Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain
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If the approach was unstable and it was absolutely clear that the airplane was not actually on the plotted approach then did the FO as PM have responsibility to abort the approach? Would seem that he commented 3 times to many. If he felt strongly enough to comment twice while situation was still salvageable then he had a professional obligation to act. (just an SLF opinion)
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How common is this?
Seems to me that we really have no idea of the frequency with which such a disagreement occurs. Only way to know wouldbe to have an independent entity review a large number of routine CVRs of approaches to see if this is in fact a rare event or not. Although I obviously don't know, I suspectthat probably no one here does either. Many of you have years of experience in such situations. Does this often, rarely or occasionally happen?
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Does this often, rarely or occasionally happen?
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Lots of room for judgement with such a rule.
That's exactly the point. Most of the posts in this thread are questioning the FO judgement. Yet if the FO has weak character or otherwise feels psychology inhibited from performing an action moving that decision making point to another location on the causal chain doesn't help him. The problem is not where the decision making should take place the problem is whether the FO should feel empowered to make the decision. Giving more room for judgement to a psychologically inhibited pilot isn't going to make him more decisive but less decisive because of the additional mental room he has to find excuses to do nothing.
The question here is age-old: what is the proper steepness of the command gradient between Captain and FO and when, if ever, can the FO violate that gradient? If there were easy or simple answers to that question they'd have been figured out and implemented by now.
At the end of the day there is one easy proposal to prevent every airline accident--everyone stay home. Once one accepts that this isn't a realistic solution then it simply becomes a question of trade-offs and risk management. Good luck trying to convince the industry that every time there is nervous Nellie as PM that a go-around is required.
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This is a cautious suggestion from a non-pilot with quite extensive involvement in maritime CRM.
Would it be practical to give the express authority to order a go around to the PNF, in all cases?
Obviously the PF can go around at his/her discretion. No need to change that.
The PNF is looking at the same instruments and the same view out of the windows. The PNF is very much less likely to become task saturated.
If the PNF has formal authority to command a GA at her/his sole discretion then the PF, even if task saturated, is much more likely to comply instantly.
Would it be practical to give the express authority to order a go around to the PNF, in all cases?
Obviously the PF can go around at his/her discretion. No need to change that.
The PNF is looking at the same instruments and the same view out of the windows. The PNF is very much less likely to become task saturated.
If the PNF has formal authority to command a GA at her/his sole discretion then the PF, even if task saturated, is much more likely to comply instantly.
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MountainBear says that
I think this issue was figured out a long time ago regarding US ICBM missile launches - you need two crew members to turn their keys at the same time to launch a missile. Was there not a movie about a US nuclear missile submarine recently that featured exactly this dilemma? The decision of the second officer is always required before a positive commitment.
Surely, MountainBear, modern airlines are acutely aware of the need to eliminate the possibility of letting any pilot get through a training process so as arrive at the situation that you describe, viz: "FO has weak character or otherwise feels psychology inhibited from performing an action."
I support Methersgate's revision of my PNF veto idea - the PNF should have an express authority to order a go around.
Yet if the FO has weak character or otherwise feels psychology inhibited from performing an action moving that decision making point to another location on the causal chain doesn't help him. The problem is not where the decision making should take place the problem is whether the FO should feel empowered to make the decision. Giving more room for judgement to a psychologically inhibited pilot isn't going to make him more decisive but less decisive because of the additional mental room he has to find excuses to do nothing.
The question here is age-old: what is the proper steepness of the command gradient between Captain and FO and when, if ever, can the FO violate that gradient? If there were easy or simple answers to that question they'd have been figured out and implemented by now.
The question here is age-old: what is the proper steepness of the command gradient between Captain and FO and when, if ever, can the FO violate that gradient? If there were easy or simple answers to that question they'd have been figured out and implemented by now.
Surely, MountainBear, modern airlines are acutely aware of the need to eliminate the possibility of letting any pilot get through a training process so as arrive at the situation that you describe, viz: "FO has weak character or otherwise feels psychology inhibited from performing an action."
I support Methersgate's revision of my PNF veto idea - the PNF should have an express authority to order a go around.
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There always has (rightly) been, in UK ops, the 'authority' for an F/O to order a g/a. For decades we have worked on the '3 challenges then assume incapacitation' rule although commonsense suggests if getting near 'invisible' Cumulo-granitus one might speed up that process.
