TACA aircraft crashed in Honduras

[RWA]

Originally Posted by DL-EDL

I'm referring to your apparent concern that pilots are "taught to rely on" the only indication that seems to be available on most types.

I know that on some aeroplanes, even today, you can still see most of the wing; just didn't know whether the A320 was one or not. In addition, as alf5071h says, it must be difficult for younger pilots nowadays to gain much experience of judging the behaviour of the aeroplane by use of the seat of the pants as well as the panel indications.

On top of that ,there is one documented case (one of the 'wrong throttle-lever position' A320 accidents, the one at Taipei) where the F/O called the spoilers even though they had not in fact deployed:-

"The pilot monitoring announced “spoiler” automatically when the aircraft touched down without checking the ECAM display first according to SOP before made the announcement, as such the retraction of ground spoilers was ignored. (2.3.3)"

Originally Posted by DL-EDL

Doesn't that depend greatly on where the accident takes place and who's conducting the investigation?

Not usually, in my experience? In the case of BA038, we knew very early on what had actually happened - that the engines failed to respond. Plus all the details about how it landed, where it landed, etc. The investigators have made it clear that they cannot work out why, up to this time, because nothing like it has ever happened before or since, and the phenomenon cannot be reproduced in simulated studies.

The case of Armavia was similar - we knew early on what had happened - an approach in thick weather, a late instruction to go around, the pilot apparently losing control. Much of the delay in getting further information was caused by the fact that it took two months to locate and fish up the recorders from the bottom of the Black Sea. And they still don't know why the captain became disoriented, only that (on the limited information available) he probably did.

I cannot recall any previous case where no factual information at all was published more than six weeks after an accident; except for a leaked, and plainly-incomplete, CVR transcript.

And, as I've pointed out, the authorities have more information available than most investigators do - the FDR, the CVR, and presumably the testimony of a surviving pilot. It's 100-1 that they know exactly where the aeroplane landed, and pretty well everything about what the pilots did and how the engines, the reversers, the spoilers, and the brakes responded.

So you tell me - what possible explanation could there be for them not revealing ANY of the facts, up to this time? Especially if it can be shown to have been 100% 'pilot error'? As has been said earlier, 'pilot error' tends to be the 'preferred' verdict for most people involved in an accident - airports, airlines, manufacturers, governments - everyone except, presumably, the pilots themselves?

[kwick]

As I have it understood, pilot error (in his various variants) acounts to the majority of aircraft accidents nowadays. Maybe this is because the human being is reluctant to quick changes, and automation is taking a lot of aviation people by surprise, development is faster than what it used to be just a few years ago. Then, and consequently, full reliance in automated cabins is required, letting the pilot a little margin to "think" and correct errors. ¿Does it sound familiar in this particular accident?

[DL-EDI]

I know that on some aeroplanes, even today, you can still see most of the wing;

By pressing ones face right against the side window and peering backwards during a crucial phase in the landing, perhaps one can see a couple of spoilers on one wing. How practical is that, though? How do you check for asymmetric spoiler deployment?

The case of Armavia was similar - we knew early on what had happened - an approach in thick weather, a late instruction to go around, the pilot apparently losing control.

Some of the information issued early on included gunfire on board and missing crew members. I think you'll find "some of us" only thought we knew what had happened early on. In fact, someone(!) speculated that the pilot had managed to "stall" the A320. When that was dismissed as highly unlikely, that speculation switched to fuel exhaustion, even though the evidence suggested otherwise. It's true that some with experience thought it more likely that they'd become disoriented in the poor visibility and were eventually proved right but that wasn't in any official releases for quite some time.

So you tell me - what possible explanation could there be for them not revealing ANY of the facts

That the authorities, in this case, have chosen to stick with what they're obliged to do, rather than feeding the internet. It will only become a "cover-up" if significant information is withheld from relevant parties and the final report is deliberately flawed. Perhaps they're just not accustomed to keeping Joe Public informed - I don't know.

