Bad Airmanship
Lots of theories as to why this would happen and what could have prevented it BUT ... we used to show a video during recurrent CFIT training of a 47 Classic (two pilots AND A FLIGHT ENGINEER) who misheard, and accepted, a clearance on a Non Precision approach to 400feet (instead of "cleared 2400 feet") and sat, fat, dumb and happy through EIGHT GPWS "Pull up" calls with no reaction and the last recorded remark before impact was ... "Oh ****". Combined crew flying hours totalled many thousands. 
So ... any more helpful ideas as to how to prevent people doing what people have always done and will continue to do? 
There is one which hasn't yet been mentioned and which will NEVER happen - institute an Aircraft Commander - an experienced type-qualified pilot on the jump seat who has no part in the physical flying of the aircraft but who is in overall command. NOTHING concentrates the mind in Flight Safety terms, as regards self-preservation, more than being responsible but NOT having control.
So ... any more helpful ideas as to how to prevent people doing what people have always done and will continue to do? There is one which hasn't yet been mentioned and which will NEVER happen - institute an Aircraft Commander - an experienced type-qualified pilot on the jump seat who has no part in the physical flying of the aircraft but who is in overall command. NOTHING concentrates the mind in Flight Safety terms, as regards self-preservation, more than being responsible but NOT having control.
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Yep ..I remember reading with horror about that Non prevision/non full procedure/modified by the crew to a straight in approach accident.
Correct me if I am wrong but was it not a long haul crew asked to do a ultra short empty positioning flight after a long haul day/night?
The all American crew on this flight and the all American crew of the AA B767
accident who also decided to modify a full procedure Non Precision approach into an attempted straight approach accident...
Plus the GF 320 Airbus accident which had 3 Arabic pilots in the cockpit also attempted to modify a full Non precision approach into a straight in accident all goes to prove the aircraft is no respect-or of nationalities and an unhurried full
procedures Non precision approach flown according to the approach plate can keep pilots out of a lot of trouble...and aircraft warnings and ATC high workload confusions largely avoided.
This gear up/ flap less incident picture reminds me of a Dan Air Comet that I saw at Newcastle similarly configured...I was told 22 qualified Comet pilots and the CAA pilots were on that "training flight". Fate is the hunter.
Correct me if I am wrong but was it not a long haul crew asked to do a ultra short empty positioning flight after a long haul day/night?
The all American crew on this flight and the all American crew of the AA B767
accident who also decided to modify a full procedure Non Precision approach into an attempted straight approach accident...
Plus the GF 320 Airbus accident which had 3 Arabic pilots in the cockpit also attempted to modify a full Non precision approach into a straight in accident all goes to prove the aircraft is no respect-or of nationalities and an unhurried full
procedures Non precision approach flown according to the approach plate can keep pilots out of a lot of trouble...and aircraft warnings and ATC high workload confusions largely avoided.
This gear up/ flap less incident picture reminds me of a Dan Air Comet that I saw at Newcastle similarly configured...I was told 22 qualified Comet pilots and the CAA pilots were on that "training flight". Fate is the hunter.
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Lots of theories as to why this would happen and what could have prevented it BUT ... we used to show a video during recurrent CFIT training of a 47 Classic (two pilots AND A FLIGHT ENGINEER) who misheard, and accepted, a clearance on a Non Precision approach to 400feet (instead of "cleared 2400 feet") and sat, fat, dumb and happy through EIGHT GPWS "Pull up" calls with no reaction and the last recorded remark before impact was ... "Oh ****". Combined crew flying hours totalled many thousands.
