Lionair plane down in Bali.
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When you have been in a microburst it is not something that gives you some vague feeling of unease, you very quickly know that things are not right, bigtime
For whatever reason the co-pilot seems to have been way behind the aircraft.
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but the real cause, in my opinion, will most likely be decisions made by the company and the regulator.
Framer you raise a good point. If Lionair copilots are not allowed to be pilot flying below 5000 feet as you appear to suggest, what on earth was he doing flying a non precision approach in poor weather? Although I am not a fan of captains doing all the landings, this accident does suggest why under certain circumstances it may be the least bad alternative.
Frankly even over here with a newish FO, (900 hours on type is about a year's experience at Lionair) I would have suggested under these conditions that it make more sense for the more experienced pilot to fly the approach.
This airline is definitely not one I would allow any of my family to use. 737 NGs have a pretty good safety record, but if you look at aircraft losses you come up with an interesting list of airlines. What it says about those airline's procedures, regulators and pilots you need to decide yourself. As I have droned on previously I hope the insurance industry will think hard about them too.
Frankly even over here with a newish FO, (900 hours on type is about a year's experience at Lionair) I would have suggested under these conditions that it make more sense for the more experienced pilot to fly the approach.
This airline is definitely not one I would allow any of my family to use. 737 NGs have a pretty good safety record, but if you look at aircraft losses you come up with an interesting list of airlines. What it says about those airline's procedures, regulators and pilots you need to decide yourself. As I have droned on previously I hope the insurance industry will think hard about them too.
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Quote:
For whatever reason the co-pilot seems to have been way behind the aircraft.
How about because he had 1200hrs total time...
For whatever reason the co-pilot seems to have been way behind the aircraft.
How about because he had 1200hrs total time...
As somebody mentioned, the crew appear to have left in the AP and followed the offset LNAV approach track all the way in, which is prima facie evidence that they never had sufficient visual contact to align with the runway.
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This is just another CFIT incident where a confused crew flew a perfectly serviceable aircraft into the water, had it been hard terrain they probably would have killed everyone on board. No CRM or bad CRM who knows, one could look at fatigue with average of 90 plus hrs for the PIC over the past 3 months, only 60 plus for the FO, however, looking at the weather, pics etc, there are no reasonable excuses for this nonsense. Initial recommendations may as well say " don't crash"
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When you have been in a microburst it is not something that gives you some vague feeling of unease, you very quickly know that things are not right, bigtime.
The 737 800 has enhanced EGWPS, with predictive windshear
A question for any tech geek out there...if the FMS predicts wind sheer is that prediction recorded on the FDR?
Last edited by MountainBear; 16th May 2013 at 19:58.
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Winds hear
Mountain bear
They had a "windshear" just before the minima. The GS versus CAS indicate about a 9 knot headwind reducing to a 7 knot tailwind that caused an increase in vs and a steepening of the FDA and pitch angle, although the CAS appears to have increased. All of this does indicate a very mild windshear, absolutely consistent to a moderate shower, but it no way approaching something that would trigger a WS warning, and nothing that accurate hand flying would not have coped with.
The is also a very strong tendency to "drop" the nose when attempting to fly the aircraft by visual reference in very poor visibility( this is why bloggs tends to splonge in short of the threshold when attempting a visual approach when he shouldn't be). This is a manoeuvre that has been done many many times before in aviation history. Think of it this way, no one has managed to destroy an aircraft in a unique way in the last 50 or so years, they just keep doing the same dumb things. The captain should have been heard loud and clear saying Go around! Because of any of the following 1, unstable 2,loss of visibility 3 vs greater than 1000 fpm. The flight continued because there was an unshakeable belief that the aircraft was going to land successfully, after all isn't that what always happens?
There was no windshear, just very very poor hand flying, and very poor command judgement.
They had a "windshear" just before the minima. The GS versus CAS indicate about a 9 knot headwind reducing to a 7 knot tailwind that caused an increase in vs and a steepening of the FDA and pitch angle, although the CAS appears to have increased. All of this does indicate a very mild windshear, absolutely consistent to a moderate shower, but it no way approaching something that would trigger a WS warning, and nothing that accurate hand flying would not have coped with.
