Air Canada A320 accident at Halifax
On first read a rather well prepared report with no window washing. What I find rather sobering is the number of uncovered shortcomings both on the side of the airport and the operator, many of which were not a contributing cause and would have remained unnoticed were not for the accident.
Ironically, exactly the opposite result from what is intended in today's SMS focussed world...
I don't know how one "likes" a post here, but grizzled's post is +1! Oversight AND inexperience...SMS is not a DIY safety tool. It still requires regulatory validation and verification. Well said, grizz.
I am genuinely surprised that nobody in the Airbus training department thought the way they were flying NPAs was dangerous.
I find it crazy that nobody was checking the vertical profile after the FAF by any means, and that this was:
1. SOP for the fleet
2. Not in accordance with the FCOM
3. Not picked up by any form of audit
I am reminded of comments after Gemini 8 "The crew reacted as they were trained, and they reacted wrong because we trained them wrong" - the most sobering part for me is that the crew flew the approach as per SOP, were slightly late picking up how wrong the visual picture looked in
weather and ended up drilling it in.
I find it crazy that nobody was checking the vertical profile after the FAF by any means, and that this was:
1. SOP for the fleet
2. Not in accordance with the FCOM
3. Not picked up by any form of audit
I am reminded of comments after Gemini 8 "The crew reacted as they were trained, and they reacted wrong because we trained them wrong" - the most sobering part for me is that the crew flew the approach as per SOP, were slightly late picking up how wrong the visual picture looked in
weather and ended up drilling it in.
Join Date: Mar 2001
Location: I wouldn't know.
Posts: 4,497
Likes: 0
Received 0 Likes
on
0 Posts
I have to say, that was the first thoughts i had myself. How can a company have a set of SOPs that is against its own FCOM? What kind of audit did they have that they didn't notice something as dangerous as not checking a vertical profile on a non precision approach?
If they were really trained that way, the fault does not lie with the chaps in the front row, although i would have thought that basic airmanship is more common on the north american continent.
If they were really trained that way, the fault does not lie with the chaps in the front row, although i would have thought that basic airmanship is more common on the north american continent.
Join Date: Apr 2010
Location: IRS NAV ONLY
Posts: 1,230
Likes: 0
Received 0 Likes
on
0 Posts
Otherwise, really looks like a strange thing, not checking DME vs. altitude table during non-precision approach, especially when flying with selected guidance in bad weather. Perhaps it's time for the Airbus to finally step up and come up with a way to fly LOC-only approaches with managed vertical guidance.
Join Date: Apr 2008
Location: HK
Posts: 513
Likes: 0
Received 0 Likes
on
0 Posts
Perhaps it's time for the Airbus to finally step up and come up with a way to fly LOC-only approaches with managed vertical guidance.
Join Date: Mar 2001
Location: I wouldn't know.
Posts: 4,497
Likes: 0
Received 0 Likes
on
0 Posts
Otherwise, really looks like a strange thing, not checking DME vs. altitude table during non-precision approach, especially when flying with selected guidance in bad weather. Perhaps it's time for the Airbus to finally step up and come up with a way to fly LOC-only approaches with managed vertical guidance.
Join Date: Dec 2001
Location: what U.S. calls ´old Europe´
Posts: 941
Likes: 0
Received 0 Likes
on
0 Posts
which were not a contributing cause and would have remained unnoticed were not for the accident.
If no problem is visible, there is none.
Join Date: Oct 2007
Location: Wherever I go, there I am
Age: 43
Posts: 804
Likes: 0
Received 0 Likes
on
0 Posts
I find it crazy that nobody was checking the vertical profile after the FAF by any means, and that this was:
...
3. Not picked up by any form of audit
...
3. Not picked up by any form of audit
It becomes especially dangerous when the auditor questions a company representative and the question is answered sufficiently that the auditor feels there is no issue. On more than a couple of occasions, I would have to ask the auditors to put in every question they had into the findings report on the theory that just because I could answer their question, did not mean a line pilot could.
Also, auditors are people too. They are often all looking for the same things, but one can only be so effective cross-referencing manuals all day.
Join Date: Sep 2014
Location: Canada
Posts: 1,257
Likes: 0
Received 0 Likes
on
0 Posts
Having been on both sides of the audit game:
1. Audits can't check for everything. It would be impossible from a time/effort perspective and the purpose of an audit is not to QA. At most, an audit can check for a sample of possible issues, selected semi-randomly (risk-weighted).