On February 19, 1989, a Boeing 747-249F operating as Flying Tiger Flight 66 was flying an Non-directional beacon (NDB) approach to Runway 33 at Sultan Abdul Aziz Shah Airport, Kuala Lumpur, after having flown half an hour from an airport in Singapore. In descent, the flight was cleared to "Kayell" with a morse code of "KL" of which four separate points on the ground were commonly called by Malaysian ATC albeit with different frequencies. Two separate radio beacons where identically coded "KL" as well as the VOR abbreviation (Kuala Lumpur shortened to "KL") and the airport was also sometimes referred to as "KL" by local ATC (instead of the full "Kuala Lumpur"). The crew was unsure of which point they were cleared to. ATC then radioed to the flight, "Tiger 66, descend two four zero zero [2,400 ft]. Cleared for NDB approach runway three three." The captain of Tiger 66, who heard "descend to four zero zero" replied with, "Okay, four zero zero" (meaning 400 ft above sea level, which was 2,000 ft too low). Subsequent warnings triggered by the onboard Ground Proximity Warning System were cancelled as false alarms, and the aircraft hit a hillside 600 ft above sea level, killing all four people on board. The proper radio call from ATC, instead of "descend two four zero zero", should have been "descend and maintain two thousand four hundred feet". The First Officer had complained that he did not have an approach plate. The second officer was 70 years old and used a magnifying glass to see with. This accident created the GPWS escape maneuver which all airlines now use. The probable cause was the non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions.[1]
To the list of ad hoc modified NDB approaches that became CFITs can be added the Canadian Forces C-130 that flew into high terrain approaching Alert in 1991.
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Tiger 66 Malasian ATC's fault - I don't buy it for a second.
Dave Clark Fife.
I take issue with this statement of yours: “The probable cause was the non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions”. I followed your link; and don’t believe what Wikipedia and the Aviation Safety Network have the final say on cause. It would be similar to saying the KLM-Pan Am Tenerife accident was caused by “antiquated tower/ATC equipment”. Well yes there is an element of truth in that statement, but to walk away believing ATC was the only cause is to miss much of what that accident can teach the aviation community.
Tiger 66 taught me to pay attention to the NOTAMS and the paperwork. The ILS was NOTAMED out of service. The captain and crew set up and briefed (poorly) an ILS that was not available to them and never was.
When Malasian ATC corrects them that the approach in use is an NDB approach not the ILS they have some non-complimentary comments regarding the ATC specialist’s family origins. Being an U.S. citizen I find myself as patriotic, flag waving and pro-American as most. However pinning Tiger 66’s demise on Malasian ATC offends my even greater commitment to the “truth”.
It’s not the Malasian ATC controller’s fault that English uses “To”, “Too”, and “Two”. The clearance was to descend to 2400; the captain and FO responded descend “to” 400. So yes there are some phraseology problems. Notice the FAA changed the read back/hear correctly rule about two years ago. Now if you misunderstand and read back the incorrect clearance, and ATC does not catch your error, the fault lies with the pilots (not ATC).
And then there is the little matter of descending down to 400’ to intercept. You and I know an ILS will take you down to about 200’. What non-precision NDB approach in SE Asia would you intercept at 400’? Further, whose responsibility is it to have situational awareness concerning airport elevation, and surrounding terrain when you are running around the clouds close to the ground in a Boeing 747? I would be looking at the people in the left and right front seat (and on the panel). 400’ AGL for an intercept to a non-precision NDB approach does not pass the “reasonability” test! Most/many MDA’s on NDB approaches are above 400’. If memory serves me correctly they crashed into a 600’ +/- hill a few miles short of the runway. Using a 3:1 ratio if you are at 600’ (about where they died) you should be somewhere around 1.8 NM from the airport – they were so far out of those parameters it should have made the hair on the back of their necks stand out. In fact it did.
Listen/read what the FO is saying during the time leading up to this accident. He is extremely uncomfortable with how the flight is progressing. He is hinting/questioning clearances and is out of his comfort zone. The Captain doesn’t seem to really care and seems to ignore his partner’s obvious discomfort.
And then there is the matter of the ground proximity alerter issuing warnings. Warnings ignored. “Wait we are at 200’ RA” (words to that affect) !!@$%##!!! – Bang and it is over. I think the wreckage burned for 2 or more days.
FlightSafety has a good analysis of this accident. I have spent many hours going over the material for my own education. This accident taught me to read and understand the NOTAMS, pay attention to my crew members and the importance of keeping situational awareness. Unfortunately none of those are anything new in aviation. In this case 4 people died in the jet. To infer that they died because an Malasian ATC specialist used non-standard phraseology is to miss the vastly more important lessons that cry to be learned from this accident. And I don’t care what Wikipedia says.
