Pilots and ATC both at fault in TCAS incident
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Pilots and ATC both at fault in TCAS incident
Taipei Times - archives
Pilot, controller to blame for air incident, ASC says
FASTEN YOUR SEATBELATS: An investigator said that passengers on an FAT flight experienced something like a rollercoaster ride when their plane took evasive action
By Meggie Lu
STAFF REPORTER
Saturday, Aug 16, 2008, Page 2
The Aviation Safety Council (ASC) yesterday concluded a 21-month investigation of a midair incident over South Korea between Taiwanese and Thai passenger aircraft, and said that both the Taiwanese pilot and the South Korean air traffic controller were at fault.
The incident occurred on Nov. 16, 2006, when Far Eastern Air Transport (FAT) flight EF306, which was flying to South Korea, made an abrupt midair dive in order to avoid another passenger plane, Thai Airways (TA) flight TG659.
The maneuver resulted in 20 passengers and crew suffering injuries, said the ASC’s director of accident investigation, James Fang (方粵強).
Passengers would have been able to avoid injury had they been wearing their seat belts at the time of the plane’s sudden descent, Fang said.
“The near-collision was the result of a chain of events,” said the director of the ASC’s investigation laboratory, Michael Guan.
TOO CLOSE
As the FAT and the TA aircraft were too close to each other, the traffic advisory (TA) signal on both planes was triggered, Guan said.
At about this time, the controller at Incheon International Airport made several vital mistakes.
Initially he gave flight EF306 contradictory instructions and then referred to the plane as “EF308,” Guan said.
“The controller later said that because he was busy trying to find a plane that had disappeared off his radar screen, and since he was the only person tracking both incidents, his hands were tied,” he said.
Without clarifying the instruction, and with the auto-pilot turned off in response to the TA signal, the FAT pilot, upon seeing the resolution advisory alarm triggered, failed to obey the traffic collision advisory system (TCAS) on his plane and put the aircraft into a nosedive, Guan said.
“Making a decision based solely on visual data is against protocol … the pilot later claimed that he had seen a shadow above him, which was why he descended, however later analysis confirmed that there was no object near his plane; he should have followed TCAS advice and gradually descended,” he said.
Though the pilot only dipped the plane for four seconds, the aircraft plummeted a total of 2,400 feet (730m) in 17 seconds because of the acceleration, he said.
To the passengers inside the plane, the experience was similar to riding a rollercoaster, he said.
To avoid future aviation safety mishaps, the ASC has formulated several guidelines.
STAFF LEVELS
The council suggested that Incheon International Airport increase staff levels at its air traffic control center, that pilots as well as controllers use professional language when communicating and that the public be made aware of the importance of wearing seat belts during flights.
“In many air accidents we found that those passengers who were injured almost always did not have their seat belts on, whereas those who wore seatbelts had a much better chance of coming out uninjured,” he said.
Pilot, controller to blame for air incident, ASC says
FASTEN YOUR SEATBELATS: An investigator said that passengers on an FAT flight experienced something like a rollercoaster ride when their plane took evasive action
By Meggie Lu
STAFF REPORTER
Saturday, Aug 16, 2008, Page 2
The Aviation Safety Council (ASC) yesterday concluded a 21-month investigation of a midair incident over South Korea between Taiwanese and Thai passenger aircraft, and said that both the Taiwanese pilot and the South Korean air traffic controller were at fault.
The incident occurred on Nov. 16, 2006, when Far Eastern Air Transport (FAT) flight EF306, which was flying to South Korea, made an abrupt midair dive in order to avoid another passenger plane, Thai Airways (TA) flight TG659.
The maneuver resulted in 20 passengers and crew suffering injuries, said the ASC’s director of accident investigation, James Fang (方粵強).
Passengers would have been able to avoid injury had they been wearing their seat belts at the time of the plane’s sudden descent, Fang said.
“The near-collision was the result of a chain of events,” said the director of the ASC’s investigation laboratory, Michael Guan.
TOO CLOSE
As the FAT and the TA aircraft were too close to each other, the traffic advisory (TA) signal on both planes was triggered, Guan said.
