AAL 331 Kingston final report

[aa73]

OK465,

They were accepted into ASAP due to the fact that 1) Jamiacan ATC and authorities were also found at fault, 2) they did not intentionally violate any regs, and 3) due to 1 and 2 above, this accident fell into the classic scenario of the crew being led into the circumstances....i.e., it was deemed an accident that has the potential of misleading any crew if they're not vigilant, which is the whole purpose of ASAP to begin with. In other words, FAA and NASA deemed this accident very worthwhile to learn from and accepting them into ASAP was well worth the consequences for future prevention. This as opposed to the type of accident where the crew is found blatantly negligent and intentionally violated regs, in which case they'd not only NOT be accepted into ASAP but terminated as well.

I will restate once again that I'm not clearing the flight crew from blame, their actions in the end led to the accident....but rather, I'm more concerned about posting ALL the facts surrounding this accident, since most posts here have only focused on the flight crew's actions, as well as correcting some of the misinformation that was posted. Finally, I'm also more concerned about pointing out the traps we can all fall into, that MAY lead us into making that one last bad decision that can have unfortunate results. There is much to learn from this accident.

Regards

[Aluminium shuffler]

All other things being equal, and ILS is safer than an NPA, and so a bias towards the ILS is to some extent natural. But when the other variables are added, that may no longer be the case, and it is the crew's responsibility to weigh all the information and do what is appropriate. I this case, the safety of the ILS was outweighed by the winds in conjunction with wet conditions. This is usually a grey area, though in this instance, if the crew were given the correct winds, there seems to be less leeway. What is still indefensible is to press-on when there is such a massive energy excess over the runway - that only ever ends up one way, and yet pilots still do it several times a year. Serious efforts need to be made into getting pilots to be less committed to landing off an approach where they are visual.

[johnnyringo42]

Not true, 3 guys landed ahead of them on 30 without going thru any major weather but they insisted to MLY tower that they will go straight in 12 after repeated warnings from the tower about the prevailing conditions and the fact that the runway in use was 30.

[safetypee]

OK465, #32 , but don’t confuse benefit of the doubt with an understanding of various points of view.

Re First Air 737, I disagree, there could have been greater consideration, if only in supposition, and where many people ask why didn’t the FO intervene because it appeared that his awareness differed from the Capt's, perhaps this was not the required (correct) awareness / understanding; thus identifying weaknesses of in the expectation of cross monitoring.
In this accident, it appears that both crew had a similar understanding of the situation, but not necessarily the required one, which again questions the expectations of cross monitoring.


Offchocks “a Captain is ultimately responsible”. ‘Ultimate’ often infers overall responsibility – last in the defensive chain, first at the accident, etc, which is not 'responsibility'. This accident involved many powerful organisational issues; ‘responsibility’ in these areas should be considered.
“Responsibility lies with those who could act but do not, it lies with those who could learn but do not and for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer”. P. Capper, Cave Creek Commissions of Inquiry.


aa73, I dislike the ‘legal’ approach to decision making (#37); it implies searching for a way round the rules and regulations – “how can I do this” opposed to questioning “should I be doing this”, which might lead to a safer option.
This crew unintentionally violated rules; but as James Reason stated – “it’s not the violation which gets you, it’s the errors when violating”, thus the focus should be on the origins of the errors.


Phantom Driver, you use automation (#41) – Rad Alt, Computed wind, but how accurate? Rad Alt is very accurate, less so the assessment along the runway / over the THR when you are ‘on top’; the majority of FMS generated winds lack accuracy, or have a time delay, this was covered in the report.

[Offchocks]

safetypee ...... Point taken, however I was referring to a mistake made in a cockpit is the Captain's responsibility and perhaps should have made that more clear.

[Callsign Kilo]

The Accident & RNAV Approaches

There are many CRM points to take from this report. Situational Awareness, due to the lack of knowledge of an RNAV procedure for RW30. Decision making, FL30 landing with a tailwind on a rain soaked runway close to max landing weight on the -800. Advocacy, Inquiry, Anticipation…you name it.

Yes, the crew got it wrong on the night. All the holes lined up, but spare a thought. These guys have relived the horror over and over again. Maybe we should all just learn from it rather than repeatedly kick the **** out of them? The report is very well written and a great learning tool.

As for some comments that an ILS is easier. Well, it might be. However an RNAV approach using VNAV for vertical guidance isn't exactly Chuck Yeager stuff. This isn't a slight at the crew in question whom, with their level of combined experience, would probably admit so too. Yes, more can go 'wrong' than with a standard ILS, however a timely brief covering the contingencies should keep everyone in the loop. It just requires a little more thought beforehand. And on this flight, there would have been time for that.

