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

[aterpster]

Originally Posted by PEI_3721

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.

I come down somewhere between you and Pattern is Full.

[pattern_is_full]

Originally Posted by PEI_3721

pattern is full, #279.
Unsubstantiated, unjustified, and unfair conclusion..

Not a conclusion at all. Just a noting of a coincidence of events, that perhaps TSB might want to examine as signs of a possible endemic problem. Maybe their conclusion will be that there is nothing there, and then again, they might conclude there is a "cultural" problem - not a defect in any one crew or individual - that needs to be addressed.

[slast]

I am with PEI, I don't think anyone should just attribute this to "lack of discipline" and "busting minima". There's no real evidence of that IMO.

However it has become clear from my own reading of about 120 reports of approach accidents over the last 25 years that a very common factor (as in this case), is when valid instrument information is discarded prematurely in favour of dubious or inadequate visual cues. This is very frequently associated with an expectation that things can only get better, when in fact it doesn't .

There MAY be cultural / psychology elements contributing to some of these. For example in the current case we have two extremely experienced (14,000 and 12,500 hours) Canadian pilots who are used to "real" bad weather. Surely a few Caribbean shower clouds are not going to be a big deal for them. Nevertheless, being professionals they prepared for an instrument approach anyway. On the way in, they know about the shower clouds, but NOT that the visibility has now gone below minimum. Would it have been prudent to ask? Would that imply acknowledging that getting in might actually be questionable - "don't ask, don't tell"? I emphasise I'm only speculating here. In any case visibility minima don't guarantee that sufficient visual reference WILL be available at DH/MDA, only that it's reasonably likely, and there's no evidence of this crew deliberately ignoring minima.

But in this case, just prior to reaching the MAP both pilots seem to have switched to using the very poor visual references as their primary guidance. Quote from the report: "given that THEY [plural] had the shoreline in sight and expected to see the runway shortly afterward, they would continue the approach visually." So the F/O must have been at least peripherally aware that some visual cues exist, and now concentrated on identifying anything that looks appropriate as being the "right" cues. He must have been sure he was looking at the "runway" within 1/2 mile of the MAP because he disconnected the autopilot and then pitched down. Pitch down is a known instinctive reaction to a reducing visual segment or to distortion caused by rain on the windshield. The 50% increase in descent rate caused the autothrust to reduce, following which it was disconnected and apparently stayed at 52% until the eventual go-around. Then, "As the crew crossed MAPON, the PF advised that he had the runway in sight. He began to roll left."

Just after the MAP they entered a heavy shower and were subject to much reduced visibility for about 20 seconds. Even though the aircraft track was maintained towards the "runway" (actually the hotel), the vertical path was significantly steeper than it should have been, with no means of detecting this visually, because since the "runway" wasn't one it obviously wouldn't give the necessary cues. On leaving the shower, the dominant feature was the lateral asymmetry of the runway being off to the right, so that was the instinctive priority to correct.

Understanding the new visual picture is such a compelling and demanding task that with no approach lights, limited runway lighting and no surface texture, the vertical displacement and rate was so much harder to detect that it was still not fully recognised. The F/O increased thrust from 52% to 75% as he made the first correcting turn, but that did not bring the RoD back to the correct value, let alone regain the correct descent path. Even after the first GPWS alert there was only a partial understanding of the situation, and a full realisation and response is delayed until after the second warning 9 seconds later.

In my opinion this crew were persuaded to become mentally committed to landing by two things: sight of the absolute minimum of appropriate information at the MAP, and the expectation that this would increase. This expectation was based on their own experience that usually it does, and reinforced by the report from the previous landing aircraft. Having made this decision, they were simply unable to reverse it until forcibly reminded by a totally independent external stimulus - the GPWS.

