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So WestJet almost puts one of their 737 in the water while landing at St-Maarten...

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So WestJet almost puts one of their 737 in the water while landing at St-Maarten...

Old 9th Jun 2018, 10:38
  #261 (permalink)  
 
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Before the report comes out it's all just speculation and we shouldn't speculate. After the report comes out the facts are known and so there's nothing to speculate about and nothing to talk about!
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Old 9th Jun 2018, 13:34
  #262 (permalink)  
 
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When you add this to their -700 ft/min glide-path, this should explain why they had an increased rate of descent prior to them taking their avoiding action.
Disagree. Nothing to do with a CB and in any case the Investigation report stated the PF disconnected the autopilot and reduced the pitch from 0.5° nose up to 1.2° nose down. Incredible error and a potentially fatal action at that low altitude. Generally the result of slow scan rate while manually flying and thus poor instrument flying ability. A common trait with automation dependency.
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Old 9th Jun 2018, 13:45
  #263 (permalink)  
 
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Seems many have lost interest by the time the report comes out.
Possibly, but it's often the case the report doesn't say much that hasn't already been concluded/conjectured here, even though the process may have been somewhat convoluted.
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Old 9th Jun 2018, 14:16
  #264 (permalink)  
 
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Investigation report stated the PF disconnected the autopilot and reduced the pitch from 0.5° nose up to 1.2° nose down.

Ouch! That's get the ROD screaming. I wonder what happened to the speed. Equally, one has to assume the a/c was basically in trim and on speed from the automatics at the time of disconnect. i.e. do nothing, but easy to say if no visual reference. However, why would you disconnect if no visual reference? The reduction of pitch and increase of ROD smacks of 2 heads outside searching for clues. EGPWS is not supposed to replace correct PM duties.

Last edited by RAT 5; 10th Jun 2018 at 13:58.
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Old 10th Jun 2018, 13:24
  #265 (permalink)  
 
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Causes and risks.

Another TSB report of dubious quality in identifying the causes of a near catastrophe. Leaving aside the organisational failures to recognise the seriousness of this event, and the consequent loss of data which would devalue any report, the bottom line here is that the aircraft deviated very dangerously from the desired flight path below DH/MDA with neither pilot recognising it, but the report contains nothing to avoid such events in future.

The report only outlines how this deviation might have happened, but doesn't provide an answer to why. IMHO it is the combination of inadequate crew coordination procedures and Transport Canada's failure to adhere to ICAO SARPs in respect of required visual reference to continue an approach - identical to Air Canada's near catastrophe at Halifax in 2014.

ICAO Annex 6 requires the pilot landing to have visual references that have already confirmed the flight path is correct before leaving DH/MDA. Canada only requires that cues "enable" an assessment of it (report 1.18.2) - you can take as long as you like doing it, and may come to the conclusion that it's unsatisfactory. Which is what happened on reaching runway level at Halifax, resulting a crash that wrote off the aircraft. In this case it was at 40ft, and only after the second GPWS warning.

Here, incorrect identification of the cues at MDA, combined with the EXPECTATION of improvement, led the First Officer to wrongly assess the flight path. In his mind it now needed a correction, which de-stabilised the approach both laterally and vertically.

The difficulties of making this type of assessment are well described in 1.18.3, so no-one can claim that it's not a long recognised risk. Crew procedures that involve both pilots in the visual assessment inevitably make the situation worse, by deliberately exposing two pilots to the same risk of using inadequate visual cues, while perfectly valid instrument information slips out of sight and out of mind.

Also in this case, these problems were probably exacerbated by the fact that it was the F/O's leg. As being able to land had now become questionable, the Captain was likely concerned that the F/O's decision was in fact the correct one, causing his instrument monitoring to drop even further down his mental priority list. Result : 2 pilots head up, trying to make sense of the visual picture, and no-one registering that the flight path was into the water.

But unfortunately you can't rely on getting that sort of analysis in a TSB report. Notably, the "findings as to risk" look only at the consequences of (1) not implementing ICAO PANS-OPS regarding light settings, and (2) crew not identifying and managing threats. How about a few others?

"If Transport Canada regulations do not clearly identify that the pilot's visual references must have allowed him or her to complete an assessment of the aircraft position and rate of change of position before descending below an MDA or DH for a manual landing, as required by ICAO Annex 6, there is a risk that the assessment will not be completed in time to avoid impact with obstacles."

"If airline crew procedures are not based on a plan that the pilot flying the approach will execute a missed approach at DH/MDA unless the pilot landing has made a positive announcement that the aircraft's position and rate of change of position are suitable for continued approach, there is a risk that plan continuation bias will result in descent below DH/MDA without adequate visual cues to avoid obstacles or complete a safe landing."