At about this time, the controller at Incheon International Airport made several vital mistakes.
Initially he gave flight EF306 contradictory instructions and then referred to the plane as “EF308,” Guan said.
“The controller later said that because he was busy trying to find a plane that had disappeared off his radar screen, and since he was the only person tracking both incidents, his hands were tied,” he said.
Without clarifying the instruction, and with the auto-pilot turned off in response to the TA signal, the FAT pilot, upon seeing the resolution advisory alarm triggered, failed to obey the traffic collision advisory system (TCAS) on his plane and put the aircraft into a nosedive, Guan said.
“Making a decision based solely on visual data is against protocol … the pilot later claimed that he had seen a shadow above him, which was why he descended, however later analysis confirmed that there was no object near his plane; he should have followed TCAS advice and gradually descended,” he said.
Though the pilot only dipped the plane for four seconds, the aircraft plummeted a total of 2,400 feet (730m) in 17 seconds because of the acceleration, he said.
To the passengers inside the plane, the experience was similar to riding a rollercoaster, he said.
To avoid future aviation safety mishaps, the ASC has formulated several guidelines.
STAFF LEVELS
The council suggested that Incheon International Airport increase staff levels at its air traffic control center, that pilots as well as controllers use professional language when communicating and that the public be made aware of the importance of wearing seat belts during flights.
“In many air accidents we found that those passengers who were injured almost always did not have their seat belts on, whereas those who wore seatbelts had a much better chance of coming out uninjured,” he said.
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It seems to be a belief among more than a few pilots that an RA requires an extremely aggressive action to avoid a collision. It does not. If you get an RA to descend like this pilot did, do a basically normal although purposeful descent placing the VSI needle in the range where you are being directed to do so. It is a 1/4 g manouver. In other words if you were at 1g like normal, the manouver for descent will initially have you at 3/4g. People should not be floating in air.
It seems to be a belief among more than a few pilots that an RA requires an extremely aggressive action to avoid a collision.
Some carriers have used their FDA Programs intelligently by actually doing studies on crew TCAS responses. The data on crew response is enlightening to say the least. No.1 error was responding incorrectly to negative RA's, (don't climb nnnn fpm, don't descend nnnn fpm, maintain nnnn fpm etc). Interpreting the "fly to" commands ("maintain vert spd" especially if one was in the red area) was next and the largest "contributing" factor was leaving the flight directors ON (Airbus fleet types). Most noted errors in correct responses was "too aggressive" - overshooting altitudes, exceeding vertical speed requirements and by virtue of that, exceeding 'g' levels required.
So it isn't only ignoring ATC instructions to climb or descend that is the issue in TCAS responses. Crews are mis-interpreting commands, not turning f/d's off on Airbus and responding too aggressively.
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Another Side of the Story
TCAS Resolution Advisory (RA)
Our Company’s procedures for a TCAS RA are identical to Airbus’s procedures to my knowledge, and that is:
AUTOPILOT –-------------- OFF
BOTH FLIGHT DIRECTORS -- OFF
VERTICAL SPEED –--------- ADJUST TO THE GREEN (promptly & smoothly)
Note: Avoid excessive maneuvers ....
Apparently the TCAS systems are designed to give the pilot(s) 5 seconds to respond to a primary RA (Resolution Advisory) which is carried out only in the vertical plane (eg no turns). In the unlikely event of a secondary TCAS RA occurs (you’re diving or climbing into the path of a third aircraft) while carrying out the first RA maneuver (nightmare scenario) the pilots have 2 1/5 seconds to respond correctly to the secondary RA.
5 seconds is a fairly long time so there is no need to rush it, but also there is no time to sit on your hands either. Just a normal disconnect of the A/P and F/Ds - OFF then push or pull gently in the direction that TCAS is directing. TCAS events should be part of every simulator training and license renewal, but unfortunately they are not. If they were, then line pilots would not get startled at an occasional real world RA occurrence and possibly overreact.
