Lionair plane down in Bali.
To a greater extent I see it as a lack of regulation.
Human beings do the best they can with the resources they have at the time - this includes such items as training and culture whether company wise or other
We need to have two well trained professionals in the flight deck (or more if required) for safe operation.
Am surprised nobody has mentioned the monitored approach system which has been proven to be a safe way of operation. Of course both crew members must be proficient and trained for any system to work every time but having used different systems I am convinced (and statistics seem to back this up) that the monitored approach system is sound.
I know from other threads this can be an emotive topic but for those of you who have never flown monitored approaches I ask you to be a little more open minded. I was very sceptical until I practised same and soon became a convert.
Human beings do the best they can with the resources they have at the time - this includes such items as training and culture whether company wise or other
We need to have two well trained professionals in the flight deck (or more if required) for safe operation.
Am surprised nobody has mentioned the monitored approach system which has been proven to be a safe way of operation. Of course both crew members must be proficient and trained for any system to work every time but having used different systems I am convinced (and statistics seem to back this up) that the monitored approach system is sound.
I know from other threads this can be an emotive topic but for those of you who have never flown monitored approaches I ask you to be a little more open minded. I was very sceptical until I practised same and soon became a convert.
People, please.
It will never be "culturally acceptable" to fly any serviceable aircraft into the sea.
This accident still looks like criminal negligence and recklessness on behalf of the crew. Sure, there probably were some circumstances which have put the crew into this situation: Bad training. Bad regulatory oversight, etc.
But even then, it is everyone's own bloody responsibility, that when you find out that you have joined an outfit in which things are badly safeguarded for whatever reason: GET OUT. Find another job. Otherwise you will end up getting arrested for having committed criminal negligence and reckless flying.
It will never be "culturally acceptable" to fly any serviceable aircraft into the sea.
This accident still looks like criminal negligence and recklessness on behalf of the crew. Sure, there probably were some circumstances which have put the crew into this situation: Bad training. Bad regulatory oversight, etc.
But even then, it is everyone's own bloody responsibility, that when you find out that you have joined an outfit in which things are badly safeguarded for whatever reason: GET OUT. Find another job. Otherwise you will end up getting arrested for having committed criminal negligence and reckless flying.
Last edited by fox niner; 17th May 2013 at 08:28.
Just read the initial report. A full CVR transcript and some N1s would complete the picture but it doesn't look pretty as it is.
Can we learn anything from this accident that we don't know already? Don't bust minima, especially on an offset NPA? I think that one was settled some time in the last millennium.
I'm sure there will be compounding factors of fatigue, poor selection, training, supervision, CRM and oversight. Add in authority gradient, cultural differences/mores and there you have it.
If this was a western airline, the authorities would probably be initiating criminal proceedings against the pilots. I presume the insurance company (assuming they were insured) isn't overjoyed either...
Can we learn anything from this accident that we don't know already? Don't bust minima, especially on an offset NPA? I think that one was settled some time in the last millennium.
I'm sure there will be compounding factors of fatigue, poor selection, training, supervision, CRM and oversight. Add in authority gradient, cultural differences/mores and there you have it.
If this was a western airline, the authorities would probably be initiating criminal proceedings against the pilots. I presume the insurance company (assuming they were insured) isn't overjoyed either...
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Far too many incidents with Lionair.
Pay to fly Pilots including Captains and voila...
Get this pathetic insult to Aviation safety out of the skies Indonesia, and get your act together!
Pay to fly Pilots including Captains and voila...
Get this pathetic insult to Aviation safety out of the skies Indonesia, and get your act together!
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‘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.
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Originally Posted by fireflybob
Am surprised nobody has mentioned the monitored approach system which has been proven to be a safe way of operation
I'm sure that in both systems you simply have to go around if you're not visual by the minima. If the crew elects elect to ignore basic SOP, catastrophe is bound to occur in either system.
Quick suggested test for airline managers perhaps for use by the insurance industry. Read the following statements and decide which best reflect your airline's attitude and allocating points as follows:
Strongly agree 1 point, somewhat agree 2 points, unsure 3 points, disagree 4 points, strongly disagree 5 points
We carefully select a variety of pilots, on average with several thousand hours
We train to real proficiency and money on training is money well spent
Pay to fly with the training department as a profit centre is dangerous
Ensuring our pilots are well rested and avoiding roster changes is important
Safety is our priority, there is no punishment for go-arounds or diversions
If you have 10 points or less well done, we will be happy to insure you.
