Crash-Cork Airport
Join Date: Apr 2008
Location: Up high
Posts: 555
Likes: 0
Received 0 Likes
on
0 Posts
That was not the plan as they did not keep a stable power setting until flare height but retarded the thrust levers below flight idle above 100 feet. These guys where winging it and pushing their luck big time, a luck which run out on them. The choices made by the commander where wrong and that cannot be glossed over. The only way this accident will not be repeated is if pilots in small unresourced outfits such at this one realize that going off piste for the sake of "getting the job done" is not worth loosing your life over. Procedures have a safety margin for a reason.
Join Date: May 2001
Posts: 10,815
Likes: 0
Received 0 Likes
on
0 Posts
I am a 60 year old pilot, 14,500 hrs, no accidents, paid for all my training 35 years ago. One day I hope to have a job again!
500 hours since the 18th of January and not even working that's impressive.
Or your the resident village idiot walter mitty from the Instructors forum with yet another login.
But either way if you can't understand that I think the chances of you getting a job are pretty much nil.
Join Date: May 2003
Location: Cote d'Azur
Posts: 136
Likes: 0
Received 0 Likes
on
0 Posts
This tragic and regrettable event, among its many complexities, illustrates the danger of permitting uncertainty about who has control.
Once the commander had taken control of the throttles, while leaving the co-pilot to control pitch and roll attitudes, the distinction between PF and PNF became essentially meaningless. Unless this was a specific, drilled SOP, both of them (i.e. neither of them) were now in control. Any ambiguity in their perceptions or intentions was now potentially disastrous.
With control of the flight path now split between two persons, conflicting communications could have played a further part in the accident:
<<speculation alert>>
The CVR dialogue would indicate that the co-pilot (still nominally but no longer fully the PF having deferred control of the throttles - a psychologically stressful situation) was expecting to go around in the event the commander was not visual at minimums. They had referred to an element of the missed approach procedure at 2:54 from the end of the recording: ("Okay missed approach three thousand") and subsequently in the final descent the commander called out heights to minimums as one would when prepared to go around if landing criteria were not met. Two missed approaches had already been made, and alternate fields had been discussed.
At 0:13 the commander made the call "Okay minimum... continue".
My speculation is that the co-pilot, primed mentally for another missed approach, interpreted this call as meaning "go around", whereas the commander, anxious to get in, meant it to signify "continue on the glide slope". As evidence for this contention, FDR data (fig. 5 in the report) shows that from about 0:12 altitude was held level (indeed at 0:11 it shows a slight increase); pitch attitude is increased slightly; and both are sustained until beyond the power reduction at 0:09. My guess: the co-pilot thought they were doing a go-around, but he couldn't do it fully, because the other guy had the throttles. Energy bled off while he sustained the pitch. At about 0:08 power is abruptly restored (likely although not necessarily by the commander) and suddenly the unexpected differential thrust aggravates the situation. A second later the stall warning sounds, and now they are trapped: low, slow, turning, asymmetric, devoid of useful energy (and at odds with what each other is doing?) and with no time, height, or visibility to react effectively.
One of the many lessons we may perhaps take from this event is to ensure that it is always clear "who has control".
Edited for spelling.
Once the commander had taken control of the throttles, while leaving the co-pilot to control pitch and roll attitudes, the distinction between PF and PNF became essentially meaningless. Unless this was a specific, drilled SOP, both of them (i.e. neither of them) were now in control. Any ambiguity in their perceptions or intentions was now potentially disastrous.
With control of the flight path now split between two persons, conflicting communications could have played a further part in the accident:
<<speculation alert>>
The CVR dialogue would indicate that the co-pilot (still nominally but no longer fully the PF having deferred control of the throttles - a psychologically stressful situation) was expecting to go around in the event the commander was not visual at minimums. They had referred to an element of the missed approach procedure at 2:54 from the end of the recording: ("Okay missed approach three thousand") and subsequently in the final descent the commander called out heights to minimums as one would when prepared to go around if landing criteria were not met. Two missed approaches had already been made, and alternate fields had been discussed.