Granted, if an RA occurs and at that same instant you fly under a dark cloud that shadows the flight deck and the unexpected combination sends a chill up your backside, thinking another aircraft is descending onto the flight deck from above, you might over-react and shove a bit too fast and too hard on the yoke or side stick. That’s a natural human adrenalin response to fear invoking situations. (P.S. Pilots are human too.)
The quick abrupt response of the Taiwanese pilot would have been correct and would have saved lives if there really was an aircraft present and descending onto his flight deck from above, but the identical same pilot actions are easily criticized by the Media, Management, Safety Review Boards, etc, if there was no other aircraft; just the perception of one.
In my early days of flying, I climbed out of a small uncontrolled airport with no radar coverage and well before TCAS was invented. During climb passing 3500’ a sudden shadow above the aircraft caused me to look up abruptly through the eyebrow windows to see the underbelly of another aircraft a few meters above us. The other aircraft had flown overhead the airport without seeing us taking off below because we were below his line of sight over the glare shield. We did not see him because he was above and behind us.
Only my quick abrupt response of pushing the nose down and pulling off power avoided a mid-air collision, but all onboard floated up against their seat belts with the negative g's produced. The two aircraft could only have missed one another by a few feet. And yes everyone thankfully had their seat belts fastened so no one got hurt.
It’s easy to throw stones at pilots that have to make split second decisions during a “oh-sh*t” moment, but that’s why we get paid the big bucks (or the little bucks as the case may be). Our lives and the lives of the crew and passengers depend upon the pilot’s quick reflexes tempered with experience and training.
Be that as it may, if no one had gotten hurt in the TCAS RA event executed exactly as the Taiwanese pilot referred in the primary article did, then the ASC investigation, if any at all, would have centered on the Inchon ATC under-staffing, or inattention due to overloading in his sector, or lack of procedures, or lack of supervisory oversight, that contributed to the circumstances that produced two aircraft at the same level and then giving contradictory ATC instructions using the wrong call-sign numbers.
Seatbelts fastened make a heck of a lot of difference to outcomes under such unexpected circumstances.
I hasten to add that the Cabin Crew working the cabin and galleys would have still been vulnerable to injury even if all passengers had been belted in, and therefore, such abrupt maneuvers must be avoided as much as possible in airline operations.
That’s another side of the story to consider. Cheers, Magnet77
Our Company’s procedures for a TCAS RA are identical to Airbus’s procedures to my knowledge, and that is:
AUTOPILOT –-------------- OFF
BOTH FLIGHT DIRECTORS -- OFF
VERTICAL SPEED –--------- ADJUST TO THE GREEN (promptly & smoothly)
Note: Avoid excessive maneuvers ....
Apparently the TCAS systems are designed to give the pilot(s) 5 seconds to respond to a primary RA (Resolution Advisory) which is carried out only in the vertical plane (eg no turns). In the unlikely event of a secondary TCAS RA occurs (you’re diving or climbing into the path of a third aircraft) while carrying out the first RA maneuver (nightmare scenario) the pilots have 2 1/5 seconds to respond correctly to the secondary RA.
5 seconds is a fairly long time so there is no need to rush it, but also there is no time to sit on your hands either. Just a normal disconnect of the A/P and F/Ds - OFF then push or pull gently in the direction that TCAS is directing. TCAS events should be part of every simulator training and license renewal, but unfortunately they are not. If they were, then line pilots would not get startled at an occasional real world RA occurrence and possibly overreact.
Granted, if an RA occurs and at that same instant you fly under a dark cloud that shadows the flight deck and the unexpected combination sends a chill up your backside, thinking another aircraft is descending onto the flight deck from above, you might over-react and shove a bit too fast and too hard on the yoke or side stick. That’s a natural human adrenalin response to fear invoking situations. (P.S. Pilots are human too.)
The quick abrupt response of the Taiwanese pilot would have been correct and would have saved lives if there really was an aircraft present and descending onto his flight deck from above, but the identical same pilot actions are easily criticized by the Media, Management, Safety Review Boards, etc, if there was no other aircraft; just the perception of one.
