AAL 331 Kingston final report
The crew displayed grossed ineptitude. How can a captain of a 737NG be unable to perform an rnav approach? How can he touch down in here last third of a runway at close to mlw (wet one at that,with a strong tailwind), and expect to stop on the remaining hard surface?
I revisit my earlier point about the cultural/racial bias displayed on these forums. An AA crew makes a monumental cockup such as this, and the third is full of posts regarding institutional problems, systemic training issues and error chains. A lion air, Asiana, or some third world crew make a similar mistake, and pages and pages of comments regarding fly for pay, incompetent brown people being let lose in high tech machinery, ensue, etc. Never fails.
Clearly American Airlines has forgiven him. He's back in the left seat, didn't lose any seniority either. Need to get the phone number for his lawyer. That guys worth every penny!
I revisit my earlier point about the cultural/racial bias displayed on these forums. An AA crew makes a monumental cockup such as this, and the third is full of posts regarding institutional problems, systemic training issues and error chains. A lion air, Asiana, or some third world crew make a similar mistake, and pages and pages of comments regarding fly for pay, incompetent brown people being let lose in high tech machinery, ensue, etc. Never fails.
I'm sorry, Safetypee, but I disagree with you. As soon as I see a tailwind, I think Flap 40. As soon as I see a weight close to MLW, I think Flap 40. As soon as I see "wet", I think Flap 40. Maybe the runway is huge, and reconsider the flap selection if I have had one of those prompts, but two or more of them and I will land Flap 40 regardless of the runway. If there is any suspicion over stopping distances, and this crew should have had some with the combination above, then I'll do the numbers.
What is unforgivable, given the above lapse, is to try to press a landing in a thunderstorm.
That they refuse to go around when the touchdown zone ran out was plain stupidity. Like I said, I have seen that elsewhere, and it has been done to me by FOs mishandling the flare and resulted in the terrain escape maneouver being applied and preventing a run-off. This element concerns me most because of its frequency and its blatency - if you miss the touch-down carpet, you have to go around, no ifs, no buts, so why do so many pilots press a bad landing and crash the aircraft.
I'm sorry, but I can't forgive this crew. They failed to apply basic airmanship principles every step of the way.
What is unforgivable, given the above lapse, is to try to press a landing in a thunderstorm.
That they refuse to go around when the touchdown zone ran out was plain stupidity. Like I said, I have seen that elsewhere, and it has been done to me by FOs mishandling the flare and resulted in the terrain escape maneouver being applied and preventing a run-off. This element concerns me most because of its frequency and its blatency - if you miss the touch-down carpet, you have to go around, no ifs, no buts, so why do so many pilots press a bad landing and crash the aircraft.
I'm sorry, but I can't forgive this crew. They failed to apply basic airmanship principles every step of the way.
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I revisit my earlier point about the cultural/racial bias displayed on these forums. An AA crew makes a monumental cockup such as this, and the third is full of posts regarding institutional problems, systemic training issues and error chains. A lion air, Asiana, or some third world crew make a similar mistake, and pages and pages of comments regarding fly for pay, incompetent brown people being let lose in high tech machinery, ensue, etc. Never fails.
Sounds to me like you are another chip on the shoulders/I get discriminated against types. How many put downs per page do you require.
How about instead you give us factual info for your earlier statement of "There's a lot that went on behind the scenes in this investigation/report. Backs scratched, tracks covered". But I doubt you actually have any info to tell us though.
looks like I hit a nerve. No chips on my shoulder mate. And as far as discrimination goes can't recall ever being discriminated against by anyone. But I do shake my head every time I read these prune accident washups. Invariably, when the crew involved is from a First World, North American of European country, the tone of the posters, even when criticizing, is a lot more measured and empathetic. Not so when it comes to the rest of the World.
As for knowledge on what really took place, this accident took place in my neck of the woods, and there was collusion between the local authorities and the Yanks, to sort of cover up and sanitize a lot of what really took place. The report took ages to make public, when anyone could see almost from day one, that it was gross pilot negligence. Yet the report is filled with references to atc training, runway grooving, etc, etc. I'll put my head on the chopping block, that if this accident occurred anywhere in the USA, under similar circumstances, that Captain would be working as a greeter at Walmart. But....mysteriously he's back on the line. Guess I have a chip on my shoulder for finding that a bit...odd.