[Lemurian]

alf5071h,

Perhaps your view and that of Lemaurin previously, places too greater emphasis on normal (routine) operations, particularly in the context of this accident.

There is a possible misunderstanding here : Adherence to SOPs, and particularly standard call-outs, is at the source of modern airliners' flying and one of the main contributors to the safety level air transport has achieved.
My emphasis on normal routine operations was in response to some wild ideas in which we can say just about anything in case of - any- failure / fault...(the "in amber..." utterance). My point is that I would expect this crew -who at this point had no particularly high level of stress - to act *by the book* and follow the normal sequence of events : Cancel caution / Announce ECAM fault / Reorganize if necessary job attribution / ECAM actions......
Enough of that .

Re : the braking.
We do not have, as you write "vastly differing opinions". You are right and to an enormous amount I agree with you that foot-braking can be vastly more efficient than auto-brakes (btw, this crew demonstrated it as, according to my computations, they achieved a deceleration higher than the *maximum* setting available on the 320, i.e MED). On the other hand, I have noticed that few pilots manage that sort of effectiveness and it's mainly a matter of training. Or a matter of over-relying on the auto-brakes (which is the same thing, really).
This said, my experience, my inner ear, my stereoscopic vision don't change when auto-brakes are used ; I am still capable of visualising where I will be at a stop with this kind of deceleration...but (here again I agree with you ) I am just witnessing what George Brake is doing, and If I use him, I will let him do so until I decide that it's time to take over. I know why and I know how : the experience of olderr jets with steel brakes made us modulate braking to a fine point (the l-1011 comes to mind as the brakes would overheat quite rapidly).
On the other hand, I am grateful that my airplane is equipped with A/B, especially on strong x-wind landings on which achieving effective symetrical pressure on the foot-pedals is more difficult than normal.

May I suggest that just because the runways is short, wet, or requires a steep approach, it does not call for a change in the choice of braking; precision and promptness in flying and retarding actions, yes.

In my opinion, unless there is an emergency, one should not diverge from one's normal operating method. It is not for me to criticize their option in this braking matter.But... considering that the runway surface conditions allowed some "virile" braking, an A/B MED setting, achieving .3G would have stopped that aircraft in 26 seconds with a stopping distance -from brake application 2 seconds afterT/D - of some 950 meters. Would that have been enough ? I posit yes.

It may be very difficult to determine the significant contributing factors in this accident, but if as it appears that “in the Captain’s opinion” the attempt to land was safe, then the investigators might determine (in their opinion) some factors which show that the decision was imprudent or more likely the situation was not as expected.
But that’s just an opinion.

It happens to be mine, too.

kwick

As I have it understood, pilot error (in his various variants) acounts to the majority of aircraft accidents nowadays. Maybe this is because the human being is reluctant to quick changes, and automation is taking a lot of aviation people by surprise

The problem has been identified long time ago and addressed, still as we speak. Some ground breaking tools are being used (have a look at the work of Bielefeld University for instance...or PM bsieker )

bubbers44

My last post showed my 1200 fpm as normal and I noticed you showed the 40 to 20 ft calls at 800fpm. The reason for that is we always got a 40 call crossing a hill turning final and that hill was well above field elevation.

Thanks ; that confirms what a pilot, well experienced on that approach, wrote to me. It also confirms that their touch-down point was normal, even possibly before the markers.

It even made flying fun again flying for a mega airline

Don't I know that feeling !

Cheers.

[RWA]

Originally Posted by DL-EDI

It will only become a "cover-up" if significant information is withheld from relevant parties

With respect, DL-EDI, I reckon that we've already arrived at that point. C and D traffic has now been cleared to use Toncontin again. How are the pilots and crews (leave alone the passengers!) going to feel about that, when no facts at all have been revealed about the possible causes of a recent fatal accident? Surely they're 'relevant parties'?

Incidentally, the re-opening of the airport is based on an ICAO report on the runway etc. which said that it was safe. However, the press report said that the ICAO had further recommended that A320s should not land there, and that A319s should be used instead.

