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AAL 331 Kingston final report

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AAL 331 Kingston final report

Old 13th May 2014, 20:14
  #61 (permalink)  
 
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Dodgy ATC set us up all the time. I filed two reports for one approach and landing because the ATCU was so bad just the other day, at a major EU airport, but I didn't let them talk me into something foolish. Regardless, poor ATC doesn't explain why the crew refused to go around. Let's not look for excuses - if this had been an oriental or African crew, the reactions on here by many would have been quite different.
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Old 13th May 2014, 20:24
  #62 (permalink)  
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True enough, aa73. They, like anyone else who sits at front of a jet, have been led in to a classic error chain. The blame for which, is usually distributable in all directions.

That said, regardless of met conditions, any competent, safe crew would have abandoned an attempt at landing that deep, regardless of conditions.

We're the last line. Binning an unstable/out of limits/deep approach is often the final link in the chain to be broken. It should, in most instances (this one included) be an easy decision.

If the wind was 120/20 and th rwy dry, any competent pilot with a priority on safety would still go-around when he's half way down the runway with all wheels in the air.

In summary; yes, we've all seen and been part of error chains, and nobody blames the pilots exclusively for that.

Trying to press on with a landing, thousands of feet beyond the touch down zone is criminal negligence.
 
Old 13th May 2014, 23:06
  #63 (permalink)  

DOVE
 
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First of all thank you Aluminum shuffler for expressing several times, but especially with your post 43 exactly my thought. I could not do it better!

Has anybody ever heard of:

"9 multiplied the square root of PSI (tire pressure)?"

Yes: AQUAPLANING!

No one has mentioned it. Nor in the briefging as a possible contributing cause of the paramount increase in landing distance

The ultimate and fatal hole in the cheese.
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Old 13th May 2014, 23:11
  #64 (permalink)  
 
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Rainfall rates are defined by MET definition or WXR return which depends on selections and settings.
How can ATC determine the rainfall rate without met/measured input? ATC reported moderate rain (a subjective assessment?) which agrees with the reported WXR picture. No active Cbs were reported in the immediate vicinity.
The crew described the noise as heavy (who would use ‘moderate’ without being able to distinguish between that and heavy, the assessment ‘heavy’ was also quoted after the evac, again subjective).
“As the aircraft approached Kingston there was light to moderate rain on the weather radar, there were no significant storm cells to fly around, and the radar was indicating a broad area of moderate rain”. P26
“When they intercepted the ILS runway 12, the weather radar painted light to moderate rain”. P27
“ … approach was noisy, because of the heavy rain”. P27 (subjective – noise)
“The first officer reported checking the weather radar returns in the Kingston area, noting that he saw a wide area of green with some yellow, indicating moderate rainfall, but saw no red to indicate convective cloud buildups with heavy rain. P54
The radar was painting light to moderate rain. P65

Runway braking action is based on the measured conditions or assessment according to the Braking Action Chart.
The reported water depth was 0.1in, but it was not established if this was actually measured nor if the next measured increment would be 0.2in.
0.1 equates to wet/good braking, the accident analysis showed medium/fair, yet 0.125 is flooded by definition; (note the possibility of a data gap #64).
How might the crew decide on the braking action based on the information available; according to procedure the WXR and audio cues should have prompted medium. The FO suggested a higher A/B setting which was set; but within this there may have been an underlying belief that the charted performance was sufficient. The crew apparently thought that a wet/good rating was sufficient (supposition from advanced analysis – wet/good may have provided a small safety margin, medium would not). The operator declined to explain ‘Advanced Analysis’; perhaps a gap between operators procedures and practice !!!

This is not to excuse the crew from their professional responsibilities, but an attempt to understand the issues which makes behaving as required very difficult.
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Old 14th May 2014, 00:13
  #65 (permalink)  
 
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Too much political correctness here . Even if the defenders here wish to deflect all the "insufficient data " given to the crew or the timeliness answer this .