Human nature is such that when exposed to such a visual puzzle it is extremely easy to become absorbed in it to the exclusion of other things, and no amount of exhortation about emphasising cross-monitoring of instruments etc. is going to change it. There's nothing cultural or ill-disciplined about it. To me, this sort of thing is a compelling reason NOT to deliberately expose both pilots to the same potential problem.

But regarding "sight of the absolute minimum of appropriate information" there may also be a specifically Canadian issue. I think Canada's rules, and by implication underlying training, may actually encourage this hazardous decision making. (It may be true elsewhere but I have no knowledge of that).

At some past date, someone must have made a specific decision that ICAO standards about what constitutes "adequate visual reference" to allow descent below DH/MDA were inappropriate for Canada. In my opinion the subsequent wording is much less conservative (i.e. less biased to the safe side).

The ICAO pilot's decision is "I've ALREADY seen enough to be sure of where we are and where we are going, and I can maintain a safe flight path using those listed elements - lights, markings, runway etc". (ICAO: The cues "should have been in view for sufficient time for the pilot to HAVE MADE an assessment of the aircraft position and rate of change of position in relation.... ").

Someone in Canada decided this should read : [the cues] "ENABLE the pilot to make an assessment of the aircraft position and rate of change of position...... ", followed by the CAP laundry list of items to be "distinctly visible and identifiable" including "the runway". Lawyers would doubtless have a field day about the difference but it seems to me that for practical purposes this can be interpreted as meaning "the runway being distinctly visible and identifiable at MDA enables you to make an assessment of position and flight path: consequently you may continue". Which rapidly becomes just "if I can see the runway at MDA I can continue".

Since these pilots clearly thought they HAD identified the runway (perhaps the "distinctly" visible is bit iffy!) they were not deliberately breaking any rules - any more than the AC crew at Halifax were by descending solely on the sight of the "rabbit" ODALS. Arguably, the Canadian rule is simply unsafe, since in essence it can be interpreted as allowing a look-see operation, which was never intended when the concept of DH was put into place.

Anyone Canadian AWOPs experts out there know the origin of this wording?

[Capn Bloggs]

Gotta hand it to you, Slast, that (and your previous) was good!

[RAT 5]

To me, this sort of thing is a compelling reason NOT to deliberately expose both pilots to the same potential problem.

If I interpret this as to what I think you mean, are you leaning towards the Monitored Approach concept when conditions become close to minima. I operated under the more old fashioned conventional of PF makes all the decisions to a MA as an SOP when conditions required it. Indeed, one time after making a GA under the old conventional method we briefed a MA for the 2nd approach and succeeded. I'll admit it was not an SOP, it just seemed like a good idea at the time and the F/O PF, who flew both approaches, agreed. It was not a problem as it was just like a single channel LVO approach, which was an MA as SOP.
IMHO crew discipline on NPA's is critical. One head in one head in/out approaching cloud base and then head out approaching DA. PF is 'the GA guy'.

Is that what you meant by not exposing both pilots to the same problem? Anything to avoid 2 heads out close to the ground. This is exacerbated by captain as PM. He's 2 responsibilities being PM and also captain with overall responsibility for the flight and trying to help PF acquire the clues. Clear defined duties for both would help avoid this. Asking not what Canada's CAA guidance is on what to do at DA, what does Westjet's NPA SOP say? That is an approved document? is it well written, unambiguous and sensible; or does it need rewriting to prevent reoccurrence?

[slast]

Thankee, Capn!

[PJ2]

Yep, excellent writing, slast, particularly your first point regarding 'valid instrument information', which is primary training material regarding cockpit discipline, as far as I'm concerned. Thanks.

[scifi]

Do you think that for the price of a bucket of paint, the airport authorities could prevent a re-occurrence, by offering to paint the Hotel with a suitable design that would not be confused with a runway.
.

[PEI_3721]

RAT et al, re #285.
The weakness with the monitored approach and safety calls for even more monitoring, depends on having parameters of relevance and accuracy, which can be monitored meaningfully.
It is the lack of these that are part of the hazards of NPAs. Either there is no glide-slope or if FMS generated (RNAV / GPS) it might not be sufficiently accurate below MDA.

