understand – but most of the media doesn’t!
- Read the thread.
The ‘down*******’ issue and it’s origins have been discussed, clarified, etc, etc, ad nauseum. I have total sympathy for /agreement with PK-KARs feelings on the matter. It’s a classic media ‘red herring’ from the very people you think are ‘trying to accurately dissect events’. I’m afraid they, themselves, without any help from little me, have proven the point: “Accuracy again - obviously the Sydney Morning Herald has not had the benefit of browsing this thread! “. Simply by mentioning the downdraught myth – SMH have ,themselves, demonstrated the common ability to imitate a parrot – just repeating what everyone else is waffling – while, in all probability, NONE of them even remember where they heard it first. Whatever happened to the idea of 'two verifiable sources'?...........
well actually, in fairness, SMH used the phrase "raises the prospect"
But to be brutally honest - I couldn't give a rats what the story says - I'd rather know what the report actually says without the journalistic filter.
---------------------------------------------
alf5071h - Hi there, just saw you got your post in before me - can't read it right now - hope I'll get back to you later
I agree about the issue of speed of response. The video seems to give a pretty clear idea of the response time, at least as far as response on the ‘field is concerned. I can’t remember the layout of access gates to off field at Yogya from when I was there. Given the apparent response time ‘on field’, the crash site ‘off field’(rice field with tegalan), the criticism by media and others always seemed a little unfair if not invalid. I recall an incident here a few years ago, where civil fire engines needed to gain access to the airfield through an access gate, which, by chance, was only a couple of hundred yards from the incident. The local fire crews turned up at the gate, as indicated by emergency planning directions, but the gate couldn’t be opened……….involving travelling back down a public road to another gate about half a mile away. The unlockable gate would have been the crucial one for the evacuation of injured if the incident hadn’t had a favourable outcome!
This all seems to mirror the criticism flung at the cabin crew, some of which was thrown only hours after the crash.
The issue of ‘stopway’, is a little bit of a distraction for us and the media, I think. I recognise that this would be an obvious point to include from the investigators’ perspective and could/should be part of the contributory factors. Of course there is a technical breach of regulations concerning requirements. I agree, between the road and stopway consideration, it most likely was a major factor in the severity of the crash. But from a pilot decision making perspective, with (I assume) Yogya being a regular destination for an experienced GA captain – I would regard the lack of ‘stopway’ as being an intrinsic part of landing there. But then I have always regarded the stopway as being critical in terms of takeoff calculations(when operating in the limiting extreme for the most part) and not an ‘assumption’ or ‘given’ for the landing (baulked or messed up) case – in terms of ‘LDA’ and no (or small) stopway declared on charts. I understand “familiarity breeding contempt” in a lot of circumstances, but, as you’ve previously described Yogya’s peculiarities – this would seem a strange place to ‘get sloppy’.
From another perspective. I’m curious to consider the Min ICAO requirement and what you think about the following:
I’m curious to get an indication of speed when she left the tarmac. Should then be able to make a reasonable ‘guesstimation‘ of the difference the min’ run-off requirement would have made. If we assume the same geography – position of road, rice field(tegalan and embankment) – the effect of the extra 30m min requirement as displacing the entire runway or just the initial contact point. Considering the energy at the tarmac end-point (as you observed earlier from lack of damage on road divider, embankment – enough energy to ‘float’ that gap – 70, 80 kts or a lot more ????) – would it really have made much of a difference?..........I could see that putting us into a “more direct” conflict with that embankment! – maybe even more serious consequences?
I think the critical understanding will come along if and when the full FDR data is available.
I’m focusing on the min requirement, because 260m sounds really nice – but Indonesia doesn’t have a monopoly on having airports than don’t or can’t meet the recommendation.
From the flap/speedbrake info – without going into the area of good airmanship and energy management. Since it seems he was determined to ‘give it a try’ after the first F/O intervention – another question arises as to why he never used speedbrakes (albeit from 2500’, speed 272kts, for example
) – I believe on type -400 with AD’s, etc, legally they would have been available up to flap 15 and down to 500’ in vmc.------------------------------------
Markf – how do you know what the report says – unless you have a copy?....you’re not…………. by any chance……… a journalist???
Theamrad in particular
, despite the obvious fact that others indicate the SMH’s attempts at ‘trying to accurately dissect events’ are a BIT short of the mark with statements like: “nearly double normal landing speed” – You won’t, of course, mind me returning the favour.
poke fun at the coverage of
It’s a full frontal attack on journalistic quality – I’m giving my opinion on their lack of journalistic integrity – in common with SOME other elements of media coverage on this accident. If you, or anyone else want to debate/discuss the factual issues about the crash, I genuinely welcome it. Conversely, if you, or anyone else, don’t like criticism of media coverage – tough !
attempting to accurately dissect events
the report criticises the type of foam and hoses available, and the lack of an internal access road to the crash site.
lack of an internal access road to the crash site.
Please tell me more about the winds
The ‘down*******’ issue and it’s origins have been discussed, clarified, etc, etc, ad nauseum. I have total sympathy for /agreement with PK-KARs feelings on the matter. It’s a classic media ‘red herring’ from the very people you think are ‘trying to accurately dissect events’. I’m afraid they, themselves, without any help from little me, have proven the point: “Accuracy again - obviously the Sydney Morning Herald has not had the benefit of browsing this thread! “. Simply by mentioning the downdraught myth – SMH have ,themselves, demonstrated the common ability to imitate a parrot – just repeating what everyone else is waffling – while, in all probability, NONE of them even remember where they heard it first. Whatever happened to the idea of 'two verifiable sources'?...........
the actual story stated the 60 metre safety run-off ANd the failure of emergency services....could have contributed to the crash AND the number of fatalities
But to be brutally honest - I couldn't give a rats
what the story says - I'd rather know what the report actually says without the journalistic filter.---------------------------------------------
alf5071h - Hi there, just saw you got your post in before me - can't read it right now - hope I'll get back to you later
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Theamrad,
The Ch7 Vid coverage, the one that wasn't edited for the newsfeed (careful, there are 2 versions circulating), does show the equipment reaching the end of the fence... but couldn't get any further. As a local who's familiar with how the public obstructs emergency vehicles, I'd say it was pretty fortunate that a local fire engine was able to reach the site within 5-10 mins and start spraying. The criticism on the firetrucks were not one of MarkF, but, disappointingly, from the NTSC.