"If crew procedures involve the pilot NOT intending to make the landing making visual assessments prior to, and/or on behalf of, the pilot who IS intending to make the landing doing so, there is an increased risk of a hazardous plan continuation bias."

"If crew procedures do not ensure that there is continuous instrument monitoring from the FAF until landing, there is a risk that essential instrument information and warnings will go unnoticed. "

"If the wording of crew procedures that require an exchange of instrument monitoring obligations does not specifically require announcement of exchanged tasks, there is a risk that instrument monitoring will not be continuous and essential instrument information and warnings will go unnoticed. "

"If procedural callouts alerting the pilot to arrival at DH/MDA (and the end of the decision process) are phrased as advisory (e.g. "minimums") rather than imperative (e.g. "Decide!") they risk being ineffective as salient triggers, allowing inadvertent descent without adequate visual reference."

Just a thought.....
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Old 10th Jun 2018, 14:31
  #266 (permalink)  
 
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Very good, Slast.
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Old 10th Jun 2018, 22:06
  #267 (permalink)  
 
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Steve, #265, somewhat harsh and narrow ‘thoughts’. The TSB made the best of what they had as enabled by other agencies.

A lot has been said about monitoring, but monitoring what and how. No precision guidance, visual only, with references of dubious quality, but as enabled by ICAO, the Regulator, or the Operator.

RNAV / GPS were widely promoted as ‘Precision-Like’ approaches, yet may be no better than most NPAs. Do these present an illusion of accuracy?

Who previously thought about deteriorating visibility over the sea.

Nose down pitch, equally likely due to an illusion due to reducing visual range in heavy rain where crews try to maintain the same slant visual range, but lacking the ground features to help combat it.

A habit of ‘ducking under’ at this airport; instruments were as expected.

Investigations and reports such as this cannot be expected to provide a complete explanation for human behaviour in the circumstances as presented.

Instead of requiring ‘findings as to risk’ or explanation, we must consider what has been published, and thus what we might learn, individually and collectively.

The actual cause of this accident should be of no consequence to our safety thoughts and actions.

Future safety depends on what we do, what we learn from the event; not what was wrong with reporting or in operations.

First how might the situation be avoided, then what help can be provided for the crew, especially for them to mitigate any unforeseen circumstances.

There may be as many views of what can be learnt as there are posts, but which are of greater value and most likely to be implemented.
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Old 10th Jun 2018, 23:21
  #268 (permalink)  

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PEI, excellent heading for the discussion.

We do not need monitored approaches as long we have better understanding and discipline than the generations for whom it had been developed. That concept was most efficient in treating certain "childhood diseases".

And the report describes exactly one: actions of crew confused about the protocol of flying NPA in real weather. So did we outgrow that concept or not:? Or worse yet, how come we didn't?

Last edited by FlightDetent; 11th Jun 2018 at 01:56.
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Old 11th Jun 2018, 00:40
  #269 (permalink)  
 
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Originally Posted by FlightDetent View Post
PEI, excellent heading for the discussion.

We do not need monitored approaches as long we have better understanding and discipline than the generations for whom it had been developed. That concept was most efficient in treating certain "child diseases". And the report describes exactly one: actions of crew confused about the protocol of flying NPA in real weather. So did we outgrow that concept or not:? Or worse yet, how come we didn't?
I am glad I got through that "childhood disease." No monitored approaches at TWA from my hire in 1964 until perhaps 1985. Whew!!
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Old 11th Jun 2018, 02:02
  #270 (permalink)  

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Good for you. I just searched for an article out of "I learned about Flying from That", and found this instead https://www.flyingmag.com/aftermath-scud-run.
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Old 11th Jun 2018, 07:56
  #271 (permalink)  
 
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FD, alterpster,

My point on monitoring relates to how the process of ‘monitoring’ - cross monitoring, checking, is undertaken. I did not wish to target the ‘monitored approach’ procedure specifically which has its place in flying with many benefits.

Many senior people in the industry quote ‘monitoring’ as a solution for the problems of approach and landing, yet provide little guidance on how this can be achieved in operation, instrument flying vs visual, workload, or which parameter is more important according to the situation - which implies awareness of the situation.
_

Other posts express their disbelief or failure to understand the human performance involved. Consider this; how with this inability, or unwillingness to comprehend a past situation might a similar future situation be avoided.

