Go Back  PPRuNe Forums > Flight Deck Forums > Rumours & News
Reload this Page >

AAL 331 Kingston final report

Rumours & News Reporting Points that may affect our jobs or lives as professional pilots. Also, items that may be of interest to professional pilots.

AAL 331 Kingston final report

Old 8th May 2014, 06:36
  #1 (permalink)  
Thread Starter
 
Join Date: Mar 2006
Location: USA
Posts: 1,973
AAL 331 Kingston final report

Seems the crew made some poor choices. I wonder if they're still flying for AA?

Accident: American B738 at Kingston on Dec 22nd 2009, overran runway on landing


http://www.jcaa.gov.jm/NEWS_UPDATES/...May%202014.pdf
Check Airman is offline  
Old 8th May 2014, 11:48
  #2 (permalink)  
 
Join Date: Apr 2008
Location: nowhere
Posts: 0
If you look on the thread on the North American page, you will see that the captain has returned as a captain. Once again, it looks like they had a straight in approach capability into wind but were unaware of that option which shows the importance of becoming aware of what approaches are available.

According to the report:

"If the flight crew had used the RNAV (GPS) Rwy 30 approach and landed on Runway 30, the accident would probably have been avoided."
JammedStab is offline  
Old 8th May 2014, 15:26
  #3 (permalink)  
 
Join Date: Apr 2009
Location: On the Beach
Posts: 3,298
JammedStab:

"If the flight crew had used the RNAV (GPS) Rwy 30 approach and landed on Runway 30, the accident would probably have been avoided."
That was apparent when the first authoritative reporting came out.
aterpster is offline  
Old 8th May 2014, 16:08
  #4 (permalink)  
 
Join Date: Sep 2003
Location: away from home
Age: 59
Posts: 746
Those buffoons were repeatedly offered the other runway (see CVR transcript) and still chose to stick to rwy 12, max landing wt and Flaps 30. They really piled it on themselves. Surprised they were'nt fired.
oceancrosser is offline  
Old 8th May 2014, 17:06
  #5 (permalink)  

Aviator Extraordinaire
 
Join Date: May 2000
Location: Oklahoma City, Oklahoma USA
Age: 73
Posts: 2,395
Guess they didn't like a long taxi back to the terminal ramp.
con-pilot is offline  
Old 9th May 2014, 03:03
  #6 (permalink)  
Thread Starter
 
Join Date: Mar 2006
Location: USA
Posts: 1,973
How can you be unaware of an approach to the opposite runway?

Night time
tail wind
rain
un-grooved runway

I'd like to think that under those conditions, I'd have looked into landing in the opposite direction. With a combined 17,000hrs in the cockpit, I find it amazing that a crew could say "we didn't know about the other approach".
Check Airman is offline  
Old 9th May 2014, 14:23
  #7 (permalink)  
 
Join Date: Jul 2003
Location: An Island Province
Posts: 1,169
This is a very well-crafted report which covers a range of issues from different angles; it should be safety reading for everyone, for individuals, operators and regulators to heed and learn from – to do something. It illustrates how there can be many relatively minor or insignificant aspects within normal operation or founded by training and procedure, which together with some ‘latent’ traps, come together when we (everyone) might least expect it.

The report does not conclude root cause or seek blame, but it does provide strong and timely pointers to safety actions, some which have been identified previously. Lack of activity in these areas suggest that the industry has been riding it’s luck, and to some extent did so again here – there could have been many fatalities with any one of several minor differences in circumstance.
The industry is facing a major problem with determining actual runway conditions and thus a safe landing distance; there are problems of measurement, reporting, communicating and understanding – airport, ATC, dispatch, training, and crew.
Human activity in these areas is always a problem, so perhaps this is a reminder not to rely on them too much and ensure that the defences against ill-chosen courses of action have greater depth.
alf5071h is offline  
Old 9th May 2014, 15:45
  #8 (permalink)  
Below the Glidepath - not correcting
 
Join Date: Jun 2005
Location: U.S.A.
Posts: 1,728
Not sure how your primary alternate remains a primary alternate if it's closed when you might need to use it?
Two's in is offline  
Old 9th May 2014, 17:48
  #9 (permalink)  
 
Join Date: Mar 2004
Location: Somewhere Over America
Posts: 192
There was a TRW on the other end of the runway that they would have had to flown through.
Halfnut is offline  
Old 9th May 2014, 18:41
  #10 (permalink)  
 
Join Date: Jan 2006
Location: Singapore
Posts: 319
Mr Ocean,


Those buffoons were repeatedly offered the other runway (see CVR transcript)
and still chose to stick to rwy 12, max landing wt and Flaps 30. They really
piled it on themselves. Surprised they were'nt fired.
"Buffoons"? Really? Wonder if you have read the report in any close detail. Lot of last minute traps on this approach for anyone, even the most experienced.