A table of altitude distance is very useful during the initial approach, but less so when closer to the runway due to its resolution - accuracy requires threshold referenced DME and use of Rad Alt which may not be precise due terrain.

When below MDA, what might the head down pilot (PM) look at, and why. Airspeed, yes. Attitude, VS, Hdg, might vary when manoeuvring to line up with the runway - NPAs do not guarantee precision.
What boundaries should be placed on any ‘deviations’, what is the norm, cf estimated glide path, actual wind speed/direction, and expected VS, … .

Alternatively if the PM looks up this might this help avoid cue misidentification, or help cross check the flight path with respect to the runway, use of external cues - those used for a visual landing. It still necessary to monitor airspeed, split scan, acceptable for two crew operations just as it is for single pilot ops.

There is no ‘perfect’ solution or procedure due to the ill defined context and situation.

An alternative is to provide crews with knowledge and guidelines of how to assess situations and manage the inherent variability, highlight potential hazards of situations - as should happen every flight. However due to the uncertainty of ‘the world’, human performance, people - crew, management, regulator; and procedures, equipment, weather, … …, then occasionally the variability overwhelms the crew’s ability to manage the situation.

[Capn Bloggs]

PEI, you have hit the nail on the head. If you do not have accurate in-cockpit slope reference ie RNP-AR, IAN in the 737? or a GS, then the only hope of staying on-slope is by reference to the PAPI (or more basically, "that runway looks very flat"). The fundamental mistake here was that the crew pressed on when they obviously could not see the runway and the PAPI. My takeaway here is it is critical that, before proceeding below the MDA/DDA, the runway and very shortly after the PAPI is clearly visible. As Slast has pointed out, the Canadian rules are "sus" in this area, apparently allowing descent without seeing the actual runway/PAPI.

[RAT 5]

As Slast has pointed out, the Canadian rules are "sus" in this area, apparently allowing descent without seeing the actual runway/PAPI.

Indeed; if reported correctly, they seem to be. However, even if allowed, I ask who would feel comfortable descending in manual flight below DA without the target insight. Scratching around at low level, on your own in a spam-can with ground contact at 80kts, is one thing. Descending semi-blind in a pax laden medium jet at 140kts is quite another. I'm not talking from legality it's from a self-preservation aspect. I'd be scared poo-less.

Regarding split crew duties, even MA's, it is human nature that PM, below DA with visual references, would be head in/out. They would confirm that the visual queues were correct & performance parameters were correct, but also that the visual flight path was safe. It's a glance in/out that would not reduce significantly the PM instrument scan. PF would be more out than in, PM doing both.
Regarding the hotel illusion: If that was the perceived target for visual profile, vertically, how/why did they descend so far short of that? PF did increase the ROD, but as with any landing the touchdown target is kept stationary in the window. In this scenario that could not have been the case, and for quite a long time. It must have been very scary wondering when the 'expected' runway really was going to become visible. It is a human trait that a pitch down when visual with approach lights in low vis is not uncommon. I once called a GA in a biz-jet, when the captaining was 'pinching a bit' at DH and did just that. Like I said, a bit in/out <DH. Glad I did; long before GPWS.

[slast]

Originally Posted by RAT 5

As Slast has pointed out, the Canadian rules are "sus" in this area, apparently allowing descent without seeing the actual runway/PAPI.

To clarify, I think all XAAs allow descent without seeing the actual runway/PAPI - provided you have something else in the laundry list such as approach lights.My point is that ICAO requires you to have seen whatever it is for long enough to confirm that your flight path to it is safe, BEFORE leaving DH/MDA. Canada appears to allow you to descend purely because you have seen whatever it is - you can assess whether your flight path is safe below DH.

Originally Posted by RAT 5

who would feel comfortable descending in manual flight below DA without the target in sight.?