Different airlines and different cultures used different phrases. My favourite was Lufthansa -their response was to call the Captain by his christian name.
CRM wasn't even a gleam in anyones' eye at that stage, Sir was God.
A psychiatrist died and went to heaven, St. Peter met him at the Pearly Gates, and said " Glad you've come, we're having a little trouble with God, he thinks he's a BOAC Captain "
Cultural issues can vary from country to country even within Europe. Re the comment about Lufthansa pilots using the captains first name to get his (her) attention is perfectly sensible since even now Germans seldom use first names in business contexts and so it does make some sense.
Point brought home to me when discussing a meeting I had in Germany with a former colleague who now worked at that company and had arranged the meeting. I could not remember the name of one of the German attendees and so asked my friend on the basis that 'Gert something had told me.....' , my friends reply was that he could not help, as he put it 'I would not know the first name , the man would just be Herr X to me.'
However that also illustrates the point that in most societies there is a degree of deference to senior figures, its brave junior in almost any part of the world who publicly corrects his boss in a meeting even if a serious mistake has been made. On a flight deck the consequences are much more serious but also the reluctance factor perhaps reinforced by the fact that the captain is 'THE captain, often wearing insignia to denote that and the clear traditional left seat right seat hierarchy and of course there is often very little time between noticing something is wrong and a possible disaster.
At least in the business context sometimes the junior in rank is more experienced or more expert than the higher ranking manager and they certainly are not wearing uniforms to denote rank and status. So I think this makes it harder on the flight deck , if I can make that observation as passenger, to correct/criticise the boss is always awkward at the very least and in some places virtually unthinkable.
One point that does come across in this debate is the idea of a 'disagree call' when the aircraft reaches minimums or decision height , does seem to take rank out of thinks quite bit.
All in all though this is battling human conditioned attitude and just underlines that a pilot is a different job from most others because the time between mistake and disaster can be very very short
Point brought home to me when discussing a meeting I had in Germany with a former colleague who now worked at that company and had arranged the meeting. I could not remember the name of one of the German attendees and so asked my friend on the basis that 'Gert something had told me.....' , my friends reply was that he could not help, as he put it 'I would not know the first name , the man would just be Herr X to me.'
However that also illustrates the point that in most societies there is a degree of deference to senior figures, its brave junior in almost any part of the world who publicly corrects his boss in a meeting even if a serious mistake has been made. On a flight deck the consequences are much more serious but also the reluctance factor perhaps reinforced by the fact that the captain is 'THE captain, often wearing insignia to denote that and the clear traditional left seat right seat hierarchy and of course there is often very little time between noticing something is wrong and a possible disaster.
At least in the business context sometimes the junior in rank is more experienced or more expert than the higher ranking manager and they certainly are not wearing uniforms to denote rank and status. So I think this makes it harder on the flight deck , if I can make that observation as passenger, to correct/criticise the boss is always awkward at the very least and in some places virtually unthinkable.
One point that does come across in this debate is the idea of a 'disagree call' when the aircraft reaches minimums or decision height , does seem to take rank out of thinks quite bit.
All in all though this is battling human conditioned attitude and just underlines that a pilot is a different job from most others because the time between mistake and disaster can be very very short
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I have used the TOGA switch option when a first officer didnt respond to my 2 go around requests,(unstable around 100ft)seeing the FD going up "woke him up" and after a "flaps 15?"remark he then continued the maneuver as normal and did the next approach without problem.
One of the reasons i use the AT ARM mode on the 737.
One of the reasons i use the AT ARM mode on the 737.
One of the reasons i use the AT ARM mode on the 737.
If the F/O ignores your initial warning of unstable approach then simply take over control and if a GA in needed it is quite easy to push open the thrust levers manually.
I would be interested to know what readers of this thread think might have happened if the crew had been flying a Pilot-Monitored Approach, i.e. the Captain had been the PM during the approach, planning to take control for landing, and the First Officer PF for the approach and go-around, so it is still very much "the Captain's leg".
In this conjecture, the F/O then flies the aircraft just as the PF does in the report. The Captain makes the PNF's observations etc. again just as in the report. Do you think it more likely that a go-around would have been initiated much earlier, or would it have made no difference?
