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Jet goes down on its way to Medellin, Colombia

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Jet goes down on its way to Medellin, Colombia

Old 20th Dec 2016, 12:40
  #961 (permalink)  
 
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Just wondering ... maps ...

Descending (fast) from 21,000ft through 19,000ft under highly stressful conditions ... Maps give Trans Level FL 190 and Trans Alt 18,000ft ... what altitude setting were they on ... (if not reported, then you would of course need CVR and FDR to answer that one)...

Comparing IAC maps with Jeppesen maps ref indication of ground contours/altitudes. IIRC in for example the Guam case there were comments on the contours/alts, the impact area not being properly indicated. In this case the Jeppesen appears to be superior to the IAC map. The Jeppesen contours say 8,000ft by the way.

There is a nasty isolated hump along the approach path around D5 IMDE. On the IAC map it says 8040ft (but you might overlook that). On the Jeppesen it says 8157ft (indicated more clearly, but i had to check if it said 6157 or 8157 because of the contour line).

So pilots who had been there before and pilots who looked at their maps, forgetting the 12,600/13,100 ft MSA, in an emergency would probably make sure they would stay well above 8,200ft.
Which triggers the question who was PF. The FO being reported talking to ATC, would suggest the Capt to be PF. How familiar was the PF with this specific airport. What kind of terrain map would he have had in mind.

IIRC the Lamia flight at some stage reported being 'visual with ground'. They were flying in the dark. The most likely visual might have been La Ceja. If you look at videos from the approach and aerial pictures, then La Ceja has quite typical contours. Wonder if having grating type contours of towns on the maps would be beneficial in this specific area.

Just wondering ...
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Old 20th Dec 2016, 12:49
  #962 (permalink)  
 
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Originally Posted by ATC Watcher View Post
This accident report is extremely interesting , especially beyond the 130 first pages.
If you are 35 knots slow on final, you fail your check ride.
If you are 30 knots slow on final, you fail your check ride
If you are 25 knots slow on final, you fail your check ride
If you are 20 knots slow on final, you fail your check ride
If you are 15 knots slow on final, you fail your check ride.

And you really fail your check ride if you get into those conditions on final and 1) you don't act to correct it and 2) you don't initiate a go around before you get to 35+ knots slow on final. That a training captain was in one of the seats is deeply disturbing from the PoV of the system and culture in that airline. I appreciate Mr Sumwalt's points on how the pilots ended up in a situation where they failed their check ride with a plane full of passengers, in terms of training and culture. There is certainly an element of habits that will hopefully be addressed in that company.


This accident, however, is from a significantly different organizational set up and culture. Asiana is a major airline with some depth. This company, LaMia, was small and has/had no depth. From an organizational aspect, they were more vulnerable to any problems in culture, training, and habits. Fewer opportunities for the 'system' to catch aberration.
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Old 20th Dec 2016, 13:26
  #963 (permalink)  
 
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But ...
Passing your check ride will not ensure that you act correctly in all situations, especially in circumstances which demand high mental workload or rely on experience.
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Old 20th Dec 2016, 14:05
  #964 (permalink)  
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Lonewolf : I am not a 777 pilot , but I am a Human factors guy, and I would bet those guys all passed all their check rides on the Knot, but the interesting bit for me is why they dot not monitor speed this time : lapse, negligence or training issue ?

And the answer is in the report : they all 3 said expected the automation to protect speed in all modes but they stated they did not know it would not do so when in the " Hold " mode " . Further the PF sated he never did a visual approach without a Glide slope before.
Those were not inexperienced pilots, both in the 10.000 hours range.

The aircraft is know to have a few automation traps ( most a/c do, not only Boeing 777s ) and the airline recognized those were not emphasized or taught to the crews during their training although the philosophy of the Airline was to : "make full use of all automation and did not encourage manual flight during line operations " (quote from the report)

So negligence from who ?

sorry for the thread Drift..

Oh, and by the way Lonewolf, totally agree with your last paragraph. Although one could debate that the what I would call "military Cockpit authority culture" could perhaps apply to both LaMia and Asiana. .