It will be interesting to see whether TACA resumes A320 services, or substitutes A319s as recommended?

Originally Posted by DL-EDI

Perhaps they're just not accustomed to keeping Joe Public informed - I don't know.

As it happens, only hearsay, but an acquaintance of mine hails from Central America (Panama). He told me that the government runs El Salvador with an iron hand - and that TACA more or less 'runs' the government..........

[kwick]

Checking on their website today, TACA offers the Toncontin, Tegucigalpa (TGU) destination via San Salvador (SAL), Guatemala (GUA) or San Pedro Sula (SAP) using the Aerospatiale turboprop airplanes. These flights have Taca International flight numbers, but are operated by a different carrier.

[bubbers44]

AA starts normal operations from MIA AUG 1. AA953 and return AA954. I am very happy this happened.

[kwick]

bubbers,
Do you know if AA will use the same approach procedures, or have been asked to do something different like reducing weight? I know AA was doing it right, but you know the pressures from the competition since they were asked to go with the A319.

[alf5071h]

kwick, ‘pilot error’ (#366) is an old way of viewing human error, it implies blame, often unwarranted, and thus is a term best to be avoided - see refs.
Human behaviour and performance are cited as causal factors in the majority of aircraft accidents. Those contributions relating to human factors might influence perception, choice, and action, or involve other factors beyond the control of the pilot, originating from the organisation or within the situation. These present opportunity for error, which apart from intentionally breaking rules, pilots do not intend to commit, but due to human fallibility, often experience error, which is only definable after the event.

Ref:
The new view on error and performance – Dekker.

Punishing People or Learning from Failure? - Dekker.

Thoughts on the New View of Human Error , also see Air Safety Letter 4/2006 and 1/2007.

[alf5071h]

Lemurian (#368) – thanks, a convergence of opinion, with some misunderstanding!

However, re: “Adherence to SOPs, etc … .”
In principle, this is sound strategy, but depending on how adherence is taught / implemented, there is a risk of pilots not breaking-away from a ‘routine operations’ mindset in situations where there are no SOPs. In addition, with the growth of SOPs from this strategy, there is increasingly more poorly written (inappropriately thought out) documentation; this is probably a normal outcome of rising complexity in operations – not just with aircraft, the total aviation system.
Thus in the TACA situation, as you say, the crew probably followed their ‘habits’ based on SOPs; their expectation was for a normal operation.
However, at some point, the operation crossed the boundary of ‘normal’. In this context, the other side of the boundary is not an ‘emergency’ or abnormal, or even ‘non-normal’, it’s a situation that requires a change or reconsideration of the plan; more a normal situation but with “personal SOPs”.
These situations involve assessments and decisions – aspects airmanship; thus, it is the trigger to apply airmanship, the need to change the plan, which is an important event.
We have yet to establish that the crew had a good plan – an approach and landing briefing; absence of which might be a significant contribution to the accident.
From the above, I suggest that this landing ‘went wrong’ much earlier in the sequence of events than has been discussed. I equate the focus on the crew/aircraft to that of blame syndrome by choosing who (or what) was closest to the event, but this is not to dismiss later human / technical failure completely.

Re the braking: I would not disagree with the logic of your analysis other than to emphasise the assumption about the runway enabling ‘virile’ braking, and that of the assumed touchdown position.
Whilst these remain unknown to us, it might be worth reconsidering the use of factored landing distances; I recall earlier discussions, which suggested that the operator did not require them after dispatch.
If a factored landing distance had been required on this wet runway in a tailwind, and it was more than the LDA, then the decision to change the plan could have occurred earlier.

[bubbers44]

kwick, Even if they reduce landing weights it won't affect us because we ferried fuel in because of the high cost at TGU so even though landing weight isn't normally a factor unless landing on a wet runway downhill we will just land lighter on fuel. I always accepted the extra fuel knowing we would land on a dry runway and save on fuel costs on most days. I usually landed at about max landing weight because it saved a lot on fuel cost and it never caused a problem on landing distance.