JOG:
The NTSC criticized the strength of the foam trucks... but I wonder, what is the required foam spray distance? I have my doubts that a lot of the criticism of the airport was based on the concept of the actual certification requirements and the "foreseeable" concept, but rather on a hindsight basis.
On the issue of stopway and runway end safety area, I agree that this is a HUGE distraction for everyone. Annex 14 recommends/requires 240m + 60m stopway at each end of the runway. But the number of airports that violate or is deficient in this in the world is also huge (LCY anyone?). This is why crew do not calculate landing requirements and dispatchers do not approve loads where factored distances will end up having to rely on those Annex14 requirements, but on the actual available length of runway, TODAs, ASDAs and LDAs. Personally, blaming the crash on those deficiencies is like accepting Lion's PR manager saying the MD80 crash in Solo was blamed on the concrete bound Localizer antennae being hit by the aircraft nose up at >80kts! It's just silly. In the case of GA200, the aircraft left the threshold of 27 at 100kts, and flung itself across the road at around 80kts. In my opinion, a fully compliant RESA in this case do not guarantee a write off or a break up or a fire will be prevented! The lack of clearway at the end is not a cause or a major factor in the accident, it is no more than a contributory factor to the deaths, and is not a cause.
Stopways and clearways should not be regarded for "out of the slot" or "unrecoverable" landings with the exceptions of "when there's no other choices"... which is not the case in this landing.
Theamrad, use the above numbers for your guesstimates! Bear in mind reversers were stowed 5 secs before the FDR data ended and a small positive throttle was applied somehow after that.
On the SMH/The Age article, despite its inherent errors and inaccuracies, it is still better than some other I've read on this accident. Driving away or shoowing away journalists for the history of inaccurate reporting isn't the solution. Professionals, enthusiasts and journos working together can and DO redress a heck of a lot of the series of inaccurate reporting baggage!
AAAARRRGHHH! Someone get me some valium!
---
alf5071h,
Having the police trying to catch you for negligent manslaughter at the first opportunity isn't a way to get the pilot to talk!
It's a bloody thin line!
What could the F/O have done? A lot, but then, one needs to see also why he ended up not taking over. Fear due to low experience can affect someone greatly and in the wrong way. You I presume is aware of the factors affecting that.
There can be many recommendations to come out of this, but a lot of those recommendations may or may not be implemented. Re-emphasizing the need to see wind conditions through the various altitudes the aircraft will go through is one, but routine and boredom will quickly erode that away. How many short haul pilots will just go and look at the dispatch papers, look at distance, origin airport, origin wx, destination airport, destination wx, alternate airport and wx, and then look at the loadings, then sign off and walk off to the aircraft? A lot. Slap an out of ordinary tailwind on a straight in from the descent and things can get out of hand quickly.
I had a heated exchange of words with some crew a few weeks before the case in JOG regarding responsibilities of planning ahead, rather than just use the excuse of "not enough time when something comes up..." (and coincidentally, the situation surrounding JOG was taken as an example) This would disagree with your alternative of "experienced F/Os or new technologies", because, people's memory do tend to be selective and fade... so stuff from training do selectively get forgotten. Supportive Captains like to fly with fresh F/Os, whose memories are still fresh from the oven, but there are those who prefer experience on the right hand seat too. The key in the matter is, it is not and should not be an exclusive club based on experience, in the very end, the relationship between left hand and right hand seats is similar to the "master and his apprentice"... A good master will encourage his apprentice to develop. Despite CRM, and the erosion of the historic stereotype of authoritarian captains and subservient F/Os, there is still one last barrier that is yet to be totally overrun, that is, the reservations of the left hand seat and the still darwinian rule of the right hand seat with regards of transfer of knowledge and experience.
GA200 seems to be a case of the good master and his scared apprentice... even a good master can make a mistake, if the apprentice is too scared, enough said.
Apologies if "master and the apprentice" isn't appropriate, but if someone can find me a better term for it I'd appreciate it...
PK-KAR
The Ch7 Vid coverage, the one that wasn't edited for the newsfeed (careful, there are 2 versions circulating), does show the equipment reaching the end of the fence... but couldn't get any further. As a local who's familiar with how the public obstructs emergency vehicles, I'd say it was pretty fortunate that a local fire engine was able to reach the site within 5-10 mins and start spraying. The criticism on the firetrucks were not one of MarkF, but, disappointingly, from the NTSC.
JOG:
RESCUE AND FIRE FIGHTING
AD CATEGORY FOR FIRE FIGHTING………….. CATEGORY VII
RESCUE EQUIPMENT…………………………….. 1 ROSENBAUER TYPE-1 9000 L
1 ROSENBAUER TYPE-2 4000 L
1 MORITA TYPE-2 4000 L
1 RESCUE MULTI PURPOSE CAR
1 AMBULANCE
CAPABILITY FOR REMOVAL OF
DISABLED ACFT…............................................... NIL
REMARK…………………………………………….. NIL
AD CATEGORY FOR FIRE FIGHTING………….. CATEGORY VII
RESCUE EQUIPMENT…………………………….. 1 ROSENBAUER TYPE-1 9000 L
1 ROSENBAUER TYPE-2 4000 L
1 MORITA TYPE-2 4000 L
1 RESCUE MULTI PURPOSE CAR
1 AMBULANCE
CAPABILITY FOR REMOVAL OF
DISABLED ACFT…............................................... NIL
REMARK…………………………………………….. NIL
On the issue of stopway and runway end safety area, I agree that this is a HUGE distraction for everyone. Annex 14 recommends/requires 240m + 60m stopway at each end of the runway. But the number of airports that violate or is deficient in this in the world is also huge (LCY anyone?). This is why crew do not calculate landing requirements and dispatchers do not approve loads where factored distances will end up having to rely on those Annex14 requirements, but on the actual available length of runway, TODAs, ASDAs and LDAs. Personally, blaming the crash on those deficiencies is like accepting Lion's PR manager saying the MD80 crash in Solo was blamed on the concrete bound Localizer antennae being hit by the aircraft nose up at >80kts! It's just silly. In the case of GA200, the aircraft left the threshold of 27 at 100kts, and flung itself across the road at around 80kts. In my opinion, a fully compliant RESA in this case do not guarantee a write off or a break up or a fire will be prevented! The lack of clearway at the end is not a cause or a major factor in the accident, it is no more than a contributory factor to the deaths, and is not a cause.