2. As such, audits tend to focus on broad processes and controls. E.g., does Air Canada have X process in place to mitigate against risk Y, and if so where is the evidence?
3. The unfortunate reality is that item 2 often devolves into chasing documentation (paperwork) against a checklist of risk items.
It's not an auditor's job to go through Air Canada's manuals/SOPs line by line to see if there are gaps (that's Air Canada's job). The auditor is there to check if there are specific controls in place, and that those set of controls -- as a whole -- are generally adequate and effective.
1. Audits can't check for everything. It would be impossible from a time/effort perspective and the purpose of an audit is not to QA. At most, an audit can check for a sample of possible issues, selected semi-randomly (risk-weighted).
2. As such, audits tend to focus on broad processes and controls. E.g., does Air Canada have X process in place to mitigate against risk Y, and if so where is the evidence?
3. The unfortunate reality is that item 2 often devolves into chasing documentation (paperwork) against a checklist of risk items.
It's not an auditor's job to go through Air Canada's manuals/SOPs line by line to see if there are gaps (that's Air Canada's job). The auditor is there to check if there are specific controls in place, and that those set of controls -- as a whole -- are generally adequate and effective.
When I say "audit" I mean both airlines I have worked for have had guys from different fleets/management positions or external guys come and sit on the jumpseat and in the sim and watch what was going on.
On the line, they looked for both procedural compliance and areas of procedural weakness. That's more what I was getting at. What the report doesn't say is what the other AC fleets did for NPAs - was this an airline wide practice or just the Airbus fleet?
On the line, they looked for both procedural compliance and areas of procedural weakness. That's more what I was getting at. What the report doesn't say is what the other AC fleets did for NPAs - was this an airline wide practice or just the Airbus fleet?
Join Date: Sep 2001
Location: Eagan, MN
Posts: 339
Likes: 0
Received 0 Likes
on
0 Posts
What a wonderful idea, a DME vrs. Altitude graph, right on the approach plate! When I first saw that, on one of the first constant descent NPA approach charts, I thought it was brilliant (and it was!) back in the 80's. However, in Canada especially, there is the issue of low temperature; to be accurate, you'd have to calculate an additive to each DME point, based on surface temperature, and altitude above the field for each fix. I surmise that TC, having been faced with that problem, just decided it wasn't worth the hassle of adjusting each fix for temperature (at, say, -42, or whatever) for each fix, and shuffled it under the rug. If you just check the altitude vrs. DME, without temperature compensation, as a procedure, you could be really low; to check each fix could take 10-15 minutes in a holding pattern. TC probably said, "Why bother? Don't want that can of worms! Just let's not reference DME vrs. Altitude." Sam
Audits
Safety Audits differently.
http://www.safetydifferently.com/saf...s-differently/
Should we do a safety audit or do safety differently.
http://www.safetydifferently.com/sho...y-differently/
http://www.safetydifferently.com/saf...s-differently/
Should we do a safety audit or do safety differently.
http://www.safetydifferently.com/sho...y-differently/
Alternatively, your forward thinking company could produce an App that allows you to stick the temperature, QNH AND the altitudes and produce a set of corrected altitudes in seconds. Or a rough and ready table on the winter ops guide. I have worked for airlines that have done both.
It really is isn't difficult. It takes 5 minutes away from reading the paper in the cruise. Checking your vertical profile in IMC is a business of life or death. With the switchover to paperless flight decks it surely can't be long before LIDO, Jepp, Navtech insert a function into their approach plates for you to enter the QNH and temperature and automatically display the correct crossing altitudes.
It really is isn't difficult. It takes 5 minutes away from reading the paper in the cruise. Checking your vertical profile in IMC is a business of life or death. With the switchover to paperless flight decks it surely can't be long before LIDO, Jepp, Navtech insert a function into their approach plates for you to enter the QNH and temperature and automatically display the correct crossing altitudes.
Join Date: Sep 2007
Location: Birmingham
Posts: 244
Likes: 0
Received 0 Likes
on
0 Posts
Great quote:
"Spurway [spokesman for the Halifax Stanfield International Airport] said the incident was not a crash because it is believed the plane was under control as it came in. He said there's no indication what caused the hard landing and he did not know the condition of the plane."