[Lemurian]

alf5071h

re: “Adherence to SOPs, etc … .”
In principle, this is sound strategy, but depending on how adherence is taught / implemented, there is a risk of pilots not breaking-away from a ‘routine operations’ mindset in situations where there are no SOPs.

This is where the whole system can fail, for quite a few reasons :

• No written procedure meaning no emergency (Saudia Tristar at Riyadh)
• Adherence to the book (Swissair 11)
• The very safe airline environment leading to some sort of complacency
• The relative low experience of to-days airline crews compared to those of just 20 years ago.
• The economy of a flight which promotes system operation as opposed to airmanship....
  ...

This said, SOPs do work and so is CRM and we can't just forget them off-hand.
I guess that is the price of progress and people have accepted that we can't, for reasons of history cover everything...

We have yet to establish that the crew had a good plan – an approach and landing briefing; absence of which might be a significant contribution to the accident.

That plan... No way it could have been a good one : For reasons of weather and visibility, for reasons of a challenging approach, for reasons of the 10 kt-tail wind, for reasons of possible choice (7243kg of remaining fuel, well enough to divert), for reasons of mounting ire against ATC...etc...
There doesn't seem to be any sort of urgency in that cockpit, just an everyday occurrence, and here I join you :

From the above, I suggest that this landing ‘went wrong’ much earlier in the sequence of events than has been discussed.

I put that beginning at the time ( when ?) the decision was made to reject their initial stratedy of "runway 02 if the wind is less than five knots", accepting instead a 10 kt tail wind.
Had they had the same QRH I am using, that attempt at landing would have been a no-no.
Had they made the in-flight computations on *required landing distance*, they would have gone somewhere else (San Pedro, for instance !).
What their assessment was, I don't know, but they had, at that time put the first *unsafe* in their flight.
The second *unsafe*, which is to me incomprehensible is their ceasing the deceleration -as if everything was "normal" - at seventy knots IAS.
The third *unsafe* is the apparent lack of trying to veer off the runway : they went straight down the runway and kept going on the extended centerline. Was the runway surface friction that bad at that point ?

Re the braking: I would not disagree with the logic of your analysis other than to emphasise the assumption about the runway enabling ‘virile’ braking, and that of the assumed touchdown position.

Just guesstimates based on an estimated landing weight (which may prove to be 1 to 2 tons lower than actual as it doesn't include any cargo and my fuel estimation is some 1,200 kg lower than the figure they gave OPS), a strict adherence to Vapp and a touch-down near the markers (otherwise they would have seen the urgency sooner and exited the runway faster).
At least, these figures give some appreciation of what happened.

Regards.

[bubbers44]

Lemurian, Yes the last A320 Taca almost lost off the end of that cliff was I believe in 1999. They spun it around and put it in the ditch between the runway and tha taxiway right before the cliff. I read the report and they landed long and the pilot said the autobrakes didn't work and 500 meters from the end he used manual brakes. Later reports said the brakes failed. I don't know which one is accurate. I didn't think it was possible for a pilot to not use manual brakes on a short runway if auto brakes failed but that is what the report said. Why they chose to land with the 10 knot tailwind wet downhill on a short runway is very hard to understand. Taca has a history of pressing the envelope.

[Lemurian]

Lemurian, Yes the last A320 Taca almost lost off the end of that cliff was I believe in 1999.

Hello,bubbers44.
Can't find any report on that incident on ASN.
Do you have any more details ?

. I didn't think it was possible for a pilot to not use manual brakes on a short runway if auto brakes failed but that is what the report said.

Yep ! Very curious !

Cheers !

[RWA]

Originally Posted by Lemurian

Can't find any report on that incident on ASN.
Do you have any more details?

It was a 'no deaths or injuries, minor damage' incident, Lemurian. Therefore it didn't exactly get the spotlight turned on it. Best (unofficial) account I've seen about it is this:-

"The most recent accident occurred on February 3, 2001. Fortunately no one on board was injured or killed. The TACA Airbus A320, N465(PA/TA), suffered from a reverse thrust malfunction once on the ground. The pilots are to be considered the heroes. Had they not turned the airplane onto the closest taxiway to the end of the runway, they may have gone over the cliff, which is found only 100 ft (30 m) from the end of the runway."