The is also a very strong tendency to "drop" the nose when attempting to fly the aircraft by visual reference in very poor visibility( this is why bloggs tends to splonge in short of the threshold when attempting a visual approach when he shouldn't be). This is a manoeuvre that has been done many many times before in aviation history. Think of it this way, no one has managed to destroy an aircraft in a unique way in the last 50 or so years, they just keep doing the same dumb things. The captain should have been heard loud and clear saying Go around! Because of any of the following 1, unstable 2,loss of visibility 3 vs greater than 1000 fpm. The flight continued because there was an unshakeable belief that the aircraft was going to land successfully, after all isn't that what always happens?
There was no windshear, just very very poor hand flying, and very poor command judgement.
Avenger, #826. You post a glib narrow minded view representing older interpretations of ‘human error’.
If the crew were confused or exhibited poor CRM then what were the confusing factors, which aspects of CRM were weak, why? We might assume (with some confidence based on human nature) that the crew did not deliberately choose to fly into the sea, thus there could have been a decision making issue, a decision to continue, a decision of who and how to fly the aircraft, and when or not to go-around.
Until we have an understanding of the crews belief we cannot conclude anything for sure – gazumped how do you know that there was “unshakeable belief that the aircraft was going to land successfully”, the aircraft didn’t; thus a conclusion might be that there was a mistaken belief – the crew and your reasoning.
If we are to learn from these unfortunate accidents then the contributing factors have to be identified, even with speculation in advance of an official report there could be much to learn.
If windshear was a factor then perhaps predictive (radar) systems might not detect a rapidly forming or descending microburst (NB. AFAIR neither EGPWS nor FMS predicts W/S #827).
Crew’s might not experience ‘vague feelings of unease’ or interpret turbulence or change of speed with an impending threat; possibly factors of training or experience.
Why does disconnecting the autopilot from a VNAV approach apparently destabilize the flight path – are crews aware of this, what should be done.
There are lots of good points to be learnt, whether they apply to this event or not; our job is to learn and improve knowledge and hopefully be able to recall this and apply it when the occasion arises.
If the crew were confused or exhibited poor CRM then what were the confusing factors, which aspects of CRM were weak, why? We might assume (with some confidence based on human nature) that the crew did not deliberately choose to fly into the sea, thus there could have been a decision making issue, a decision to continue, a decision of who and how to fly the aircraft, and when or not to go-around.
Until we have an understanding of the crews belief we cannot conclude anything for sure – gazumped how do you know that there was “unshakeable belief that the aircraft was going to land successfully”, the aircraft didn’t; thus a conclusion might be that there was a mistaken belief – the crew and your reasoning.
If we are to learn from these unfortunate accidents then the contributing factors have to be identified, even with speculation in advance of an official report there could be much to learn.
If windshear was a factor then perhaps predictive (radar) systems might not detect a rapidly forming or descending microburst (NB. AFAIR neither EGPWS nor FMS predicts W/S #827).
Crew’s might not experience ‘vague feelings of unease’ or interpret turbulence or change of speed with an impending threat; possibly factors of training or experience.
Why does disconnecting the autopilot from a VNAV approach apparently destabilize the flight path – are crews aware of this, what should be done.
There are lots of good points to be learnt, whether they apply to this event or not; our job is to learn and improve knowledge and hopefully be able to recall this and apply it when the occasion arises.
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The FDR shows a good demonstration of an increasing performance shear, albeit quite small. The autopilot is pitching below the horizon, the flight path is ballooning, the airspeed is increasing, and the ground speed eventually begins to decrease. Of course the auto-throttles were probably reducing thrust too. Automation is not always your friend. Click, click, maintain attitude and slope, accept the airspeed excursion. Non-event.
The power lever angle and AOA traces would also be informative.
The power lever angle and AOA traces would also be informative.
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The very simple reluctance to go around is well documented as a major cause of landing accidents. IMHO one reason for this is check and training concentrates on the difficult manoeuvres of V1 cuts, OEI missed approaches, raw data ILS etc, the garden variety multi mised approach is not practiced because it is so simple!