Air Canada flight leaves runway in Halifax, 25 sent to hospital - Nova Scotia - CBC News
"Spurway [spokesman for the Halifax Stanfield International Airport] said the incident was not a crash because it is believed the plane was under control as it came in. He said there's no indication what caused the hard landing and he did not know the condition of the plane."
Air Canada flight leaves runway in Halifax, 25 sent to hospital - Nova Scotia - CBC News
Let's look at the pictures again
Nah - no crash I was mistaken!
If the spokesman actually believes his own statement I think he should take a short break to regain perspective!
Join Date: Sep 2014
Location: Canada
Posts: 1,257
Likes: 0
Received 0 Likes
on
0 Posts
Alternatively, your forward thinking company could produce an App that allows you to stick the temperature, QNH AND the altitudes and produce a set of corrected altitudes in seconds. Or a rough and ready table on the winter ops guide. I have worked for airlines that have done both.
It really is isn't difficult. It takes 5 minutes away from reading the paper in the cruise. Checking your vertical profile in IMC is a business of life or death. With the switchover to paperless flight decks it surely can't be long before LIDO, Jepp, Navtech insert a function into their approach plates for you to enter the QNH and temperature and automatically display the correct crossing altitudes.
It really is isn't difficult. It takes 5 minutes away from reading the paper in the cruise. Checking your vertical profile in IMC is a business of life or death. With the switchover to paperless flight decks it surely can't be long before LIDO, Jepp, Navtech insert a function into their approach plates for you to enter the QNH and temperature and automatically display the correct crossing altitudes.
I'm with mcdhu here, how could any competent crew fly any approach without monitoring both the lateral profile and the vertical profile. Okay, they saw the localiser neatly aligned, but did they honestly just sit there and make absolutely no effort to monitor the vertical profile?
I've used FPA before - albeit not on a Bus, but did these guys ever wonder how the automation was positioning the aircraft. Did they really just hit the mode button and expect to be on profile all the way to MDA?
I've used FPA before - albeit not on a Bus, but did these guys ever wonder how the automation was positioning the aircraft. Did they really just hit the mode button and expect to be on profile all the way to MDA?
Monitoring both the lateral profile and the vertical profile.
Why the apparent lack of monitoring of the vertical profile ...?
Perhaps this is a symptom of reducing exposure to NPAs because of the availability of 'precision like approaches', which is related to automation dependency - the skills of monitoring are degrading.
Extracts of a study into "Loss of manual flying skills" suggest that this is due to the lack of recency in monitoring the flight path and increased mental workload, irrespective of automatic or manual flight.
In addition, modern aircraft offer the crew more technical options and facilities, e.g. FPA, which require thought about which one, and when to use them, including hazards they might generate.
A dominant mantra of the ALAR Tool Kit was to monitor altitude against distance - altitude first because that's the life saver. Yet with the availability of advanced displays and navigation features, simple cross checks may be overlooked or never be part of flying awareness (weak training).
"The majority of the cognitive demands were associated with the vertical profile and energy management aspects of the approach task rather than the lateral aspect, suggesting that the former is a more cognitively complex activity.
... the vertical profile and aircraft energy is heavily dependent on mental computation and can demand significant working and long term memory capacity if an efficient model, simplified through heuristics (rules of thumb), is not available."
Continued learning (professionalism) may also feature; lack of exposure, fewer opportunities to learn / refresh knowledge, and even a complacency of not requiring to learn because the automatics will provide the answer.
"... at under certain conditions pilots are slower to acquire this knowledge structure, or perhaps learning simply fails to occur at all."
Note that this is not about auto / manual flight skills, it is the willingness and ability to employ mental skills associated with forming and retaining a good mental model, planning ahead, and knowing what systems to use, when and why - which are the important parameters to monitor.
The study concludes -
"Subjective data and anecdotal evidence suggested that pilots of highly automated airliners may be vulnerable to the loss of their manual flying skills. However, there was insufficient objective data to support this safety concern and guide any remedial action. ...
The cognitive task analysis study revealed the dominant role of cognition (mental activity) in manual flying skill. Expert pilots reported using highly refined mental model structures and heuristics (rules of thumb) in order to predict the performance of their aircraft in its dynamic environment. The study found that the level of refinement of these models is closely linked to the performance achieved in manual flight. Pilots reported using advanced meta information gathering meta-cognitive (the method of our thinking) skills to isolate elements of the control problem, reducing its complexity, and narrow their information scan and reducing cognitive workload . ... expertise was closely linked to mental model structure. "
Where operators allow more manual flight practice, then the tasks must also be mentally challenging.