At 0:13 the commander made the call "Okay minimum... continue".
My speculation is that the co-pilot, primed mentally for another missed approach, interpreted this call as meaning "go around", whereas the commander, anxious to get in, meant it to signify "continue on the glide slope". As evidence for this contention, FDR data (fig. 5 in the report) shows that from about 0:12 altitude was held level (indeed at 0:11 it shows a slight increase); pitch attitude is increased slightly; and both are sustained until beyond the power reduction at 0:09. My guess: the co-pilot thought they were doing a go-around, but he couldn't do it fully, because the other guy had the throttles. Energy bled off while he sustained the pitch. At about 0:08 power is abruptly restored (likely although not necessarily by the commander) and suddenly the unexpected differential thrust aggravates the situation. A second later the stall warning sounds, and now they are trapped: low, slow, turning, asymmetric, devoid of useful energy (and at odds with what each other is doing?) and with no time, height, or visibility to react effectively.
One of the many lessons we may perhaps take from this event is to ensure that it is always clear "who has control".
Edited for spelling.
Last edited by justanotherflyer; 3rd Feb 2014 at 14:41.
Join Date: Jun 2001
Location: Wherever someone will pay me to do fun stuff
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
Originally Posted by Big Pistons
I respectfully disagree. The accident chain started with the deliberate decision to continue the approach below minimums. By removing all of the altitude margin they made a crash inevitable when the engine asymmetry caused the fatal roll.
....
You are correct in the fact that there are many lessons to be learned from this terrible tragedy but for professional pilots the primary take away should IMO be Do not descend below minimums EVER.
....
You are correct in the fact that there are many lessons to be learned from this terrible tragedy but for professional pilots the primary take away should IMO be Do not descend below minimums EVER.
There is no question that the crew made errors on the day of the accident. The report offers proposals to explain some of their actions. They were at the sharp end and sadly, along with some of the pax, paid for these errors with their lives. But the most important question is why/how they were put in a position for which they were so poorly equipped and supported. In the report there is a catalogue of weaknesses in the systems that put the crew where they were and which should have ensured that the Operator/Owner supported better the people at the front end. These weaknesses were there either because of incompetence or deliberate by unscrupulous people running the various organisations.
Yes, you may well be right that if the crew had not busted minimums, the accident may have been prevented. But if the chain of events had been broken at any opportunity - and there were many - the accident may not have happened.
Let's go right back to the start, or at least one starting point - Manx2, the virtual airline. You cannot blame anyone, let alone someone who thinks they are a businessman, for exploiting loopholes or grey areas in a legal system.
The report illustrates that there were many clear and, in some cases, blatant breaches of law and regulations but the existence of a 'virtual airline' wasn't one of them. As I read it, Manx 2 set themselves up as the ticket-seller and sold tickets; something that appears to be entirely legal. At the root of it all is the European Commission's desire to have a common and mutually recognised set of aviation regulations but in making it all legal the failed woefully to establish an oversight framework that was fit to deal with cross-border activities. Instead, we now see most opportunities for effective oversight missed by national agencies saying 'I thought it was their job' and pointing to any one of the others in the frame.
If you've got this far, please bear with me while I continue my rant by pointing out that the European Commission was actively aided by EASA which drafted the legislation. This is an agency that is happy to develop reams of sometimes barely comprehensible regulations for all parts of the aviation system.....and also happy to pass the buck to national oversight agencies when weaknesses in the regulatory system contribute to an accident like this.
Much of the reason we have safety regulation is to stop events of this sort. So that the fare-paying passenger, who knows very little about the business of aviation, doesn't need to be afraid of getting on an aircraft because there are experts overseeing what is happening on their behalf. But in this instance, almost all of the multitude of opportunities for the regulatory agencies to challenge the way in which the aircraft were operated were wasted. So yes, the crew made mistakes, and if they had the chance to relive the day with the benefit of hindsight, I have no doubt they would act differently. But though they may have held licenses and been 'legal' up to a point they could easily control, the licences prepare people to work in an environment where the rest of the rules are applied properly - and this, most certainly, wasn't the case in this organisation(s). This crew were working at the entry level to the business, and although fewer lives may be at risk, crews at this point in their careers may well be faced with many more difficult (given their level of experience) decisions and choices to make, and very different pressures, every day than a crew in an organisation where the proper support is provided. This shouldn't be a surprise for any professional working in aviation - and the same issues exist in other sectors of the industry - and it should mean that the regulators are more rigorous (and I don't mean inspect the small operators to death) and ensure that what the crew on the day have a right to expect from the organisation they work for is actually in place.