In this conjecture, the F/O then flies the aircraft just as the PF does in the report. The Captain makes the PNF's observations etc. again just as in the report. Do you think it more likely that a go-around would have been initiated much earlier, or would it have made no difference?
Last edited by slast; 3rd Apr 2014 at 13:47.
Steve, there could be merit in using a shared monitored approach. The more experienced pilot, relieved of the flying workload might have detected the deteriorating situation earlier. However, this view should not assume that the more experience pilot will always provide a better understanding or have sufficient mental resource for establishing the situation and deciding to act. Also, there are some very experienced and capable First Officers in the industry – yet over time we all have to learn and thus could be vulnerable at some point.
An encouraging aspect is that many HF texts relate decisions to the quality of understanding; thus any procedure which enhances situation awareness and use of experience to aid understanding should contribute to safety.
Too often the industry, and as in this thread, assumes that the monitoring pilot will be able to understand the situation and decide to act. It is equally likely that in this accident the FO/PM crossed-checked the PF displays to improve his understanding, and noticing the disparity, accepted the PF display and actions as being better than his, thus there was no intervention.
Based on what we now know this view might be considered as a failure in understanding and intervention (hindsight bias), but the behaviour was exactly the same as would expected if the Capt/PF displays were correct and the FO/PM were in error; the disparity might have been noticed but not commented on, except with good mentoring the Captain could have debriefed it after landing.
A problem in some parts of the industry is the belief that SOPs and CRM (human activity) will provide adequate safety in all circumstances. This is not an anti SOP / CRM view, but acknowledging that these tools have limits in particular circumstances, which operations appear to be encountering more frequently.
Thus anything which questions this attitude and considers alternative procedures will be of benefit.
An encouraging aspect is that many HF texts relate decisions to the quality of understanding; thus any procedure which enhances situation awareness and use of experience to aid understanding should contribute to safety.
Too often the industry, and as in this thread, assumes that the monitoring pilot will be able to understand the situation and decide to act. It is equally likely that in this accident the FO/PM crossed-checked the PF displays to improve his understanding, and noticing the disparity, accepted the PF display and actions as being better than his, thus there was no intervention.
Based on what we now know this view might be considered as a failure in understanding and intervention (hindsight bias), but the behaviour was exactly the same as would expected if the Capt/PF displays were correct and the FO/PM were in error; the disparity might have been noticed but not commented on, except with good mentoring the Captain could have debriefed it after landing.
A problem in some parts of the industry is the belief that SOPs and CRM (human activity) will provide adequate safety in all circumstances. This is not an anti SOP / CRM view, but acknowledging that these tools have limits in particular circumstances, which operations appear to be encountering more frequently.
Thus anything which questions this attitude and considers alternative procedures will be of benefit.
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the Captain had been the PM during the approach, planning to take control for landing, and the First Officer PF for the approach and go-around, so it is still very much "the Captain's leg".
Over the years it has evolved into the captain's "leg" or the first officer's "leg" with the perceived dumbing down of the captain's authority to being the PNF. Recently I heard of the case where it was the first officer's "leg" on a five hour sector and radar showed storms ahead. The captain called ATC and asked for deviation 20 miles from track due weather. ATC approved the deviation. The F/O then turned to the captain, who was keeping a close eye on the radar, and said "I understood it was MY leg and that means MY decisions." The captains response was rightly unprintable.
Too many captains are reluctant to step in simply because it is the first officer's "leg" and the captain feels it is maybe wimpish to exert his legal authority to run the show. There is nothing wrong with the captain saying to his first officer "would you like to do this take off and departure?: And then when it suited him, just take over control for the rest of the flight. Where he need several breaks he simply hands over control to the first officer until it suits him to take over again. He may then use his discretion to offer the first officer the approach and landing. It is not the God Almighty "right" of the first officer to be given a leg at all - and never has been. He is employed as the support pilot in a two man crew - not a pseudo captain.
Last edited by A37575; 4th Apr 2014 at 00:22.
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CYRB
As a once earth bound provider of signals, I have this observation:
Report seems spot-on but for maybe one point; the perceived inadvertent movement (by a pilot) of control yoke during the capture phase of the approach.
