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Air Canada A320 accident at Halifax

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Old 24th Sep 2017, 03:03
  #421 (permalink)  
 
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Originally Posted by FlyingStone
Is anybody still doing "dive and drive" with jets these days?
Bingo, I was wondering the same. Rarely used FPA to the MDA.
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Old 28th Oct 2017, 09:02
  #422 (permalink)  
 
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Slast: I agree with your sentiments. Crew actions at & below MDA were very dangerous. I've read the final paragraphs of the report including the consequential actions by AC. What still seems to be missing is an SOP requirement to X-check ALT v DME during descent from FAF. They seem to have adopted most of TC's recommendations, but that one was not mentioned. It is very scary to read about the inside workings of AC & TC. The discrepancy between AC's FCOM & SOP manual were glaring, yet approved. That casts shadows on the quality of TC's oversight and true understanding of what they were approving; and AC's own in-house FLT Ops dept that they could produce two such differing documents. It also is scary that they could produce such lax SOP's for such a critical manoeuvre. Their whole philosophy seems gash compared to those we use in EU. One would naturally think that AC was of the same quality standard as all other national carriers in EU & USA. Apparently they operated well below. The airmanship mindset in FLT OPs is surprising.
In EU there is an approach ban based upon VIS/RVR. In Canada they could even make an approach, in some circumstances, with a reported vis 50% of that charted?? They could continue below MDA with a call only of "LGHTS". What lights? It could be the carpark of motorway?? They had no SOP to monitor the ALT v DME during descent towards the concrete stuff?? Astonishing. (And a friend on B767 tells me it's the same there and they don't use FPA). The captain is PF in bad weather, rather than monitored approach. (a matter of debate, I know). They had an SOP allowing them to continue below MDA if lights were seen in the belief that the runway would become more visible. OMG. There was no calculation of DA/MDA taking into account the length of the ALS, so that the height above the runway at MDA coincided with the visibility and lighting system. This can encourage press-onitis below MDA if a LIGHT is seen in the belief that more lights will become visible. Considering the harsh conditions that Canada can present I would have expected ultra-cautious procedures, even if that resulted in more GA's even diversions.

It was all an astonishing eye-opener, and if I read the conclusions correctly the vertical path monitoring by raw data is still not in SOP's. It does make one wonder about the thinking in FLT OPs & TC that this behaviour could be promoted. It also make one wonder about the individual pilot's self survival instincts. The hairs on the back of my neck are very twitchy if nothing is seen at +100. To continue below MDA, still without the runway/full approach lights not in sight, would be beyond my courage. It's like driving down the road at a speed where the braking distance is greater than the visibility, in the hope that no other nutter is out there in such bad Wx.
One wonders what other scary gems are hidden in AC's SOP's. Is it a coincidence that their name is in lights a few times quite recently on what seem to be basic airmanship hiccups?

Does anyone on the inside have any more information about changes in operating culture? Is Canada going to move closer to FAA & EU procedures/philosophies/techniques.

Last edited by RAT 5; 28th Oct 2017 at 10:38.
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Old 28th Oct 2017, 11:44
  #423 (permalink)  
 
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RAT 5

I am considering Canada in maybe a two to five years.
I have to do some research , and I am with you Rat 5. Something seems off in some of the incidents with Canadian Ops.

The WestJet in the Caribbean is another NPA incident I find interesting.

I have the greatest respect for Canadian pilots, dont get me wrong, but I have seen some local CAAs in Europe loosing the plot the last 15 to 20 years.

You would think Canada with ICAO in Montreal would be a beacon of proper , safe procedure.

Looking forward to some enlightenment from Canada.
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Old 28th Oct 2017, 14:47
  #424 (permalink)  
 
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I don't know what the big deal is when it comes to a landing minima in Canada.

To continue an approach below a specified DH or MDA for that approach in Canada the visual requirements are "black and white" and very clear as follows...

Landing Minima (TC AIM October 12, 2017)…

CAR 602.128 specifies that landings are governed by published DH/MDAs.

Pilots of aircraft on instrument approaches are prohibited from continuing the final approach descent below DH or descending below MDA, as applicable, unless the required visual reference (see requirements below) has been established and maintained in order to complete a safe landing.

