Lionair plane down in Bali.
Framer well said! Safety starts at Board Level / Swiss Cheese model!
Human beings do the best they can with resources they have available at time given their own training and background etc
These type of accidents are the result of a dysfunctional system
Human beings do the best they can with resources they have available at time given their own training and background etc
These type of accidents are the result of a dysfunctional system
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framer..old school is out..it's the pigs running the farm now..bottom line is that it's more realistic to accept the prescribed hull losses than train the crew appropriately..new a/c products are supremely reliable so it's down to the most basic SOP's and no or little experience... Sad, I know. The irony now, is that the GA world requires the guys with good hands and feet..you can't fly an Otter through the QRH!!!
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Very correct and very well said Framer .
Looking at the recent final report on the Sukhoi accident , the list of recommendations is surprisingly very long and detailed and for everyone., so there are ( and I know some of them ) individuals in Indonesia that want the old mammoth moved into the XXI st century..
This accident might in the end be a blessing in disguise for them.
How many decisions/policies of the Indonesian regulating body will have a hand in this?
How many decisions/policies of the Lion Air management team ( think recruitment, training, rostering SOP's) will have a hand in this?
How many decisions/policies of the Lion Air management team ( think recruitment, training, rostering SOP's) will have a hand in this?
This accident might in the end be a blessing in disguise for them.
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As a reminder...Lion Air is considered an unsafe airline. Thatīs why they are not allowed to fly in USA and Europe. They have had many accidents and incidents. Itīs an airline where pay to fly is the method to get a job.
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For those suggesting that maybe it was a mis-set Altimeter that might have caused this crash, the normal sequence and settings would be as follows:
On each pilot's EFIS Control Panel there is a multi-function button which allows that pilot to select either QNH or 1013 (STD) on their respective altimeter.
If a pilot fails to select 1013 (STD) when climbing above Transition Altitude OR fails to select QNH when descending below the Transition Level, then the pressure reference field (at the bottom of the altimeter tape on their Primary Flight Display / PFD) will present as an amber box, i.e. to highlight that their particular altimeter is not operating in accordance with an appropriate pressure reference (as defined within the FMC).
Furthermore, were the pilots to have different QNH's set on their respective altimeters, such that the altimeters differed by more than 200 feet (for more than 5 seconds) then they would get a 'ALT DISAGREE' amber alert on their altimeters.
Also, the setting of the Altimeter (to QNH) is part of Boeing's 'Approach Checklist'.
Accordingly, in a B737-NG, if ones fails to set ones Altimeter to QNH (during descent & approach) there are at least two chances for a crew member to catch this omission, i.e. firstly via the visual 'boxed' amber cue on their altimeter, and secondly via the Approach Checklist.
And lets not forget that the Radio Altimeter would be making aural callouts at various altitudes (airline specific) and that these should normally be cross-referenced to the Altimeter(s) to confirm a level agreement (aka. 'airmanship').
The above not withstanding, there is nothing to prohibit the pilots from both having set an identical but incorrect QNH, in which case the above would all function correctly (aside from the Radio Altimeter being in error) in terms of procedure & matched settings, albeit that the aircraft would not in fact be at the correct altitude.
Nb. this would be a fairly major f**k-up for both pilots to make, but certainly not unheard of.
Given that the approach being flown was, by all accounts, a VOR, there are a number of way that this can be flown in a B737-NG, typically either via the autopilot and / or with reference to the Flight Director(s):
1) Fly it by use of VOR/LOC and Vertical Speed (with reference to distance versus height, from off of the relevant approach chart), with either the MDA set (or the closest 100' above) on the MCP, therein prohibiting the aircraft (if being flown via the autopilot / flight-directors) from descending below MDA (but which risks the aircraft levelling off, which might not be ideal); OR activating vertical speed mode but setting the Missed Approach Altitude on the MCP, which then allows the aircraft to maintain a Continuous Descent Approach down to, through, and below the MDA with all the risks that that entails.
2) Select the relevant VOR approach in the FMC and then fly it via LNAV / VNAV, which assumes that all the correct buttons & options are pressed in the FMC and on the MCP. The typical failures here are the pilots forgetting to set a lower altitude on the MCP to allow the aircraft to descend (and / or then failing to reset the MCP altitude window for a missed approach) or, more insidiously, during the descent towards the runway, the aircraft switches mode from 'VNAV PATH' to 'VNAV SPD' (as annunciated on the FMA), which - in VNAV SPD - effectively means the aircraft is descending without following the prescribed vertical path: Such a mode change requires careful monitoring of the FMA by the pilots, and probable action to get the aircraft back on to the VNAV path.