I could quite accept an argument that the accident chain started the day that Manx2 started up. And the report identifies plenty of holes in the cheese in just the latter parts of the chain.
Join Date: Mar 2004
Location: schermoney and left front seat
Age: 57
Posts: 2,438
Received 0 Likes
on
0 Posts
I could quite accept an argument that the accident chain started the day that Manx2 started up. And the report identifies plenty of holes in the cheese in just the latter parts of the chain
I doubt it.
Join Date: Jun 2001
Location: Wherever someone will pay me to do fun stuff
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
What if Flightline would have sold the tickets themseves ? Do you honestly think it would have changed this flights fate ?
But to use the Swiss cheese analogy (with thanks to Jim Reason), the fact that Manx2 sold the tickets was one more slice with a hole. Clearly some of the weaknesses in the system that allowed this accident to happen are more significant than others, but keeping to the simplistic analysis - that is to say, putting some of the dependencies to one side for the moment - plugging the hole in just one slice of the cheese could well have prevented this accident. Of course, on a different day the remaining holes could line up, which is why every weakness that we find needs to be fixed.
Join Date: Jan 2008
Location: Hotel Sheets, Downtown Plunketville
Age: 76
Posts: 0
Likes: 0
Received 0 Likes
on
0 Posts
Cork Crash
This is simply a Human Factors accident. Unlike a high profile accident such as the THY Schipol crash where Human Factors were investigated, in this instance and in the abscence of a similar investigation, we shall never know why the crew made not one but three illegal attempts to land.
A salutary reminder is the 1989 incident at Heathrow of BA flight B741. The cost of busting approach and landing minima to the captain was a criminal conviction, followed by the very sad loss of his life by his own hand.
Command of an aircraft is a heavy responsibility, the duties of which must be discharged with great care and attention to every detail by all and every person who are concerned and involved in its operations. The person(s) who appoint a pilot to command carry in my humble view equal if not a greater degree of responsibility for his suitability and training for the task.
A salutary reminder is the 1989 incident at Heathrow of BA flight B741. The cost of busting approach and landing minima to the captain was a criminal conviction, followed by the very sad loss of his life by his own hand.
Command of an aircraft is a heavy responsibility, the duties of which must be discharged with great care and attention to every detail by all and every person who are concerned and involved in its operations. The person(s) who appoint a pilot to command carry in my humble view equal if not a greater degree of responsibility for his suitability and training for the task.
Join Date: Feb 2011
Location: France
Age: 54
Posts: 25
Likes: 0
Received 0 Likes
on
0 Posts
So I bought a ticket to Vienna from France on Saturday on the Lufthansa website. The flight was going to be performed by Austrian Airlines as it is a partner and in the end it was operated by Tyrolean Airways. Is this cause for an accident? No, not really.
Manx2 was acting as a ticket seller within their legal limits. They contract an Air Operator Company to supply them aircraft to fly their routes. They give their roster to the Air Operator company and the AOC holder is responsible by law to supply an airworthy aircraft with a trained, certified and current crew who are within their limitations regarding rest and duty times/fatigue and other limitations by law.
The AOC holder did not do this, thats why this outfit was flying around uncontrolled. And thats why the Spanish CAA got a kick for not catching it. The pilots were the last link. Sure, if they had not busted minimums, it would not have happened. But believe me, if people in the management of a company prefer to break limitations for the sake of making a profit and push this on the pilots, your chances that somewhere you will have an accident is many, many times bigger than when that same management kicks your butt if they found out you were breaking a regulation. Wether a pilot can resist those pressures or not is not really the case as it is always in the subconscious somewhere and influences decisions. Thats why I sadly conclude that if this accident had not happened, it would have happened (with this company) somewhere else anyways sooner or later. I'm 100% sure of that.