I take issue with this statement of yours: “The probable cause was the non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions”. I followed your link; and don’t believe what Wikipedia and the Aviation Safety Network have the final say on cause. It would be similar to saying the KLM-Pan Am Tenerife accident was caused by “antiquated tower/ATC equipment”. Well yes there is an element of truth in that statement, but to walk away believing ATC was the only cause is to miss much of what that accident can teach the aviation community.
Tiger 66 taught me to pay attention to the NOTAMS and the paperwork. The ILS was NOTAMED out of service. The captain and crew set up and briefed (poorly) an ILS that was not available to them and never was.
When Malasian ATC corrects them that the approach in use is an NDB approach not the ILS they have some non-complimentary comments regarding the ATC specialist’s family origins. Being an U.S. citizen I find myself as patriotic, flag waving and pro-American as most. However pinning Tiger 66’s demise on Malasian ATC offends my even greater commitment to the “truth”.
It’s not the Malasian ATC controller’s fault that English uses “To”, “Too”, and “Two”. The clearance was to descend to 2400; the captain and FO responded descend “to” 400. So yes there are some phraseology problems. Notice the FAA changed the read back/hear correctly rule about two years ago. Now if you misunderstand and read back the incorrect clearance, and ATC does not catch your error, the fault lies with the pilots (not ATC).
And then there is the little matter of descending down to 400’ to intercept. You and I know an ILS will take you down to about 200’. What non-precision NDB approach in SE Asia would you intercept at 400’? Further, whose responsibility is it to have situational awareness concerning airport elevation, and surrounding terrain when you are running around the clouds close to the ground in a Boeing 747? I would be looking at the people in the left and right front seat (and on the panel). 400’ AGL for an intercept to a non-precision NDB approach does not pass the “reasonability” test! Most/many MDA’s on NDB approaches are above 400’. If memory serves me correctly they crashed into a 600’ +/- hill a few miles short of the runway. Using a 3:1 ratio if you are at 600’ (about where they died) you should be somewhere around 1.8 NM from the airport – they were so far out of those parameters it should have made the hair on the back of their necks stand out. In fact it did.
Listen/read what the FO is saying during the time leading up to this accident. He is extremely uncomfortable with how the flight is progressing. He is hinting/questioning clearances and is out of his comfort zone. The Captain doesn’t seem to really care and seems to ignore his partner’s obvious discomfort.
And then there is the matter of the ground proximity alerter issuing warnings. Warnings ignored. “Wait we are at 200’ RA” (words to that affect) !!@$%##!!! – Bang and it is over. I think the wreckage burned for 2 or more days.
FlightSafety has a good analysis of this accident. I have spent many hours going over the material for my own education. This accident taught me to read and understand the NOTAMS, pay attention to my crew members and the importance of keeping situational awareness. Unfortunately none of those are anything new in aviation. In this case 4 people died in the jet. To infer that they died because an Malasian ATC specialist used non-standard phraseology is to miss the vastly more important lessons that cry to be learned from this accident. And I don’t care what Wikipedia says.
Last edited by Northbeach; 30th Mar 2010 at 15:51. Reason: My error Malasia not Indonesia
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Too Low - Gear
An early poster suggested that if the "Too Low; Gear" warning had been in Spanish, the accident might have been averted.
Surely there is a simpler solution. "Too Low; Gear" and "Too low: Flap" both have the same number of syllables. In years past, the RAF determined an unmistakeable instruction from the bomb aimer. To turn to port, the command was "Left, Left" ie two syllables. To turn to starboard, the command was "Right," just one syllable.
Why not change the warnings to: "Too Low, Flap" and "Too Low, Landing Gear." The disparate number of syllables should then alert the ICAO Level 2 English speaker to the imminent danger!
Remember, ICAO Level 4 is only a requirement for international flights.
Surely there is a simpler solution. "Too Low; Gear" and "Too low: Flap" both have the same number of syllables. In years past, the RAF determined an unmistakeable instruction from the bomb aimer. To turn to port, the command was "Left, Left" ie two syllables. To turn to starboard, the command was "Right," just one syllable.