3) Select the relevant VOR approach in the FMC and then press the APP button on the MCP and fly the VOR approach via the IAN mode, this being a mode which presents flight guidance in a manner akin to an ILS, albeit that this is still a VOR approach.
4) Fly the approach entirely 'manually' with reference to raw-data and distance versus height (from off of the relevant approach chart).
Now unless the VOR involves step down altitudes, or very cold weather, or a very steep approach angle, by far the easiest method of flying a VOR (in a B737-NG) is via the IAN option (see 3 above) !
Along with this, its likely(?) that this B737-NG was also fitted with something known as the 'Vertical Situation Display' (VSD) which presents a profile view to the pilots (on their Navigation Display / ND) of the decent phase down to the runway, including symbology to show the aircraft position wrt the planned descent profile and also its projected descent path.
So, in order to fly a perfectly serviceable B737-NG into ground / ocean, when following a VOR approach, one would either had to have suffered or instigated a number of systematic and / or SOP failures and / or major loss of situational awareness. Failing those, it must be an atmospheric anomaly (such as windshear), though one wonders why the wind-shear alerting function (also fitted in the B737-NG) did not activate, and for which the only course of action is an immediately flown go-around using all available power (and aggressively applied)!
- Takeoff: Departure airfield QNH.
- Climbing and passing the Transition Altitude and / or cleared to a FlightLevel: 1013 (STD).
- Cruise (above transition altitude): 1013 (STD).
- Descending and passing the Transition Level / and or cleared to an Altitude: Arrival Airfield QNH.
On each pilot's EFIS Control Panel there is a multi-function button which allows that pilot to select either QNH or 1013 (STD) on their respective altimeter.
If a pilot fails to select 1013 (STD) when climbing above Transition Altitude OR fails to select QNH when descending below the Transition Level, then the pressure reference field (at the bottom of the altimeter tape on their Primary Flight Display / PFD) will present as an amber box, i.e. to highlight that their particular altimeter is not operating in accordance with an appropriate pressure reference (as defined within the FMC).
Furthermore, were the pilots to have different QNH's set on their respective altimeters, such that the altimeters differed by more than 200 feet (for more than 5 seconds) then they would get a 'ALT DISAGREE' amber alert on their altimeters.
Also, the setting of the Altimeter (to QNH) is part of Boeing's 'Approach Checklist'.
Accordingly, in a B737-NG, if ones fails to set ones Altimeter to QNH (during descent & approach) there are at least two chances for a crew member to catch this omission, i.e. firstly via the visual 'boxed' amber cue on their altimeter, and secondly via the Approach Checklist.
And lets not forget that the Radio Altimeter would be making aural callouts at various altitudes (airline specific) and that these should normally be cross-referenced to the Altimeter(s) to confirm a level agreement (aka. 'airmanship').
The above not withstanding, there is nothing to prohibit the pilots from both having set an identical but incorrect QNH, in which case the above would all function correctly (aside from the Radio Altimeter being in error) in terms of procedure & matched settings, albeit that the aircraft would not in fact be at the correct altitude.
Nb. this would be a fairly major f**k-up for both pilots to make, but certainly not unheard of.
Given that the approach being flown was, by all accounts, a VOR, there are a number of way that this can be flown in a B737-NG, typically either via the autopilot and / or with reference to the Flight Director(s):
1) Fly it by use of VOR/LOC and Vertical Speed (with reference to distance versus height, from off of the relevant approach chart), with either the MDA set (or the closest 100' above) on the MCP, therein prohibiting the aircraft (if being flown via the autopilot / flight-directors) from descending below MDA (but which risks the aircraft levelling off, which might not be ideal); OR activating vertical speed mode but setting the Missed Approach Altitude on the MCP, which then allows the aircraft to maintain a Continuous Descent Approach down to, through, and below the MDA with all the risks that that entails.
2) Select the relevant VOR approach in the FMC and then fly it via LNAV / VNAV, which assumes that all the correct buttons & options are pressed in the FMC and on the MCP. The typical failures here are the pilots forgetting to set a lower altitude on the MCP to allow the aircraft to descend (and / or then failing to reset the MCP altitude window for a missed approach) or, more insidiously, during the descent towards the runway, the aircraft switches mode from 'VNAV PATH' to 'VNAV SPD' (as annunciated on the FMA), which - in VNAV SPD - effectively means the aircraft is descending without following the prescribed vertical path: Such a mode change requires careful monitoring of the FMA by the pilots, and probable action to get the aircraft back on to the VNAV path.