With 10 to 20 points you might like to consider some element of self insurance
Over 20 points we would strongly recommend you stop flying to Greece and other countries which have a history of sentencing airline managers to large fines and jail time.
Strongly agree 1 point, somewhat agree 2 points, unsure 3 points, disagree 4 points, strongly disagree 5 points
We carefully select a variety of pilots, on average with several thousand hours
We train to real proficiency and money on training is money well spent
Pay to fly with the training department as a profit centre is dangerous
Ensuring our pilots are well rested and avoiding roster changes is important
Safety is our priority, there is no punishment for go-arounds or diversions
If you have 10 points or less well done, we will be happy to insure you.
With 10 to 20 points you might like to consider some element of self insurance
Over 20 points we would strongly recommend you stop flying to Greece and other countries which have a history of sentencing airline managers to large fines and jail time.
Last edited by lederhosen; 17th May 2013 at 09:33.
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It would appear pretty clear as to what happened, I would like to put forward some suggestions as to why it happened and what can be done about it.
Waiting for a third world regulator to take some form of decisive action, could end up just trying your patience.
Having worked for a couple of companies that put pressure on crew to break the rules in order to improve profitability, I feel that I am in some way qualified to comment.
Firstly pilots love to "get the job done", and there is a tendency to feel a failure if you go around and, end up diverting to an alternate. Low quality companies make no attempt to defuse this natural tendency or to indoctrinated pilots into the secrets of professionalism.
The secret of aviation professionalism is OBEY THE BLOODY RULES!
On the other hand good quality companies actively encourage crew to follow all legal and company SOP's.
This is reflected in the accident and incident statistics of good companies versus low quality companies, and Lionair is a classic case in point.
If you are unfortunate to be working for a dodgy operator, apply like mad to all of the good companies, but in the meantime, try to maintain your professional standards. If a critical mass of pilots maintain a professional standard, they can actually slowly change the corporate culture of dodgy operators. And it is the corporate culture of an organisation that ultimately drives the safety standard. Let me say that again, it is the corporate culture that ultimately drives the safety standard. P2F would have to defined as very poor corporate culture.
So bottom line, if your company fails to supply professional direction, supply the professionalism from your own resources. Work hard at knowing the rules, maintain as high a standard as you are able to. If you are an FO, don't be shy to speak up, command a go around if things are getting out of shape, hit the TOGA button and take over if you have to, the very worst that can happen is your employment may be terminated, at least you will be alive and you can hold your head high. If you have a command maintain your standards! The overall goal is to die as an old retired codger with lots of wrinkles, and lots of grey hair.
Lastly keep accurate records. Accurate documentation will be invaluable in defending your position, should that become necessary. Remember All crooks hate being publicly exposed. The power of public opinion can be a powerful lever. Above all else do your best to stay safe. The safety of world aviation is collectively in our all of hands.
Waiting for a third world regulator to take some form of decisive action, could end up just trying your patience.
Having worked for a couple of companies that put pressure on crew to break the rules in order to improve profitability, I feel that I am in some way qualified to comment.
Firstly pilots love to "get the job done", and there is a tendency to feel a failure if you go around and, end up diverting to an alternate. Low quality companies make no attempt to defuse this natural tendency or to indoctrinated pilots into the secrets of professionalism.
The secret of aviation professionalism is OBEY THE BLOODY RULES!
On the other hand good quality companies actively encourage crew to follow all legal and company SOP's.
This is reflected in the accident and incident statistics of good companies versus low quality companies, and Lionair is a classic case in point.
If you are unfortunate to be working for a dodgy operator, apply like mad to all of the good companies, but in the meantime, try to maintain your professional standards. If a critical mass of pilots maintain a professional standard, they can actually slowly change the corporate culture of dodgy operators. And it is the corporate culture of an organisation that ultimately drives the safety standard. Let me say that again, it is the corporate culture that ultimately drives the safety standard. P2F would have to defined as very poor corporate culture.
So bottom line, if your company fails to supply professional direction, supply the professionalism from your own resources. Work hard at knowing the rules, maintain as high a standard as you are able to. If you are an FO, don't be shy to speak up, command a go around if things are getting out of shape, hit the TOGA button and take over if you have to, the very worst that can happen is your employment may be terminated, at least you will be alive and you can hold your head high. If you have a command maintain your standards! The overall goal is to die as an old retired codger with lots of wrinkles, and lots of grey hair.