Stopways and clearways should not be regarded for "out of the slot" or "unrecoverable" landings with the exceptions of "when there's no other choices"... which is not the case in this landing.
Theamrad, use the above numbers for your guesstimates! Bear in mind reversers were stowed 5 secs before the FDR data ended and a small positive throttle was applied somehow after that.
On the SMH/The Age article, despite its inherent errors and inaccuracies, it is still better than some other I've read on this accident. Driving away or shoowing away journalists for the history of inaccurate reporting isn't the solution. Professionals, enthusiasts and journos working together can and DO redress a heck of a lot of the series of inaccurate reporting baggage!
The ‘down*******’ issue and it’s origins have been discussed, clarified, etc, etc, ad nauseum. I have total sympathy for /agreement with PK-KARs feelings on the matter.
---
alf5071h,
I wonder if the investigation will ever be able to determine why the Captain failed to discontinue the approach; unless of course, with hindsight, he is able to provide a plausible explanation – enabling us to have an understanding of the event.
Failed decision making or is this ‘partial incapacitation’?
What could the F/O have done? A lot, but then, one needs to see also why he ended up not taking over. Fear due to low experience can affect someone greatly and in the wrong way. You I presume is aware of the factors affecting that.
There can be many recommendations to come out of this, but a lot of those recommendations may or may not be implemented. Re-emphasizing the need to see wind conditions through the various altitudes the aircraft will go through is one, but routine and boredom will quickly erode that away. How many short haul pilots will just go and look at the dispatch papers, look at distance, origin airport, origin wx, destination airport, destination wx, alternate airport and wx, and then look at the loadings, then sign off and walk off to the aircraft? A lot. Slap an out of ordinary tailwind on a straight in from the descent and things can get out of hand quickly.
I had a heated exchange of words with some crew a few weeks before the case in JOG regarding responsibilities of planning ahead, rather than just use the excuse of "not enough time when something comes up..." (and coincidentally, the situation surrounding JOG was taken as an example) This would disagree with your alternative of "experienced F/Os or new technologies", because, people's memory do tend to be selective and fade... so stuff from training do selectively get forgotten. Supportive Captains like to fly with fresh F/Os, whose memories are still fresh from the oven, but there are those who prefer experience on the right hand seat too. The key in the matter is, it is not and should not be an exclusive club based on experience, in the very end, the relationship between left hand and right hand seats is similar to the "master and his apprentice"... A good master will encourage his apprentice to develop. Despite CRM, and the erosion of the historic stereotype of authoritarian captains and subservient F/Os, there is still one last barrier that is yet to be totally overrun, that is, the reservations of the left hand seat and the still darwinian rule of the right hand seat with regards of transfer of knowledge and experience.
GA200 seems to be a case of the good master and his scared apprentice... even a good master can make a mistake, if the apprentice is too scared, enough said.
Apologies if "master and the apprentice" isn't appropriate, but if someone can find me a better term for it I'd appreciate it...
PK-KAR
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GA200 seems to be a case of the good master and his scared apprentice... even a good master can make a mistake, if the apprentice is too scared, enough said
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Alf5071h -
I agree with the way your describing this – there are numerous examples of similar situations. Not sure if I’d include Qantas at Bangkok though, if we might consider some ‘mitigation’ of pilot action: poor weather; vis deteriorating considerably just before touchdown; failed/flawed policy of flap 25 with idle reverse being considered the norm; baulked comms leading the crew to believe (reasonably) aircraft ahead had touched-down safely. Another factor was the much smaller time scale from when things were ‘out of the box’ and the time available for correct decision making. Burbank, though, is a pretty good match.
“In these events, the situational cues for the safest course of action appeared to be obvious (with hindsight)” Well – I try to remember myself that we are looking on with the benefit of 20/20 hindsight – but in this case, as in a few others, I think we know enough know to maybe lower the hindsight guard. However, you are correct, there is a fundamental weakness. I know of another incident (with luck only aircraft damage) which mirrors GA200 in almost every way. An approach being conducted when it should obviously have been abandoned, F/O calling for GA (both before AND after touchdown in my example), F/O not forcing the issue or taking control, captain ignoring calls.
Well from low vis monitored approaches – it would be the norm for those operators who practice it.
If we extend your idea about F/O taking over along the lines of ‘low vis monitored procedures’ being the norm. That is to suggest on every approach – the same philosophy as applies in low vis conditions: that the monitoring pilot should consider things as an ‘approach to mins’ – then automatic go-around at mins by him, if out of the box – unless the contrary is the case ; everything ok to ‘allow’ the PF to proceed to landing. If I’m not way off the mark – I’d go along with the logic behind that. But then – it still comes down to a system which is dependent on training and discipline, and we still have a problem if the F/O is inexperienced or lacks assertiveness.
As far as your suggestion about reversing the primary roles (if I might refer to it in those terms), again I see the logic there. But I think, it still leaves us as slaves to some of the same potential problems. In addition to monitoring aircraft performance, how the approach is proceeding – an additional stress on the commander would be monitoring(or ‘dealing-with’) an in-experienced F/O’s airmanship/flying technique. With regards to how F/O’s with little experience fit into the equation in this – were into a ‘chicken and egg’ situation. With the best training, CRM, organisational involvement, etc – there’s still only one way to gain experience!
True – but for some airlines there is already a policy of ‘restricting’ their f/o’s abilities/oportunities to gain experience. So you’d probably have a battle with organisational culture in a few places.
mmm- well he could have at any stage right down to the tarmac – possibly for a short time after too (there could have been no doubt in their minds, even at that stage, that it was a baulked landing).
-----------------------------------------------------------------
PK-KAR,
It’s ok, it was the full version I saw. Can’t remember the exact timings, but the on-field response didn’t seem unreasonable. I agree about the notion of a reasonably ‘forseeable concept’ being behind regulatory requirements – but extending it cover all eventualities is a little stupid. As for GA200, the criticism seems misplaced – obviously the NTSC think differently and don’t agree with you or I.