[framer]

You have an ‘inbuilt’ awareness / relationship with tailwind and F40. Excellent, but how was this achieved, learnt, taught; whatever that process was/is, it was apparently lacking in the accident scenario (a difference in views) – this doesn’t discount the possibility that the crew knew about F40, but just failed to recall it on the day. Your ‘trigger’ appears to be ‘tailwind’ – I fully agree with that concept.

There is a good point here. A lot of the time we think things are " just basic common sense" but if we dig deeper and question why they are so obvious to us, we find that it is because of the environment we have learned in, trained in, operated in. Prior to operating in Asia I would have put much of my 'inbuilt awareness' into the category of basic common sense. But after I had been operating with crews from all over the planet with sometimes very poor training backgrounds, I realised that at some stage I had been taught these things, or observed them in others and taken them on myself, and the chaps I was flying with had not been so fortunate. Personally I would have thought that an AA crew would have had the benefit of great training and experience but I have never flown in the US so I'm not sure.

and so a bias towards the ILS is to some extent natural.

I wonder if that is in part due to the fact that the US has a lot of ILS's available to crew. For a 737 crew in this part of the world an RNAV approach is very common and I don't think it would put many people off changing runways.

a last minute change to an RNav 30 is not an option if not already prebriefed/set up

I strongly disagree with that. It is up to the crew to make the time to brief it and set it up via a holding pattern or vectors. If it can't be done without losing the option of a divert then maybe the divert is the best choice? Maybe fuel policy needs addressing?
On that note, how important are accident reports to aiding pilot decision making? Ten years ago I read a report about an aircraft that had a runway change just before joining an arc, instead of turning right to arc left they were asked to turn left and arc right. They accepted the change and quickly lost SA and crashed 7 miles short of the field. At the time I was new to command and decided that if faced with that situation I would request direct to the overhead to hold and brief the new approach. Guess what, a month later that exact scenario happened to me approaching an NDB arc .the F/o read the new clearance back but I asked him to request direct to the overhead for the hold. It was easy because I had made the decision a month earlier, that was the benefit of the report to me, advanced decision making. So in my mind, if we are serious as an industry about improving decision making, why not use our findings from reports? What would be wrong with rostering one day a year in the classroom to dissect an accident report or three? It will cost money but will it make the industry safer?

[wingview]

While almost everybody is bashing the crew, I can hardly see anything about missing plates to the crew, standing water not told by ATC, almost no rwy light's, no paint to see in the dark and a 12 hr duty with only 2 men crew.

This was an accident waiting to happen and will happen again with the lack of info and fatique! Just maybe an other airliner next time!

[SKS777FLYER]

Framer, I hear you about the value of accident reports to load ones personal information, decision making mechanism.
The Captain of the accident flight had been a Miami based 727 Check Airman and was very experienced thruout the Carribean and Central America.

Within AA , was passed down some of our most egregious accidents and words of wisdom/ directives / procedures / techniques derived from those accidents. One of those accidents regularly talked and taught about was flight 625, a B-727 touching down about 2,800 feet past the threshold of a 4,658 foot runway at St. Thomas in 1976.
Floating, touchdown zone and speed bleed-off was one of those almost constantly discussed hot topics during my career at AA, tho long touchdowns continued year after year as I think we pilots wrestle so often with attempting to finesse the sink rate for a dazzling touchdown at the expense of precious runway behinds us

[framer]

Thanks sks777, with that in mind, what would you put the decisions made here down to?

[SKS777FLYER]

Framer,
I would guess, task saturation with the evolving deteriorating situation.
Insufficient or no plan for abandoning approach.
Fixation on low sink rate for smooth touchdown.

Just some of the thoughts reading the accident report evokes.
Glad both pilots,retained their jobs. They have some valuable experience to pass along during the remainder of their careers.

[aa73]

Safe typee, I also definitely do not condone the whole "legal,so must be safe" philosophy, not by a long shot...was just pointing out that a big part as to why they were accepted into ASAP was b/c they did not intentionally do anything illegal (until they landed outside of the t/d zone, anyway.) the procedures back in 2009 was that the 737 could legally accept up to a 15kt tailwind on a wet runway and still get stopped. now, of course that implies flaps 40 and Max auto brakes with no float and a firm touch down, but you see where I'm going with this: the bad decision making was but one of the "holes" that lined up on them that night...another was the fact that they were, technically, legal (although definitely not on the conservative safe side.)

