Jet goes down on its way to Medellin, Colombia
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.
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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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. .
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 13:11. Reason: addition .
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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.
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 17:30. Reason: + Visuals for SKRG, ++ VFR versus IFR +++ Best advice?
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 18:28.
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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.
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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@ CHfour
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?
Uncalled-for
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."
Full article:
Bolivia: Human error caused crash that killed soccer team - CNN.com
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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.
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; 20th Dec 2016 at 23:25.
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!
Lets keep our eyes on the ROOT cause!
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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.
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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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.
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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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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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?
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?
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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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.
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.
lemme, your speculation increasingly relies on assumptions of what the crew were thinking; their plan at the time, not ours with hindsight.
For future safety it's good question why did an aircraft with a reasonable chance of achieving some form of landing, ended up on a hill side; particularly when the industry recalls at least two previous events with a successful outcome (Gimli, VIE), involving higher tech aircraft, in a similar technical scenarios, and of the same certification basis.
The degree of success depends on being on/off an airport, the distance vs altitude available, weather, and terrain. The latter two in this event were unfavourable.
A pilot might be more interested in conserving altitude, not descending early to meet some objective, particularly if this is defined by range information which the crew may not be aware of (no DME display). Also, the speculative 3-4D navigation assumed that the crew had accurate altitude information; this required resetting the StBy altimeter scale; the alternative is ILS GS. Is there any evidence that ATC broadcast the airfield datum.
I doubt that the crew would recall the glide ratios for configuration; I would not recall 15:1*, but for other reasons 6:1 is remembered, 1nm/1000 ft (note range requirement). Thus a plan might involve stretching the glide until committed to the final configuration selection.
Emergency navigation information is shown overlaid on the StBy attitude gyro (not IRS) as a two axis cross pointer. Without care this display could be interpreted as a FD command.
With a VOR tuned the lateral axis would provide directions to the ground station; I cannot recall what the vertical axis displays, but if shown and followed as a FD command, then a null reading could result in unmonitored flight into terrain. AFAIR there is no range information.
With an ILS tuned then both axis would be valid, but the aircraft would have to maintain flight at or above the GS. If the display was used as a FD command with the aircraft closing from above or being on the GS, then there would be a point at which the aircraft would be unable to maintain both speed and GS if fully configured (but 15:1 clean or low flap, low wt vs high alt, might be an interesting challenge).
* 20 years on type, including steep approaches.
The 146/RJ aircraft types have never to date, suffered 'deep stall'. The 'straight' wing design has a conventional stall which is forcefully assisted with a stick push for the manual controls.
For future safety it's good question why did an aircraft with a reasonable chance of achieving some form of landing, ended up on a hill side; particularly when the industry recalls at least two previous events with a successful outcome (Gimli, VIE), involving higher tech aircraft, in a similar technical scenarios, and of the same certification basis.
The degree of success depends on being on/off an airport, the distance vs altitude available, weather, and terrain. The latter two in this event were unfavourable.
A pilot might be more interested in conserving altitude, not descending early to meet some objective, particularly if this is defined by range information which the crew may not be aware of (no DME display). Also, the speculative 3-4D navigation assumed that the crew had accurate altitude information; this required resetting the StBy altimeter scale; the alternative is ILS GS. Is there any evidence that ATC broadcast the airfield datum.
I doubt that the crew would recall the glide ratios for configuration; I would not recall 15:1*, but for other reasons 6:1 is remembered, 1nm/1000 ft (note range requirement). Thus a plan might involve stretching the glide until committed to the final configuration selection.
Emergency navigation information is shown overlaid on the StBy attitude gyro (not IRS) as a two axis cross pointer. Without care this display could be interpreted as a FD command.
With a VOR tuned the lateral axis would provide directions to the ground station; I cannot recall what the vertical axis displays, but if shown and followed as a FD command, then a null reading could result in unmonitored flight into terrain. AFAIR there is no range information.
With an ILS tuned then both axis would be valid, but the aircraft would have to maintain flight at or above the GS. If the display was used as a FD command with the aircraft closing from above or being on the GS, then there would be a point at which the aircraft would be unable to maintain both speed and GS if fully configured (but 15:1 clean or low flap, low wt vs high alt, might be an interesting challenge).
* 20 years on type, including steep approaches.
The 146/RJ aircraft types have never to date, suffered 'deep stall'. The 'straight' wing design has a conventional stall which is forcefully assisted with a stick push for the manual controls.
Safetypee, I think the stby attitude nav display is for ILS only. If ILS is not tuned then the bars move from view. The #1 DBI is available at the emerg power level with a bearing pointer for tracking a VOR or NDB. The possibility of treating the stby ILS bars as a flight director is very real and could easily lead to trouble.