I didn’t hear that one before – bit like adamair’s statements along the lines of routine maintenance on the ‘white banana’. I’ve seen quite a few ‘contributory factors’ listed in various reports worldwide which seem to be bordering on the irrelevant – at least in relation to the specifics of the particular accident. I guess in a general sense – for the most part, investigators have to include all the facts, even if only remote possibilities for completeness (sometimes to avoid criticism). Given about 100kts off the tarmac, I’d personally rate this one as necessarily included (as a ‘technical breach’ perhaps)– but pushing the ‘reasonableness’ factor as to causal effect.
Being anxious to take statements quickly is one thing – holding in custody for days (including the F/A’s!!!) is another.
There appears to be similarities with the accidents in Bangkok (747) and Burbank (737). In these events, the situational cues for the safest course of action appeared to be obvious (with hindsight), but for some inexplicable reason the pilot did not perceive them or they did not trigger the required action
I agree with the way your describing this – there are numerous examples of similar situations. Not sure if I’d include Qantas at Bangkok though, if we might consider some ‘mitigation’ of pilot action: poor weather; vis deteriorating considerably just before touchdown; failed/flawed policy of flap 25 with idle reverse being considered the norm; baulked comms leading the crew to believe (reasonably) aircraft ahead had touched-down safely. Another factor was the much smaller time scale from when things were ‘out of the box’ and the time available for correct decision making. Burbank, though, is a pretty good match.
“In these events, the situational cues for the safest course of action appeared to be obvious (with hindsight)” Well – I try to remember myself that we are looking on with the benefit of 20/20 hindsight – but in this case, as in a few others, I think we know enough know to maybe lower the hindsight guard. However, you are correct, there is a fundamental weakness. I know of another incident (with luck only aircraft damage) which mirrors GA200 in almost every way. An approach being conducted when it should obviously have been abandoned, F/O calling for GA (both before AND after touchdown in my example), F/O not forcing the issue or taking control, captain ignoring calls.
Have there been any successful ‘FO’ takeovers in erroneous situations (ignoring incapacitation)?
If we extend your idea about F/O taking over along the lines of ‘low vis monitored procedures’ being the norm. That is to suggest on every approach – the same philosophy as applies in low vis conditions: that the monitoring pilot should consider things as an ‘approach to mins’ – then automatic go-around at mins by him, if out of the box – unless the contrary is the case ; everything ok to ‘allow’ the PF to proceed to landing. If I’m not way off the mark – I’d go along with the logic behind that. But then – it still comes down to a system which is dependent on training and discipline, and we still have a problem if the F/O is inexperienced or lacks assertiveness.
As far as your suggestion about reversing the primary roles (if I might refer to it in those terms), again I see the logic there. But I think, it still leaves us as slaves to some of the same potential problems. In addition to monitoring aircraft performance, how the approach is proceeding – an additional stress on the commander would be monitoring(or ‘dealing-with’) an in-experienced F/O’s airmanship/flying technique. With regards to how F/O’s with little experience fit into the equation in this – were into a ‘chicken and egg’ situation. With the best training, CRM, organisational involvement, etc – there’s still only one way to gain experience!
by changing the process of monitoring to use the most experienced pilot as the monitor, this also enables FOs to gain experience quickly
his interjections were probably started too late, ultimately too late to takeover even if he could have
-----------------------------------------------------------------
PK-KAR,
It’s ok, it was the full version I saw. Can’t remember the exact timings, but the on-field response didn’t seem unreasonable. I agree about the notion of a reasonably ‘forseeable concept’ being behind regulatory requirements – but extending it cover all eventualities is a little stupid. As for GA200, the criticism seems misplaced – obviously the NTSC think differently and don’t agree with you or I.
blaming the crash on those deficiencies is like accepting Lion's PR manager saying the MD80 crash in Solo was blamed on the concrete bound Localizer antennae being hit by the aircraft nose up at >80kts! It's just silly
Having the police trying to catch you for negligent manslaughter at the first opportunity isn't a way to get the pilot to talk!
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Just in:
http://www.abc.net.au/news/newsitems...4/s1894980.htm
http://www.abc.net.au/news/newsitems...4/s1894980.htm
Garuda crash pilot may have been trying to save fuel
By Geoff Thompson
The pilots' association for Indonesia's Garuda Airlines says a bonus scheme for saving fuel could be encouraging pilots to attempt dangerous landings.
By Geoff Thompson
The pilots' association for Indonesia's Garuda Airlines says a bonus scheme for saving fuel could be encouraging pilots to attempt dangerous landings.
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Yeeeaaaay! G***f's back!!
Maybe certain people/organisations should just try copying Reuters verbatim a bit more often
. I have to admit, inspite of my previous outbursts about SOME of the media, Reuters are doing quite well on the accuracy front.
Last Update: Sunday, April 1, 2007. 12:14pm (AEST):
"Pilot argument could have led to Garuda crash: investigator"
"Pilot argument could have led to Garuda crash: investigator"
Last Update: Sunday, April 1, 2007. 1:08pm (AEST)
"No evidence of in-air argument between Garuda pilots: investigator"
"No evidence of in-air argument between Garuda pilots: investigator"
Maybe certain people/organisations should just try copying Reuters verbatim a bit more often. I have to admit, inspite of my previous outbursts about SOME of the media, Reuters are doing quite well on the accuracy front.
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I knew those old ladies were tough......
Reuters:
Or AP:
JAKARTA (Reuters) - An Indonesian airliner that crashed at Yogyakarta airport last month killing 21 people came down too fast and at a sharp angle, preliminary results from a crash investigation showed on Wednesday.
The chief of the country's Transport Safety Commission said the Garuda Indonesia operated Boeing 737-400 plane bounced and skidded off the runway before bursting into flames.
"When the plane was about to land, it looked too high over the runway coming down with a quite high speed," Tatang Kurniadi told a news conference.
"After touching the ground, the plane bounced twice and around exit delta the front wheel broke causing the plane to slide with the shock strut exposed." Exit delta refers to a point on the runway.
"This caused friction between metal and the runway igniting sparks," he said.
The commission's statement said flight GA 200 approached the runway at a 40 degree angle.
Kurniadi said the investigation had not yet reached a conclusion so could not apportion blame.