[aa73]

sks777,

my personal opinion is that they were not going for the smooth touchdown, rather, the tailwind plus the pitch up at 70ft is what contributed to the long float. at least that is what I think happened. as you mentioned, the CA was a well experienced ex check airman who was very well versed in Caribbean/SA ops and I think he would have been aware that almost all runways in the Carib are not grooved, hence he would not have been going for the smooth landing. Jmho

[safetypee]

Al Shuff, I reiterate that my approach is not to defend the crew, but an attempt to understand and learn from the circumstances and behaviours of everyone involved.
I really do agree with your concerns and frustration around runway overruns; the industry still struggles with the problems associated with these. Baulked landings are a final mitigation; ops/trng must have keen awareness of this and promote skills of decision making and flying. However, there are other mitigating activities, perhaps less sensitive to time pressured human decisions on the runway, which arise from preceding circumstances, and where many are organisational aspects that contribute to the difficulties in changing a course of action.

Attitude; again I agree, but are we in charge of our attitude – are there factors which influence awareness and decision making which we might not be fully aware of.

If we consider the circumstances and events completely independently of the outcome, would the decisions and activities still be open to criticism.
How many of the contributing factors appear in every day operations, are tolerated, excused, not checked/debriefed; would this ‘normal’ so-called ‘safe-attitude’ lead to an ‘unsafe-attitude’ as might be identified in this accident? I would argue that there are the same, thus solutions must start with our attitude to every day ‘normal’ operations, activities, objectives, regulations, procedures, and as has been stressed, checking and correcting errant activity.

An important aspect of this unfortunate event is that provides an opportunity to learn. What factors could have prevented it, what combination of factors led to it; there may be very little difference between these, again only our attitude might differentiate between them.

[aterpster]

ok465:

True, the claim was made that they were unaware of the RNAV approach, and though I fully appreciate AA73's input, I'm a bit surprised this made it thru the ASAP process, but not my call.

I'd lay that one at the feet of AAL training and flight ops management rather than the crew.

Why would flight ops management permit any crew to go to this remote island airport without making certain it is understood by all that one runway end has only an RNAV IAP? Being qualified for RNAV IAPs essentially on paper only cries out for some cultural changes at AAL, similar to what we thought would happen after Cali.

[waves-dubai]

I am still trying to find the answer as to why this aircraft was not properly configured for landing.

IMO, I see no reason why ATC should be at fault.

[Aluminium shuffler]

If ATC did pass the correct weather information, and recommendations were made to use RW30, then ATC did all they could to prevent the accident and cannot be held at fault.

Any way you cut it, this accident was due to the plots ignoring the conditions of the approach and electing to fly an inappropriate approach in an inappropriate configuration. That is only the first major lapse. Refusing to go around from an irrefutably dangerous situation in the long flare was a separate issue, albeit triggered by the first, which was again treated in a dire manner. There are just no excuses for these guys, and I would never want to be in an aircraft they were flying - they may have learnt something from the accident, but they clearly don't have to required mindsets to be safe.

[alf5071h]

Some questions/observations about the landing performance referred to in the report.
I assume that this version of the 737 does not have any credit for thrust reverse in the certificated data, but it might do for estimated slippery/contaminated data or in the manufacturer’s actual distances.
There are minor differences in the operator’s presentation of the certificated data. Bulletin -07 refers to the total landing distance based on FAR +67/92%, but the landing card using the same basis, infers that the air distance is 1000ft, although the actual certification value might be a lot less. Thus the 1000ft quoted could hide the fact that even a 1000ft touchdown point eats-into the total factored distance.

The landing card also presents both the certificated factorised FAR data (WET/GOOD) and the estimated wet/contaminated data on the same page. Although the basis of each data set may be explained, the proximity of information might not provide sufficient emphasis to identify the significant difference in the risk to be considered when using the estimated wet/contaminated data vice wet/good.
How do other operators publish this data?

Bulletin –07 ‘runway condition table’ (Page 203) does not refer to water in the Medium (Fair) category, implying that this is associated with either fully factored wet performance (1.92) or standing water (>1/8in, 3mm) for the estimated contaminated performance. This omission might create a gap in stopping performance between those runway conditions covered by the 1.92 factored data and those using estimated - contaminated data; would 1.92 be sufficient for <1/8 Wet/Good, but not enough for Medium (fair) wet.
This method of presentation and the lack of descriptors might hinder crews’ consideration of wet conditions below the wet/good definition, because there is a weak (no) correlation between the reported conditions – rainfall rate, and the braking performance.
How do other operators publish this data?

On this latter point the FAA’s TALPA proposals use the same format; however they do acknowledge differences between wet grooved, smooth, and PFC runways but do not differentiate between them except for ‘slippery when wet’.
Other significant influences on performance are the runway texture (and condition) and depth of the tyre treads, but there are few references alerting pilots to these aspects.

[aa73]

If ATC did pass the correct weather information, and recommendations were made to use RW30, then ATC did all they could to prevent the accident and cannot be held at fault.