Last edited by ATC Watcher; 20th Dec 2016 at 14:11. Reason: addition .
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Old 20th Dec 2016, 16:55
  #965 (permalink)  
 
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Just wondering ... maps ... again

In my post #974 my area of interest was on what ground you might expect between the VOR "RNG" and Cordova airport.

The next map in my stack was a Visual for Medellin airport. That showed more ground contour information. That map color-indicated the VOR plateau at 8,000ft without showing specific peaks/ridges.
Bit of a surprise then when taking the AIP Colombia next which gives the DVOR "RNG" an elevación of 8,669 ft.

No problem at all if you are following MSA guidance, but can give you a nasty surprise if you do not take a detailed look at the available information in an emergency descent.


When you go to the AIP SKRG Visuals you find values of peaks/ridges around the VOR of between 8,450-8,900 ft.

I dont know the altitude of the initial impact ridge. A rough estimate is that it is at the VOR altitude level plus/minus a few hundred feet.

Gives a bit of a 'Guam' feeling.

It suggests that the "map resolution"/"cut-off" criterium for VFR is indeed different from that of IFR and neither shows consistency in application.

Best advice with these maps appears to be to ignore all specific peak/ridge information and just add 1,000ft to all contour information. Which means in this case that the plane should have stayed above 9,000 ft over the VOR.

Last edited by A0283; 20th Dec 2016 at 18:30. Reason: + Visuals for SKRG, ++ VFR versus IFR +++ Best advice?
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Old 20th Dec 2016, 19:06
  #966 (permalink)  
 
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Originally Posted by PEI_3721 View Post
But ...
Passing your check ride will not ensure that you act correctly in all situations, especially in circumstances which demand high mental workload or rely on experience.
Not a good reply, since it implies that the only time you have to be "on" is during a check ride. We both know that isn't so. Many companies have FOQA programs ... can't recall if Asiana does or not, but I suspect they do. Let's not forget the general requirement for a stabilized approach applies to the visual approach, does it not? Being 20 knots off is hardly stabilized in the end game, no less 35 or so.

If you aren't maintaining airspeed, and correcting it when it's wrong, you aren't flying the plane, the plane is flying you. Apologies for further digression, will stop.


@ATC: I fully embrace the importance of human factors, based on the mishap I was in and the ones I investigated. I also used to teach CRM. I understand the issues of supervisory/cultural errors, and the power of norms both formal and informal. On top of that, I am very cognizant of cockpit gradients since during my time in the Navy, flying, that particular issue got massive amounts of attention and the difference between what goes on in a cockpit in 1983 and 2003 was profound. Beyond that, I was once getting a check ride from the Naval Air Forces NATOPS evaluator who, inadvertently, while giving me a simulated engine failure actually pulled the engine off line. (hehe, the debrief on that one was good fun). We put the bird on the deck, got it all started again, and proceeded to complete the check ride. (We handled the engine loss as a crew right out of the PCL/emergency action items, just as you'd hope).


If we are to try and compare Asiana with LaMia, perhaps the only useful point of comparison is in the cockpit gradient on the flight involved -- but I am guessing at that. We have one report and not the other one to refer to.

Last edited by Lonewolf_50; 20th Dec 2016 at 19:28.
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Old 20th Dec 2016, 20:45
  #967 (permalink)  
 
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@lemme - your photo clearly shows what i call the saddle - on the left 8,232ft then the downward curve and up the 8,127ft to the right.

When you are not sure about your heading, even if you know your DME distance, you would have to add the 1,000ft i mentioned in my previous post to the 8,000ft before you could think about starting a descent. So even if they had cleared the VOR ridge there would have been a real risk of hitting either side of the saddle. And if they had kept that safer 9,000ft it would have forced them into a steeper descent on finals.
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Old 20th Dec 2016, 22:01
  #968 (permalink)  
 
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Lemme, your posts help me get to sleep in the evening. Thank you.
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Old 20th Dec 2016, 22:27
  #969 (permalink)  
 
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@HT
Lemme, your posts help me get to sleep in the evening. Thank you.
Uncalled-for
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Old 20th Dec 2016, 23:29
  #970 (permalink)  
 
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@ CHfour

Uncalled-for
We can all speculate until the cows come home, but lemme takes it to another level. I just do not see any value whatsoever in his lengthy and detailed speculations. What does it achieve?
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Old 20th Dec 2016, 23:44
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Bolivian Minister of Public Works Milton Claros told reporters: "After investigations we have concluded that the pilot of the plane and the airline LaMia are responsible for the crash."
So!