The ILS (30-yr. old parts, relocated to YRB, contrary to ICAO SARPs) is known to radiate False-Capture (FC) signals. This antenna can further increase FCs in high humidity (fog, rain). FC complaints resulted in TC posting “Safety Notices” to switch from capture to approach only within ~ 8-degrees of centreline (re-Posted by NC, ~ 2010). Flight Inspection(s) don’t report FC, Safety Notice eliminates the need. But, ancillary facilities are required if flight crews are to identify a FC. All that being said; the captain didn’t catch the FC for whatever reason (A/C switched to “coast mode” on flight-director???) Seems the FO noticed something wrong, the captain eventually did, but too late. If the “RU” NDB (2.1 NM before threshold, on centreline) was in service (decommissioned just months prior) they may have realised sooner how far “inland” they were?
. . . just my observations as a once once earth-bound provider . . . .
Report seems spot-on but for maybe one point; the perceived inadvertent movement (by a pilot) of control yoke during the capture phase of the approach.
The ILS (30-yr. old parts, relocated to YRB, contrary to ICAO SARPs) is known to radiate False-Capture (FC) signals. This antenna can further increase FCs in high humidity (fog, rain). FC complaints resulted in TC posting “Safety Notices” to switch from capture to approach only within ~ 8-degrees of centreline (re-Posted by NC, ~ 2010). Flight Inspection(s) don’t report FC, Safety Notice eliminates the need. But, ancillary facilities are required if flight crews are to identify a FC. All that being said; the captain didn’t catch the FC for whatever reason (A/C switched to “coast mode” on flight-director???) Seems the FO noticed something wrong, the captain eventually did, but too late. If the “RU” NDB (2.1 NM before threshold, on centreline) was in service (decommissioned just months prior) they may have realised sooner how far “inland” they were?
. . . just my observations as a once once earth-bound provider . . . .
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Tools last ditch effort to get attention.
Interesting discussion highlights the lack of training in how to get the PF's attention after all the usual attempts. A suggestion I have passed on is to place your palm two inches in front of the PF's face/eyes with a loud "look at me look at me" then when the PF reacts by pushing your hand away or looking at you say "you must go around." or whatever.
No actual physical interference with the PF or the controls.
If he cant see he cant fly but you WILL get his or her attention.
if it does not and the aircraft is in danger save yourself any way you can you have a big problem sitting next to you.
Works with kids too.
No actual physical interference with the PF or the controls.
If he cant see he cant fly but you WILL get his or her attention.
if it does not and the aircraft is in danger save yourself any way you can you have a big problem sitting next to you.
Works with kids too.
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if it does not and the aircraft is in danger save yourself any way you can you have a big problem sitting next to you.
He KNEW the instruments were overwhelmingly telling him they were off-course
heKNEWthere was high ground ahead
heKNEW they were in breach of SOP's
he KNEW his own life and the lives of the Pax and crew were at risk
he KNEW the Captain was following a wrongful course of conduct.
Under those circumstances, I would suggest thatself-preservation and duty to obey safety=rules should transcendall deference to another, wilfully violating crewmember.
Take control, mitigate the danger, argue about it on the ground.
Had the results not been so tragic, the Captain would have had to concede he failed to execute his professional duties.
The paying public had a right to expect better than they got.
DOVE
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In case of doubt ther is no doubt: Go Around!
A Pilot incapacitation can be either overt or subtle.
In order to diagnose the second some airlines have adopted the following:
If the other crew member does not answer any of three calls after he made a deviation from a SOP
or only once if his behavior has affected the safety of the flight, his subtle incapacitation can be assumed.
And then the other pilot has to declare: "Emergency athority! I have control!"
Learn from John Wayne:
The High and the Mighty Promo - IMDb
And let's hope and pray that this ends the series:
http://www.pprune.org/rumours-news/5...nt-around.html
In order to diagnose the second some airlines have adopted the following:
If the other crew member does not answer any of three calls after he made a deviation from a SOP
or only once if his behavior has affected the safety of the flight, his subtle incapacitation can be assumed.
And then the other pilot has to declare: "Emergency athority! I have control!"
Learn from John Wayne:
The High and the Mighty Promo - IMDb
And let's hope and pray that this ends the series:
http://www.pprune.org/rumours-news/5...nt-around.html