As for knowledge on what really took place, this accident took place in my neck of the woods, and there was collusion between the local authorities and the Yanks, to sort of cover up and sanitize a lot of what really took place. The report took ages to make public, when anyone could see almost from day one, that it was gross pilot negligence. Yet the report is filled with references to atc training, runway grooving, etc, etc. I'll put my head on the chopping block, that if this accident occurred anywhere in the USA, under similar circumstances, that Captain would be working as a greeter at Walmart. But....mysteriously he's back on the line. Guess I have a chip on my shoulder for finding that a bit...odd.
I'll put my head on the chopping block, that if this accident occurred anywhere in the USA, under similar circumstances, that Captain would be working as a greeter at Walmart. But....mysteriously he's back on the line. Guess I have a chip on my shoulder for finding that a bit...odd.
However, after reading between the lines, it might be a bit more accurate to say that the Captain is represented by a powerful union and the F/O pays his dues in hopes that some day he too will become a caption and enjoy that same high level of representation. This wouldn't be the first time that an F/O got thrown under the bus in a hearing. I logged a lot of time in the right seat before I moved over and whenever some captain tried doing something a bit sketchy I always thought to myself, "How is this going to sound when I have to explain it in a hearing?". On more than one occasion that prompted me to express my disagreement with the actions of the caption. I have never been afraid to die, but I never wanted to look bad, if you get what I mean. As of this moment, I've never used the evacuation check list and I never had to go to a hearing either.
Perhaps the F/O in this instance should have thought ahead to what he was going to say in his hearing and, equally as important, what the captain was going to say.
Last edited by Mozella; 11th May 2014 at 03:02.
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Once again...no details. You are lying in your cover-up accusations.
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Sadly, I have seen others do this, and it appears there is a huge black hole in aircrew training: who has ever done any missed approached from below minima in training? I have never heard of it - all airlines condition their pilots to go around from minimums because they aren't visual or land; there is no baulked landing profile training.
OK465, everyone will have their own view of what is important depending on training, experience, etc; this is human and to be expected, and welcome in safety debates. However, my attempt is to view this accident (via the report) without bias (probably impossible), and by considering human centred factors, each with equal importance.
If, as in some modern views of accident causation these factors are all required to generate the event, it may be useful to understand how and from where the factors originated, and then how they came together at that time. After the event it is much easier to identify one (or more) factors which would have prevented the accident – hindsight bias, yet the crew had to work in real time. Now our responsibility (the industry) is to work with this knowledge to provide foresight, or at least identify mitigating factors to help avoid such situations – the factors and the timings of an occurrence.
Attempting to understand the points raised, consider what happens every day;
Every approach and landing warrants consideration of the intended touchdown point, an acceptable zone varies with runway length, wt, speed, etc, etc, and particularly runway condition for which there may be little accurate information. That’s the judgement and airmanship we strive for.
Yes, there can be two or more views of accidents (Safety 1, Safety2). Also consider that both crew had apparently similar understandings of the situation at the time; thus this involves more than one person, or even the crew, but also the operator and regulator, who’s understandings might be based on what they expected from their regulations, procedures, and training opposed to what actually happens in operations – we don’t ask them to put their hands up.
Hands up everyone who has made a night landing from an offset LOC, with a recently increased tailwind limit, at max landing wt, on a limiting wet runway with questionable braking action.
If, as in some modern views of accident causation these factors are all required to generate the event, it may be useful to understand how and from where the factors originated, and then how they came together at that time. After the event it is much easier to identify one (or more) factors which would have prevented the accident – hindsight bias, yet the crew had to work in real time. Now our responsibility (the industry) is to work with this knowledge to provide foresight, or at least identify mitigating factors to help avoid such situations – the factors and the timings of an occurrence.
Attempting to understand the points raised, consider what happens every day;
- Do we always know the height at which we cross the threshold? +10ft probably not. +20ft possibly yes; particularly with experience, but then explain how we know. Qualify this with the conditions of the accident where there may have been greater focus on aircraft control following the late hdg change, then perhaps it’s more likely that neither pilot noticed the height difference in the demanding conditions.
- Do we always know where we touchdown? + 100ft probably not, + xxx probably yes, but according to conditions, etc, … as above .... We might have a good understanding of a situation after an event with the aid of the FDR, but this tells us little about the understanding at the time of an event.