1) does "RNAV equipped means RNAV approach approved ? Not quite the same . Many airlines can be enroute RNAV , hence the ATC filing ,but not RNAV SID,STAR or APPR approved . Responsibility falls in the front end to ask for what you need .
2) do you need more than 5 minutes to re.assess your risk level ? What if the crew were given a 25 knot landing clearance wind check at 500 ' ? Or an aircraft blocked the runway ? You ned ATC to tell you to GO?
3) braking reports , even when given are advisory,
4) many,many regions all around the world do not conform to this "requirement" to assign the into wind runway as active " . Aviation would cease if we couldn't land with tailwinds !
5) Should ATC also tell them when to flare , where to touchdown , To GO AROUND , if you float halfway down a freaking wet runway with a tailwind !!


AA73 ...good job defending your colleagues , but the preferred runway in both Jamaican airports have always been easterly and requested even with tailwinds , even wet ! No incident prior to this .You should watch your airline's " kids of the magenta circle " ! It's no wonder management and manufacturers consider us the weakest link . We are paid and expected to think and make decisions . While you may wish to deflect attention to the "fluff" , no one but the front end forced them to continue with the approach and landing !

We are in no way immune and incidents could happen to each and all , but cease the kindergarten / politically correct stuff . If you are man enough to screw it up , be man enough to accept the consequences .

So it is not about it not happening to any of us , it can . However , if one is responsible , then accept that responsibility , which hopefully the Captain has( at least privately) , because if he hasn't and is satisfied with his union's defence of his actions or lack thereof , then HE has not learned from it .
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Old 14th May 2014, 01:10
  #66 (permalink)  
 
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I am not making any excuses for this accident.

But a good warning to people / pilots everywhere is to watch out for illusions.

I'm not talking about the one in which you can see the flight attendant naked.

But the ones through rain soaked windshields, or on upsloping runways etc.

Look em up. Be aware.

I'd bet he would have made a better landing with the HUD off!
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Old 14th May 2014, 01:31
  #67 (permalink)  
 
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Gents,

good discussion. Pease keep in mind, I'm not so much defending my fellow aa pilots as much as using this accident to point out the traps that can get each and every one of us. I think many of you are missing the fact that I am agreeing with you in regards to pilot error, and that maybe many of you consider it blasphemy that I actually brought up other factors that influenced this crew into making the wrong decisions. Be that as it may, this crew screwed up, but the FAA deemed them retrainable and I'm sure they are safely and conservatively carrying AA passengers to this day, and I would gladly be one of them.
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Old 14th May 2014, 02:51
  #68 (permalink)  
 
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stone cold:

1) does "RNAV equipped means RNAV approach approved ? Not quite the same . Many airlines can be enroute RNAV , hence the ATC filing ,but not RNAV SID,STAR or APPR approved . Responsibility falls in the front end to ask for what you need .
Oh please! Read the accident report and the thread
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Old 14th May 2014, 10:33
  #69 (permalink)  
 
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Yes ATP ...your point being ??

I state again that filing RNAV on your icao flight plan is not an indication that you can conduct an RNAV approach . ATC may assume this but the approach ,enroute and arrival phases are all generically filed under RNAV .To conduct the APPR requires regulatory approval . So quite simply , if they wanted it , they could have requested it , but guess what , they didn't review their options . Maybe ATC should have conducted their approach briefing also .

So yes , ATC could have offered , ATC could and should have..ad infinitum.

Perhaps everyone should read the report : the probable cause is attributed solely to pilot error .

The rest are findings ..In case you don't grasp the difference( I assure you , there is ).

The approach Controllers wx data of tailwind and moderate showers doesn't ring alarm bells and the fact that the crew requested straight in ..(traffic permitting , most if not ATC will comply with the Pilot's request ) ..seems a lot of cues were there .

Not the first time either , was it?
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Old 14th May 2014, 11:27
  #70 (permalink)  

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If I remember well, an increase of 50 feet over the runway threshold and 10 knots of V-th each produce an additional 1,000 feet of landing distance, all other condintions been equal.