The final report will take more than two months more to complete and it would only be issued publicly after parties related to the flight had received a copy, he said.
Garuda's operations director, Ari Sapari, said the pilot and co-pilot had been grounded until the final report is out.
Survivors of the crash have described how the aircraft approached the runway in Yogyakarta at a "crazy" speed. It had 140 people on board when it overshot and then burst into flames.
Five Australians were among the casualties. They were part of a group who had been accompanying Australian Foreign Minister Alexander Downer, who was not on board the ill-fated plane, on a visit to Indonesia.
Rapid growth in air travel in Indonesia, a country of more than 17,000 islands, has raised questions over whether safety has been compromised and whether the infrastructure and personnel can cope with the huge increase.
The chief of the country's Transport Safety Commission said the Garuda Indonesia operated Boeing 737-400 plane bounced and skidded off the runway before bursting into flames.
"When the plane was about to land, it looked too high over the runway coming down with a quite high speed," Tatang Kurniadi told a news conference.
"After touching the ground, the plane bounced twice and around exit delta the front wheel broke causing the plane to slide with the shock strut exposed." Exit delta refers to a point on the runway.
"This caused friction between metal and the runway igniting sparks," he said.
The commission's statement said flight GA 200 approached the runway at a 40 degree angle.
Kurniadi said the investigation had not yet reached a conclusion so could not apportion blame.
The final report will take more than two months more to complete and it would only be issued publicly after parties related to the flight had received a copy, he said.
Garuda's operations director, Ari Sapari, said the pilot and co-pilot had been grounded until the final report is out.
Survivors of the crash have described how the aircraft approached the runway in Yogyakarta at a "crazy" speed. It had 140 people on board when it overshot and then burst into flames.
Five Australians were among the casualties. They were part of a group who had been accompanying Australian Foreign Minister Alexander Downer, who was not on board the ill-fated plane, on a visit to Indonesia.
Rapid growth in air travel in Indonesia, a country of more than 17,000 islands, has raised questions over whether safety has been compromised and whether the infrastructure and personnel can cope with the huge increase.
Indonesian jet's landing speed was 100 mph too fast
JAKARTA, Indonesia — An Indonesian passenger jet was flying at close to 265 mph, almost double the normal landing speed, when it crash-landed one month ago, killing 21 people, a chief investigator said Saturday.
A preliminary accident report has not yet determined, however, if pilot error caused the Boeing 737-400 to overshoot the runway, skid into a rice field and burst into flames at the Yogyakarta airport, Marjono Siswosuwarno said.
"The plane was flying well above the normal landing speed of 140 knots [160 mph] when it crash-landed," he said, putting the speed as it approached the runway at between 255 mph and 264 mph.
"We are still interrogating the pilots to figure out why this happened ... we haven't determined yet if it was pilot error."
Aviation experts confirmed that speed and flap warnings would have sounded in the cockpit and the pilot should have aborted the landing, according to The Sydney Morning Herald, which said it obtained a copy of the confidential Transport Safety Committee report.
It claimed the airport runaway also did not meet international safety standards — with a safety run-off a quarter of the recommended length — and that weather was good despite claims by pilots of a serious downdraft.
The March 7 crash was the fourth accident involving a commercial jetliner in Indonesia since 2005. Experts say poor maintenance, rule-bending and a shortage of properly trained pilots may contribute to the sprawling country's poor aviation-safety record.
JAKARTA, Indonesia — An Indonesian passenger jet was flying at close to 265 mph, almost double the normal landing speed, when it crash-landed one month ago, killing 21 people, a chief investigator said Saturday.
A preliminary accident report has not yet determined, however, if pilot error caused the Boeing 737-400 to overshoot the runway, skid into a rice field and burst into flames at the Yogyakarta airport, Marjono Siswosuwarno said.
"The plane was flying well above the normal landing speed of 140 knots [160 mph] when it crash-landed," he said, putting the speed as it approached the runway at between 255 mph and 264 mph.
"We are still interrogating the pilots to figure out why this happened ... we haven't determined yet if it was pilot error."
Aviation experts confirmed that speed and flap warnings would have sounded in the cockpit and the pilot should have aborted the landing, according to The Sydney Morning Herald, which said it obtained a copy of the confidential Transport Safety Committee report.
It claimed the airport runaway also did not meet international safety standards — with a safety run-off a quarter of the recommended length — and that weather was good despite claims by pilots of a serious downdraft.
The March 7 crash was the fourth accident involving a commercial jetliner in Indonesia since 2005. Experts say poor maintenance, rule-bending and a shortage of properly trained pilots may contribute to the sprawling country's poor aviation-safety record.
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As for GA200, the criticism seems misplaced – obviously the NTSC think differently and don’t agree with you or I.
Garuda could have partially defended the pilot based on his past reputation, and in turn, avoid blatant finger pointing and stereotyping by the public and media... It took over a month to get a character defence of the pilot to come to light...
From the SMH...
"The question puzzling investigators is why Komar remained so focused on continuing the landing when established procedures necessitated a go-around. An experienced 737 pilot, Komar has a reputation for observing safety standards, unlike some of his "cowboy" colleagues.?
It claimed the airport runaway also did not meet international safety standards — with a safety run-off a quarter of the recommended length — and that weather was good despite claims by pilots of a serious downdraft.
Anyways, I find it baffling that Garuda isn't actively doing a "PR Campaign" to defend it's reputation that is, in my opinion, unjustly overattacked. Only this morning, after over 30 days of speculation on pilots "out of control" and whatever else, did they release information that they were already in the process of ironing out whatever remains on flight ops "problems".
It is long suspected that the NTSC would recommend a refocus on "Approach and Landing Accident Reduction/ALAR" program and "Flight Operation Quality Assurance/FOQA"...
GA stated to one of the local media this morning that they have already planned installation of FOQA on their fleet of 48 aircraft, and it was targetted to be implemented this year.
This would have quelled some accusations directed at Garuda regarding safety and training. Accidents attract these kinds of speculation and accusations, and sometimes I wonder if they look at the bigger picture at all. Several press releases from Garuda roughly along the lines of "Hey, we're already doing something about this before the accident happened! The accident shows that such a system is needed for Garuda to prevent future accidents!" would do wonders to the whole public sentiment during the investigations, and show exceptional example amidst...