3) Select the relevant VOR approach in the FMC and then press the APP button on the MCP and fly the VOR approach via the IAN mode, this being a mode which presents flight guidance in a manner akin to an ILS, albeit that this is still a VOR approach.
4) Fly the approach entirely 'manually' with reference to raw-data and distance versus height (from off of the relevant approach chart).
Now unless the VOR involves step down altitudes, or very cold weather, or a very steep approach angle, by far the easiest method of flying a VOR (in a B737-NG) is via the IAN option (see 3 above) !
Along with this, its likely(?) that this B737-NG was also fitted with something known as the 'Vertical Situation Display' (VSD) which presents a profile view to the pilots (on their Navigation Display / ND) of the decent phase down to the runway, including symbology to show the aircraft position wrt the planned descent profile and also its projected descent path.
So, in order to fly a perfectly serviceable B737-NG into ground / ocean, when following a VOR approach, one would either had to have suffered or instigated a number of systematic and / or SOP failures and / or major loss of situational awareness. Failing those, it must be an atmospheric anomaly (such as windshear), though one wonders why the wind-shear alerting function (also fitted in the B737-NG) did not activate, and for which the only course of action is an immediately flown go-around using all available power (and aggressively applied)!
Last edited by Old King Coal; 16th Apr 2013 at 13:18.
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OKC
thanks for the very clear information.perhaps you could also add:
How low can you go on Autopilot on a non precision approach?
If you should disconnect the A/P at very low level, but leave the autothrust engaged , what would happen if you pitch up to go around and push the power levers forward,but dont press the TOGA buttons?
thanks for the very clear information.perhaps you could also add:
How low can you go on Autopilot on a non precision approach?
If you should disconnect the A/P at very low level, but leave the autothrust engaged , what would happen if you pitch up to go around and push the power levers forward,but dont press the TOGA buttons?
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Camel asked the following questions:
A) It very much depends on which of those first three modes (which I described above) that you have selected, e.g. :
Mode 1) If aircraft is descended via vertical speed mode and the MCP altitude window is set to MDA (usually rounded to closest 100 ft above), the autopilot will level off at that altitude defined on the MCP: OR, if the aircraft is descended via vertical speed mode and the MCP altitude window is set to the Missed Approach Altitude, the autopilot will descend the aircraft until it impacts the ground (or ocean).
Mode 2) If the aircraft is descended via VNAV PATH the autopilot will stop the descent at whichever level is defined as the lowest level in the legs page of the FMC for the selected approach.
Mode 3) If the aircraft is descended via IAN, the autopilot will follow the vertical profile exactly as if the approach was an ILS (down to about 50' ?), and / or I suspect there will come a point when it might drop back into Control Wheel Steering (CWS).. though I've never investigated just what are the limits on this (company procedures prohibit it... though perhaps it's one to try in the sim?!)
A) You will probably have a speed set in the MCP speed window, i.e. a speed appropriate to the flap setting. With the auto thrust engaged (regardless of whether you descending, or flying level, or climbing) the auto thrust system will do its best to maintain that MCP speed. Indeed you wouldn't actually need to push the power levers forward yourself, as the AutoThrust system will do this for you, i.e. to maintain the MCP speed.
Nb. In the scenario you describe, the aircraft / FMA will still think it's in the selected approach mode (because you haven't told it otherwise, e.g. by pressing the 'go-around' button, or re-selecting another mode on the MCP) and as such the flight directors will command a nose down pitch, i.e. to try an get you to follow the vertical profile of the descent (from which you are now rapidly diverging in a climb).
I should add (hence the edit) the due to the potentially bogus guidance that the Flight Director system can give you, i.e. when descending below the MDA on a non-precision approach, it is customary (and good practice) on the B737 - once you are visual with the runway (and certainly if continuing below the MDA) - to turn both Flight Directors briefly off and then on again. The causes the Flight Directors to disappear out of view for the remainder of the approach to the runway (i.e. you continue the landing entirely 'visually'), however, should you press the TOGA button, the Flight Directors will then reappear to provide go-around guidance. This is typically known as 'Flight Director Pop-Up Mode'
Q) How low can you go on Autopilot on a non precision approach?