Aviation Articles | Airliners.net

[bubbers44]

RWA just found what I found. Initially the report was the captain went to manual braking with 500 meters remaining. I flew into TGU a few days before they pulled it out of the ditch right before the cliff between the taxiway and runway. The pilot had skidded it around to the left about 150 degrees to keep it from going off the end. I can not find that report now but as RWA said, it was considered an incident, not an accident. Eye witnesses said they landed long. I have had reverser failures landing there and stopped with plenty of runway left. They did quite a bit of maintenance checking for engine FOD and replaced tires. That must have been quite a ride skidding backwards into the ditch probably using forward thrust to stop.

[NVpilot]

You provide a caveat for this landing – ‘I would use manual braking’ – why? What perception (in hindsight), directs this course of action, what’s different about this situation that results in the ‘bending’ of you opinion of the value of auto brake?

This runway and the one in Brazil have no over run, my choice of braking is just part of a technique, the most important aspect is not to select TH/REV until a positive spoiler indication is received, without spoilers you don't have a chance, after T/R's are deployed you are committed.

[kwick]

Thank you alf5071h for the links provided. They are very interesting

In the report Punishing People or Learning from Failure? - Dekker, states:
"Human error was the starting point for Fitts' and Jones' studies—not the conclusion."

Maybe I was missunderstood, and I do not think that I made a final sentence saying that pilot error is "The Cause" of this accident or confirm it was my conclusion. As everyone on this thread, we are all throwing comments and data to try to understand why the whole thing happened. Many guessing ideas and assumptions will be used, for days to come until more data is available, a lot of which we do not have. Then, we will all use the best of our knowledge to provide answers, and possibly help to avoid this thing from happening again (at least, to readers of this thread).

Like Fitts and Jones, and many of us, I think we should all encourage the hunt for deeper, more systemic conditions that lead to consistent trouble. Cutting the links of the accident chains really saves lives. This thread is working great in the hunt.

[safetypee]

bsieker Re Autobrake MAX: (#340)

“ this setting provides maximum possible braking, limited only by anti-skid. If you have to do a landing with such a short landing distance available that it would require autobrake MAX, you would not land there. It would almost certainly severely overheat and damage the brakes and tyres.

Max braking is not the potential disaster that you indicate.
Apart from a max or near max brake-energy RTO, severe brake or tyre damage is unlikely. The use of max braking during normal landings is an allowable option and one which should be encouraged if the runway conditions turn out to be less than anticipated. On wet, very wet, or contaminated runways, max braking will not produce a harsh deceleration (often quoted as another reason not to use max as it ‘upsets’ the cabin).

IMHO there is a danger in making such poorly qualified statements, it enables the information to be stored in memory and consciously or unconsciously used to bias decision making in future events.

Are you implying that the auto brake MAX landing distance would not provide an adequate safety margin (1.67/1.92) for the landing?

Do you have an SOP for braking when landing on a contaminated runway – JAR OPS rules?

[bubbers44]

Max or Med braking doesn't seem important in this accident because if they were reducing max reverse thrust at 70 knots they were at that time satisfied that they didn't need that much reverse thrust any more. No pilot would reduce max reverse thrust at 70 knots if he wasn't sure he could turn off safely. They shouldn't have landed with that 10 knot tailwind but why were they reducing reverse thrust if they didn't know they could stop before the cliff? Would you? I don't think so. I have been in that situation at Reno on ice and the only thing that stopped the aircraft was reverse thrust. Brakes were totally not effective. I used max reverse thrust until taxi speed then idle reverse to clear the runway at the end. Coming out of reverse at 60 knots was when it was obvious we couldn't stop so going back into reverse let us stop. Sometimes it is difficult to know how well the brakes are working until reversers are stowed.