Lastly keep accurate records. Accurate documentation will be invaluable in defending your position, should that become necessary. Remember All crooks hate being publicly exposed. The power of public opinion can be a powerful lever. Above all else do your best to stay safe. The safety of world aviation is collectively in our all of hands.
If you are an FO, don't be shy to speak up, command a go around if things are getting out of shape, hit the TOGA button and take over if you have to
That's very commendable and obvious, but if the FO is from an Asian culture, it may be impossible.
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India four two
It is a fact that Asian carriers have a substantially worse safety record than western airlines, and your comment bears testament to that fact.
Do you wish to change that situation? If you do, and for the sake of aviation safety, you should, attempt to change corporate culture one person at a time, (starting with you own mindset), it is the only logical course of action available.
Of course the other course of action is just give up and go with he flow. A personally easier path but not constructive, as far as safety is concerned.
Do you wish to change that situation? If you do, and for the sake of aviation safety, you should, attempt to change corporate culture one person at a time, (starting with you own mindset), it is the only logical course of action available.
Of course the other course of action is just give up and go with he flow. A personally easier path but not constructive, as far as safety is concerned.
I don't have experience with monitored approaches and therefore I'm not in a position to criticise or praise them, but I don't see how it would have prevented the outcome.
I'm sure that in both systems you simply have to go around if you're not visual by the minima. If the crew elects elect to ignore basic SOP, catastrophe is bound to occur in either system.
I'm sure that in both systems you simply have to go around if you're not visual by the minima. If the crew elects elect to ignore basic SOP, catastrophe is bound to occur in either system.
I am sticking my neck out a bit here but would suggest that statistics show that airlines which use the monitored approach concept have far fewer accidents on NPAs.
In the promotion of the Monitored Approach we were advised that a survey of approach accidents over a ten year period found that in circa 75% of cases the approach was a NPA and the Captain was flying the aircraft.
I am not saying this is the sole cause of this accident but venture to suggest that if this crew had been taught and were practised in monitored approaches we would not be discussing this accident now.
It's a bit of a Hijack there firefly. There is a whole thread on monitored approaches. I do them and think they are just fine but you are missing the point if you think you can prevent a crash like this by teaching them a different way of flying the approach. For a start that involves the crew displaying discipline at adhering to SOP's and it would surprise me if this crew have followed their SOP's with discipline. In addition the company has allegedly had so many incidents with P2F at the controls that they don't allow the F/O's to be at the controls below 5000ft, yet they persist with the recruitment system. I doubt they are now going to suddenly trust these same pilots to fly all the NPA's.
The solution isn't monitored approaches, the solution is reform at an Organizational and Industrial level.
If it were to occur it would be a slow grind but results could be seen within a couple of years. Unfortunately about the only motivator I can think of to initiate this type of reform would be if enough airlines were banned from operating internationally. That might gee a few of the politicians into making something happen.
The solution isn't monitored approaches, the solution is reform at an Organizational and Industrial level.
If it were to occur it would be a slow grind but results could be seen within a couple of years. Unfortunately about the only motivator I can think of to initiate this type of reform would be if enough airlines were banned from operating internationally. That might gee a few of the politicians into making something happen.
It's a bit of a Hijack there firefly. There is a whole thread on monitored approaches.
The solution isn't monitored approaches, the solution is reform at an Organizational and Industrial level.
We need corrective actions to prevent the next Lion Air similar accident. Criminal prosecution of these pilots provides nothing more than the satisfaction of extraordinary punishment for poor CRM.
Some of us are looking for a heavier hand to be laid on Lion Air by their regulator to minimize the occurences of crew errors.
I would look to the adequacy of training as well as the failure rate culling process of those who do not display expected CRM abilities under pressure. Standing down a few pilots before an accident might be in the right direction.
I don't know what problems exist with the regulatory body so no comment there as yet. I typically don't look to them as causing an accident other than permitting the situation that contributes to an accident.
Some of us are looking for a heavier hand to be laid on Lion Air by their regulator to minimize the occurences of crew errors.