The Loss of Manual Flying Skills in Pilots of Highly Automated Airliners
Perhaps this is a symptom of reducing exposure to NPAs because of the availability of 'precision like approaches', which is related to automation dependency - the skills of monitoring are degrading.
Extracts of a study into "Loss of manual flying skills" suggest that this is due to the lack of recency in monitoring the flight path and increased mental workload, irrespective of automatic or manual flight.
In addition, modern aircraft offer the crew more technical options and facilities, e.g. FPA, which require thought about which one, and when to use them, including hazards they might generate.
A dominant mantra of the ALAR Tool Kit was to monitor altitude against distance - altitude first because that's the life saver. Yet with the availability of advanced displays and navigation features, simple cross checks may be overlooked or never be part of flying awareness (weak training).
"The majority of the cognitive demands were associated with the vertical profile and energy management aspects of the approach task rather than the lateral aspect, suggesting that the former is a more cognitively complex activity.
... the vertical profile and aircraft energy is heavily dependent on mental computation and can demand significant working and long term memory capacity if an efficient model, simplified through heuristics (rules of thumb), is not available."
Continued learning (professionalism) may also feature; lack of exposure, fewer opportunities to learn / refresh knowledge, and even a complacency of not requiring to learn because the automatics will provide the answer.
"... at under certain conditions pilots are slower to acquire this knowledge structure, or perhaps learning simply fails to occur at all."
Note that this is not about auto / manual flight skills, it is the willingness and ability to employ mental skills associated with forming and retaining a good mental model, planning ahead, and knowing what systems to use, when and why - which are the important parameters to monitor.
The study concludes -
"Subjective data and anecdotal evidence suggested that pilots of highly automated airliners may be vulnerable to the loss of their manual flying skills. However, there was insufficient objective data to support this safety concern and guide any remedial action. ...
The cognitive task analysis study revealed the dominant role of cognition (mental activity) in manual flying skill. Expert pilots reported using highly refined mental model structures and heuristics (rules of thumb) in order to predict the performance of their aircraft in its dynamic environment. The study found that the level of refinement of these models is closely linked to the performance achieved in manual flight. Pilots reported using advanced meta information gathering meta-cognitive (the method of our thinking) skills to isolate elements of the control problem, reducing its complexity, and narrow their information scan and reducing cognitive workload . ... expertise was closely linked to mental model structure. "
Where operators allow more manual flight practice, then the tasks must also be mentally challenging.
The Loss of Manual Flying Skills in Pilots of Highly Automated Airliners
Low temperature corrections
I am a bit puzzled by several aspects of this report, but can someone confirm that the chart on page 5 is correct?
It has an INDICATED altitude scale on the left which presumably means what the altimeters were showing, including the 2200 ft adjusted Split Crow crossing altitude. It then shows a calculated MDA of 813ft ASL - presumably Above Sea Level, and the Threshold Elevation at 449 ft ASL.
Working on the basis of 2 degC/1000ft lapse, for -6C at (roughly) 500ft field elevation, the sea level temp would be -5C, so the air mass temperature was ISA-20.
Applying the PANS-OPS approximation rule of thumb of 4% per 10 degrees below ISA, the correction would be 8%.
Shouldn't the threshold elevation shown also be corrected to 485' on the INDICATED altitude scale, and the calculated FPA be crossing the threshold higher as well? In fact doesn't it also need to be a bit higher to take the FPA to the intended touchdown point which is actually 463 feet AMSL = 500ft indicated???
It has an INDICATED altitude scale on the left which presumably means what the altimeters were showing, including the 2200 ft adjusted Split Crow crossing altitude. It then shows a calculated MDA of 813ft ASL - presumably Above Sea Level, and the Threshold Elevation at 449 ft ASL.
Working on the basis of 2 degC/1000ft lapse, for -6C at (roughly) 500ft field elevation, the sea level temp would be -5C, so the air mass temperature was ISA-20.
Applying the PANS-OPS approximation rule of thumb of 4% per 10 degrees below ISA, the correction would be 8%.
Shouldn't the threshold elevation shown also be corrected to 485' on the INDICATED altitude scale, and the calculated FPA be crossing the threshold higher as well? In fact doesn't it also need to be a bit higher to take the FPA to the intended touchdown point which is actually 463 feet AMSL = 500ft indicated???