Canada Rouge at Montego Bay
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The PF probably intended to land with A/T off but was habitually conditioned to having A/T on (AC Rouge SOP strongly recommends A/T on from takeoff to landing). The PM probably thought A/T was on and did not monitor the speed.
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NOTAMs, Go-arounds etc. aside..
There was a point, although a tad late, when this aircraft was 'in the slot' for landing. From that point this incident resembles the Asiana very much. Thrust idle, speed drops, pitch increases... until impact. Even in an Airbus proper pitch+power isn't too much to ask for, is it? Someone pointed out, they probably 'forgot' that A/THR wasn't there to save them. Probably true, but did they get so confused when the A/THR failed to respond that they didn't do it themselves?
Is it not time for regulators to mandate that crew is comfortable with all modes of operation? In the process, ban the "Maximum use of automation" quote from all Operations Manuals. That could be a starter for a cultural change that takes time to change.
There was a point, although a tad late, when this aircraft was 'in the slot' for landing. From that point this incident resembles the Asiana very much. Thrust idle, speed drops, pitch increases... until impact. Even in an Airbus proper pitch+power isn't too much to ask for, is it? Someone pointed out, they probably 'forgot' that A/THR wasn't there to save them. Probably true, but did they get so confused when the A/THR failed to respond that they didn't do it themselves?
Is it not time for regulators to mandate that crew is comfortable with all modes of operation? In the process, ban the "Maximum use of automation" quote from all Operations Manuals. That could be a starter for a cultural change that takes time to change.
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It will drift off the thread, but the question was asked. Gehenna asked, and has the correct attitude. I used to beat into my students that every takeoff was an RTO until V, and every approach was a GA until TR's were selected. GA training in the sim is very little of training and more tick in the box stuff. An ATC wave off at 50' is a non event. An automatic GA at 30' LVO is a non event. A W/S ahead GA is a non event. When it goes wrong is when it is rushed and complicated. One airline in my portfolio had such a rushed 2 engine GA SOP, with lots of mouth music and actions close to the ground, that it was so easy to make a real mess; and often it was. Take it slowly & relaxed, but expedite. Treat it like a takeoff, that manoeuvre we do every day. (Why oh why did B737 reinvent the acceleration to be via the flap lever and not the MCP window????? And why retract the flaps at 400'???????) Don't panic with fire walled thrust levers and lots of screaming.
If a GA is the default of any approach it should never be a surprise. It should be a simple manoeuvre. So why is it messed up so often?
1. It is often rushed and SOP complicated.
2. It is not the same sequence as a normal takeoff.
3. It is seldom trained in recurrency.
I still remember the most important learning experience of my commercial apprenticeship. An IMC GA at Le Bourget as a young biz-jet RHS'er. & a CAVOK GA as F/O in B732 due to wind shifts on short finals and a subsequent long landing on a short runway. Both were a huge learning experience and both were a non event due to the character in LHS.
Other opinions and solutions invited.
If a GA is the default of any approach it should never be a surprise. It should be a simple manoeuvre. So why is it messed up so often?
1. It is often rushed and SOP complicated.
2. It is not the same sequence as a normal takeoff.
3. It is seldom trained in recurrency.
I still remember the most important learning experience of my commercial apprenticeship. An IMC GA at Le Bourget as a young biz-jet RHS'er. & a CAVOK GA as F/O in B732 due to wind shifts on short finals and a subsequent long landing on a short runway. Both were a huge learning experience and both were a non event due to the character in LHS.
Other opinions and solutions invited.
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I, for one agree with the last part of 172 driver's post.
There are far too many accidents and incidents where some degree of automation between "maximum" and "none" is involved. This is the area where there are dragons.
Most of us can monitor an autoland, and most of us can fly it around just like a real one.
There are far too many accidents and incidents where some degree of automation between "maximum" and "none" is involved. This is the area where there are dragons.
Most of us can monitor an autoland, and most of us can fly it around just like a real one.
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If the crew think "we've got this", then they see no reason to perform a go around. I think the problem is that it can very difficult to take a mental step back, and objectively assess your own performance. Ideally, the PM performs this role, but the PM can be as much "in the loop" as the PF. This psychology affects all teams of people, in any discipline. People assigned to monitor can become too closely involved in the execution of the task.
Trained procedures and SOPs help the crew to assess their performance, but when you go outside that envelope you can also lose the awareness and ability to recognise that you are dangerously outside the envelope.
Trained procedures and SOPs help the crew to assess their performance, but when you go outside that envelope you can also lose the awareness and ability to recognise that you are dangerously outside the envelope.
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Ideally, the PM performs this role, but the PM can be as much "in the loop" as the PF. This psychology affects all teams of people, in any discipline. People assigned to monitor can become too closely involved in the execution of the task.