In my early days of flying, I climbed out of a small uncontrolled airport with no radar coverage and well before TCAS was invented. During climb passing 3500’ a sudden shadow above the aircraft caused me to look up abruptly through the eyebrow windows to see the underbelly of another aircraft a few meters above us. The other aircraft had flown overhead the airport without seeing us taking off below because we were below his line of sight over the glare shield. We did not see him because he was above and behind us.
Only my quick abrupt response of pushing the nose down and pulling off power avoided a mid-air collision, but all onboard floated up against their seat belts with the negative g's produced. The two aircraft could only have missed one another by a few feet. And yes everyone thankfully had their seat belts fastened so no one got hurt.
It’s easy to throw stones at pilots that have to make split second decisions during a “oh-sh*t” moment, but that’s why we get paid the big bucks (or the little bucks as the case may be). Our lives and the lives of the crew and passengers depend upon the pilot’s quick reflexes tempered with experience and training.
Be that as it may, if no one had gotten hurt in the TCAS RA event executed exactly as the Taiwanese pilot referred in the primary article did, then the ASC investigation, if any at all, would have centered on the Inchon ATC under-staffing, or inattention due to overloading in his sector, or lack of procedures, or lack of supervisory oversight, that contributed to the circumstances that produced two aircraft at the same level and then giving contradictory ATC instructions using the wrong call-sign numbers.
Seatbelts fastened make a heck of a lot of difference to outcomes under such unexpected circumstances.
I hasten to add that the Cabin Crew working the cabin and galleys would have still been vulnerable to injury even if all passengers had been belted in, and therefore, such abrupt maneuvers must be avoided as much as possible in airline operations.
That’s another side of the story to consider. Cheers, Magnet77
Last edited by Magnet77; 18th Aug 2008 at 11:13.
AUTOPILOT –-------------- OFF
BOTH FLIGHT DIRECTORS -- OFF
VERTICAL SPEED –--------- ADJUST TO THE GREEN (promptly & smoothly
BOTH FLIGHT DIRECTORS -- OFF
VERTICAL SPEED –--------- ADJUST TO THE GREEN (promptly & smoothly
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Ah, fair question....ON the Airbus (319 anyway), the FD are intrinsically linked to the autothrottle. So assuming a high rate climb, and then a Descend TCAS RA, if you ignored the FD on an Airbus, disconnected the AP and pushed down the FD would still be commanding a climb, the autothrust would follow the FD and command CLB thrust and you would dive away from the RA with climb thrust set, the Thrust would Lock to climb (so even closing the thrust levers would not close the thrust). So, there would be a massive risk of an overspeed (despite the aircraft attempting to protect itself it would still overspeed). The only get out woud be to both disconnect the A/T and close them, this is not a normal Airbus manouver as the natural inclination is to leave the A/T on. So with Airbus, switching the FD off removes the link between FD and A/T, so diving away and closing the thrust would work normally. Does that make sense? (I refer only to my explanation and not to why the Airbus works this way 
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FD's OFF on Airbus
Quote from Centaurus #6
“I don't know about the Airbus types but why the urgency to switch off the FD? It takes a finite time to click off the autopilot and get cracking on the avoidance and at least 2-3 seconds for the PF to lift a hand to switch off both FD.”
Great question and observation Centaurus. From your comments, you are not familiar with the Airbus models so I will give a few general tidbits for you to consider, having flown both manufacturers and currently flying the A330.
On Boeing aircraft, generally, when you disconnect the Autopilot (AP), you must also disconnect the Auto Thrust (A/T) and should likewise turn the Flight Directors (FDs) OFF. A lot of pilots simply look through the FDs on the Boeing and ‘fly the airplane.’ So, when manually flying the Boeing models (disconnecting the AP), the thrust should also be disconnected (manual) as well. However, on Airbus models and by Airbus procedure, the A/T is left engaged even with the AP disconnected. The A/T does a great job of looking after the thrust and speed for the pilot.
As pointed out above by DeeTee, on Airbus, the thrust settings will follow the FDs if left engaged during a TCAS maneuver and create all manner of havoc, so the FDs are turned off procedurally along with the AP OFF.
