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Airblue down near Islamabad

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Airblue down near Islamabad

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Old 1st Sep 2010, 01:34
  #601 (permalink)  
 
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HundredPercentPlease # 595
In training, we have 2 clear scenarios for dealing with a GPWS warning.
1. If IMC, perform the escape manoeuvre.
2. If visual, continue if it's false, otherwise escape.
and “… something that may need changing.”

I suggest that the safety attitude and training are very outdated and both require changing.
Enhanced GPWS (EGPWS) is a very much more capable and reliable system than in previous years. Also, with improved aircraft systems and installations, and the use of embedded GPS, it is more likely that the crew will be mistaken than experience an ‘inappropriate’ warning. Even in visual conditions, humans can suffer illusions or incorrectly interpret a situation (Celebrating TAWS ‘Saves’: But lessons still to be learnt. Incidents 1, 3, 4, 7, and 8).
Any delay in pulling up, such as a few seconds considering the validity of a warning, could be fatal. It’s only after the event, with the luxury of time (and safe altitude) that the appropriateness of a warning might be established.
Never assume that a warning is false.

p51guy, # 599. I suggest that you review your safety reporting and investigating procedures, and contact Honeywell for assistance. There are very few airports where a fully configured EGPWS (embedded GPS, latest software and database updates) will cause problems.

bearfoil, # 601. “… so these two crashes were essentially opposites, …”
Not if both crews were head down? And if Airblue were ‘head down’ and failed to respond to a warning (or without a warning due to a map shift), we have another similar accident.
Accidents of human nature?
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Old 1st Sep 2010, 01:58
  #602 (permalink)  
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InRe: my #601. I used a broad brush. Here's my point. Islamabad was by definition in vmc (CTL). AA was on approach and IMC. AA had the best reason to have there eyes down, Airblue had no defense for not keeping their peeps on the outside. So as a responsibility consideration, AA got done in. Islamabad did themselves in, the Captain for being oblivious, the F/O for being attentive, but fearful to the extent he died rather than risk a change to his control. ?? Am I making any sense? it is late here in Cali.
 
Old 1st Sep 2010, 02:38
  #603 (permalink)  
 
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bearfoil

"It is at this precise moment when the "generic" computer uncouples the poor performers, steps in and performs its work with an expectation (statistically) of nearly certain success, even in emergency conditions. Or vice versa."

I understand what you are saying but I don't agree. Once you introduce a human being into the cockpit you introduce the certainty, sooner or later, of human error. It's superficially appealing to think that man and machine can coexist on the flight deck in a "best of both worlds" mode but the question remains if that best of both worlds mode is really safer than the pure robotic alternative.

I don't know the answer to that question. It may be that in the long-run the threat of terrorists getting access to the controls, the ever changing weather, and other such risks means that an airplane without a human pilot just isn't as safe as one with a human pilot, even after accounting for human error. What I do know is that when I look back at the last three or four decades and see how automation has improved flight safety I think that those who favor complete automation of flight have earned the opportunity to demonstrate what they can do.

Looking at the distant past tells us what flight looked like without computer automation. Looking at the recent past and the present tells us what flight looks like with both computer and man on the flight deck. A rational person would want to know what the third alternative looks like--pure automated flight--before passing judgment on the matter as to which of the three choices is actually safer.
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Old 1st Sep 2010, 05:29
  #604 (permalink)  
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BOAC;
PJ - I see you appear to have begun this '60 deg of bank' thing which seems to be running amok now as an 'idea' for some here.
The notion should not be running amok among experienced airmen as the standard response should be perfectly clear for those flying the Airbus, but I can understand the concern with those who follow in our footsteps and may be confused about what an airplane is capable of and what is required by SOPs.

I made these statements as observations of the Airbus A321's capabilities, not as a statement of the recommended procedure for the escape maneuver.

In the Islamabad case, from unconfirmed anecdotal comments, the aircraft was started on a turn to the left on the autopilot (and may have responded by turning to the right if the heading select went past 180deg...NOTE PLEASE - all this is complete conjecture and must be confirmed by the actual data!), and so I offered the thought that a bank angle of up to 60deg was available if required. It is not necessary nor is it SOP.