Again, the official accident report clearly reports that, under cause and findings, ATC shared some of the blame. Here are some snippets from the report:

3) ATC did not offer AA331 the option of the RNAV (GPS) Rwy 30 approach (the flight plan showed the aircraft was RNAV capable.)

44) ATC runway surface condition reporting did not fully conform to the ICAO recommendations.

46) ATC did not alert the crew that no braking report had been received, as required by ATS MANOPS.

47) ATC did not inform AA331 that the runway was wet until less than five minutes before the aircraft landed.

48) ATC did not inform AA331 of the reported "heavy rain."

49) ATC did not assign runway 30, the into-wind runway, as the active runway, as required by ATS MANOPS.

50) ATC did not follow the ATS MANOPS in terms of active runway assignment, placing of Weather Standby, reporting of weather, and giving the arriving traffic a braking action report.

51) The Enroute and Approach controllers gave the AA331 flight crew estimated weather reports, and did not state this was ATC observed weather, not official weather reports.

52) Neither NMIA nor ATC had any specific procedures for conducting runway condition inspections during inclement weather , and disseminating this information to landing traffic, contrary to ICAO recommendations.

Granted, these look like "small potatoes" contributing factors and it remains important to realize that the flight crew's direct actions are what ultimately led to the accident. however, there remains a very good possibility that ATC could have been the ones to have broken one link in the chain, by adhering to approved ICAO procedures, that could have prevented the accident. That is why the flight crew were ultimately accepted into ASAP, as there was no intentional violations of FARs. I'm also going to repeat that the flight crew really underestimated the runway and weather conditions that night, due to inadequate reporting by ATC, that "set them up" for their fateful decision to land on 12. The rest of the decisions, such as Flaps 30, autobrakes 3, the long float, were clearly the flight crew's errors and are mentioned as such. But it must also be said that ATC helped set the stage, and that is why they are mentioned in the accident report as contributory causes.

As far as these gentlemen's qualifications and reputations, I wouldn't hesitate to put my family on their flights every day of the week and twice on Sunday. They are highly experienced aviators who made some bad decisions after the stage was set for them. We've all been in their shoes, however, the difference is that we were able to break a link or two on the chain and prevented the holes from lining up. There but for the grace of God go I. Apparently the FAA, NTSB and NASA agree as well.

[aa73]

Speaking in general terms only (aa73 correct me please if I say something inaccurate, I'm speaking from memory and things may have changed)....

....in the early days of ASAP, the lion's share of ops ASAP matters were 'pilot deviations' although not exclusively of course. The untested question would occasionally come up, 'What if it involved hull loss, injury, or worse fatalities, would it be admissible?' The conclusion was that 'admissibleness' was a matter primarily of meeting the LOA requirements.

Without debating this, of more interest was that ASAP committee meetings and findings were as one would expect, confidential and any external party attending a meeting, to include reps from other carriers, signed a confidentiality agreement....the specific carrier committee deciding what and in what format other carrier reps could pass on to their fleets.

It was also often asked that if there were to be an accident referred to this program, would an NTSB rep be invited to attend. The answer was unequivocally, 'of course', but they would sign the same confidentiality agreement, prompting the speculation that they would most likely decline the invite for this reason.

In this light, of interest here is the fact that you've got a non-US AIB and an operator internal committee sworn to confidentiality, i.e. not necessarily having access to all of each other's info, but both 'investigating' the same incident for learning and prevention purposes, but lending to a potential for the conduct of and existence of two very different analyses....further complicating not only what can actually be learned, but what can rightly be distributed, and to whom.

Good questions OK465 and I am probably not able to answer in depth as I am not an expert on ASAP.

What I can tell you is that, quite simply, a hull loss will not exclude a crew from ASAP admission if it was found that the hull loss was not caused by an intentional violation of the regs. The folks who run the ASAP program (company, union, and FAA) are highly experienced folks who go to great lengths to remain neutral and anonymous when investigating reports. As long as the criteria for admission into ASAP are met, the flight crews will get accepted. However, ALL of the criteria need to be met and it has to be an unanimous approval from everyone. We've had several incidents where flight crews were not accepted simply by one vote, or due to the fact that they intentionally violated a reg or two. All airlines have this situation.

As far as confidentiality agreements and such, I'm in the dark. The tone of your post sounding like you were suggesting there might be some conflicts of interest in the ASAP program, some CYA stuff, etc... I have no clue if that's correct or not. In this accident, it was deemed acceptable into ASAP quite simply because it was the unanimous decision that they had met all of the ASAP criteria and fell under the definition of "non intentional" pilot deviation as a result of outside influences (ATC, etc.)