And if even more for aircraft with tail engines, but also for those with engines under the wings (reverse thrust behind the c.g.), I recall that due to the lateral component of reverse thrust, a phenomenon is triggered whereby the more the axis of the aircraft deviates from QFU (having lost the center, and trying in vain to regain it) the greater a force is generated that takes us out of the Rwy, forcing us to decrease reverser, giving up the best means of deceleration at high speeds.

So if there is a moral in this story, let’s learn from:

Aluminium shuffler
This is not an issue of technical skills. It's an issue of attitude. That is why I can't forgive such events.
high temperatures and altitudes, winds, runway slopes, approach gradients, runway length, desired exit point and surface conditions. Most of my cadet FOs process the same factors with ease and without input from me, choosing flap and autobrake settings and reverse thrust amounts very similar or identical to my own assessments and raising the same "threats" I see, or at least most of them, as they brief me on their approach. It is not some mystical and hard acquired intuition but simple application of Performance A and attention to detail. That is a combination we are all supposed to have.
framer
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.

Last edited by DOVES; 14th May 2014 at 15:53.
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Old 14th May 2014, 18:53
  #71 (permalink)  
 
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Mandating HUD use is perhaps a poor SOP.
Touchdowns might be more accurate in the primary mode with FD guidance. In this accident the offset LOC prevented accurate computation of precision guidance and the HUD mode was changed (Page 28).
FPV was still available, but the Captain considered this to be too much information. FPV is a valuable tool, but if not well practiced it can be demanding. Furthermore the vector has to be referenced to both a desired approach slope (probably the same as the GS in this case) and a ground reference point – the intended point of touchdown, e.g. PAPI. There are no indications that this was the situation nor that it would be easy for this approach, thus the HUD could have been a considerable distraction.
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Old 14th May 2014, 22:11
  #72 (permalink)  
 
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Don't know about European 737 operators but I believe all US 737NG operators require HUD use for all T/O and landings - VMC or IMC - mainly for tail strike guidance.
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Old 16th May 2014, 02:30
  #73 (permalink)  

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-600 and -700 also...?
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Old 16th May 2014, 05:01
  #74 (permalink)  
 
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Am I the only one who thinks that some contributing to this thread are dancing all around the real problem?



I'm retired now, but I still remember when I was a young student Naval Aviator not yet 20 years old. A crusty old instructor (he was about 27 years old) told me, "Land into the wind". And then he gave me a long stare. Since that time I've made countless landings in high performance fighters, various commercial airliners, sailplanes, and to a lesser extent, light aircraft. Most of them were into the wind, but naturally sometimes a down-wind landing is required or at least preferable for one reason or another. Thinking back, downwind landings received my highest level of attention and my personal margin for error became more narrow.


As we all know, sometimes pilots get less than perfect information on which to base their decisions. For example, "standing water" is reported as "wet". The 6 knot tailwind is really 10 knots, HUD on, HUD off, etc, etc. etc. blah blah blah. The list of contributing factors (and semi-lame excuses) is endless and there must have been a hundred of them mentioned in this thread alone.



But all of us have had plenty of bad information passed to us and few of us here have ever crashed an airliner, so it can't be the lousy contributing factors alone.


To me, it boils down to one thing; poor airmanship resting squarely on the Captain's shoulders. The Captain elected to not land into the wind; not a serious mistake in and of itself. However, he apparently didn't couple that downwind landing with a promise to himself that he would make every possible effort to exercise good flying practices, especially given the other conditions.


How in the world could this Captain accept a landing half way down a runway under ANY circumstances (other than landing a Piper Cub at Edwards A.F.B. ) much less on a wet runway with a tailwind? I'm quite certain I've never floated half way down ANY runway, ever. I know for a fact I've never landed an airliner outside the prescribed landing zone although I've watched a few from the F/O's seat (none dangerous, just sloppy).


No matter what the circumstances leading up to this accident, I can't think of any reason to continue an approach which results in a touchdown after flying past the first half of the runway unless the airplane is on fire, and a big fire at that. Even if every single external factor were working against this crew, had the pilot flown the aircraft properly, this accident wouldn't happened. Flying a proper approach to a good landing OR going around if and when things go south is something any Captain should think about well ahead of time.