When the required visual reference is not established or maintained, a missed approach must be initiated. Pilots must be cautioned that the missed approach segment that provides for obstacle clearance originates at the published MAP. The published MAP on a precision approach is coincidental with the DH. Obstacle clearance will not be assured for missed approaches initiated beyond the MAP.

Certain published approaches that contain multiple lines of minima may have step-down altitudes that are lower than a published line of minima. Pilots should not descend to a stepdown altitude that is lower than the altitude on their selected line of minima.

The visual references required by the pilot to continue the approach to a safe landing should include at least one of the following references for the intended runway, and should be distinctly visible and identifiable to the pilot by:

(a) the runway or runway markings;
(b) the runway threshold or threshold markings;
(c) the touchdown zone or touchdown zone markings;
(d) the approach lights;
(e) the approach slope indicator system;
(f) the runway identification lights;
(g) the threshold and runway end lights;
(h) the touchdown zone light;
(i) the parallel runway edge lights; or
(j) the runway centreline lights.


So just seeing the ground or some lights while on the approach is a non starter.

It is of my opinion that the crew of that Air Canada flight saw "something" and decided to continue their descent below MDA without meeting any of the above requirements or did not control their aircraft and allowed it to descend below the MDA into the ground.

Last edited by Jet Jockey A4; 29th Oct 2017 at 18:41.
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Old 28th Oct 2017, 17:24
  #425 (permalink)  
 
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Thanks JJ A4. What you've written is IAW EU Ops and makes sense. It is dated October 12 2017. Were these the requirements at the time of the crash, or updated from the report? The call of "lights only', or "ground contact" early in an approach had always been taught to me as an absolute No No. It risked, as in the case, continuation bias, yet it was an AC SOP. The report says they think they saw the first 2 approach lights and during the analysis of what they were seeing decided to continue. We do not know if these '2 lights' were 2 single centreline lights, or 2 bars of approach lights. I would have thought that 2 single lights would be difficult to assess as approach lights, whereas 2 bars would be confirmation. Single lights do not allow assessment of position, attitude, bank angle, create of closure: a horizontal bar does; and if you can see a horizontal bar you can also see centreline lights of the approach light system. Thus there needs to be a wider definition of 'approach lights'. In EASA I believe it says at least 1 horizontal bar. This allows you to determine roll attitude. Remembering that the rules are written for many types of a/c and operation, i.e. even hand flown twin pistons. 'Runway centreline lights' even needs expanding e.g. how many? Surely if you can see centreline lights you must be able to see Threshold lights as well; and therefore centreline lights on their own do not define a runway. Centreline lights need to be in combination with other lights.
It seems you are local to Canada. What is the now published requirement to confirm the vertical profile inside FAF?
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Old 29th Oct 2017, 08:51
  #426 (permalink)  
 
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The AIM manual is updated twice a year and this version is the latest one from October 12th 2017 with the new one due in April 2018.

Unfortunately I don't have access to older versions to see if or when the standards were changed (it could have been years ago).

I will try to find other info on your questions but may take awhile because I'm on a flight through Europe at this time.

The approach lighting on RWY 05 consist of HIRL, CL, SSALR, and a PAPI on the left side. The opposite side (RWY 23) is a CAT II runway with much better lighting.

If the approach to that runway as not changed since the accident, then the approach that night to RWY 05 was a LOC only approach (no G/S) but with a DME. The MDA was 820' (357') and the MAP was at 1.7 DME (taken from another DME freq.) which brought the MAP to the threshold of RWY 05.

However if you the crew had decided to do a constants descent from the final fix to RWY 05 they would have done their missed approach a lot sooner than the 1.7 DME point.

Last edited by Jet Jockey A4; 29th Oct 2017 at 18:34.
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Old 29th Oct 2017, 16:39
  #427 (permalink)  
 
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Canadian DH rules

RAT 5, thanks, your comments are very appropriate.

JJA4, with all respect, the problem with Canadian minima is not the list of visual references, which is pretty common. It is what decision the rules expect the pilot to make.

The concept of Decision Height (ICAO and elsewhere) is that the pilot must answer Yes or No to the question "Has what you have already seen on the ground confirmed that you are in the right place and going in the right direction?", and continue or go around as appropriate. This is also written into for example the Airbus FCTM.