Up to 5 mins before landing, everything was within limits for a (preferred ILS) to 12.

Now, being told at this juncture that the runway is wet introduces a whole new set of complications. (Hell, landed at ANC several times at night in the winter with slippery runway and no word from the tower; to them, that was "normal ops"; ramps and taxiways covered in snow, no visible markings; lots of fun taxiing a 744 around there.

(back to subject...) a last minute change to an RNav 30 is not an option if not already prebriefed/set up in the FMC/crew authorised etc to shoot that approach. Forget night low level visual circling; invitation to disaster and banned by most enlightened commercial operators these days.

So, continue the ILS approach, only slightly high over the threshold, but thereafter the traps come into effect-(rain, excessive flare into black hole, no TDZ lighting exacerbating matters), float, and there but for the grace of God go many.

Flaps 30 landing? Company SOP should explain that.


How can you be unaware of an approach to the opposite runway?
Good question, and again, I doubt the veracity. Am sure AA ops would have addressed this point in the full report. As mentioned before, there must have been other factors at play here (qualification, etc}. Not everybody is cleared to go shoot RNav approaches straight off the bat.

If it is true that the Captain has been reinstated, then that is good news; "Probe, don't Punish".
Phantom Driver is offline  
Old 9th May 2014, 18:42
  #11 (permalink)  
 
Join Date: Oct 2012
Location: caribbean
Posts: 12
The Captain has been reinstated to full flight duties. Must have a real good union and lawyer behind him.


The First Officer has taken out a civil lawsuit against the Captain.


There's a lot that went on behind the scenes in this investigation/report. Backs scratched, tracks covered.
marck_c is offline  
Old 9th May 2014, 18:46
  #12 (permalink)  
 
Join Date: Oct 2012
Location: caribbean
Posts: 12
Bet if this bad decision was made by a Lionair/Asiana (or any nationality south of the Equator for that matter) Captain, there wouldn't be a call for "probe, not punish".
marck_c is offline  
Old 9th May 2014, 18:51
  #13 (permalink)  
 
Join Date: Jan 2006
Location: Singapore
Posts: 319
Alf,


This is a very well-crafted report which covers a range of issues from
different angles; it should be safety reading for everyone, for individuals,
operators and regulators to heed and learn from – to do something. It
illustrates how there can be many relatively minor or insignificant aspects
within normal operation or founded by training and procedure, which together
with some ‘latent’ traps, come together when we (everyone) might least expect
it.

The report does not conclude root cause or seek blame, but it does
provide strong and timely pointers to safety actions, some which have been
identified previously. Lack of activity in these areas suggest that the industry
has been riding it’s luck, and to some extent did so again here – there could
have been many fatalities with any one of several minor differences in
circumstance.
The industry is facing a major problem with determining actual
runway conditions and thus a safe landing distance; there are problems of
measurement, reporting, communicating and understanding – airport, ATC,
dispatch, training, and crew.
Human activity in these areas is always a
problem, so perhaps this is a reminder not to rely on them too much and ensure
that the defences against ill-chosen courses of action have greater depth.
..

Precisely.

(post hilighted again because, sadly in this forum, the more important details get lost amongst all the chaff}
Phantom Driver is offline  
Old 9th May 2014, 19:00
  #14 (permalink)  
 
Join Date: Jan 2006
Location: Singapore
Posts: 319
Bet if this bad decision was made by a Lionair/Asiana (or any nationality south
of the Equator for that matter) Captain, there wouldn't be a call for "probe,
not punish".
No sir; in aviation there is only one rule. Safety. Applies to all of us, regardless of nationality, race, gender, etc, etc. Probe...gross negligence?/dereliction of duty?/incompetence? Punish, regardless of who you are. Basic common sense, isn't it?
Phantom Driver is offline  
Old 9th May 2014, 20:40
  #15 (permalink)  
 
Join Date: Dec 2002
Location: UK
Posts: 2,090
OK465, “discontinuing an approach … taking the time and space”.
The crew were balancing a max wt landing in demanding conditions, with min fuel for diversion; they judged that a circling approach involved higher risk or less chance of success (airmanship/judgement).

The absence of the knowledge of RNAV is as much an organisational issue as for the crew – who were working hard in difficult circumstances. In their mind a late change to RNAV (or even circling) may have equated to a missed approach and diversion; thus lack of knowledge was not significant at a late stage of the approach. Lack of knowledge at the time of briefing might have been similarly insignificant as the then reported conditions did not trigger a need to change runways (7kts tail). Remember that the crew’s time-line was real time, whereas ours is the last 4 years.
The chosen option – misjudged as safe, and not aided by a multitude of contributory organisational and regulatory factors, was to continue the approach and landing, although this was not well executed.