Full article:

Bolivia: Human error caused crash that killed soccer team - CNN.com
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Old 21st Dec 2016, 00:13
  #972 (permalink)  
 
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@testpanel - an interesting (short) CNN article:

A Bolivian government minister talking about investigation results.
An investigator talking about people that have been arrested.

Never too old to be surprised.

@Hotel Tango - no need to speculate indeed, the cows are already at home :-)

On a much more serious note - Earlier in the thread i mentioned that i hoped someone would separate the international safety and criminal investigations and make the result public. I am still hoping. Does not make the ICAO job of the Colombians easier.

Last edited by A0283; 21st Dec 2016 at 00:25.
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Old 21st Dec 2016, 00:19
  #973 (permalink)  
 
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Why does anyone think that a person who will willingly depart with insufficient fuel will have any capacity to consider terrain clearance.

Lets keep our eyes on the ROOT cause!
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Old 21st Dec 2016, 00:42
  #974 (permalink)  
 
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@Right Way Up

Don't you think that terrain clearance is one aspect that can be discussed to try to test that capacity. The way you phrase it could be extrapolated to any aspect. It would surprise me if that is what you mean to say.

In my view there never is a single root cause. A 4D interrelated chain of events is a better description. Discussing the root cause that you probably refer too must wait till an investigation publishes an extensive set of documents. That's something you might expect from/in a US NTSB investigation docket, but not per se from this multinational investigation.
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Old 21st Dec 2016, 02:16
  #975 (permalink)  
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But A0283 surely any root cause(s), if there are multiple causes for this particular accident, had to be before the departure. The fuel calculation, the decision to depart with that fuel load and flight plan without a fuel stop, all these are the root cause.

Perhaps there could be other causes that influenced that decision, eg commercial pressures, some misguided belief that the plane used less fuel than the book said (hypothetical speculation here), etc. But anything that happened after they pushed the throttles forward on departure is just reaction not cause.

Sure they might have been able to get recover, get away with it, save the day with some skilled cool headed flying. Then it would have been a near accident caused by the fuel decision. That decision was still the cause.

The improper handling of the fuel emergency (by the pilots) was not great. But the previous aircraft getting priority did not cause the accident. ATC did not cause it. Those two didn't even contribute. Maybe it was unlucky that that airplane was there. But flying isn't supposed to depend on luck.
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Old 21st Dec 2016, 07:59
  #976 (permalink)  
 
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Regarding the root cause, I would say it is simply that the airline company and the pilot/owner was a "cowboy" totally neglecting any prudent planning and industry standard for flight planning, safety margins, CRM and whatever. So, the root cause goes well before what happened on the departing airport.
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Old 21st Dec 2016, 08:11
  #977 (permalink)  
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Looking at the Aerosucre 727 attempted take off video on the other thread reminds me of my early days looking at CL-44s out of Luxemburg and brings me the following question:

For those in the known : how far can you stretch the MTOW on an RJ ? 2 tons ? (5% ?) or is it not possible at all on this type?
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Old 21st Dec 2016, 09:12
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No idea. Have only ever been landing weight limited, not take off limited.
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Old 21st Dec 2016, 09:21
  #979 (permalink)  
 
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how far can you stretch the MTOW on an RJ ? 2 tons ? (5% ?) or is it not possible at all on this type?
5% easily on any type, I'd say, provided you could takeoff at the legal MTOW ie not performance-limited). Just don't have an engine failure.
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Old 21st Dec 2016, 10:06
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SteinarN,
Agree with You, see previous post of me.
But hopefully not only the crew will be blamed, it is the system that allows these kind of operators, cowboys if You will, to start up and keep on going, with everybody looking away. Or worse, being paid to look away. This kind of people will always be pushing the limits, until they run out of luck if not stopped by the system.

Now I am not that an EU fan, but at least they have a reasonable system to keep operators like that outside the EU.
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