Our safety activity must involve reflection and learning, opposed to expecting an answer from an accident report. Individual effort beforehand is more likely to maintain safe operation and help with an attitude that ‘it wouldn’t happen to us’.

Human behaviour is very hard to understand - ‘theres nowt so queer as folk’, and even more difficult to change, thus the need to focus on potential situations and precursors - ‘monitored thinking’ for regulators, management, and pilots.



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Old 11th Jun 2018, 10:18
  #272 (permalink)  
 
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#267 - Good morning Dan. OK yes I was a bit harsh on the TSB, they did have very little to go on really. However, "Findings as to risk" is their term not mine, and they seemed to be a bit selective in picking up St. Maarten's non-compliance with ICAO but not Canada's! Interestingly it appears that Westjet added the recommendation to go consider going around if the runway is not visible 1/4 mile before the MAP - which pretty much WOULD meet the Annex 6 requirement in this case.

I'll also concede that in this instance a different procedure (PiCMA) would have been less likely to have affected the outcome here than in the Halifax accident, where it would have had a very high probability of preventing it. But it might have given the landing pilot more time to interpret the cues at the MDA, and put more emphasis on subsequent instrument monitoring by the Captain to pick up the pitch change, increased RoD and decreasing rad alt, rather than (apparently) being both head up to the exclusion of almost everything else .

FD, I'm not sure quite sure what the relevance of your (interesting) reference article is - is it that experience is no protection against plan continuation bias and getting sucked into increasingly bad situations? That is certainly a major human flaw - as is the tendency to get task fixated and tunnel vision and all the rest of it. Since we certainly haven't succeeded in growing or training ourselves out of it, surely we still need to use other defences against it, e.g. by more appropriate procedures. Similarly, nothing's changed about the fact that weather is not actually 100% predictable, communications aren't 100% reliable, facilities aren't 100% working, etc., etc. Surely all operations should be based on being prepared for the worst every time - these guys were going to a holiday resort where the weather's pretty near perfect most of the time, but things ganged up on them and they came scarily close to ending up in the water.

PEI is absolutely right that there are lots of pious platitudes about urging pilots to "monitor better" but precious little actual practical action on what that involves, both physically or psychologically. OK, we shouldn't expect that from an accident report, but we do need to take a serious look at why these things are still happening.
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Old 11th Jun 2018, 12:59
  #273 (permalink)  
 
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Originally Posted by FlightDetent View Post
Good for you. I just searched for an article out of "I learned about Flying from That", and found this instead https://www.flyingmag.com/aftermath-scud-run.
I am very familiar with that CFIT. He and his sons owned an FBO in the area and he had "get-home-itis by attempting a VFR flight through a very unforgiving area (not that far from where I live). He was a retired AAL 777 captain. So what, was my observation at the time of his CFIT. He was a light-twin GA pilot who made a very stupid decision that day. I don't see how his foolish decision is in any way related to instrument approach procedures and SOP at a Part 121 air carrier (or Canada's equivalent regulation).
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Old 11th Jun 2018, 13:03
  #274 (permalink)  
 
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Originally Posted by slast View Post
PEI is absolutely right that there are lots of pious platitudes about urging pilots to "monitor better" but precious little actual practical action on what that involves, both physically or psychologically. OK, we shouldn't expect that from an accident report, but we do need to take a serious look at why these things are still happening.
Isn't this near accident essentially an issue of lack of cockpit discipline resulting in busting minimums?
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Old 11th Jun 2018, 15:41
  #275 (permalink)  
 
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at, #274, (as I assume you know) accidents or near misses are rarely a simple issue.
_

The crew expected visual conditions, they elected to fly a RNAV NPA. Unknown to them, and as explained in the report, the wx vis reduced below minimums (new, but unannounced ATIS).

The assumptions (and hazards) in NPAs are that the final approach will be completed visually, requiring contact with the airport environment, that the content of a visual scene is sufficient to determine position, and manoeuvre vertically and laterally towards the runway.

The crew appeared to have contact with the ‘ground’ - sea, the local coastline and hotel, but not necessarily the runway. Did the featureless seascape provide sufficient cues to establish pitch reference, altitude, and manoeuvre; were the costal features sufficient for navigation.

As the actual visibility in the rain shower was less than required we might assume that the cues were insufficient; the vis was below minima, but how would the crew know (old ATIS), how do you judge viability in rain over the sea. Would a crew fair any better in other circumstances e.g. night if allowed, snow covered terrain.

Does the regulator assume a reference glide path based on RNAV, but RNAV may not be approved below MDA, particularly if dependent on altitude-range.