But that's exactly what existing minima expect you to do. For example at 200ft on a 3deg. slope you are 4,000ft / 1,200m from the target, but if you have 550m/1,800ft RVR you can only expect to see the initial approach lights at DH. That's exactly why ICAO requires you to have confirmed that what you have seen combined with your training tells you that you are on a stable safe flight path to the (still invisible) target, BEFORE going below DH. Theoretically, provided it is, ballistics or momentum will get you safely down the next 100ft, with the visual segment continuously expanding until the TDZ (target) DOES come into view at 100ft when you are 550m from it.

But if it isn't already confirmed as you pass DH, all bets are off. It's also all bets off if you do the common instinctive thing of reacting to a visual segment (e.g. lights) which don't expand as fast as you're accustomed to seeing, by pushing the nose down..... just as you (RAT) experienced in the bizjet. Or if the shape, texture etc of a hotel mistaken for a runway doesn't change as you expect a runway to do.

Originally Posted by RAT 5

Regarding split crew duties, even MA's, it is human nature that PM, below DA with visual references, would be head in/out. They would confirm that the visual queues were correct & performance parameters were correct, but also that the visual flight path was safe. It's a glance in/out that would not reduce significantly the PM instrument scan. PF would be more out than in, PM doing both.

That's quite right. I have never said that it's essential that below DH the co-pilot (as PM) should be rigidly locked head-down until touchdown in all conditions. That's neither necessary, desirable or achievable. The key is to avoid exposing both pilots to the potentially serious "information gap" just before and after DH, where as PEI says, instrument guidance becomes progressively less reliable, but visual information is not adequate to replace it. The less adequate the visual cues, the harder they are to interpret and the more compelling it is to strive to do so and NOT go back to instruments, even if the SOP says the PM should. That's how we get events where both pilots are head up below DH with inadequate visual reference, especially on NPAs - Birmingham, Kathmandu, Hiroshima, Halifax to name some in the last few years.

In most operations - probably 99% of the time - it turns out that there's way more than enough visual information, well above DH. In a small percentage, when operating close to the approved minima, it's marginal but approaches are stable enough to get across the gap. But on a tiny number of occasions, both things occur - the information gap is significant AND the flight path either is or becomes wrong. Fortunately most pilots will never experience this. Neither will they experience the other critical case - total loss of thrust just before V1 on a weight -limited take-off. We prepare and brief for that every day. But nearly all approaches are flown based on various reasons why "the problems that actually lead to "crew-caused" events won't affect us today", so we don't need to deal with them.

At top of descent the Westjet crew were told "unlimited visibility, few clouds at 1400ft, weather nil", but still came within a few moments of hitting the sea. Is there some cognitive dissonance in our industry?

[BluSdUp]

Gentlemen
Some excellent analysis here, and some more productive then the report!
I would love to have the SOP and training manual for WJ at hand, but at the end of the day ANY NPA must be laterally and vertically " monitored " or checked somehow!
I was not a big fan of the monitored approach when we started it, but now I love it! Gives me all the time in the world to supervise the approach if Jr is a low timer.
He is the Approach PF and the GA PF, and I get to asses the cues as we approach minima. If happy , " My controls, Click Click."
He backs me up on speed vertical and transits outside as Papi , CL becomes primary.

Anyway
Lets imagine this was a line check or a sim check !!
It would be a FAIL, the crew is clearly not competent and would have been grounded.
And, a NPA is a simple ting , BUT some very basic rules has to be applied and respected.
Know were You are , horizontally and vertically and make sure you land at the intended runway.

[RAT 5]

who would feel comfortable descending in manual flight below DA without the target in sight.?
But that's exactly what existing minima expect you to do

Indeed; I expressed it badly. By target I meant one more of the 'required shopping list' of items. Required visual reference as we call it. They are official approved aerodrome structures, not car parks or even just 'lights'. There have been enough NPA CFIT crashes where we heard the PM call "ground contact" well before MDA and sucked PF into continuing into the gloom. Vertical visibility at 500' is not 2400m forward vis.
Now someone has told us the published meteo it is even easier to understand how they became sucked into being relaxed and continuing. If correct that is a very large swiss hole in the process.