Beware of hindsight bias; instead of seeking to criticise, look for aspects that might help us avoid similar circumstances.
Don’t assume that the crew will catch the shortfalls in performance planning and requirements originating from operational procedures, and organisation and regulatory slackness. Crews have enough problems detecting their own errors let alone those much higher in the organisation.
Beware complacency, crew, operator, regulator, and particularly politicians if baulking regulatory action.
safetypee is online now  
Old 9th May 2014, 21:25
  #16 (permalink)  
 
Join Date: Sep 2013
Location: UK
Posts: 730
Come on guys, this is elementary. They approached a soaked runway with a very strong tail wind at MLW and flap 30. That in itself is stupid. That they didn't go around from an extremely long float half way down the runway is outrageous.

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. I regularly see FOs move their hands onto the reversers during the flare, removing their ability to quickly go around. I try to correct them, but it is over 95% of them who do this and they are clearly picking up this bad habit in line training. So, while the AA pilots showed stunning ineptitude, the industry as a whole has helped create a psychological channel that causes these sorts of overruns.
Aluminium shuffler is offline  
Old 10th May 2014, 07:18
  #17 (permalink)  
 
Join Date: Apr 2008
Location: nowhere
Posts: 0
Originally Posted by Phantom Driver View Post
a last minute change to an RNav 30 is not an option if not already prebriefed/set up in the FMC/crew authorised etc to shoot that approach.
Should be straight forward. Done on a regular basis in the sim. Just ask for a hold and then brief if fuel allows.

Originally Posted by Aluminium shuffler View Post
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.
We train on occasion as part of a script where the runway vis goes to zero immediately after touchdown. A go-around is made as long as reverse was not selected. Because of a company incident of course.
JammedStab is offline  
Old 10th May 2014, 13:49
  #18 (permalink)  
 
Join Date: Dec 2002
Location: UK
Posts: 2,090
OK465, these types of accident are far from straight forward. In our highly reliable and safe industry, accidents usually have many contributing factors. There is no psychobabble, just another point of view; attempting to understand the crew’s view at that time and to consider ‘what if’.
What if you were confronted with these factors; not just to conclude that you wouldn’t make the same judgement, but to consider why you would not and how this might help others.
Read through the report, how long did it take; how long to read (and understand) just the relevant sections of operators documents, then consider how a crew might do this in real conditions; remembering rule 1, first fly the aircraft.

Some of the safety shortfalls are appalling; the problems of landing distance calculation have been under discussion for many years.
Has the Boeing advisory data been updated to more realistic values representative of what a crew might achieve, like that of the Airbus OLD/FOLD data? The operator could have done this independently.
Why hasn’t the FAA mandated a prelanding performance check similar to EU-OPS? The operator could have done this independently.
How could the hazards of an increased tailwind landings be so overlooked by both the FAA and operator’s safety checks?

There is an option; either to ask these questions and try to learn, or just blame the crew and conclude that ‘it won’t happen to me’; perhaps deferring your learning until the time that ‘it’ does happen to you.


Al shuff, the ‘stupidity’ could be with our hindsight of believing that the crew knew the runway was soaked at that time, and that they considered it to be different from a wet runway – for which there was scant or confusing advice.
The flap oversight was more the airline’s problem – flap 30 was not an issue at 10kts tail (hidden in the assumptions of ‘Advanced Analysis’), but with a change to 15 kts flap 30 was an issue; flap 40 was required by the small print, but not clearly identified or taught.

How can crews identify a long landing – a tailwind gives a higher GS, the relative times of flare might be similar, but distance is not; - night, weak lighting, heavy rain … distance gone?
What part did the HUD play; the display can provide more readily accessible information, but tends to channel the attention to the lateral and vertical aspects of landing, not to the ideal point of touch down point on the runway (in the mode used).

‘The industry as a whole has helped create a psychological channel that causes these sorts of overruns’, The industry has placed great emphasis on timely use of all retarding devices, and your observations and intervention to overcome shortfalls in training are something for everyone to learn from; but why were such techniques taught or interpreted as such, was there sufficient explanation and understanding or why prompt use of reverse was important during training?
safetypee is online now  
Old 10th May 2014, 17:09
  #19 (permalink)  
 
Join Date: Sep 2003
Location: away from home
Age: 59
Posts: 746
Originally Posted by marck_c View Post
The Captain has been reinstated to full flight duties. Must have a real good union and lawyer behind him.


The First Officer has taken out a civil lawsuit against the Captain.


There's a lot that went on behind the scenes in this investigation/report. Backs scratched, tracks covered.
This begs the question, was the F/O, the "fall guy"? Is he no longer employed by AA? If so, interesting.
oceancrosser is offline  
Old 10th May 2014, 17:37
  #20 (permalink)  
 
Join Date: Sep 2013
Location: UK
Posts: 730
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.
Aluminium shuffler is offline  

Thread Tools
Search this Thread

Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service - Do Not Sell My Personal Information -

Copyright © 2018 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.