Experts say poor maintenance, rule-bending and a shortage of properly trained pilots may contribute to the sprawling country's poor aviation-safety record.
PK-KAR
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FAA lowers Indonesian Airline Safety Rating
In related news, the State Department warns US citizens to avoid travel on Indonesian flag carriers.
FAA Release 16 Apr 07:
FAA Release 16 Apr 07:
FAA Lowers Safety Rating for Indonesia
WASHINGTON, D.C. – The U.S. Department of Transportation’s Federal Aviation Administration (FAA) today announced that Indonesia does not comply with international safety standards set by the International Civil Aviation Organization (ICAO), following a consultation with the Indonesian civil aviation authority on March 6, 2007.
The FAA had previously assessed Indonesia's civil aviation authority in September, 1997, and found it in compliance with ICAO standards. However, after the latest consultation, the agency determined that Indonesia was no longer overseeing the safety of its airlines in accordance with international standards.
Indonesia’s safety rating was lowered from Category 1 to Category 2. A Category 1 rating means the country’s civil aviation authority complies with ICAO standards. A Category 2 rating means a country either lacks laws or regulations necessary to oversee air carriers in accordance with minimum international standards, or that its civil aviation authority – equivalent to the FAA – is deficient in one or more areas, such as technical expertise, trained personnel, record keeping or inspection procedures.
The FAA will remain engaged with the civil aviation authority in Indonesia and will periodically review the situation with the intention of encouraging improvements that will qualify Indonesia for a Category 1 rating.
As part of the FAA’s International Aviation Safety Assessment (IASA) program, the agency assesses the civil aviation authorities of all countries with air carriers that operate to the United States and makes that information available to the public. The assessments determine whether or not foreign civil aviation authorities are meeting ICAO safety standards, not FAA regulations.
Countries with air carriers that fly to the United States must adhere to the safety standards of ICAO, the United Nations’ technical agency for aviation that establishes international standards and recommended practices for aircraft operations and maintenance.
WASHINGTON, D.C. – The U.S. Department of Transportation’s Federal Aviation Administration (FAA) today announced that Indonesia does not comply with international safety standards set by the International Civil Aviation Organization (ICAO), following a consultation with the Indonesian civil aviation authority on March 6, 2007.
The FAA had previously assessed Indonesia's civil aviation authority in September, 1997, and found it in compliance with ICAO standards. However, after the latest consultation, the agency determined that Indonesia was no longer overseeing the safety of its airlines in accordance with international standards.
Indonesia’s safety rating was lowered from Category 1 to Category 2. A Category 1 rating means the country’s civil aviation authority complies with ICAO standards. A Category 2 rating means a country either lacks laws or regulations necessary to oversee air carriers in accordance with minimum international standards, or that its civil aviation authority – equivalent to the FAA – is deficient in one or more areas, such as technical expertise, trained personnel, record keeping or inspection procedures.
The FAA will remain engaged with the civil aviation authority in Indonesia and will periodically review the situation with the intention of encouraging improvements that will qualify Indonesia for a Category 1 rating.
As part of the FAA’s International Aviation Safety Assessment (IASA) program, the agency assesses the civil aviation authorities of all countries with air carriers that operate to the United States and makes that information available to the public. The assessments determine whether or not foreign civil aviation authorities are meeting ICAO safety standards, not FAA regulations.
Countries with air carriers that fly to the United States must adhere to the safety standards of ICAO, the United Nations’ technical agency for aviation that establishes international standards and recommended practices for aircraft operations and maintenance.
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Yes I am a journalist who wrote the SMH story, but was responding personally.
All to easy sometimes to blame the messenger and while I would not defend all media coverage of the Yogya incident, but I note that with the release of the preliminary report it is clear the criticisms raised in my story came from the KNKT, not media editorialising.
Of course I don't like inaccurate criticism Theamard, you seem to be the same, but if you are going to launch an "attack on journalistic integrity", pick the right target, I think my stories stand up pretty well.
To quote you:
"Maybe IF they have the report – they SHOULD report accurately what it contains and they SHOULDN’T be editorialising it, or adding a ‘cause/blame’ section on, or stating fictional remarks like “pilot's claims of a massive down draught” as fact?"
This is something I can help clear up, at risk of further criticism. The "massive downdraft" claim of the pilot first came from a story of mine published two days after the crash. It was a quote from the head of the Garuda pilots association made directly after he and other officials had interviewed the Pilot.
Interestingly, I also interviewd the Commission chairman, Tatang, on Tuesday this week, he stated the pilot was continuing to make a similar claim to investigators, but phrased it differently. To remove any "journalistic filter", here are his comments:
Q: the pilot has actually answered the question of why there was overspeed?
A: yes but we have to find out more things to conform the answer.
Q: did he say the reason for overspeed?
A: it is the question which answer we have to find out
Q: basically he was surprised himself of the overspeed?
A he did not try to reduce (speed). But then we have to find out why. Whether at that time there was wind pushing out or he was not at alert condition. We have to find out (many things).
Q: but basically he has answered the question (about overspeed)?
A: The NTSC has to find out. We connect (the
facts) with (the pilot’s information). That is why it takes time.
Q: but he did not give winds as reason (for overspeed)?
A: he felt he was pushed, (he felt) there were winds.
The winds at higher level was different to the lower level.
I agree it would be better for all to have had full access to the KNKT report immediately, it was a shame it had to be leaked to me to ensure it was made public.
I am as interested as anyone in seeing the full facts of the crash revealed. I lost two of my friends that morning.
All to easy sometimes to blame the messenger and while I would not defend all media coverage of the Yogya incident, but I note that with the release of the preliminary report it is clear the criticisms raised in my story came from the KNKT, not media editorialising.
Of course I don't like inaccurate criticism Theamard, you seem to be the same, but if you are going to launch an "attack on journalistic integrity", pick the right target, I think my stories stand up pretty well.
To quote you:
"Maybe IF they have the report – they SHOULD report accurately what it contains and they SHOULDN’T be editorialising it, or adding a ‘cause/blame’ section on, or stating fictional remarks like “pilot's claims of a massive down draught” as fact?"
This is something I can help clear up, at risk of further criticism. The "massive downdraft" claim of the pilot first came from a story of mine published two days after the crash. It was a quote from the head of the Garuda pilots association made directly after he and other officials had interviewed the Pilot.