The other reason is the vast majority of approaches terminate in a successful landing, so therefore most crew come to expect that will be the case. When conditions conspire against the, especially when not expected, the chances of a landing accident increase. A version of "get homeitis", if you like.
Nitpicker330 makes a very good point, if the crew had visual reference then they just flew into the water(not likely). The only logical conclusion, supported by mild undershoot (via the published FDR, )is a lack of visual reference, certainly insufficient visual reference to identify profile decay. Hence a land short. When the captain recognised this it was far far too late. Any comment, and I mean any comment about runway unsighted @ 150 feet (unless conducting cat11or cat111) is call for an immediate go around. Scenario, if one of the crew members makes a statement that he can't see the runway, and the other crew continues, exactly what use to you is the unsighted pilot? He may as well not be on the flight deck. By contueing descent after that statement the unsighted pilot is rendered useless to you as a PM. Who in their right mind would willingly render their PM useless to them?
Two crew is two crew, and as such requires two brains two different points of view, believe me you want your PM to be on the ball actively monitoring, supporting, challenging you etc. when one crew member states" I can't see the runway" @ 150, that is as big of a red flag you are ever going to get.
If this scenario were in a simulator, and you could flight freeze the situation, and ask a couple of open questions of each crew member, then they would collectively decide that the only option at 150 feet was a go around.
We can all learn from this, because most crew in this situation usually end in up in the morgue and an interview is not possible. This crew are very very lucky, and their interview should reveal why they kept descending on an NPA without sufficient visual reference, and why oh why did they not carry out missed approach at the very latest @ 150 feet.
The other reason is the vast majority of approaches terminate in a successful landing, so therefore most crew come to expect that will be the case. When conditions conspire against the, especially when not expected, the chances of a landing accident increase. A version of "get homeitis", if you like.
Nitpicker330 makes a very good point, if the crew had visual reference then they just flew into the water(not likely). The only logical conclusion, supported by mild undershoot (via the published FDR, )is a lack of visual reference, certainly insufficient visual reference to identify profile decay. Hence a land short. When the captain recognised this it was far far too late. Any comment, and I mean any comment about runway unsighted @ 150 feet (unless conducting cat11or cat111) is call for an immediate go around. Scenario, if one of the crew members makes a statement that he can't see the runway, and the other crew continues, exactly what use to you is the unsighted pilot? He may as well not be on the flight deck. By contueing descent after that statement the unsighted pilot is rendered useless to you as a PM. Who in their right mind would willingly render their PM useless to them?
Two crew is two crew, and as such requires two brains two different points of view, believe me you want your PM to be on the ball actively monitoring, supporting, challenging you etc. when one crew member states" I can't see the runway" @ 150, that is as big of a red flag you are ever going to get.
If this scenario were in a simulator, and you could flight freeze the situation, and ask a couple of open questions of each crew member, then they would collectively decide that the only option at 150 feet was a go around.
We can all learn from this, because most crew in this situation usually end in up in the morgue and an interview is not possible. This crew are very very lucky, and their interview should reveal why they kept descending on an NPA without sufficient visual reference, and why oh why did they not carry out missed approach at the very latest @ 150 feet.
gazumped, #831, 
, yes I would agree with all of that, but there could be more.
IMHO failure to go-around is much more than ‘get home it is’; the issues are deep within decision making and a range of biases, including misplaced training.
‘I can’t see the runway’ is an important cue, but may not have to be a trigger to go-around if the airport environment is in sight. There is of course the risk of wish think, familiarity with the airport, or the assumption that it’s only a small shower where the aircraft will pop-out the other side, etc, etc, but only with hindsight do we judge an (in)action to have been ill chosen.
One major issue could be with discipline; the operator, culture, and self (aspects of airmanship and CRM), but even with this there is usually some other contributions which all add up to result in an accident. We need to identify a wide range of contributors to gain an understanding and the reasons why they might come together at this point of an approach, and then teach pilots to recognize these and avoid the situation.
, yes I would agree with all of that, but there could be more.IMHO failure to go-around is much more than ‘get home it is’; the issues are deep within decision making and a range of biases, including misplaced training.