The Airbus A320 series "Ground Contact" escape maneuver is:

Simultaneously:

- Select thrust levers to TOGA thrust
- Ensure autopilot is disengaged
- Pitch nose up, Apply up to full back sidestick
- Roll wings level to initiate the pull up and then adjust as required.

The standard procedure for escape from ground contact after an EGPWS or GPWS warning occurs in poor/low visibility should now be quite clear to all pilots.

As pilots are trained on this equipment they will learn that their aircraft is capable of such bank angles but such bank angles are neither required during the maneuver nor are they immediately necessary without cause which is readily apparent to the crew.

I hope this clarifies my comments. Thanks for your important responses BOAC and Neptunus Rex.

PJ2
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Old 1st Sep 2010, 08:13
  #605 (permalink)  
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bearfoil:

So as a responsibility consideration, AA got done in.
We don't know a whole lot about Islamabad. But, we do about AAL 965. That crew did it to themselves beyond any doubt. They had a database issue, which was their responsibility to resolve without letting the aircraft fly away into oblivian. It would have been very easy to have reverted to heading mode (pointed in the proper direction) or gone to raw data on a very simple arrival/IAP procedure. They were originally set up for the ILS (landing Runway 1 instead of Runway 19) but the accepted the offer of the approach landing south. They sure were not required to do that. But, they were running late so why not shave off a few minutes. Plus, there was a lot of idle, diverting chit-chat with a flight attendant while they were working hard to become passengers instead of pilots.

The Cali controller did nothing wrong. In fact, within the limits of Colombian non-radar air traffic procedures and English as a second language, he did rather well as I recall.

Additional comment added: The controller could be faulted for approving the request by the crew to proceed direct to the NDB (Romeo?). In the first instance the crew should not have made such a request during descent on an arrival route onto an IAP in a non-radar ATC environment. In response, the controller should have disapproved the request and, instead, told the crew to remain on the published transition and IAP.

Last edited by aterpster; 1st Sep 2010 at 09:01. Reason: Added last paragraph about request for "direct-to"
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Old 1st Sep 2010, 11:53
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I wouldn't like to see this thread contaminated with discussion about a non-relevant accident, but it seems as if things might be going that way. Let me try to head it off by referring to some real work which was done on the Cali accident, and suggest that those of us who wish to discuss the nearly fifteen-year-old accident start a new thread, say in the "Safety" Forum?

Originally Posted by aterpster
But, we do about AAL 965. That crew did it to themselves beyond any doubt.
Not so. Many other factors were involved. The Texas court found that the FMS manufacturer and the nav database supplier were also responsible. Further responsibility lies with the Colombian government for installed two NDBs with identical frequencies and idents within reception range of each other, and with the controller for replying "affirmative" to the mistaken readback of a clearance (indeed, the readback clearance could physically not be flown).

Then there were presupposition problems in the crew's intuitive understanding of how approaches are named, which caused some confusion. That is nobody's fault, least of all the crew's. See the cult paper Cali Conversation Comments

Originally Posted by aterpster
The Cali controller did nothing wrong.
Also not so, as mentioned in the last sentence of the above paragraph.

We digitised the Cali report, which was offered to us by a contact at the NTSB who read the above paper, and performed a Why-Because Analysis of the accident, from which the above is derived. All available through AG RVS - Computer-Related Incidents with Commercial Aircraft

It's nice to know that work we did 14 years ago is still relevant.

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Old 1st Sep 2010, 13:56
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bearfoil, re # 604, thanks.
Quite clear, hence my reference to human nature – AA being flown IMC had no choice but to manage the situation (assessment and choice of a course of action).
Airblue may have exercised a choice; not that there should have been a choice during a CTL (VMC only). Thus, this is a classic situation where the crew might have misunderstood the situation, or with good understanding, chosen a poor option. What we lack is the detail of the crew’s understanding of the situation and the decisions taken.

Hence my points in # 603 to remove the option of assessing and deciding that a EGPWS warning is false, and then the option to ignore it. Also, by eliminating ‘routine’ warnings which might be ignored habitually in other situations.