Every approach and landing warrants consideration of the intended touchdown point, an acceptable zone varies with runway length, wt, speed, etc, etc, and particularly runway condition for which there may be little accurate information. That’s the judgement and airmanship we strive for.
Yes, there can be two or more views of accidents (Safety 1, Safety2). Also consider that both crew had apparently similar understandings of the situation at the time; thus this involves more than one person, or even the crew, but also the operator and regulator, who’s understandings might be based on what they expected from their regulations, procedures, and training opposed to what actually happens in operations – we don’t ask them to put their hands up.
Hands up everyone who has made a night landing from an offset LOC, with a recently increased tailwind limit, at max landing wt, on a limiting wet runway with questionable braking action.
Al shuff, there’s no problem that we disagree, everyone has their view; it’s the difference in views which often provide the most value for safety.
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.
Similarly I agree with your view of stopping distance; but how do you arrive at ‘suspicion’ – experience, intuition, (factors of airmanship)? This may be acceptable in most circumstances, but occasional it could be misjudged. Thus a better technique would be to always check the numbers, and then use these to trigger suspicion. Better still, check the performance in the reported conditions against the next worst-case scenario; this could both quantify your suspicion and define a margin of safety, the landing zone, the ability to absorb a failure (no reverse etc), …
As for the other issues, all humans lapse, we misjudge situations or inappropriately bias our plans, etc. I hope that these points can be related to the HF training given, if not, then … reconsider.
What would be unforgivable is to label others in that way with insufficient consideration or understanding of their view at the time.
It’s not for us to label, judge, or excuse other’s behaviour, but as professionals it is our responsibility to learn from what we might observed and understand.
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.
Similarly I agree with your view of stopping distance; but how do you arrive at ‘suspicion’ – experience, intuition, (factors of airmanship)? This may be acceptable in most circumstances, but occasional it could be misjudged. Thus a better technique would be to always check the numbers, and then use these to trigger suspicion. Better still, check the performance in the reported conditions against the next worst-case scenario; this could both quantify your suspicion and define a margin of safety, the landing zone, the ability to absorb a failure (no reverse etc), …
As for the other issues, all humans lapse, we misjudge situations or inappropriately bias our plans, etc. I hope that these points can be related to the HF training given, if not, then … reconsider.
What would be unforgivable is to label others in that way with insufficient consideration or understanding of their view at the time.
It’s not for us to label, judge, or excuse other’s behaviour, but as professionals it is our responsibility to learn from what we might observed and understand.
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I usually don't comment on accidents, hopefully my knowledge is reaffirmed or I learn something from reading the report.
I'm not sure if it is the case, but it would seem from reading Mozella's post (#27) that the Captain returned to flying but the FO was let go. If this is the case I think it is terrible and no matter where the fault may lay, a Captain is ultimately responsible for anything that happens in the cockpit.
I'm not sure if it is the case, but it would seem from reading Mozella's post (#27) that the Captain returned to flying but the FO was let go. If this is the case I think it is terrible and no matter where the fault may lay, a Captain is ultimately responsible for anything that happens in the cockpit.
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Never one to be an apologist for the sky nazis, however in 2009, the only Rnav approaches most US pilots would have seen would have been in the sim on their PC. 7 kt tailwind ILS v. an Rnav approach, I think most would opt for the ILS.
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I'd like to make a few comments pertaining to the misinformation that permeates through this thread.
First, the F/O, as well as the CA, are both still employed and flying the line for AA today.
Second, these unfortunate individuals who made a bad choice that night, were also very evidently misled by improper reporting of the runway condition by Jamaican ATC which took part of the blame. As such, the two flight crew were accepted into the ASAP program and retrained to the line, standard procedure with the ASAP program.
While several on here are thumping their chests about how the powerful union attorneys got their jobs back, the truth is that the pilots were deemed acceptable by ASAP standards and were deemed retrainable. They did not intentionally (key word here) violate the regs, but rather fell prey into accepting a runway they thought would be within limits for landing, due to the misreporting by Jamaican ATC (runway was actually flooded, aka "underwater", not just "wet", most likely resulting in braking action fair to poor. although to be fair ATC probably did not realize just how bad it was.) At the time, the 737 was approved for 15kt tailwind landings in certain conditions, albeit with a bunch of cautions.