But Canada's rule (CAR 100.01(1) definitions) doesn't ask that. It poses a very different question: "is what you can see on the ground right now going to allow you to find out if you are in the right place and going in the right direction?". So the crucial decision is delayed to some undefined point in the future. ICAO requires the pilots assessment to finish at DH. Canada allows it to START there.

Under CAR, below DH the pilot has ceased to have sufficiently accurate instrument information to avoid obstacles, but as in this case he/she may still be assessing from visual information whether its position and velocity are satisfactory. The pilot eventually concluded that its position and trajectory were NOT safe and that a go-around was required, but by that time the aircraft was only just above the touchdown zone elevation and well below the altitude at which a go-around can safely be carried out. IMHO this difference was a direct cause of the accident.

In this case, when it was reached, well below the DH/MDA, the pilots' subsequent decision was "no our position and rate of position are not satisfactory, we need to go around", by which time it was too late to avoid ground impact.

While the report makes considerable play of Canadian non-compliance with ICAO and EASA rules regarding CVR power supplies, it makes no mention of the (far more serious) fact that CAR 100.01(1) is in direct conflict with both ICAO Annex 6 and EASA wording intended specifically to prevent this situation arising.
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Old 29th Oct 2017, 16:44
  #428 (permalink)  
 
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If they became visual what caused the undershoot? Back in the day a VC8 touched down on the grass to the left of the RWY. (All 3 u/c) snaked about a bit till it got back on the hard surface. Well neither pilot could explain why they had let the aircraft touch down in that position only mitigation was they saw the RWY late. (250’) something within humans that despite what they are seeing they see what they want to see.
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Old 29th Oct 2017, 17:00
  #429 (permalink)  
 
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Unofficial diagram

An unoffical diagram from the information in the report.
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Old 29th Oct 2017, 17:22
  #430 (permalink)  
 
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Info at the time of the accident

Originally Posted by Jet Jockey A4
The approach lighting on RWY 05 consist of HIRL, CL, SSALR, and a PAPI on the left side....
If the approach to that runway as not changed since the accident, then the approach that night to RWY 05 was a LOC only approach (no G/S) but with a DME. The MDA was 820' (357') and the MAP was at 1.7 DME (taken from another DME freq.) which brought the MAP to the threshold of RWY 05.
For clarification, I expect your data is current but at the time of the accident the runway had left-side PAPI, high-intensity threshold, end, centre-line, and edge lighting, but only a medium-intensity omnidirectional approach lighting system (ODALS) extending 1500 feet from the threshold with 5 lights spaced approximately 300 feet apart, which flash sequentially every second (60 times per minute).

The runway also has a significant up-slope from the threshold to the TDZ. The MDA was 740ft (277) with a temperature correction.

So since the accident the approach lighting has been upgraded and the MDA raised. Can you tell me what the current visibility minima are? It's also my information (not confirmed) that the Captain has left the company.
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Old 29th Oct 2017, 17:47
  #431 (permalink)  
 
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Originally Posted by slast
RAT 5, thanks, your comments are very appropriate.

JJA4, with all respect, the problem with Canadian minima is not the list of visual references, which is pretty common. It is what decision the rules expect the pilot to make.

The concept of Decision Height (ICAO and elsewhere) is that the pilot must answer Yes or No to the question "Has what you have already seen on the ground confirmed that you are in the right place and going in the right direction?", and continue or go around as appropriate. This is also written into for example the Airbus FCTM.

But Canada's rule (CAR 100.01(1) definitions) doesn't ask that. It poses a very different question: "is what you can see on the ground right now going to allow you to find out if you are in the right place and going in the right direction?". So the crucial decision is delayed to some undefined point in the future. ICAO requires the pilots assessment to finish at DH. Canada allows it to START there.
I disagree, and I have flown this approach into YHZ, with a certain Airline

On a Coupled/Selected approach, you fly the selected Flight Path Angle to minimums (+50 ' in this case) plus low temperature corrections at the FAF and MDA.. No contact at minimums then , immediate Go-Around. The 50 foot additive protects you from descending BELOW the published MDA during the GA.