Situation awareness, decision making, and self discipline – all aspects of airmanship; and in this respect, the accidents would be similar.
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Old 1st Sep 2010, 14:14
  #608 (permalink)  
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I still think you may be a victim of bias. I recognize it sometimes because I am too often carrying it myself. "Introducing" human factors into any pursuit means defining a "modality". The exact same thing is true when discussing Computerized control. I don't wish to help derail this accident discussion; The first consideration when defining a way to harvest the "best" of dual modality flight is to start with an inventory. "What does each do best"? The Computer doesn't flirt, The pilot (pray) doesn't have non abstract "thinking" (only). Both are sampling "data", sensing a dynamic flight envelope, and coming up with solutions to a challenging problem that itself wants a thorough definition.

"Error"? Each approach is a limitless challenge here, notwithstanding the attempt to merge the two on a mechanical flight deck, whose own idiosyncratic profile is a new and constantly progressing domain.

I stopped flying commercially at 48 yoa. I am 64 yoa this very day. I stopped because in my own punishing self assessment, I had lost the "edge". And it wasn't the kind of fun I had grown to love. As that chapter fades, I gain huge understandings (at a distance, and especially here), of current "approaches".

A cliche, but Karl, my FAA examiner when acquiring the first certificate (and the one to which all progress is appended), says, "The certificate is a "License to Learn".

Consider me a student here.

Last edited by bearfoil; 1st Sep 2010 at 15:22.
 
Old 1st Sep 2010, 14:27
  #609 (permalink)  
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PBL:

I wouldn't like to see this thread contaminated with discussion about a non-relevant accident, but it seems as if things might be going that way. Let me try to head it off by referring to some real work which was done on the Cali accident, and suggest that those of us who wish to discuss the nearly fifteen-year-old accident start a new thread, say in the "Safety" Forum?
If you would be willing to start such a thread, I would certainly participate.

I followed the accident very closely and wrote an article about it for the U.S. ALPA magazine.

I view the court's assessment as mostly a red herring to award damages. There is no doubt the database had some issue, as did (and still does) the simplistic naming of nav aids in many parts of the world.

But, had the Jeppesen chart in effect at the time been properly used along with situational awareness and Airmanship 101 it would have been a routine ending to the flight.

I was, after all, a VOR/DME arrival/IAP; not an RNAV procedure. And, Colombia was certainly not WGS84 compliant in 1995.
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Old 1st Sep 2010, 15:19
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Absolutely, and where is the "final" decision? Ultimate action is by its nature the result of 100 per cent confidence or utter defeat (or a "guess"). A routine warning isn't a warning, it is a fruit fly landing on your nose, and defying a state of the Art set up isn't a guarantee of failure either. I say a successful merging of the best of both modalities would improve the safety record. (Vastly?)

Certainly leaving petty and stubborn bias against one or the other behind has to help. If the safety record degrades further, we are in danger of doing that very thing, "One or the Other". At this point, unfamiliar with either accident as I am, I'll just watch here on in.

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Old 1st Sep 2010, 15:56
  #611 (permalink)  
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You are all most welcome on the thread I began in 2009 http://www.pprune.org/safety-crm-qa-...-aviation.html which covers these very dilemmas, and since July 2009 we have seen many unfortunate examples of either over-reliance on automation or lack of understanding of it.

PEI - I cannot see how you could contemplate the Airblue crew being 'head down' - it would be MOST unusual at around 840' AGL, especially with 2 calls of visual contact with features! It puts a whole new meaning to 'cojones' (or whatever that is in Urdu..............).
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Old 1st Sep 2010, 18:36
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BOAC, “ I cannot see how you could contemplate the Airblue crew being 'head down' …”.

An understandable thought, but rule nothing out. I have encountered such ‘unbelievable’ extremes in incident / accident investigation. These were predominantly aspects of human behaviour – mis-understanding, mis-conception, poor training, etc, etc, even the influence of modern technology or ‘automation’.
The crew ‘sneak a peek’ at the ND for a position check, inadvertently loose contact with the airport environment, then revert head down – to fly a go-around, but don’t, because the ND map provides adequate cues to continue the CTL until they become visual, i.e. the crew know better, fail to appreciate / consider the risks, discipline, – done it before, etc, etc, - human behaviour.