Why not change the warnings to: "Too Low, Flap" and "Too Low, Landing Gear." The disparate number of syllables should then alert the ICAO Level 2 English speaker to the imminent danger!
Remember, ICAO Level 4 is only a requirement for international flights.
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Red on Blue ???
Minor(?) nitpick, Northbeach ...
Kuala Lumpur is in Malaysia, north of Singapore, while Indonesia is South ...
Not that that negates the rest of your argument ...
Kuala Lumpur is in Malaysia, north of Singapore, while Indonesia is South ...
Not that that negates the rest of your argument ...
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I find it difficult to believe that nobody in the tower looks out of the window at landing aircraft to see that three greens are what the drivers should be seeing.
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Dave Clark Fife.
I take issue with this statement of yours: “The probable cause was the non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions”. I followed your link; and don’t believe what Wikipedia and the Aviation Safety Network have the final say on cause. It would be similar to saying the KLM-Pan Am Tenerife accident was caused by “fog”. Well yes there is an element of truth in that statement, but to walk away believing fog was the only cause is to miss much of what that accident can teach the aviation community.
I take issue with this statement of yours: “The probable cause was the non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions”. I followed your link; and don’t believe what Wikipedia and the Aviation Safety Network have the final say on cause. It would be similar to saying the KLM-Pan Am Tenerife accident was caused by “fog”. Well yes there is an element of truth in that statement, but to walk away believing fog was the only cause is to miss much of what that accident can teach the aviation community.
[/quote]And I don’t care what Wikipedia says.[/quote]
So why bother haranguing me then??
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Flight Detent writes:
Is it the case that, following the realization that a flapless landing will be necessary, that the crew cannot disable the "TO LOW FLAP" GPWS aural warning?
This is 'normally' done during the non-normal checklist as a result of the malfunction, is it not?
I would bet that, had the "TO LOW FLAP" GPWS warning been inhibited, the gear warning "TO LOW GEAR" would have been the trigger to do something!
Is it the case that, following the realization that a flapless landing will be necessary, that the crew cannot disable the "TO LOW FLAP" GPWS aural warning?
This is 'normally' done during the non-normal checklist as a result of the malfunction, is it not?
I would bet that, had the "TO LOW FLAP" GPWS warning been inhibited, the gear warning "TO LOW GEAR" would have been the trigger to do something!
It strikes me as poor engineering if the crew would be unable to dismiss a "nag" once the problem had been understood and dealt with.
During approach to Barcelona at an altitude of about 3500 feet the flaps lever was selected to 8 degrees, the flaps however remained in their retracted position and a FLAPS FAIL message was generated at the Engine Indication and Crew Alerting System (EICAS). The crew subsequently communicated with ATC that they needed a higher landing speed of about 170 KIAS, but needed no emergency services, the tower stating 3352 meters of runway were available on 25R.
The EGPWS on board however began to to produce aural alerts "TOO LOW, Minimums", "TOO LOW GEAR", "TOO LOW TERRAIN", "SINKRATE" and "DISAGREE GEAR". The warning "TOO LOW GEAR" was repeated 15 times. Two minutes prior to touch down the gear unsafe horn starts to sound and continues until after ground contact.
Neptunus Rex writes:
Why not change the warnings to: "Too Low, Flap" and "Too Low, Landing Gear." The disparate number of syllables should then alert the ICAO Level 2 English speaker to the imminent danger!
Remember, ICAO Level 4 is only a requirement for international flights.
Why not change the warnings to: "Too Low, Flap" and "Too Low, Landing Gear." The disparate number of syllables should then alert the ICAO Level 2 English speaker to the imminent danger!
Remember, ICAO Level 4 is only a requirement for international flights.
Quick question: Level 4 is only required for int'l flights, but how much proficiency training/testing is done for "talking" cockpits?