If the above applies, or even if not, then what might we learn; what forethought might a regulator or operator apply in order to avoid a similar situation.

Do all operators duck under; we have records of what happens in incidents, but few (none) in normal operation. Why should we judge a single ‘non standard’ event when we have no ‘norm’ base line for comparison. No norm for approach path, for communication, wx / ATIS, navigation standard, crew and system procedures, etc?

What might we learn, as much we choose to?
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Old 11th Jun 2018, 17:20
  #276 (permalink)  
 
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Originally Posted by PEI_3721 View Post
at, #274, (as I assume you know) accidents or near misses are rarely a simple issue.
_

The crew expected visual conditions, they elected to fly a RNAV NPA. Unknown to them, and as explained in the report, the wx vis reduced below minimums (new, but unannounced ATIS).

The assumptions (and hazards) in NPAs are that the final approach will be completed visually, requiring contact with the airport environment, that the content of a visual scene is sufficient to determine position, and manoeuvre vertically and laterally towards the runway.
references for the intended runway is distinctly visible and identifiable to the pilot:


What I am bound to flying an FAA-registered aircraft below MDA or DA, at least one of the following:

(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as a reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.

(ii) The threshold.

(iii) The threshold markings.

(iv) The threshold lights.

(v) The runway end identifier lights.

(vi) The visual glideslope indicator.

(vii) The touchdown zone or touchdown zone markings.

(viii) The touchdown zone lights.

(ix) The runway or runway markings.

(x) The runway lights
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Old 11th Jun 2018, 18:34
  #277 (permalink)  
 
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Gents, if you look at the report again, you will see a significant amount of writing on how the hotel had the appearance of being the runway. The started flying toward the hotel for landing until they got closer and realized that the hotel was not the runway and that the runway was now in view to their right. This is when they levelled off(or reduced their rate of descent). Therefore, I interpret this incident to be a case of suddenly going after the first thing that comes into view(which led to their descending more quickly and laterally from final approach.

A case of visual illusion. As for required visual reference, I would assume that they felt they had the reference(what they felt to be the runway) although in fact they were mistaken. I have seen a guy suddenly go for something he thought was the runway when it wasn't even close to being the runway. It happens sometimes. The best we can do to learn from this experience is to ask ourselves how to avoid this happening to us. With most NPA now being near-equivalent to ILS approaches, it actually shouldn't be too difficult....maintain your stabilized approach and resist the temptation to change things suddenly based on an outside picture that may be legal but misleading.
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Old 12th Jun 2018, 07:25
  #278 (permalink)  
 
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JS #277 has the gist of the issue.

Without actually knowing what the crew saw, or think that they saw, we should not cite deviation from the norm (poor discipline) as a conclusion.

Furthermore if we were to question what good discipline is, or what constitutes discipline, I suspect that there would be many lengthy ‘CRM’ type answers, dependant on cross - crew ‘monitoring’ and call outs; but most would overlook erroneous or illusionary instances where both crew could have the same situational awareness.

The safety problem is to identify these situations beforehand, thinking about ‘what - if’, with regular updating from incidents and accidents; the endless process of learning.
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Old 12th Jun 2018, 17:09
  #279 (permalink)  
 
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Let's just say that recent events seem to show a pattern of Canadian crews trying to land on something other than the runway (hillside/Resolute, approach lights/Halifax, occupied taxiway/SFO, water or hotel/St. Maarten). A tiny percentage of flights, certainly, but it does seem to recur.

I think this (and the TSB's "sympathetic" attitude) may stem from Canada's internal aviation environment, which, like Indonesia, involves a lot of necessary flying to remote places inaccesible to any other form of transport, often with bad weather. If one doesn't "press on regardless" at such places, people may go hungry. The problem is if that becomes a habit and transitions to flights elsewhere.
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Old 12th Jun 2018, 21:59
  #280 (permalink)  
 
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pattern is full, #279.
Unsubstantiated, unjustified, and unfair conclusion.
Correlation is not cause; human kind is designed to see patterns, but less well equipped to extract meaning.

Consider the incidents: https://www.icao.int/safety/fsix/Lib...plus%20add.pdf
All unreported via formal channels, modern well equipped aircraft, associated with ‘major’ operators, in different countries, but as might be expected the majority in the one with the larger number of aircraft.

Note incident #4, and particularly #5 soon after 9/11, and #7 and #8, close to home.

‘Stones and glasshouses’; or realisation that all of us operate in a very fragile environment which can fall in on us as happenstance; except on occasion, in the majority, we are able to intervene and manage situations as we perceived them, and achieve a sufficiently safe outcome.
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