Trained procedures and SOPs help the crew to assess their performance, but when you go outside that envelope you can also lose the awareness and ability to recognise that you are dangerously outside the envelope.
You may be correct, but 2 comments on your points.
1. PM, if a recent cadet F/O, creates a steep cockpit gradient. Having said that, in today's new world the LHS might well be a cadet captain as well. That brings in its own problems in a critical situation. Pilots, especially new F/O's, have it drummed into them to 'advocate their position' and not be afraid to question and speak up. Easy to say. However, wth a low experience base it can cause hesitation to speak up because their 'envelope of experience' or 'comfort zone' is so small. It is easy to become outside it, but are you sure there is danger.
2. That brings us to the point about 'dangerously outside the envelope'. I've been through TR courses on many Boeing a/c in many companies. What has been noticeable, sadly, is that since the rapid growth of the new airlines, IMHE, the envelope experienced under training is very small; well within the the boundaries of the a/c design. They have been taught, even restricted by SOP's and philosophy, to operate within such a very tight box that is astonishingly easy to stray outside, either by lack of attention, outside elements including ATC or Mother Nature, or non normals or a combination of some of those. The scenario is perfectly manageable by a well trained crew, but to the many who have been drilled in the world of automation first and factory fed rigid system they become a fish out of water in search of a paddle.
Years ago we were taught, extensively, how to fly the a/c, then how to operate it according to SOP's and then how to manage it under normal & non-normal conditions. We were encouraged and expected to maintain those skills every day. Our abilities, based on knowledge & gained experience, was huge compared to many of today's crowd. Sad but true, but not universal.
I speak to friends in different national carriers who fly B747 B777 A320 A330. They can pole it around onto visual approaches & short finals as they see fit and circumstances allow. The maintain their learnt & developed competence every day: and there are some destinations where those skills are vital.
I have trained pilots, for some operators, on base training where the standard circuit used as part of their licence & type rating is not allowed on the line; and even extended visual circuits manually flown are discouraged. Go figure.
There is such a diversity of standards and philosophy amongst operators that finding a common solution to these reoccurring problems will be nigh impossible. During all this discussion I know of some operator's TR syllabi where the amount of manual flying in the sim as been reduced. Go figure, again!
Trained procedures and SOPs help the crew to assess their performance, but when you go outside that envelope you can also lose the awareness and ability to recognise that you are dangerously outside the envelope.
You may be correct, but 2 comments on your points.
1. PM, if a recent cadet F/O, creates a steep cockpit gradient. Having said that, in today's new world the LHS might well be a cadet captain as well. That brings in its own problems in a critical situation. Pilots, especially new F/O's, have it drummed into them to 'advocate their position' and not be afraid to question and speak up. Easy to say. However, wth a low experience base it can cause hesitation to speak up because their 'envelope of experience' or 'comfort zone' is so small. It is easy to become outside it, but are you sure there is danger.
2. That brings us to the point about 'dangerously outside the envelope'. I've been through TR courses on many Boeing a/c in many companies. What has been noticeable, sadly, is that since the rapid growth of the new airlines, IMHE, the envelope experienced under training is very small; well within the the boundaries of the a/c design. They have been taught, even restricted by SOP's and philosophy, to operate within such a very tight box that is astonishingly easy to stray outside, either by lack of attention, outside elements including ATC or Mother Nature, or non normals or a combination of some of those. The scenario is perfectly manageable by a well trained crew, but to the many who have been drilled in the world of automation first and factory fed rigid system they become a fish out of water in search of a paddle.
Years ago we were taught, extensively, how to fly the a/c, then how to operate it according to SOP's and then how to manage it under normal & non-normal conditions. We were encouraged and expected to maintain those skills every day. Our abilities, based on knowledge & gained experience, was huge compared to many of today's crowd. Sad but true, but not universal.
I speak to friends in different national carriers who fly B747 B777 A320 A330. They can pole it around onto visual approaches & short finals as they see fit and circumstances allow. The maintain their learnt & developed competence every day: and there are some destinations where those skills are vital.
I have trained pilots, for some operators, on base training where the standard circuit used as part of their licence & type rating is not allowed on the line; and even extended visual circuits manually flown are discouraged. Go figure.
There is such a diversity of standards and philosophy amongst operators that finding a common solution to these reoccurring problems will be nigh impossible. During all this discussion I know of some operator's TR syllabi where the amount of manual flying in the sim as been reduced. Go figure, again!
Last edited by RAT 5; 11th Jan 2017 at 19:46.