There is no doubt the flight crew screwed up, but rather than lobbing insults onto them and preaching about how "I would never do that..." perhaps it would be more prudent to realize that, under the right conditions, any one of us could be set up in a similar way when the holes in the Swiss cheese line up just right... and to remain vigilant against that happening, using the lessons learned from this unfortunate accident.
First, the F/O, as well as the CA, are both still employed and flying the line for AA today.
Second, these unfortunate individuals who made a bad choice that night, were also very evidently misled by improper reporting of the runway condition by Jamaican ATC which took part of the blame. As such, the two flight crew were accepted into the ASAP program and retrained to the line, standard procedure with the ASAP program.
While several on here are thumping their chests about how the powerful union attorneys got their jobs back, the truth is that the pilots were deemed acceptable by ASAP standards and were deemed retrainable. They did not intentionally (key word here) violate the regs, but rather fell prey into accepting a runway they thought would be within limits for landing, due to the misreporting by Jamaican ATC (runway was actually flooded, aka "underwater", not just "wet", most likely resulting in braking action fair to poor. although to be fair ATC probably did not realize just how bad it was.) At the time, the 737 was approved for 15kt tailwind landings in certain conditions, albeit with a bunch of cautions.
There is no doubt the flight crew screwed up, but rather than lobbing insults onto them and preaching about how "I would never do that..." perhaps it would be more prudent to realize that, under the right conditions, any one of us could be set up in a similar way when the holes in the Swiss cheese line up just right... and to remain vigilant against that happening, using the lessons learned from this unfortunate accident.
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Oh well.... The skies would clearly have been safer for fare paying passengers and innocent crewmembers had the Captain been terminated.
Truly had the ego that he had to complete the mission on the first go rather than going around after floating half way down the runway.
Negative. When one can avail information from Prog. Page 2, as they watch the useable runway disappear before their eyes and not electing to go around rather than landing almost 1/2 way down the runway... there was no set up that I could see.
Truly had the ego that he had to complete the mission on the first go rather than going around after floating half way down the runway.
There is no doubt the flight crew screwed up, but rather than lobbing insults onto them and preaching about how "I would never do that..." perhaps it would be more prudent to realize that, under the right conditions, any one of us could be set up in a similar way when the holes in the Swiss cheese line up just right... and to remain vigilant against that happening, using the lessons learned from this unfortunate accident.
Negative. When one can avail information from Prog. Page 2, as they watch the useable runway disappear before their eyes and not electing to go around rather than landing almost 1/2 way down the runway... there was no set up that I could see.
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like I said.... I am not stating the crew was faultless, they clearly made bad choices. however, there were traps that night that led them into accepting runway 12 (it was legal, but not the safest course of action) and the bad state of the runway along with the actual wx conditions were not accurately reported. This all came out in the investigation. That was the set up. So the stage was set (holes in the cheese all lined up...) the crew clearly screwed up from there by not going around once the float was induced. No arguments there.
However, the FAA deemed them acceptable into ASAP. Getting accepted into ASAP means that you got yourself into a situation that could have been avoided but could also happen to anyone (it was a non-PINC event... Pilot Intentional Non Compliance - meaning they did not intentionally violate the regs.) so your statement about crew and pax being safer with them terminated is a bit of a stretch and really uncalled for. Have you ever screwed up in aviation and learned a valuable lesson from it? I'm willing to bet you are much safer because of it. No different here, that's what the ASAP program is all about.
However, the FAA deemed them acceptable into ASAP. Getting accepted into ASAP means that you got yourself into a situation that could have been avoided but could also happen to anyone (it was a non-PINC event... Pilot Intentional Non Compliance - meaning they did not intentionally violate the regs.) so your statement about crew and pax being safer with them terminated is a bit of a stretch and really uncalled for. Have you ever screwed up in aviation and learned a valuable lesson from it? I'm willing to bet you are much safer because of it. No different here, that's what the ASAP program is all about.
SafetyP.
Do we always know the height at which we cross the threshold? +10ft probably
not. +20ft possibly yes;
If I hear "50" from autocallout as I cross the threshold, then all is well. If not, then I know some work lies ahead. An eye on PP2 and wind component always advisable on finals. Maybe not all aircraft have this tool available.
Once again, for the armchair experts, landing at night, in rain on a runway with no TDZ lighting and faded TDZ markings with tailwind (reported shortly before as just within legal limits) is a challenge, even for the aces of the bases.
Flap 30? As I said before, do not know AA SOP for 738. On my machine, next lower flap only used in gusty conditions or very light landing weights.