[slast]

First Offcier minima

Originally Posted by RAT 5

This is exacerbated by captain as PM. He's 2 responsibilities being PM and also captain with overall responsibility for the flight and trying to help PF acquire the clues. Clear defined duties for both would help avoid this.

Originally Posted by BluSdUp

Gives me all the time in the world to supervise the approach if Jr is a low timer.

Too much harmony here! How about this to make a real splash in the water!

This event occurred with the (very experienced) F/O as PF throughout. This will be heresy to many readers but IMO you need different limits for a F/O's leg regardless of how experienced the F/O is, and if the weather is worse than that you need to revert to the Captain landing.

F/Os are normally capable of flying just as well as Captains, and in very many cases better. I know there are lots of operator variations of what F/Os can do when it's "their" leg, so bear with me. On an F/O leg the F/O should be (at least in my thinking) acting as "pilot in charge UNDER SUPERVISION", which means the Captain's overall responsibility for the safety of the flight gives him an additional obligation to confirm that the F/O's decisions are in fact safe and sensible.

The minima numbers are set based on the concept that "the pilot's decision" at DH/MDA will be final and correct - it's land or go-around and there's no allowance for corrections. And we know that the fewer the cues the more demanding and time-consuming the task of figuring out if the flight path is correct etc. Pop out of a 200ft cloud-base with 10km underneath - easy (but rare). 200ft DH and 550m RVR - challenging.

If you don't want to expose both pilots to this dilemma, you use the same procedure regardless of whose leg it is. So how to square the circle of doing this, while still giving the Captain the ability to check the F/O's decision when it's his/her leg - and hence procedurally his or her decision?

Practically, and accepting that there are no perfect solutions, you need to make the Captain's "supervisory" decision as easy as possible - and also allow for the possibility of reversing an unsafe one by the F/O. A dangerous one would normally only be an inappropriate decision to land, as a go-around might be inappropriate but will usually be a safe option. So to do this legally, the Captain needs to be able to make HIS decision very fast, and above the actual DH.

A practical way to do this would be to say, if it's the F/O's leg, procedure-wise raise the DH by 50 ft and set the minimum visibility to be such that the touchdown point can be expected to be visible at that height. E.g. if "normal" minima: 200ft/550m, F/O minima for the same approach would be say 250ft and 1400m. That gives the Captain an opportunity to take a quick look and crucially, there should be more than enough cues to make a very rapid decision as to whether the conditions really are suitable for landing, and call go-around if not. Since he will already be "in control" and primed for a go-around that should not present a significant risk.

In practice the principle of "different F/O limits" is applied anyway by most operators for Cat 2 and 3 - if it turns out to be Cat 2 on a F/O's leg he/she loses the landing.

As I said, it's heresy to many people to suggest this. But in my opinion, it's a reason some operators now apparently restrict F/O flying to a ridiculous extent. The "all or nothing" attitude ends up depriving young and inexperienced pilots of perfectly valid experience which could safely be obtained with a bit of lateral thinking about what actually needs to be achieved. Counter arguments?

[FullWings]

Now someone has told us the published meteo it is even easier to understand how they became sucked into being relaxed and continuing. If correct that is a very large swiss hole in the process.

It’s generally regarded as easier (psychologically) to carry on with an approach than it is to throw it away. Not long ago, we changed one of our responses at minimums to “Continue” instead of “Land” to reduce the fixation.

In my experience, it is rare in real life to encounter conditions that deteriorate to the extent that there is an adequate reference at DA(H)/MDA but not later on in the approach, so when it does happen, it’s something unfamiliar that requires positive action to remedy, especially if the deterioration is slow or subtle. Has happened to me twice in 25 years. I agree about the “shopping list” in terms of references, especially on a NPA, and just because you have managed to tick one of them off, doesn’t mean that you are stable and/or can successfully land off the approach.