The way I wrote would lead you to the conclusion that you drew, but actually the whole TCAS RA procedure happens simultaneously and takes only a few seconds at best. Your point about the time it takes to turn off the FDs is not an issue because the PF is doing it all simultaneously with disconnecting the AP and beginning the pitch movement as the PNF is turning off both FDs, (unless the PF instinctively reaches up and turns his own FD off).
At any rate, this Airbus procedure did not figure into the incident at Inchon, so the pilot apparently followed the Airbus procedure, albeit too abruptly for those in the cabin without seatbelts attached.
I hope this answers your question. Regards, Magnet77
“I don't know about the Airbus types but why the urgency to switch off the FD? It takes a finite time to click off the autopilot and get cracking on the avoidance and at least 2-3 seconds for the PF to lift a hand to switch off both FD.”
Great question and observation Centaurus. From your comments, you are not familiar with the Airbus models so I will give a few general tidbits for you to consider, having flown both manufacturers and currently flying the A330.
On Boeing aircraft, generally, when you disconnect the Autopilot (AP), you must also disconnect the Auto Thrust (A/T) and should likewise turn the Flight Directors (FDs) OFF. A lot of pilots simply look through the FDs on the Boeing and ‘fly the airplane.’ So, when manually flying the Boeing models (disconnecting the AP), the thrust should also be disconnected (manual) as well. However, on Airbus models and by Airbus procedure, the A/T is left engaged even with the AP disconnected. The A/T does a great job of looking after the thrust and speed for the pilot.
As pointed out above by DeeTee, on Airbus, the thrust settings will follow the FDs if left engaged during a TCAS maneuver and create all manner of havoc, so the FDs are turned off procedurally along with the AP OFF.
The way I wrote would lead you to the conclusion that you drew, but actually the whole TCAS RA procedure happens simultaneously and takes only a few seconds at best. Your point about the time it takes to turn off the FDs is not an issue because the PF is doing it all simultaneously with disconnecting the AP and beginning the pitch movement as the PNF is turning off both FDs, (unless the PF instinctively reaches up and turns his own FD off).
At any rate, this Airbus procedure did not figure into the incident at Inchon, so the pilot apparently followed the Airbus procedure, albeit too abruptly for those in the cabin without seatbelts attached.
I hope this answers your question. Regards, Magnet77
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I've always understood that you have 5 seconds to respond to an RA and 2.5 seconds to the reversal of that manoeuvre.
Remember, commercial air transport aircraft only certified to +2.5/-1.0 G Clean.
Remember, commercial air transport aircraft only certified to +2.5/-1.0 G Clean.
I was told in a SIM once that in response to a TCAS RA, the ROC/D relates to the Mach No as follows: At M0.7, a 1° change in pitch will result in a 700fpm vertical speed change (up or down). It works.
I am not suggesting that one looks particularly at the Mach to decide how much to pull or push when an RA occurs, but this does illustrate just how little a pitch change is required to satisfy an RA.
Secondly, the comments on the aircraft systems and in particular the Airbus FDs are interesting. In the 717, the FD bars automatically disappear when an RA occurs and pop back on when the RA goes away. I wonder why that hasn't been put into the AB (with concurrent suitable auto-throttle mode change)?
I am not suggesting that one looks particularly at the Mach to decide how much to pull or push when an RA occurs, but this does illustrate just how little a pitch change is required to satisfy an RA.
Secondly, the comments on the aircraft systems and in particular the Airbus FDs are interesting. In the 717, the FD bars automatically disappear when an RA occurs and pop back on when the RA goes away. I wonder why that hasn't been put into the AB (with concurrent suitable auto-throttle mode change)?
As a controls engineer I was wondering the same as Capn Bloggs about automatic disconnection of AT and FDs under these circumstances. Are there any situations in which you'd want the AT and FDs left ON during an RA (given their apparent 'interference' with your avoidance actions)?
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We get a special FD symbol which is red and as soon as you follow it, it turns green. So you keep the airplane in the green and everythings fine.
But that is just a Cessna (C680 Sovereign)
But that is just a Cessna (C680 Sovereign)
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It seems to be a belief among more than a few pilots that an RA requires an extremely aggressive action to avoid a collision. It does not.