Manx2 was acting as a ticket seller within their legal limits. They contract an Air Operator Company to supply them aircraft to fly their routes. They give their roster to the Air Operator company and the AOC holder is responsible by law to supply an airworthy aircraft with a trained, certified and current crew who are within their limitations regarding rest and duty times/fatigue and other limitations by law.
The AOC holder did not do this, thats why this outfit was flying around uncontrolled. And thats why the Spanish CAA got a kick for not catching it. The pilots were the last link. Sure, if they had not busted minimums, it would not have happened. But believe me, if people in the management of a company prefer to break limitations for the sake of making a profit and push this on the pilots, your chances that somewhere you will have an accident is many, many times bigger than when that same management kicks your butt if they found out you were breaking a regulation. Wether a pilot can resist those pressures or not is not really the case as it is always in the subconscious somewhere and influences decisions. Thats why I sadly conclude that if this accident had not happened, it would have happened (with this company) somewhere else anyways sooner or later. I'm 100% sure of that.
Join Date: Dec 2010
Location: Ireland
Posts: 1,167
Likes: 0
Received 0 Likes
on
0 Posts
Pappa Delta, Manx2 acted inappropriately in its relationship with Flightline along with Air Lada.
The example you have given is neither noteworthy nor any bit helpful to this thread considering Tyrolean is Austrian now.
Please read the report before ranting off about something you clearly know absolutely nothing about.
And you know this HOW? what utter rubbish.
The example you have given is neither noteworthy nor any bit helpful to this thread considering Tyrolean is Austrian now.
Please read the report before ranting off about something you clearly know absolutely nothing about.
Sure, if they had not busted minimums, it would not have happened.
Join Date: Aug 2008
Location: Spain
Age: 82
Posts: 490
Likes: 0
Received 0 Likes
on
0 Posts
This is simply a Human Factors accident.
the crew made not one but three illegal attempts to land.
Last edited by Sunnyjohn; 4th Feb 2014 at 00:39. Reason: typo
Join Date: May 2001
Posts: 10,815
Likes: 0
Received 0 Likes
on
0 Posts
I am afraid not sunnyjohn.
It is a handling factor but not the reason for the accident.
Even with the tech issue it should be within the ability's of a professional pilot to deal with it. In fact the crew had already dealt with it 2 times previously.
The cause of the accident was the crew placing the aircraft in a position and then mishandling the aircraft.
Most western pro pilots reading the report and seeing the busting of mins, two people putting primary control inputs in at the same time will see this as a recipe for an accident. The engine tech issue is a factor but not the cause of the accident. To be honest in the grand scope of things most Garret pilots would consider a lag and differences between the engines as normal.
It is a handling factor but not the reason for the accident.
Even with the tech issue it should be within the ability's of a professional pilot to deal with it. In fact the crew had already dealt with it 2 times previously.
The cause of the accident was the crew placing the aircraft in a position and then mishandling the aircraft.
Most western pro pilots reading the report and seeing the busting of mins, two people putting primary control inputs in at the same time will see this as a recipe for an accident. The engine tech issue is a factor but not the cause of the accident. To be honest in the grand scope of things most Garret pilots would consider a lag and differences between the engines as normal.
SJ
Quote:
and on the third attempt, a mechanical fault produced the crash.
Quote:
the crew made not one but three illegal attempts to land.
and on the third attempt, a mechanical fault produced the crash.
MJ
It is a handling factor but not the reason for the accident.
Even with the tech issue it should be within the ability's of a professional pilot to deal with it. In fact the crew had already dealt with it 2 times previously.
It is a handling factor but not the reason for the accident.
Even with the tech issue it should be within the ability's of a professional pilot to deal with it. In fact the crew had already dealt with it 2 times previously.