Rat5 kindly explained why the scenario described isnt easily replicated in sims in answer to my comment about being surpised at the Transport Canada comment about Rouge crews not receiving training for these situations. But I ams urprised at the numebr of coments ehre that suegst go arounds are not that common on sim checks and given the equal number fo comments about them being potentially tricky (and recent accidents in Go Around/Missed Approach situations Is till find it odd that it doesnt get that much sim time when it appears much more common that engine outs at V!. Clearly the later is very demanding and requires immediate and correct response but it seems to go back to the prop era when it wasn't the rarity it is now but a common occurrence and with aircraft with very limited performance compared to todays mature jets
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My word Britanica that was a challenging read, though I suspect either typing on a small screen or a few glasses of wine are to blame 
Very interesting reading overall. My airline encourages manual flying withing the bounds of "appropriate" conditions and has a seemingly benign but effective reporting system, where crews aren't generally called into question for a go-around decision due instability/other.
That being said the "culture" of the airline is towards keeping it well within the bounds of automatics+vectors+ILS. Flying manually with A/THR off isn't so common, nor are visual approaches (partly due to ever restrictive noise control). I don't think I've ever seen a raw data non-precision approach on the line.
Flying a manual/visual approach and messing it up (that is, go-around, nothing heroic) would be intensely embarrassing I would expect, almost a sort of bravado gone wrong, thought in other flying environments it would be considered more as a fact of life when flying a plane.
Hard to pin down why, but I'd say we're in ever more dangerous territory with regards to decaying flying skills and automatics mis-management, and unfortunately in this automation no-man's land we're risking slowly re-enforcing the idea that we might be better replaced with computers entirely.
Very interesting reading overall. My airline encourages manual flying withing the bounds of "appropriate" conditions and has a seemingly benign but effective reporting system, where crews aren't generally called into question for a go-around decision due instability/other.
That being said the "culture" of the airline is towards keeping it well within the bounds of automatics+vectors+ILS. Flying manually with A/THR off isn't so common, nor are visual approaches (partly due to ever restrictive noise control). I don't think I've ever seen a raw data non-precision approach on the line.
Flying a manual/visual approach and messing it up (that is, go-around, nothing heroic) would be intensely embarrassing I would expect, almost a sort of bravado gone wrong, thought in other flying environments it would be considered more as a fact of life when flying a plane.
Hard to pin down why, but I'd say we're in ever more dangerous territory with regards to decaying flying skills and automatics mis-management, and unfortunately in this automation no-man's land we're risking slowly re-enforcing the idea that we might be better replaced with computers entirely.
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Flying a manual/visual approach and messing it up (that is, go-around, nothing heroic) would be intensely embarrassing I would expect, almost a sort of bravado gone wrong, thought in other flying environments it would be considered more as a fact of life when flying a plane.
On a (somewhat) lighter note, maybe it's time we reverse years of tradition, and let the FO fly in more challenging situations, as the CA has been the PF for the past few incidents on approach. After all, it's probably easier for the CA to see the big picture when he's PM.
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Being unstable and landing is completely unacceptable . At most operators these days you are fired for doing it.
Late configuration , getting behind , pulling ALT, ... What was the PM doing ?!
Simple go around would have avoided all of this!
Raw data NPA with auto thrust off very rare ! What's the point ?
Why are we only hearing about this now ? Are the TSB and AC hand in hand ?
Late configuration , getting behind , pulling ALT, ... What was the PM doing ?!
Simple go around would have avoided all of this!
Raw data NPA with auto thrust off very rare ! What's the point ?
Why are we only hearing about this now ? Are the TSB and AC hand in hand ?
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Why are we only hearing about this now ? Are the TSB and AC hand in hand ?
Aviation Investigation Report A14F0065 - Transportation Safety Board of Canada
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Ive done it too in VMC, but it includes a thorough briefing including the approach strategy, missed approach procedure and threat and error management.
The fact that they didnt respect the stabilization criteria and a TSB report that took so long to come out indicates something very wrong with the system.
is the final report out on the halifax incident?
The fact that they didnt respect the stabilization criteria and a TSB report that took so long to come out indicates something very wrong with the system.
is the final report out on the halifax incident?
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In B732 days the visual approach into the Greek & Canary islands was the norm. It was a non event. Mk.1 eyeball and naff all inside the cockpit to help. Sometimes the visual ended up intercepting an ILS, or VOR, or NDB. Sometimes there was a DME as well. Sometimes not, but a CDA idle thrust approach was also the norm for such an arrival. Or even a cloud break procedure to visual low level manoeuvring.
28 years ago I joined an outfit that had upgraded from a basic needles & dials Boeing to an EFIS Boeing. We were arriving downwind to TFS, which had an ILS and was severe clear. The basic idea was to steam in right-hand downwind and with finesse and dexterity arrive via short finals over the sea to meet the runway at the correct spot at the correct speed.