I would look to the adequacy of training as well as the failure rate culling process of those who do not display expected CRM abilities under pressure. Standing down a few pilots before an accident might be in the right direction.
I don't know what problems exist with the regulatory body so no comment there as yet. I typically don't look to them as causing an accident other than permitting the situation that contributes to an accident.
CRM takes work to implement and sustain
Any comment, and I mean any comment, about runway unsighted @ 150 feet (unless conducting cat11 or 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 continuing 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.
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 continuing 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.
Third: "Who in their right mind?"
In order to "get your mind right" you have to buy into the culture that has evolved in the best airlines, where CRM has become a byword and a core competency. Your organization has to embed and nurture that cultural assumption, or it won't sustain over time.
I used to teach CRM, but the truth is that I was a reluctant convert in the 80's as it got emphasized more heavily in my organization. It wasn't until I learned the simple expedient of "hey, Bubba" as my entry level means of breaking the cockpit gradient with some of our more crusty aircraft commanders that I became a believer. Good thing I became a believer. A year later I got a "hey Bubba" froma co-pilot that probably saved us from flying into the sea. I once got a "hey Bubba" from an aircrewman that helped the two of us up front avoid a wheels up landing at an unfamiliar field.
CRM didn't come from Orville and Wilbur. The lessons learned that led to it were written in blood. While I don't disagree that the info to date show us a crew with poor discipline, sending out undisciplined crews is a profound organizational issue, as is "getting pilots' minds right" regarding how team work, CRM, and cockpit gradients (and adhering to SOP) all fit together in professional aviation outfits.
Sorry for the long post. The root causes (at the human factors level) in this one smell of supervisory error, and numerous deficiencies in organizational climate.
Last edited by Lonewolf_50; 17th May 2013 at 13:10.
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.
Neither at 500 feet. (FIVE HUNDRED)
Neither at 450 feet.
Neither at 400 feet.
Neither at 350 feet.
Neither at 300 feet.
250 feet. Nothing.
200 feet. Nothing.
150 feet. "I can't see the runway" the F/O says. Change of controls.
100 feet. nothing happens. (ONE HUNDRED)
50 feet. nothing happens. (FIFTY)
(FOURTY)
(THIRTY)
(TWENTY) the captain initiates a go around.
(TEN) (SOUND OF ENGINE SPOOL-UP)
(SOUND OF IMPACT)
Something missing.
PF didn't call go around at MDA and Captain didn't do anything. So the Captain actually wanted to descend lower in the hope of becoming visual. No one "froze" or became disorientated either I presume. The Captain had made the landing decision long before the got to the MDA.
I had Sriwijaya tell the tower the other day that he had me visual when he was actually 5 miles away heading in the other direction to turn inbound for the approach. This is very common here. Why did he say that? Well because he knows that if he says he can see me the tower will clear him for the approach. If he cant see me then he will be made to wait. The Lion Air Captain going in to Bali probably had loads of reasons why he wanted to land first time and they could be anything from needing to meet his girlfriend (going around and into the hold and then shooting another approach may take up to an hour and that's eating into my time he's thinking) to not wanting to have to eat his Nasi Goreng cold. You also have to remember that going around here will cause all sorts of nonsense not only from management but from fellow Captains not letting you hear the end of it. Not landing first time is almost like not being man enough for the job.
The question we need to ask is why had the Captain made the landing decision before he commenced the approach?
PF didn't call go around at MDA and Captain didn't do anything. So the Captain actually wanted to descend lower in the hope of becoming visual. No one "froze" or became disorientated either I presume. The Captain had made the landing decision long before the got to the MDA.
I had Sriwijaya tell the tower the other day that he had me visual when he was actually 5 miles away heading in the other direction to turn inbound for the approach. This is very common here. Why did he say that? Well because he knows that if he says he can see me the tower will clear him for the approach. If he cant see me then he will be made to wait. The Lion Air Captain going in to Bali probably had loads of reasons why he wanted to land first time and they could be anything from needing to meet his girlfriend (going around and into the hold and then shooting another approach may take up to an hour and that's eating into my time he's thinking) to not wanting to have to eat his Nasi Goreng cold. You also have to remember that going around here will cause all sorts of nonsense not only from management but from fellow Captains not letting you hear the end of it. Not landing first time is almost like not being man enough for the job.
The question we need to ask is why had the Captain made the landing decision before he commenced the approach?
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‘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.