The key difference on this third approach as I read the report, is that only on this third approach did the Commander split the primary control functions, and only on this approach was Beta selected.
As far as the ATC factor in applying minima goes, in the UK since about 2010 (IIRC) the requirement to question crews instrument approach intentions when low visibility is occurring was changed. Many controllers won't know the variations between capability/fit of crew/avionics, for example a biz jet could have had a shed load of cash thrown at it to make it and its crew CatIII capable, whereas another similar aircraft may not. I'd be surprised to see a BE200/Jetstream for example, make a CatII approach (let alone CatIII), but only because of my background. I know others in ATC whom wouldn't get those alarm bells ringing, which is one of the reasons why ATC can't be policemen for crews/aircraft busting minima.
Join Date: May 2001
Posts: 10,815
Likes: 0
Received 0 Likes
on
0 Posts
You see i ain`t convinced he did get it though the gate and into beta.
I don`t think they would have got the power back up.
And there was no beta horn sounding but i don`t know if they have one. I would be suprised if they didn`t.
I know ours tiggers with in a ball hair of going into beta the microswitch is just after the step that you have to lift the gate up to get behind and your not really into beta until you move the lever another ten degrees of arc.
There is a pic of it in that G-EEST report. It definately was in beta when it did its 5.6g landing.
I don`t think they would have got the power back up.
And there was no beta horn sounding but i don`t know if they have one. I would be suprised if they didn`t.
I know ours tiggers with in a ball hair of going into beta the microswitch is just after the step that you have to lift the gate up to get behind and your not really into beta until you move the lever another ten degrees of arc.
There is a pic of it in that G-EEST report. It definately was in beta when it did its 5.6g landing.
and on the third attempt, a mechanical fault produced the crash.
Join Date: Mar 2013
Location: Luton
Posts: 60
Likes: 0
Received 0 Likes
on
0 Posts
Any news of the money men, aka, the "company" ?
l`m sorry that l haven`t checked all posts which may well reveal the answer
but l find it too depressing to stay there long.
There but for the grace of God go l, but l was lucky enough to be given
proper training by proper management and those poor sods weren't.
l`m sorry that l haven`t checked all posts which may well reveal the answer
but l find it too depressing to stay there long.
There but for the grace of God go l, but l was lucky enough to be given
proper training by proper management and those poor sods weren't.
A salutary reminder is the 1989 incident at Heathrow of BA flight B741. The cost of busting approach and landing minima to the captain was a criminal conviction, followed by the very sad loss of his life by his own hand.
As you rightly say the final outcome for the captain was tragic.
Last edited by wiggy; 5th Feb 2014 at 12:13.
Join Date: Jan 2008
Location: Hotel Sheets, Downtown Plunketville
Age: 76
Posts: 0
Likes: 0
Received 0 Likes
on
0 Posts
Cork Crash
My thanks to Wiggy for his comments. Unless I am mistaken the following link may offer further enlightenment on whether the approach flown by Captain Glen Stewart did amount to bust of minima. Should he have descended below 1000ft agl. The crew of the inbound to Cork did.
http://theairlinewebsite.com/topic/3...ourtesy-don-h/
http://theairlinewebsite.com/topic/3...ourtesy-don-h/
Also with the Heathrow incident the AIB were snowed under at the time with the Lockerbie and other inquiries. In my opinion there should have been a full AIB investigation and then a decision, if deemed necessary, to take the Captain to court.
As it was we had, if my memory serves me correct, a jury attempting to make judgements on aviation technical issues to determine whether or not Glen Stewart was guilty or not - for me, a travesty of the justice "system".
Also if I recall correctly, someone in management on the ground gave the authorisation for the approach after the crew had made this request whilst in the hold. Something like crew not in recency for CAT 2/3??
As it was we had, if my memory serves me correct, a jury attempting to make judgements on aviation technical issues to determine whether or not Glen Stewart was guilty or not - for me, a travesty of the justice "system".
Also if I recall correctly, someone in management on the ground gave the authorisation for the approach after the crew had made this request whilst in the hold. Something like crew not in recency for CAT 2/3??