So (as I would fly it) Coupled/Selected ; descending on the 3.5 degree FPA and coupled to the LOC, at minimums, ie. published MDA + 50 feet, it was auto pilot disconnect, " Landing" , or "Go around flaps" call by Captain who would be flying. Depending on whether the runway is visible for a safe landing, aircraft alignment with center line, amount of crab, etc.. Because you are descending on a constant 3.5 degree FPA, at minimums, it is treated the same as minimums on an ILS ie a Decision Height. You have the visibility to land or not.

PNF calls would be "One Hundred above" then "Minimums" , "runway in sight" or "no contact" . Runway in sight call is made anytime runway is visible, on the approach, whereas "no contact" is a call made at minimums.


IMHO, what this Airport needs is an ILS on Runway 05
my 2c worth

Last edited by Retired DC9 driver; 29th Oct 2017 at 23:18.
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Old 29th Oct 2017, 18:57
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Originally Posted by slast
RAT 5, thanks, your comments are very appropriate.

JJA4, with all respect, the problem with Canadian minima is not the list of visual references, which is pretty common. It is what decision the rules expect the pilot to make.

The concept of Decision Height (ICAO and elsewhere) is that the pilot must answer Yes or No to the question "Has what you have already seen on the ground confirmed that you are in the right place and going in the right direction?", and continue or go around as appropriate. This is also written into for example the Airbus FCTM.

But Canada's rule (CAR 100.01(1) definitions) doesn't ask that. It poses a very different question: "is what you can see on the ground right now going to allow you to find out if you are in the right place and going in the right direction?". So the crucial decision is delayed to some undefined point in the future. ICAO requires the pilots assessment to finish at DH. Canada allows it to START there.

Under CAR, below DH the pilot has ceased to have sufficiently accurate instrument information to avoid obstacles, but as in this case he/she may still be assessing from visual information whether its position and velocity are satisfactory. The pilot eventually concluded that its position and trajectory were NOT safe and that a go-around was required, but by that time the aircraft was only just above the touchdown zone elevation and well below the altitude at which a go-around can safely be carried out. IMHO this difference was a direct cause of the accident.

In this case, when it was reached, well below the DH/MDA, the pilots' subsequent decision was "no our position and rate of position are not satisfactory, we need to go around", by which time it was too late to avoid ground impact.

While the report makes considerable play of Canadian non-compliance with ICAO and EASA rules regarding CVR power supplies, it makes no mention of the (far more serious) fact that CAR 100.01(1) is in direct conflict with both ICAO Annex 6 and EASA wording intended specifically to prevent this situation arising.
To me, like I said before the rules are clear. I have not read CAR 100.01 (1) most likely in ages and I don't really care for it because we use the rules written below. If you are a lawyer or try to interpret the rules in a different way so be it. I know by applying strictly the rules below I won't get into trouble.

CAR 602.128 specifies that landings are governed by published DH/MDAs.

Pilots of aircraft on instrument approaches are prohibited from continuing the final approach descent below DH or descending below MDA, as applicable, unless the required visual reference (see requirements below) has been established and maintained in order to complete a safe landing.

When the required visual reference is not established or maintained, a missed approach must be initiated.


The visual references required by the pilot to continue the approach to a safe landing should include at least one of the following references for the intended runway, and should be distinctly visible and identifiable to the pilot by:

(a) the runway or runway markings;
(b) the runway threshold or threshold markings;
(c) the touchdown zone or touchdown zone markings;
(d) the approach lights;
(e) the approach slope indicator system;
(f) the runway identification lights;
(g) the threshold and runway end lights;
(h) the touchdown zone light;
(i) the parallel runway edge lights; or
(j) the runway centreline lights.


Well in my book it is very clear and in our company it is very well understood that at DH or MDA if the above conditions are not met a Go-Around must be initiated immediately.
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Old 29th Oct 2017, 19:24
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Well in my book it is very clear and in our company it is very well understood that at DH or MDA if the above conditions are not met a Go-Around must be initiated immediately.
I agree....as I stated above.
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Old 29th Oct 2017, 22:30
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Slast, Is there anyway I can get your excellent Chart in a form I can expand?

(referring to post #430)
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Old 29th Oct 2017, 22:49
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Originally Posted by slast
An unoffical diagram from the information in the report.

From the conversation in the cockpit that you provide on the chart it seems to me they did not have the required light to continue below the MDA... They should have initiated an immediate Go-Around.