I've always understood that you have 5 seconds to respond to an RA and 2.5 seconds to the reversal of that manoeuvre.
it may be an agressive maneuver.
We get a special FD symbol which is red and as soon as you follow it, it turns green. So you keep the airplane in the green and everythings fine.
But that is just a Cessna (C680 Sovereign)
But that is just a Cessna (C680 Sovereign)
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Airbus is looking at the autopilot following RAs automatically. That would be good.
When I suggested this during an IFALPA ATS Committee meeting some 3 years ago, there was not a single member around to support the idea, most were absolutely against in fact.
But when we look at all the serious TCAS incidents post Ueberlingen , the vast majority occurred in the upper airspace , and all without exception would have been solved should the RAs had been linked to the AP.
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My guess is the pilot community would feel they become obsolete.
On the other hand if someone was flying his plane by hand (lower down) this could cause confusion as what to do...?
Best thing for the moment now IMO is to just keep pilots trained and informed!
On the other hand if someone was flying his plane by hand (lower down) this could cause confusion as what to do...?
Best thing for the moment now IMO is to just keep pilots trained and informed!
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Indeed, I am now also convinced that this is the solution and that it would be a good thing.
What we need is the current recommended practices to be correctly trained on a world wide basis. Collectively, the industry can't be bothered to go to the (very modest) expense of doing so. As a result we have 'one size fits all' dogma about how TCAS should be used, rather than a proper understanding of its strengths and weaknesses, in a significant proportion of the industry. So we have dumb incidents happening, which people think can be solved by yet more automation.
The existing equipment and training recommendations are fit for purpose. We just need to use them.
pb
Sorry Capt Pit Bull, I don't understand, why wouldn't automation solve the problem?
(I'm making the assumption that we're talking about two TCAS equipped a/c. I realise that if one isn't suitably equipped or isn't using the equipment, then it's effectively useless).
(I'm making the assumption that we're talking about two TCAS equipped a/c. I realise that if one isn't suitably equipped or isn't using the equipment, then it's effectively useless).
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[QUOTE=SNS3Guppy;4336348]Not necessarily. Fly what's commanded, and it may be an agressive maneuver. What's required really depends on the conflict.
Necessarily..... for an initial RA, if you fly what is commanded. Some seem to believe that a strong high G pullup or low G pushover is required. All they are doing his risking injury to pax.
From a Honeywell manual about their TCAS operation...
"A typical TCAS II maneuver requires crew response to the initial RA within 5 seconds and G-forces of ± .25 G.This force is similar to that experienced when initiating an enroute climb or descent."
On page 24 of this link.
http://www.sisadminov.net/tcas/docs/...pilotguide.pdf
Necessarily..... for an initial RA, if you fly what is commanded. Some seem to believe that a strong high G pullup or low G pushover is required. All they are doing his risking injury to pax.
From a Honeywell manual about their TCAS operation...
"A typical TCAS II maneuver requires crew response to the initial RA within 5 seconds and G-forces of ± .25 G.This force is similar to that experienced when initiating an enroute climb or descent."
On page 24 of this link.
http://www.sisadminov.net/tcas/docs/...pilotguide.pdf
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Autopilot carrying out a TCAS RA
... Airbus is looking at the autopilot following RAs automatically. That would be good.
I guess you could always disconnect the autopilot if it was leading you up the garden path, but I personally would prefer to retain the control and take decisive action. Shades of the old "Spam in a can" aversion of the astronauts in "The Right Stuff" of yore, refusing to fly in a capsule without a window and no pilot controls. The engineers lost that battle and good thing they did. The moon landing in July 1969 would have ended in disaster if Neil Armstrong had not taken over from the computers and landed the craft safely.
Computers are not afraid of dieing - pilots are. That gives the pilot's survival instinct the winning hand in almost all situations. A pilot's desire to live has gotten aviation to where it is today, albeit with a few pilot errors along the way. For the most part, pilots are the Captains of the most safe form of transportation known to man. There are no other forms of transportation even close to the safety record of commercial aviation.
Just increase the mandated pilot training for TCAS events during simulators and leave the autopilot out of the equation. That's my two bob worth. Cheers