Not 'cojones', just human. In trying to understand these behaviours, we must start with ourselves; what small transgressions do we accept, e.g. for you and I, how many times above 48k without a pressure jerkin, or above 56k … ? Do we really know the risks or are we risk takers, for fun or to achieve an objective, do we think we are helping someone?

Don’t look for the human ‘failures’ in an accident, instead look at what prevents the vast majority of pilots taking such extreme risks. Look at what should be normal, and why this normality appears not to have existed in this situation?
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Old 1st Sep 2010, 18:53
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PEI - I cannot see how you could contemplate the Airblue crew being 'head down'
An understandable thought, but rule nothing out
I'm with PEI on this one. To my mind, being heads down provides a plausible explanation for why they were 5+ nm from the airport.

Training emphasizes FMS programming to a fault. Weren't they both new to type?

Best,
GC
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Old 1st Sep 2010, 18:55
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BOAC:

You are all most welcome on the thread I began in 2009 Computers in the cockpit and the safety of aviation which covers these very dilemmas, and since July 2009 we have seen many unfortunate examples of either over-reliance on automation or lack of understanding of it.
I will post a link to my 1996 article on Cali and related issues as well as the NTSB ATC chairman's factual report. Colombia went way beyond ICAO convention by making the NTSB a partner in the investigation. The Colombian in charge of aviation matters at the time was super sharp, as are many of the aviation "wheels" in Latin America.
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Old 1st Sep 2010, 19:36
  #615 (permalink)  
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PEI - a thoughtful post, but I have to pass a few comments:

Para 1 - 100%% agreement

Para 2 - no - had they 'sneaked a look' they would have instantly seen that their heading/track and position were all wrong. I don't believe for a moment that they did nor that they knew where they were. Ground, buildings zipping past in the grot? A 10,000ft runway that seemed to go on and on for 3 or 4 miles?

Para 3 - absolutely, of course we took 'risks' - but who were our passengers? Yes, we are/were 'risk takers', but is it not 3 words? Duty of care? How many times would you bust the altitude limit of your airliner just because?

Para 4 - no argument, but was the Captain in his mind 'taking risks'?

I said many pages ago I felt I could write the CVR transcript,. I still do. I suspect the F/O had suffered the 411A 'short-CRM' course of 'Gear up shut up' - great as we know for a multi-crew environment.(oh, I forgot............). The fact that the last moments appear to have included 'Sir -pull up' speak volumes.
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Old 2nd Sep 2010, 16:37
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Interesting further (unsubstantiated) but credible postings on the PIA History forum (on which our departed friend is still insisting that CTLs are flown as teardrops with radar available).

These postings come from a Pakistani who is working in Hobart as CFI but presumably has good links back to Airblue and home.

He says that Islamabad approach saw the track and asked tower to send the AB back to him twice. On each occasion the AB replied that they were 'visual' and remained on tower.

He says the CVR and FDR were decoded a while back and are back in P but the CAA is not expected to release them, citing only 'Pilot Error'.

He repeats the '180 degrees plus' heading input which reversed the turn. (NB One supposed AB qualified poster here said that was not possible - jury out)

He interestingly describes the avoidance manoeuvre flown as the "third g/a for that aircraft" and "more than on attempt to land" with no further explanation.

The puzzle goes on. I suspect we will have to work on leaks.
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Old 3rd Sep 2010, 15:50
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Danger Airblue down near Islamabad

PEI

I enjoy reading all the comments. This topic has been very interesting according to variable comments from all pilots concerned, but your comments, I find, most challenging and worth consideration for future occurence. Hope there won't be any!
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Old 4th Sep 2010, 11:51
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This video, claiming to have been taken 5 mins after the crash, from the roof top in a nearby residential area(F-6), doesn't make the weather look that bad at all. It seems the hills are clearly visible for a CFIT.

YouTube - Air Blue plane crash at Margalla, unseen video 5 minutes after crash from F6

(though we do have to take into account whether this was really taken after 5mins of the crash and weather can change pretty quickly in the area).
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Old 4th Sep 2010, 15:00
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That chopper was pretty fast on the spot,unless she was around by chance ?
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Old 4th Sep 2010, 15:13
  #620 (permalink)  
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Certainly not looking like monsoons wot I have seen!
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