‘I can’t see the runway’ is an important cue, but may not have to be a trigger to go-around if the airport environment is in sight. There is of course the risk of wish think, familiarity with the airport, or the assumption that it’s only a small shower where the aircraft will pop-out the other side, etc, etc, but only with hindsight do we judge an (in)action to have been ill chosen.
One major issue could be with discipline; the operator, culture, and self (aspects of airmanship and CRM), but even with this there is usually some other contributions which all add up to result in an accident. We need to identify a wide range of contributors to gain an understanding and the reasons why they might come together at this point of an approach, and then teach pilots to recognize these and avoid the situation.
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We need to identify a wide range of contributors to gain an understanding and the reasons why they might come together at this point of an approach, and then teach pilots to recognize these and avoid the situation.
The Bali debacle is so very typical. Short final - sudden loss of visibility due blinding rain typical in those areas - keep it going down mate because we'll be through this lot in a couple of seconds ... **** this really is heavy rain.... only a few more seconds and we'll have to go-around - OK going around..SPLASH!... too late
I wouldn't be getting wound up by the traces indicating real windshear; deviations of +/-5° and 500ft/min are easily induced and just as easily corrected if the aircraft is bouncing around a little or one is looking in the wrong spot for too long.
EGPWS has nothing to do with windshear (unless, because of it, a high sink rate develops at low altitude; not here, by the looks of it).
The report said: "The final approach phase of the flight profile was outside the envelope of the EGPWS warning, therefore no EGPWS warning was recorded on the CVR." That would be in relation to the EGPWS profile mode where it'll warn you if you're too low, too far out on approach. This aircraft was too close to the normal approach flight path to trigger that warning.
Splonge?? I'll use that when apologising for my landing! 
Originally Posted by Mountain Bear
The preliminary report says that the EGWPS did not go off. Is this evidence, in your mind, that WS did not happen?
The report said: "The final approach phase of the flight profile was outside the envelope of the EGPWS warning, therefore no EGPWS warning was recorded on the CVR." That would be in relation to the EGPWS profile mode where it'll warn you if you're too low, too far out on approach. This aircraft was too close to the normal approach flight path to trigger that warning.
(this is why bloggs tends to splonge in short of the threshold when attempting a visual approach when he shouldn't be)
Last edited by Capn Bloggs; 17th May 2013 at 00:47.
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Pendulum swinging opinions
As much as I would like to be enlightened by this incident, to use it to prevent another occurring, it just doesnt seem to be the case anymore...I frankly cant see justification in putting what appears to be a perfectly good aircraft into the sea.. All those factors that have been mentioned fatigue, culture, beliefs training etc etc... Just start to sound like excuses to me after a while...ALL pilots should arrive at the minima with no preconcieved idea of what to expect.. Unplugging everything in what was obviously ( at some point) marginal conditions is asking for trouble if you dont have to do it... Of course we all make mistakes, and aircraft are very safe but will we as a community learn anything that will prevent the same thing happening again... Probably not as these errors have all been made before ... This is just a variation on the same theme... It may have been safer to leave lnav / vnav in and just let the autopilot fly to the ground most likely would have ended up on the runway with a heavy landing ... But that is just an opinion.. Glad no one hurt but if I read the same thing happened next week somerwhere else, I would not be surprised... It is getting monotonous hearing about ground collisions off NPAs again and again... sorry if I sound hard as*ed about this but I weary of the guys in the front seats doing silly ( if unwittingly!) things...
Of course we all make mistakes, and aircraft are very safe but will we as a community learn anything that will prevent the same thing happening again... Probably not as these errors have all been made before .
All those factors that have been mentioned fatigue, culture, beliefs training etc etc... Just start to sound like excuses to me after a while...ALL pilots should arrive at the minima with no preconcieved idea of what to expect..
We can bemoan the fact that the crew made errors until the cows come home but that will have no effect on the likelihood of this occurring again next week. What will have an effect is revisiting the decisions made by the airline and the Regulaor regarding recruitment and training.
So it comes down to this, do you want to prevent it happening again or do you want to pour scorn upon others for their mistakes made ?
PS this wee rant isn't directed at you Woodja51. It's just a 'general rant'.
So if these guys willingly continued below the minima (not talking 50' here, but CFIT!), as a crew, then lets see an appropriate penalty for negligence, or what could have resulted in manslaughter.