Interestingly, I also interviewd the Commission chairman, Tatang, on Tuesday this week, he stated the pilot was continuing to make a similar claim to investigators, but phrased it differently. To remove any "journalistic filter", here are his comments:
Q: the pilot has actually answered the question of why there was overspeed?
A: yes but we have to find out more things to conform the answer.
Q: did he say the reason for overspeed?
A: it is the question which answer we have to find out
Q: basically he was surprised himself of the overspeed?
A he did not try to reduce (speed). But then we have to find out why. Whether at that time there was wind pushing out or he was not at alert condition. We have to find out (many things).
Q: but basically he has answered the question (about overspeed)?
A: The NTSC has to find out. We connect (the
facts) with (the pilot’s information). That is why it takes time.
Q: but he did not give winds as reason (for overspeed)?
A: he felt he was pushed, (he felt) there were winds.
The winds at higher level was different to the lower level.
I agree it would be better for all to have had full access to the KNKT report immediately, it was a shame it had to be leaked to me to ensure it was made public.
I am as interested as anyone in seeing the full facts of the crash revealed. I lost two of my friends that morning.
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Garuda to get FOQA?
PK-KAR said
What actually has to be "installed"? I always thought that FOQA/FDM programs just downloaded QAR/FDR data (but not CVR) and analyzed it via proprietary software for any exceedances or other stylistic mischief.
.
Perhaps you're referring to one of the increasingly popular ramp downloading wireless fitments?
GA stated to one of the local media this morning that they have already planned installation of FOQA on their fleet of 48 aircraft, and it was targeted to be implemented this year.
.
Perhaps you're referring to one of the increasingly popular ramp downloading wireless fitments?
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Quite incredible
I find it unbelievable that anyone, from raw student to experienced captain, would try to get an airliner down under the configuration and speed conditions reported.
If this really happened as reported, the guy must have had a serious mental or physical problem.
It is a miracle that anybody lived.
I hope that the investigation is capable of getting to the bottom of this.
FC.
If this really happened as reported, the guy must have had a serious mental or physical problem.
It is a miracle that anybody lived.
I hope that the investigation is capable of getting to the bottom of this.
FC.
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I agree it would be better for all to have had full access to the KNKT report immediately, it was a shame it had to be leaked to me to ensure it was made public.
As to the downdraft, it seems that it was never explicitly said as a downdraft, all that was said was a push (direction not detailed as downward push)... now, dunno which one should we follow, the initial interview with the head of the pilot's association (A: "Push"... Q: what kind of push? wind? A: "Dunno, maybe a downdraft.")... or whether the pilots claimed the downdraft to the investigators...
Now if "push" is translated as downdraft (which it seems also shared by the invetigators), well... nuff said...
Why the overspeed? How about wind gradient?
Tailwind 10-15kts @FL270
tailwind 35kts @FL180
reducing to 21kts @ 3800ft, 3000ft @ 19, 2000@15kts...
Result, too high and "no space/time" to decelerate...
An ex GA pilot told me... "It's a bad habit for short haul pilots, they never look at the winds up there... so when the wind's stronger than normal, they get screwed up descents."
What I wanna know is, where's the FDR data beyond the last 4000ft of the flight? Has the ATSB given those data to the NTSC? In my personal opinion, it would give answers to:
Q: did he say the reason for overspeed?
A: it is the question which answer we have to find out
Q: basically he was surprised himself of the overspeed?
A he did not try to reduce (speed). But then we have to find out why. Whether at that time there was wind pushing out or he was not at alert condition. We have to find out (many things).
Q: but basically he has answered the question (about overspeed)?
A: The NTSC has to find out. We connect (the
facts) with (the pilot’s information). That is why it takes time.
Q: but he did not give winds as reason (for overspeed)?
A: he felt he was pushed, (he felt) there were winds.
The winds at higher level was different to the lower level.
A: it is the question which answer we have to find out
Q: basically he was surprised himself of the overspeed?
A he did not try to reduce (speed). But then we have to find out why. Whether at that time there was wind pushing out or he was not at alert condition. We have to find out (many things).
Q: but basically he has answered the question (about overspeed)?
A: The NTSC has to find out. We connect (the
facts) with (the pilot’s information). That is why it takes time.
Q: but he did not give winds as reason (for overspeed)?
A: he felt he was pushed, (he felt) there were winds.
The winds at higher level was different to the lower level.
How much of the 'shortened' descent time resulted in fixation or whatever else that can err when you have a shortened approach preparation time....
PK-KAR
PK re “… poor descent planning due to not taking into account the wind. … the 'shortened' descent time resulted in fixation or whatever else that can err when you have a shortened approach preparation time...”
I agree with the scenario you describe. The final approach handling difficulties may have started much earlier, which could have engaged the Captain’s attention to the detriment of his awareness of other factors and the First Officer’s intervention. A possible initiating contributor may have been the ‘unnecessary’ or erroneous use of VNAV. The downdraught (or similar) reported by the Captain could have been his perception of the conditions – where he was seeking an explanation for a steep approach / high descent rate; if he perceived ‘windshear’ (human error) it is possible that his training / knowledge would accept a higher speed because he believed that it would be ‘safer’. So the investigative questions in this area should look at the Capt’s specific beliefs and training, as well as the airlines training for descent planning, use of VNAV, and understanding of windshear.
Few cloudy, et al hindsight bias can lead to a conclusion of ‘unbelievable’ aspects in an accident. Every effort must be made to view the exact situation as seen (experienced) by the crew (with their biases, disposition, training, etc), ignore your understanding of the situation – what was theirs.
The questions to be answered must define all components of the situation as well as the crew aspects. If judgement is to be made when the appropriate facts are known (if ever), then the final question might be if you or I would had experienced the same circumstances, would we have acted in the same way. For those who respond no, then your reasons could the saviour of the industry.
We should remember the first and most important aspect of threat and error management is the recognition that anyone can suffer an error. The errors in this accident are probably similar to many that we have made, but the difference might be that our errors were both trapped and corrected earlier in the event, or they were made in more benign situations, or not simultaneously.
I recall that there might be some regulator guidance for those operators who use runways that do not have the standard margins of overrun, or other factors which could affect safety – along the lines of rescheduling LDR or landing weight. Can anyone provide details or a reference?