Again, and I said this at the beginning of this thread, it is a real shame Air Canada never equipped their older A320s with GPS so that this crew could have used GPS/WAAS do to a LPV approach. Doing a LOC approach in these weather conditions with a baro type VPath that may have been improperly programmed was looking for trouble.
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Old 29th Oct 2017, 23:28
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I just pulled the approach plate for CYHZ and it's new from just a few days ago (2017-10-17)...

The changes stated on the approach plate are D-ATIS, lighting and visibility.

I must assume since the accident they may have improved the lighting system for RWY 05. Also as you pointed out, there are new/higher minimums for that approach but the visibility is still the same at 1 mile. The rest of the approach remains the same with the same DME being used to dictate the MAP at 1.7 DME which again is the threshold of RWY 05.

NOTE: In Canada with our "Visibility Approach Bans", Air Canada (and others qualified) could start the approach with less than the 1 mile visibility required on the approach plate.

Last edited by Jet Jockey A4; 30th Oct 2017 at 10:30.
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Old 30th Oct 2017, 07:45
  #437 (permalink)  
 
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I'm still curious if AC have now included in their SOP's a DME v ALT check inside the FAF? Jeppe has the table on the charts, why not use it; especially on cold weather correction days? I still say, in response to JJ, that the term "Approach lights" needs an expanded definition. It is far too lax & simple and easy for someone to say,"I saw the lights." Yeah, but what kind of lights? JJ says that the visual criteria for landing is black & white; but if you read the list everything mentioned is within the runway it self, even the Approach Slope indicators. All the lights are in the runway surface, except 'Approach Lights'. The runway lights are identified by their position and title and thus we know what they are, where they are and what colour. "Approach Lights" is too vague and a real sucker clue, especially given the variety of approach lighting systems and layouts possible.
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Old 30th Oct 2017, 10:27
  #438 (permalink)  
 
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I can't speak for AC's SOPs and what they say but any professional pilot even if it is not written in their SOP would use the info provided on the Jepp plate and that includes the DME v Alt info provided and he would also be cross checking the altitudes over the FAF to make sure his temp correction he applied is correct... This is called airmanship.

I now understand what you meant about your "approach lights" comment but I have not found anything that would make it clearer.

If the chart posted above is correct, the PM's first call when he initially saw lights was "lights only", not "approach lights".

What did he see? Random lights on the ground or the actual approach lights for the runway?

Last edited by Jet Jockey A4; 30th Oct 2017 at 11:22.
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Old 30th Oct 2017, 11:54
  #439 (permalink)  
 
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Originally Posted by jack11111
Slast, Is there anyway I can get your excellent Chart in a form I can expand?

(referring to post #430)
Hi Jack
It's page 3 of this critique of the entire TSB report.
http://www.picma.info/sites/default/...ique%201_4.pdf.
If you want a graphic source file to manipulate etc I can supply it, send me a PM.

Any comments especially errors and corrections please let me know.
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Old 30th Oct 2017, 12:08
  #440 (permalink)  
 
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Originally Posted by Jet Jockey A4
From the conversation in the cockpit that you provide on the chart it seems to me they did not have the required light to continue below the MDA... They should have initiated an immediate Go-Around.
The chart is my best attempt to correlate the information in the report, since the TSB did not see fit to do so. The report contains several contradictory statements about this point. The analysis says "As the aircraft reached the calculated MDA, both crew members observed some approach lights. These cues meet the criteria for required visual reference per the Air Canada Flight Operations Manual, the Transport Canada Aeronautical Information Manual, and the Canada Air Pilot general pages."

But earlier it states "At 0029:27, a radio altimeter automated audio call (automated call) of “400” was made, indicating that the aircraft was 400 feet above the terrain. Almost immediately after this call, the aircraft crossed the calculated MDA at 1.2 nm from the threshold. The PM observed some approach lights and called, “Minimum, lights only,” when the aircraft was about 1.0 nm from the threshold. The PF immediately called, “Landing,” and began to observe some approach lights. By this time, the aircraft had crossed the published MDA (740 feet ASL) and was 0.3 nm farther back than the published distance. The autopilot remained engaged as the aircraft continued descending, and there was no reduction in the descent rate."
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