There is NO excuse for this behaviour, and a very clear message needs to be sent to other pilots with a similar attitude that continuing below minimas IMC during normal ops will never be tolerated. Passengers see cheap airfares, but they don't see what they're paying for. Regulators and lawmakers need to step in to even the playing field.
We've all heard anecdotes of this (continued flight below minimas) happening with different results, hence there needs to be a greater deterrent.
Fly to bali with some marijuana and you spent a large part of your life in jail, fly into the ocean with a serviceable 737 (potentially killing all on board) and you get ...
(Sorry for my strong words, but I know the standards the majority of us professional pilots operate to, and to see cowboys like this out there just pizzes me off!)
There is NO excuse for this behaviour, and a very clear message needs to be sent to other pilots with a similar attitude that continuing below minimas IMC during normal ops will never be tolerated. Passengers see cheap airfares, but they don't see what they're paying for. Regulators and lawmakers need to step in to even the playing field.
We've all heard anecdotes of this (continued flight below minimas) happening with different results, hence there needs to be a greater deterrent.
Fly to bali with some marijuana and you spent a large part of your life in jail, fly into the ocean with a serviceable 737 (potentially killing all on board) and you get ...
(Sorry for my strong words, but I know the standards the majority of us professional pilots operate to, and to see cowboys like this out there just pizzes me off!)
A little harsh, I think. If a person crashes a vehicle on a motorway due to reckless driving and causes a 30 vehicle pile up, leading to a heavy loss of life, the person would expect a jail term but nothing like that which would be imposed for mass murder. The difference, of course, is a lack of 'intent'.
I am not excusing their behaviour and poor airmanship. In fact, I agree that there are too many 'cowboys' flying these days (perhaps there always have been) but pilots need to be incentivised to fly to their professional potential. Say a pilot with good potential and a basic licence goes to fly with a cowboy operator or the same pilot instead gets lucky and goes to a legacy carrier. After 3000 hrs his or her day to day performance will be very noticeably different.
Plenty of us will admit to flying 'better' on a line check than on a day out with a long-standing buddy. Professionalism is about gaining and then maintaining standards, but no individual is perfect all the time.
What we have here is a serious case of all the holes in the Swiss cheese lining up and causing an accident. At any time, a single event - a Go Around - would have saved the day. The key point, however, is not to come down hard ONLY on the crew, but to look carefully at all the causal factors in equal measure.
An over-worked PIC? A steep cockpit gradient with an inexperienced SIC (one could argue that hours in a logbook doesn't equate to experience; whereas assertiveness from the SIC improves with experience); the whole P2Fly concept and a lack of experience in the cockpit; a lack of respect for SOPs; rostering and other factors that encourage get-home-itis; an ineffective Regulator.
There is a long list of causal factors, very few of which were touched upon in the preliminary report.
I am not excusing their behaviour and poor airmanship. In fact, I agree that there are too many 'cowboys' flying these days (perhaps there always have been) but pilots need to be incentivised to fly to their professional potential. Say a pilot with good potential and a basic licence goes to fly with a cowboy operator or the same pilot instead gets lucky and goes to a legacy carrier. After 3000 hrs his or her day to day performance will be very noticeably different.
Plenty of us will admit to flying 'better' on a line check than on a day out with a long-standing buddy. Professionalism is about gaining and then maintaining standards, but no individual is perfect all the time.
What we have here is a serious case of all the holes in the Swiss cheese lining up and causing an accident. At any time, a single event - a Go Around - would have saved the day. The key point, however, is not to come down hard ONLY on the crew, but to look carefully at all the causal factors in equal measure.
An over-worked PIC? A steep cockpit gradient with an inexperienced SIC (one could argue that hours in a logbook doesn't equate to experience; whereas assertiveness from the SIC improves with experience); the whole P2Fly concept and a lack of experience in the cockpit; a lack of respect for SOPs; rostering and other factors that encourage get-home-itis; an ineffective Regulator.
There is a long list of causal factors, very few of which were touched upon in the preliminary report.
Last edited by Mikehotel152; 17th May 2013 at 05:38.