Mode 1) If aircraft is descended via vertical speed mode and the MCP altitude window is set to MDA (usually rounded to closest 100 ft above), the autopilot will level off at that altitude defined on the MCP: OR, if the aircraft is descended via vertical speed mode and the MCP altitude window is set to the Missed Approach Altitude, the autopilot will descend the aircraft until it impacts the ground (or ocean).
Mode 2) If the aircraft is descended via VNAV PATH the autopilot will stop the descent at whichever level is defined as the lowest level in the legs page of the FMC for the selected approach.
Mode 3) If the aircraft is descended via IAN, the autopilot will follow the vertical profile exactly as if the approach was an ILS (down to about 50' ?), and / or I suspect there will come a point when it might drop back into Control Wheel Steering (CWS).. though I've never investigated just what are the limits on this (company procedures prohibit it... though perhaps it's one to try in the sim?!)
Q) If you should disconnect the A/P at very low level, but leave the autothrust engaged , what would happen if you pitch up to go around and push the power levers forward,but dont press the TOGA buttons?
Nb. In the scenario you describe, the aircraft / FMA will still think it's in the selected approach mode (because you haven't told it otherwise, e.g. by pressing the 'go-around' button, or re-selecting another mode on the MCP) and as such the flight directors will command a nose down pitch, i.e. to try an get you to follow the vertical profile of the descent (from which you are now rapidly diverging in a climb).
I should add (hence the edit) the due to the potentially bogus guidance that the Flight Director system can give you, i.e. when descending below the MDA on a non-precision approach, it is customary (and good practice) on the B737 - once you are visual with the runway (and certainly if continuing below the MDA) - to turn both Flight Directors briefly off and then on again. The causes the Flight Directors to disappear out of view for the remainder of the approach to the runway (i.e. you continue the landing entirely 'visually'), however, should you press the TOGA button, the Flight Directors will then reappear to provide go-around guidance. This is typically known as 'Flight Director Pop-Up Mode'
Last edited by Old King Coal; 16th Apr 2013 at 14:27. Reason: to describe FD 'pop-up' mode
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position of sun
@F14 #57 p.3
Anybody answered?
UT 07:10Z
Local Time Denpasar, Bali 15:10
True solar time 14:50:12
Height of the sun 43°58'
Heading to sun 248°01'
Clock position of the sun for pilots (RWY 09) 5:15
Anybody answered?
UT 07:10Z
Local Time Denpasar, Bali 15:10
True solar time 14:50:12
Height of the sun 43°58'
Heading to sun 248°01'
Clock position of the sun for pilots (RWY 09) 5:15
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OKC
Thanks again for the explanation,seems like one could get into 'finger trouble' quite quickly if things are getting a bit busy ,with a change over in control at a critical phase of flight.
Thanks again for the explanation,seems like one could get into 'finger trouble' quite quickly if things are getting a bit busy ,with a change over in control at a critical phase of flight.
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Instrument Accuracy
Just a couple of observations about Accuracy:
1. Surfers one of the most accurate meteorological measuring tools in existance. If its raining, they're in the pub, not the sea.
2. Radars are less accurate than you think. Reports of "100 ft below the approach path" are pretty meaningless.
Dont feed the animals.
1. Surfers one of the most accurate meteorological measuring tools in existance. If its raining, they're in the pub, not the sea.
2. Radars are less accurate than you think. Reports of "100 ft below the approach path" are pretty meaningless.
Dont feed the animals.
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mata abad: Sorry mate but I'm fully engaged at FlyDubai and I'm not sure that Lion Air could afford me... but, there again and much as per the old adage, "If you think safety is expensive, try having and accident!"
I should add (hence the edit) the due to the potentially bogus guidance that the Flight Director system can give you, i.e. when descending below the MDA on a non-precision approach, it is customary (and good practice) on the B737 - once you are visual with the runway (and certainly if continuing below the MDA) - to turn both Flight Directors briefly off and then on again. The causes the Flight Directors to disappear out of view for the remainder of the approach to the runway (i.e. you continue the landing entirely 'visually'), however, should you press the TOGA button, the Flight Directors will then reappear to provide go-around guidance. This is typically known as 'Flight Director Pop-Up Mode'
I found this part of your post fascinating. I've spent the last eight years in the left seat of the NG and have never heard of this procedure. Its not in our procedures.