Don't tell me hindsight is 20-20. Thinking ahead, in this case, shouldn't have been all that hard. Pressing on and having a "get-'er-done" attitude is fine, but if you call yourself a Captain you must stop being foolish before you bend the tin.
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Old 16th May 2014, 19:24
  #75 (permalink)  
 
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Very little mention (one paragraph that I saw) in the report deals with grooved vs. ungrooved runways. I do not understand why every airline runway is not grooved, particularly in this part of the world where high rainfall rates are common.

Would a grooved runway have prevented the overrun at their high energy state? No way (that I am aware of) to calculate. A grooved runway in Toronto would have probably prevented the Air France A-340 in Toronto.

The holes in the swiss cheese really lined up for this accident to occur. But knowledge of the runway not being grooved, particularly with a tailwind, should have further emphasized the importance of touching down "in the zone".
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Old 16th May 2014, 20:53
  #76 (permalink)  
 
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I understand your logic for grooved but cannot evaluate whether it would have had a positive effect on the A340 at Toronto, given that everyone evacuated.

However, Airbus has introduced a system called Runway Overun Protection System which AAL has selected for their Airbus aircraft.

My understanding is that if this system had been available on the A340 at Torornto or that AAL aircraft on that day then the crew would have been advised that given the flight to touchdown conditions and the runway conditions, the landing should be aborted. I don't pretend to understand fully how this system works but the decision of AAL to select it must indicate that they see a value.
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Old 17th May 2014, 00:02
  #77 (permalink)  
 
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Runway Overrun Protection System (ROPS) is a very good concept except like any other automation it has to be used with care and attention to its limits.
Landing performance calculations rely on data input including braking action/runway condition, which if as in this accident were ill determined, so too will be ROPS solutions.
Will pilots have too much confidence in the ROPS pre-landing calculations? The default safety margin is 15% (shown in green), yet this is the minimum recommended value (why not show in amber) and requires significant consideration of many factors, e.g. rainfall rate, runway surface, which are not available to ROPS. Thus there could be implicit human belief that the machine is always right, whereas in this accident the initial calculations would be based on the same assumptions made by the crew.

Alerting to long flare/touchdown position is a valuable tool if heeded; will humans always follow ‘machine advice’, cf EGPWS?

Grooved runways are expensive – but not in comparison to an accident, so who pays, airport or operator. Furthermore these runways require more maintenance, more expense.
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Old 17th May 2014, 07:16
  #78 (permalink)  
 
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You don't need complicated systems to prevent long landings. As Mozella stated, you know exactly what you are doing when you land long, there is no mistaking it. But pilots tend to reason the risk away: it's a long runway, don't wanna go around so close to the ground, any time now..

What we need is a change in attitude regarding long landings, passed down from training management. Send every pilot a warning email when he lands long (it IS recorded in flight data monitoring) and convey the message that landing long is NOT acceptable in any circumstance. That a balked landing is mandated EVERY time you see those last blocks of touch down zone disappearing below you windscreen.

Hammer it into the pilot workforce that just as not being stable at 500 feet and continuing is a 'crime', so are long landings.
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Old 17th May 2014, 10:51
  #79 (permalink)  
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Originally Posted by PENKO
You don't need complicated systems to prevent long landings. As Mozella stated, you know exactly what you are doing when you land long, there is no mistaking it.
- so true. But what will our amateur psychologists and those marketing expensive software do then?
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Old 17th May 2014, 13:12
  #80 (permalink)  
 
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PENCO, et al, you didn’t need complicated systems to avoid CFIT (so was the thinking several years ago); now with a simple, robust computer, based on accurate data, the industry has a very reliable safety device … if only everyone would use it.

Yes the industry does need to change its attitude to long landings, or the major contributions such as tailwind and flare training with high GS. If we continue to think that we always know what we are doing, or why we do it, then we are very mistaken.
Why does the industry land in tailwinds … a balance of economics and safety; sometimes the balance is misjudged, but by whom, pilots or management.
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