Another quick question:
Two minutes prior to touch down the gear unsafe horn starts to sound
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The shut up gringo incident/accident cos it was a very serious one I recall was Avianca not the other AA
PB
PB
However, the published CVR transcript has no mention of the legendary last words:
http://www.fomento.es/NR/rdonlyres/D...66/Anexo_A.pdf
Another CFIT accident sometimes claimed to have the exclaimation was Avianca 410 CUC-CTG on March 17, 1988. It was a 727 doing a high speed climb into the haze in mountainous terrain, with the FO flying and the captain chatting over his shoulder with a jumpseat rider.
I first recall hearing about this callout a couple of decades ago at the Pan Am training center in MIA. PAA trained Avianca's 747 and 727 crews in those days I believe.
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just a brief reading reminds me of how hard it is to be a good pilot/airman.
descend to/two/too 400? in the usa the proper phrase is: descend and maintain xxx
being of the air is much too hard to teach...piloting is one thing...but being of the air is something else. and too hard to describe here.
descend to/two/too 400? in the usa the proper phrase is: descend and maintain xxx
being of the air is much too hard to teach...piloting is one thing...but being of the air is something else. and too hard to describe here.
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Neptunus Rex, I think you should recheck youre own math. There are a few more syllables in those phrases. Remember Rule 452 from the Rules of Flying;
Rule 452: If you're going to be pedantic always make sure you're right first!
Rule 452: If you're going to be pedantic always make sure you're right first!
Does the CRJ have an EGPWS flap override switch?
Or was there failure to use the abnormal checklist which could have prevented the flap calls with a switch operation, leaving the relevant gear call with some precedence?
Select EGPWS off … don’t even think about it ... ever. TAWS ‘Saves’.
Or was there failure to use the abnormal checklist which could have prevented the flap calls with a switch operation, leaving the relevant gear call with some precedence?
Select EGPWS off … don’t even think about it ... ever. TAWS ‘Saves’.
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Dave Clarke fife,
A perfect example of a confusing presentation. Your original post had all the hallmarks of being your own work leading to the response from Northbeach.
I have long thought that the use of the phrase, "....descend to....." and similar is confusing and have tried to avoid it in my own RT use preferring something like, "Leaving 5,000 on descent 2,500" and similar.
I remember hearing an audio tape of the Tiger 66 during my ATPL theory course and thinking the same as Northbeach along the lines of, "what crew could possibly think a non-precision approach starts at 400'". The only possibility I could think of was that they were at the end of a long flight and fatigue had set in.
As to the gear warnings, I don't think it would matter how many syllables it was. The problem comes when the attention is firmly fixed on the task in hand and the mind starts excluding other senses as a distraction. I suspect this crew were concentrating so hard on the problem of the flaps and the approach that the gear warning was excluded from their loop. Perhaps if a visual stimulus cannot be provided an alternate aural warning is required to break through the concentration set of the pilots, something along the lines of "Hey effwit, lower the effing gear" in a very loud voice.
In Australia the tower, both military and civil, is required to transmit "Check gear" to landing military aircraft. Perhaps it should be required where an aircraft is making a non-normal approach.
A perfect example of a confusing presentation. Your original post had all the hallmarks of being your own work leading to the response from Northbeach.
I have long thought that the use of the phrase, "....descend to....." and similar is confusing and have tried to avoid it in my own RT use preferring something like, "Leaving 5,000 on descent 2,500" and similar.
I remember hearing an audio tape of the Tiger 66 during my ATPL theory course and thinking the same as Northbeach along the lines of, "what crew could possibly think a non-precision approach starts at 400'". The only possibility I could think of was that they were at the end of a long flight and fatigue had set in.
As to the gear warnings, I don't think it would matter how many syllables it was. The problem comes when the attention is firmly fixed on the task in hand and the mind starts excluding other senses as a distraction. I suspect this crew were concentrating so hard on the problem of the flaps and the approach that the gear warning was excluded from their loop. Perhaps if a visual stimulus cannot be provided an alternate aural warning is required to break through the concentration set of the pilots, something along the lines of "Hey effwit, lower the effing gear" in a very loud voice.
In Australia the tower, both military and civil, is required to transmit "Check gear" to landing military aircraft. Perhaps it should be required where an aircraft is making a non-normal approach.