The new to type F/O started constructing an LNAV circuit. After a WTF are you doing moment there followed a discussion about how he was going to fly this visual circuit. His idea of VNAV/LNAV FD did not match mine, but hey, if the kid wants to do that then it was too late to argue and disturb his equilibrium and dent confidence. I just felt saddened.
The older of us switched it all off and rolled it in for a 3-4nm final spooling up around 1000'.
28 years later there are some operators that have an SOP of constructing an OM or 4nm point on finals and entering SPD/ALT data to give LNAV/VNAV guidance, and you can't intercept closer than 5nm.
Full approach profiles, if no vectors, with full automatics, are the norm.
Hence the decline & dilution of basic piloting skills. If they are not trusted to fly the most basic of profiles, and thus lose handling skills, what would you expect when a GA is required and it is SOP to be flown completely as a manual manoeuvre? So if the GA is screwed up where is the root cause? It is lack of manual flying skills due to company culture; followed up by lack of recurrency training of GA's. One reason for not favouring manual visual approaches is the increase in GA's due to unstable & messed up approaches. So rather than train and maintain the skill of a manual approach the manoeuvre is removed which leads to another manoeuvre for which the skill has also been forgotten. Chicken & egg.
28 years ago I joined an outfit that had upgraded from a basic needles & dials Boeing to an EFIS Boeing. We were arriving downwind to TFS, which had an ILS and was severe clear. The basic idea was to steam in right-hand downwind and with finesse and dexterity arrive via short finals over the sea to meet the runway at the correct spot at the correct speed.
The new to type F/O started constructing an LNAV circuit. After a WTF are you doing moment there followed a discussion about how he was going to fly this visual circuit. His idea of VNAV/LNAV FD did not match mine, but hey, if the kid wants to do that then it was too late to argue and disturb his equilibrium and dent confidence. I just felt saddened.
The older of us switched it all off and rolled it in for a 3-4nm final spooling up around 1000'.
28 years later there are some operators that have an SOP of constructing an OM or 4nm point on finals and entering SPD/ALT data to give LNAV/VNAV guidance, and you can't intercept closer than 5nm.
Full approach profiles, if no vectors, with full automatics, are the norm.
Hence the decline & dilution of basic piloting skills. If they are not trusted to fly the most basic of profiles, and thus lose handling skills, what would you expect when a GA is required and it is SOP to be flown completely as a manual manoeuvre? So if the GA is screwed up where is the root cause? It is lack of manual flying skills due to company culture; followed up by lack of recurrency training of GA's. One reason for not favouring manual visual approaches is the increase in GA's due to unstable & messed up approaches. So rather than train and maintain the skill of a manual approach the manoeuvre is removed which leads to another manoeuvre for which the skill has also been forgotten. Chicken & egg.
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Some airline cultures involve a "please explain" for a missed approach and some pilots think that a missed approach is an admission of failure to perform.
Respectable airlines do not request an explanation.
Of course, many questions follow a busted aircraft.
Respectable airlines do not request an explanation.
Of course, many questions follow a busted aircraft.
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@IcePack
There's actually some thought going on on the certification/design side of the world to address the issue of GA with the high thrust levels (and other issues) on modern aircraft. Restricting the T/W achieved on a GA is one concept (like the Boeing two-press TOGA idea)
There's actually some thought going on on the certification/design side of the world to address the issue of GA with the high thrust levels (and other issues) on modern aircraft. Restricting the T/W achieved on a GA is one concept (like the Boeing two-press TOGA idea)
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Love the bureaucrats. If they'd only briefed the go-around or missed approach procedures, or called stable, this all might have been prevented.
How about getting guys to do basic automation off flying? All of the nonsense generated by mode confusion would have never occurred with a simple switch to basic, low automation mode, flying.
And it's obvious, just like in the Korean Air 777 crash in KSFO, that neither pilot ever checked the N1's below 500'. Never. Or else they would have called out the inappropriate power setting.
It gets tiring reading these reports, over and over again. "Did you ever check your power setting?" "Did you ever set up a basic, non automation mode, and fly the airplane like it's been done for the majority of the time since the Wright brothers first flew?" The answers to both questions are no. Until the industry gets their head around this issue we'll have to keep hoping it just doesn't happen more often.
How about getting guys to do basic automation off flying? All of the nonsense generated by mode confusion would have never occurred with a simple switch to basic, low automation mode, flying.
And it's obvious, just like in the Korean Air 777 crash in KSFO, that neither pilot ever checked the N1's below 500'. Never. Or else they would have called out the inappropriate power setting.
It gets tiring reading these reports, over and over again. "Did you ever check your power setting?" "Did you ever set up a basic, non automation mode, and fly the airplane like it's been done for the majority of the time since the Wright brothers first flew?" The answers to both questions are no. Until the industry gets their head around this issue we'll have to keep hoping it just doesn't happen more often.