RNav approaches? You have to be qualified. Were they? Also, not quite as easy as they sound; go from "VNav Pth" to "VNav Spd" on the approach and you are scrambling, unless fully briefed and prepared. ILS much easier.
This from AA73, pretty well sums things up, so let it be. "Probe don't Punish", (not my phrase, by the way), but I would hope and expect that punishment is meted out where deserved. As stated before by myself, conspiracy theories by some posters re racial, ethnic (etc,etc) bias should be ruled out. Aviation safety knows no boundaries. No psycho babble. We're all in this together.
I always think, if I or my family were flying on board this flight today, how would I like to be flown by the guys up front.
If there is any doubt, then there is no doubt. (easier said than done, of course....)
Do we always know the height at which we cross the threshold? +10ft probably
not. +20ft possibly yes;
Once again, for the armchair experts, landing at night, in rain on a runway with no TDZ lighting and faded TDZ markings with tailwind (reported shortly before as just within legal limits) is a challenge, even for the aces of the bases.
Flap 30? As I said before, do not know AA SOP for 738. On my machine, next lower flap only used in gusty conditions or very light landing weights.
RNav approaches? You have to be qualified. Were they? Also, not quite as easy as they sound; go from "VNav Pth" to "VNav Spd" on the approach and you are scrambling, unless fully briefed and prepared. ILS much easier.
First, the F/O, as well as the CA, are both still employed and flying the line
for AA today.
for AA today.
I always think, if I or my family were flying on board this flight today, how would I like to be flown by the guys up front.
If there is any doubt, then there is no doubt. (easier said than done, of course....)
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So are we to understand it is not approved for 15kt tailwind today?
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I still disagree with the defense of this crew. While choosing Flap 30 may be forgiveable, particularly if they were expecting windshear on approach, continuing the landing having floated so long is not, regardless of winds or surface conditions. Time and time again run-offs occur from ridiculously late touch downs, and still the idiot members of our ranks persist in trying to land from these baulked approaches. Had they gone around, we wouldn't be criticising them. Had they landed in the right zone (not a specific point, you note, but a zone), then they may have had to brake hard but would almost certainly would have stopped without a problem, even with the tail wind and wet conditions. What happened here was exactly the same as Mangalore, Chicago, Burbank and even Asiana at SFO - the pilots continued to "press a bad situation", in Hollywood parlance.
This is not an issue of technical skills. It's an issue of attitude. That is why I can't forgive such events.
I'm glad there are operators who are running training scenarios for baulked landings. Sadly, they are so few that they are near unique. It needs to be an industry wide programme.
Safetypee, my "triggers" are more than just tailwind, they are the whole performance package - 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.
As I said, making a mistake in assessing the approach is one thing, though I'd never consider making a F30 approach with a tailwind (yes, that is a "hard trigger" for me), but to do so with the conditions in this accident was grossly negligent. But the pressed landing when they were clearly so far beyond the touch down point was a disgrace, and would have been just as much so even if the approach had been perfect.
This is not an issue of technical skills. It's an issue of attitude. That is why I can't forgive such events.
I'm glad there are operators who are running training scenarios for baulked landings. Sadly, they are so few that they are near unique. It needs to be an industry wide programme.
Safetypee, my "triggers" are more than just tailwind, they are the whole performance package - 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.
As I said, making a mistake in assessing the approach is one thing, though I'd never consider making a F30 approach with a tailwind (yes, that is a "hard trigger" for me), but to do so with the conditions in this accident was grossly negligent. But the pressed landing when they were clearly so far beyond the touch down point was a disgrace, and would have been just as much so even if the approach had been perfect.
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Phantom Driver:
Did you read the report? A big point was made of the fact they were trained, qualified and authorized RNAV, but didn't seem to grasp that fact very well. All this is in the report.
They flew the ILS to Runway 12. It was strongly suggested that the RNAV IAP to Runway 30 would have probably prevented the accident. No scrambling to set up for the RNAV to 30.
RNav approaches? You have to be qualified. Were they? Also, not quite as easy as they sound; go from "VNav Pth" to "VNav Spd" on the approach and you are scrambling, unless fully briefed and prepared. ILS much easier.
They flew the ILS to Runway 12. It was strongly suggested that the RNAV IAP to Runway 30 would have probably prevented the accident. No scrambling to set up for the RNAV to 30.