As I said, it's heresy to many people to suggest this. But in my opinion, it's a reason some operators now apparently restrict F/O flying to a ridiculous extent. The "all or nothing" attitude ends up depriving young and inexperienced pilots of perfectly valid experience which could safely be obtained with a bit of lateral thinking about what actually needs to be achieved. Counter arguments?

We practice complete role reversal down to CAT I minima. Our SOP is also to use the lowest available minima when the conditions are likely to be close to limiting, therefore if we had higher numbers for a FO landing the captain would end up doing it anyway, even just for commercial reasons.

What happens when you don’t get adequate references on an approach using FO minima? You could carry on to the legal minima but that would involve a control/decision making handover at low level, which adds another layer of complication and potential for misunderstanding. Not to mention reselecting minima on the alerting system, which may or may not work.

IMHO the ideal is to provide good enough training that someone with <200hrs fresh into the RHS can operate safely and with confidence to normal minima. It could be that certain operators don’t want to invest the time and money doing this, so apply blanket restrictions instead?

[RAT 5]

Fullwings:
In my experience, it is rare in real life to encounter conditions that deteriorate to the extent that there is an adequate reference at DA(H)/MDA but not later on in the approach, so when it does happen, it’s something unfamiliar that requires positive action to remedy, especially if the deterioration is slow or subtle. Has happened to me twice in 25 years. I agree about the “shopping list” in terms of references, especially on a NPA, and just because you have managed to tick one of them off, doesn’t mean that you are stable and/or can successfully land off the approach.

We are debating NPA techniques and crew duties to try and avoid further similar dangerous scenarios. But back to root cause of the dangerous nature that eschewed; there was a perception that a 'visual clue' had been obtained, and the Canadian rules allowed them to continue, plus the earlier ATC meteo data. Would EASA or FAA rules have allowed them to continue? It would seem No. The 'hotel', or whatever, was not on the shopping list. Thus does a major root cause go back to the Canadian rules? Different crew duties and techniques might not have prevented such a low descent. Descending below MDA in manual flight without positive visual reference is an airmanship thing. Limitations of the a/c, without a glide slope, require disconnection, but scratching around over the sea, semi blind, is not calm or relaxing. That's a self preservation thing.
CAA rules are one thing, but risk to my own health & safety is another. Limits are limits, but you can always impose your own buffer.
What pressure is there for Canada to review its rules? Surely after the recent incidents/accidents they are incumbent to do so. If a threat is perceived and demonstrated does it not need to be addressed? I know it's early days, but any nudie knowledge? It is within the remit of operators to change their own rules more in line with EASA & FAA.

[underfire]

Cant see that the report has been posted:

Risk of collision with terrain WestJet Boeing 737-800, C-GWSV Princess Juliana International Airport, Sint Maarten 07 March 2017

Any of this sound familiar?

The features of a hotel located to the left of the runway, such as its colour, shape, and location, made it more conspicuous than the runway environment and led the crew to misidentify it as the runway..

Because the occurrence was originally assessed by WestJet as a non-reportable event, the cockpit voice recorder and the digital flight data recorder data were overwritten and were not available to the investigation.




The reference to the hotel seems to be suspect, they never lined up on the hotel.

[Airbubba]

Originally Posted by underfire

Cant see that the report has been posted:

Risk of collision with terrain WestJet Boeing 737-800, C-GWSV Princess Juliana International Airport, Sint Maarten 07 March 2017

Any of this sound familiar?

The link to the report was posted here on June 4:

Originally Posted by roybert

For those interested the TSB has just released the report into this incident. http://www.bst-tsb.gc.ca/eng/rapport...2/a17f0052.pdf

[underfire]

Thanks, sorry all, I really did try to find it!