I agree with the scenario you describe. The final approach handling difficulties may have started much earlier, which could have engaged the Captain’s attention to the detriment of his awareness of other factors and the First Officer’s intervention. A possible initiating contributor may have been the ‘unnecessary’ or erroneous use of VNAV. The downdraught (or similar) reported by the Captain could have been his perception of the conditions – where he was seeking an explanation for a steep approach / high descent rate; if he perceived ‘windshear’ (human error) it is possible that his training / knowledge would accept a higher speed because he believed that it would be ‘safer’. So the investigative questions in this area should look at the Capt’s specific beliefs and training, as well as the airlines training for descent planning, use of VNAV, and understanding of windshear.
Few cloudy, et al hindsight bias can lead to a conclusion of ‘unbelievable’ aspects in an accident. Every effort must be made to view the exact situation as seen (experienced) by the crew (with their biases, disposition, training, etc), ignore your understanding of the situation – what was theirs.
The questions to be answered must define all components of the situation as well as the crew aspects. If judgement is to be made when the appropriate facts are known (if ever), then the final question might be if you or I would had experienced the same circumstances, would we have acted in the same way. For those who respond no, then your reasons could the saviour of the industry.
We should remember the first and most important aspect of threat and error management is the recognition that anyone can suffer an error. The errors in this accident are probably similar to many that we have made, but the difference might be that our errors were both trapped and corrected earlier in the event, or they were made in more benign situations, or not simultaneously.
I recall that there might be some regulator guidance for those operators who use runways that do not have the standard margins of overrun, or other factors which could affect safety – along the lines of rescheduling LDR or landing weight. Can anyone provide details or a reference?
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Reasons
Alf,
You wrote:
"For those who respond no, then your reasons could the saviour of the industry".
I respond No.
My reasons are:
- A strong love of life
- A strong respect for the laws of physics
- A strong respect for the trainers and subsequent experience I gathered
- Basic common sense
These are feelings, which I put it to you are shared by all sane, healthy airline pilots, whose business it is, daily to make life in the air as safe as possible and to be on the lookout for the smallest discrepancy - let alone a glaring guarranteed accident.
If you read my post again you will see that I hope the reason is found out - the reason anybody would go against such strong feelings and knowingly put an airliner way out of its envelope like that.
FC.
You wrote:
"For those who respond no, then your reasons could the saviour of the industry".
I respond No.
My reasons are:
- A strong love of life
- A strong respect for the laws of physics
- A strong respect for the trainers and subsequent experience I gathered
- Basic common sense
These are feelings, which I put it to you are shared by all sane, healthy airline pilots, whose business it is, daily to make life in the air as safe as possible and to be on the lookout for the smallest discrepancy - let alone a glaring guarranteed accident.
If you read my post again you will see that I hope the reason is found out - the reason anybody would go against such strong feelings and knowingly put an airliner way out of its envelope like that.
FC.
I think it would be wise to take a step backwards, and have a broader look around.
The management of winds like these (pretty tame really) is something that pilots do all the time. Occasionally, despite our best efforts at correcting any profile issues, we just have to accept defeat and go around.
However, landing the aircraft in the state this captain had it in and hoping to get away with it, is about as likely as landing it upside down and hoping to get away with it.
The PF here ignored all the clues. Hints from the FO and a slightly duff intermediate profile. But sometimes we miss clues.
But then he continued to ignore real hard facts. Any normal person would react positively to any one of the hard facts:
Totally wrong and unrecoverable config.
Totally wild and unrecoverable speed.
FO instructing a go around.
To ignore all of these must surely point to a fundamental human factors issue. I'm not a medical person, but something that caused the normal thinking/hearing/seeing/reacting process to stop for a period of time.
Is this conceivable?
The management of winds like these (pretty tame really) is something that pilots do all the time. Occasionally, despite our best efforts at correcting any profile issues, we just have to accept defeat and go around.
However, landing the aircraft in the state this captain had it in and hoping to get away with it, is about as likely as landing it upside down and hoping to get away with it.
The PF here ignored all the clues. Hints from the FO and a slightly duff intermediate profile. But sometimes we miss clues.
But then he continued to ignore real hard facts. Any normal person would react positively to any one of the hard facts:
Totally wrong and unrecoverable config.
Totally wild and unrecoverable speed.
FO instructing a go around.
To ignore all of these must surely point to a fundamental human factors issue. I'm not a medical person, but something that caused the normal thinking/hearing/seeing/reacting process to stop for a period of time.
Is this conceivable?
Per Ardua ad Astraeus
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My personal view is that any attempt to analyse this within the 'normal' accident system is a total waste of time. Runway over-run distances 'available' etc are, in my opinion, irrelevant. As FC and others have said, the problem lies elsewhere. NB this is not an attempt to second guess the enquiry, but to me, unless the P1 had a 'mental' problem at some stage, we seem to have the classic 'overload and shutdown' symptoms. Why is another matter. Positive action by the F/O would have saved the day but possibly messed his career?
Lessons to be learned, I hope.
Lessons to be learned, I hope.
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To ignore all of these must surely point to a fundamental human factors issue. I'm not a medical person, but something that caused the normal thinking/hearing/seeing/reacting process to stop for a period of time.
Is this conceivable?
Is this conceivable?
Implied 'partial' or 'subtle' incapacitation has surfaced every now-and-then after this incident. If there was a fight going on in your mind between training/good sense and your "cultural programming", wouldn't that count as a kind of incapacitation?
Hmm...dangerous statement there fullwings and A37575.
Do you mean to say that certain cultural upbringings inevitably result in incapable aviators?
Anyway, you will never find that conclusion in the accident report as published by the Indonesian authorities.
"The captain, an Indonesian citizen, was overcome by a subtle incapacitation caused by his cultural upbringings, resulting in his inability to make a go-around."
The situation has to be more complicated than that. (I hope)
Do you mean to say that certain cultural upbringings inevitably result in incapable aviators?
Anyway, you will never find that conclusion in the accident report as published by the Indonesian authorities.
"The captain, an Indonesian citizen, was overcome by a subtle incapacitation caused by his cultural upbringings, resulting in his inability to make a go-around."
The situation has to be more complicated than that. (I hope)