On an IAN approach the FDs will guide you down to 50 feet above the runway. However, it's not good practice to rely on them since you are below MDA. PAPI, VASI or visual reference are the approved guidance below MDA. Our book does allow us to "observe" the FD guidance below MDA in conjunction with visual references. It will provide accurate guidance with one caveat; a difference in actual airfield QNH/Temp and VNAV Baro, may cause a difference between VGSI and the GP indication.
Interesting stuff. Excuse the thread drift.
Last edited by JPJP; 16th Apr 2013 at 16:49. Reason: Added IAN baro info
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Inside info tells me :
Go around due to heavy rain runway not inside.
Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added.
Go around due to heavy rain runway not inside.
Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added.
Inside info tells me :
Go around due to heavy rain runway not inside.
Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added.
Go around due to heavy rain runway not inside.
Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added.
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JPJP: you correctly assess the issue, but you somewhat fail to highlight the risk wherein (if you'll please excuse me saying so?!) just because an IAN derived approach 'looks' like an ILS, one need always remember that is is not an ILS signal derived from and / or emanating from a position that is know & fixed along the runway, i.e. an IAN approach is derived from multiple inputs that are 'integrated' within your aircraft's FMC to generate approach guidance that seemingly reflects what one would see were one following an ILS (but it is NOT an ILS)... and if ever proof of that were needed, try flying an IAN approach when it is either very cold (i.e. well below ISA, indeed Boeing themselves tell you not to do IAN when it's v.cold) or conversely when it is very hot (i.e. well above ISA, when you'll likely break out at minimums with 3, or maybe even 4, 'whites').... and even v.10.8.A of the FMC does not (empirically) deal with significant ISA temperature errors in this respect (of IAN specifically; though one can somewhat modify this issue wrt to VNAV derived approaches).
The point of flying a non-precision approach (VOR) via IAN is to make the process as consistent & simple as possible (much as per the ILS procedure) but always with the caveat that one can follow the IAN guidance only down as far as the MDA (i.e. the last point by which one must 'visually' acquire the runway) and after that point (i.e. below the MDA) one must fly 'visually' to the runway and should not rely upon the IAN's Flight Director guidance (no matter how good a job it might seem to be doing... always remembering that IAN is not an ILS).
The point about turning off (then back on) of the Flight Directors, when following vertical guidance that is non-precision, is that that the vertical guidance is precisely that, i.e. NON-precision, being that it is generated onboard your aircraft and therein is subject to all manner of errors, whereas an ILS signal which is projected from the ground is subject to very few errors (in the most instances).
The point of flying a non-precision approach (VOR) via IAN is to make the process as consistent & simple as possible (much as per the ILS procedure) but always with the caveat that one can follow the IAN guidance only down as far as the MDA (i.e. the last point by which one must 'visually' acquire the runway) and after that point (i.e. below the MDA) one must fly 'visually' to the runway and should not rely upon the IAN's Flight Director guidance (no matter how good a job it might seem to be doing... always remembering that IAN is not an ILS).
The point about turning off (then back on) of the Flight Directors, when following vertical guidance that is non-precision, is that that the vertical guidance is precisely that, i.e. NON-precision, being that it is generated onboard your aircraft and therein is subject to all manner of errors, whereas an ILS signal which is projected from the ground is subject to very few errors (in the most instances).
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hmmm....
Simon Hradecky just added this passage, highlighted today in yellow, to his Aviation Herald entry:
"A witness on the ground observing the arrival of the aircraft from the terminal building of Denpasar Airport said, that he could see the aircraft descend towards the aerodrome at a normal rate of descent, but only realised something had gone wrong with the approach when the aircraft hit the waters instead of touching down on the runway. There was no rain or other obstruction of visibility around." Accident: Lionair B738 at Denpasar on Apr 13th 2013, landed short of runway and came to stop in sea
This does not jibe at all with the crew coping with torrential rain and no visibility.
"A witness on the ground observing the arrival of the aircraft from the terminal building of Denpasar Airport said, that he could see the aircraft descend towards the aerodrome at a normal rate of descent, but only realised something had gone wrong with the approach when the aircraft hit the waters instead of touching down on the runway. There was no rain or other obstruction of visibility around." Accident: Lionair B738 at Denpasar on Apr 13th 2013, landed short of runway and came to stop in sea
This does not jibe at all with the crew coping with torrential rain and no visibility.
This does not jibe at all with the crew coping with torrential rain and no visibility.