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Thai low EDDF

Old 27th Mar 2020, 23:00
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Thai low EDDF

Thai A359 at Frankfurt on Jan 1st 2020, about 800 feet AGL about 7nm from touch down

Four pilots on the flight deck.

668 ft AGL
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Old 27th Mar 2020, 23:55
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BFU Interim Report:

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File Type: pdf
IR1_20-0002-AX_A350_EDDF.pdf (1.60 MB, 555 views)
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Old 28th Mar 2020, 07:30
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A very poor report indeed, illustrating again, if we needed it, that the habit of publishing ‘facts’ (and in this case very selective facts - ‘It has to be noted that in the background on the channels of the PIC and the co-pilot the on-board entertainment music can quietly be heard’) without any analysis is harmful. The BFU should also know better than to use ‘minimum altitude’ as they did, to confuse ‘descent’ with ‘descend’ and that ‘head towards 340(deg)’ and the crucial ‘speed up the descent’ (their words, not a quote) is highly ambiguous and has no place in a State publication. If their English can’t be better (and I know it can), they should stick to German.
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Old 28th Mar 2020, 09:13
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However, perhaps the most worrying thing is that this is another case of a major European airport’s ATC vectoring an aircraft towards the localiser, well above the glideslope.

Clearly, the lessons of TK1951 and others have not been learned.

Let’s hope that the BFU are not setting the crew up for a fall here, as seems to be indicated. The final report needs to focus extensively on ATC aspects.
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Old 28th Mar 2020, 12:16
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Originally Posted by Kit Sanbumps KG View Post
A very poor report indeed, illustrating again, if we needed it, that the habit of publishing ‘facts’ (and in this case very selective facts - ‘It has to be noted that in the background on the channels of the PIC and the co-pilot the on-board entertainment music can quietly be heard’) without any analysis is harmful. The BFU should also know better than to use ‘minimum altitude’ as they did, to confuse ‘descent’ with ‘descend’ and that ‘head towards 340(deg)’ and the crucial ‘speed up the descent’ (their words, not a quote) is highly ambiguous and has no place in a State publication. If their English can’t be better (and I know it can), they should stick to German.
An Interim Report typically contains neither analysis nor conclusions/probable cause (hence the "interim"). This one is no exception.
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Old 28th Mar 2020, 12:22
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Originally Posted by DaveReidUK View Post
An Interim Report typically contains neither analysis nor conclusions/probable cause (hence the "interim"). This one is no exception.
Not to worry, though. PPRuNers will have the cause of this incident worked out by this time tomorrow. ;-)
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Old 28th Mar 2020, 12:41
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Originally Posted by Kit Sanbumps KG View Post
to confuse ‘descent’ with ‘descend’
Could someone enlighten a non-native English speaker, what is wrong with "instruction to ... and descend to 3,000 ft", "to speed up the descent", "the rate of descent", which are the only cases (1x verb / 2x noun) of descent/d I can find??
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Old 28th Mar 2020, 13:05
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Originally Posted by DIBO View Post
Could someone enlighten a non-native English speaker, what is wrong with "instruction to ... and descend to 3,000 ft", "to speed up the descent", "the rate of descent", which are the only cases (1x verb / 2x noun) of descent/d I can find??
Look here

Focus on: Descent & Descend
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Old 28th Mar 2020, 14:31
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Originally Posted by DaveReidUK View Post
An Interim Report typically contains neither analysis nor conclusions/probable cause (hence the "interim"). This one is no exception.
Yes Dave, I know. (I've dealt with enough of them).

I'm saying that, in 2020, it should not be so, and this is a particularly bad example. There is enough there to begin an analysis and share it, rather than waiting months on end; there is enough to focus on areas of interest, which are plain from the report to an expert eye but should be exposed. 'The investigation continues, examining in particular:...' would be the very least one might hope for.

The 'safety investigation' world is locked into behaviour which is not relevant in this modern age, but it never changes. It is not the excellent and respectable community that many take it for, and I believe we should all get to grips with its failings.
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Old 28th Mar 2020, 14:54
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Originally Posted by Kit Sanbumps KG View Post
I'm saying that, in 2020, it should not be so, and this is a particularly bad example. .
As an example of how poor construction can cause confusion I commend the above quote. Not having a dig, just illustrating how poor construction can render a sentence meaningless, or in this case potentially understood in two utterly different ways.

In this case does "bad example" mean that the example itself is a bad one (ie unsuitable or misleading) one, or that it is an example of bad practice giving cause for concern.
It could be taken either way.

Cave!
As they say in Latin!
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Old 28th Mar 2020, 20:18
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It’s just a rubbish interim report. A graph of altitude versus time with the runway on it isn’t really very useful. Altitude versus DME? Position clearances were given?

This crew were clearly high and cocked it up. No hint is given as to how/why that occurred in this report.
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Old 28th Mar 2020, 20:29
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Originally Posted by Jwscud View Post
It’s just a rubbish interim report. A graph of altitude versus time with the runway on it isn’t really very useful. Altitude versus DME? Position clearances were given?

This crew were clearly high and cocked it up. No hint is given as to how/why that occurred in this report.
Page #5 of the report.



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Old 28th Mar 2020, 21:58
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Old 28th Mar 2020, 22:17
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JW, those images show that the radar vectored approach was significantly above the glideslope, in contravention of ICAO etc. The BFU note the ‘on-board entertainment music’ and show us the dimensions of an A350, as if we needed them, and say nothing at all about the ATC aspects. I also found the ‘seizing’ of the recorders unnecessarily dramatic.

But to look at that and say the crew ‘cocked it up’ is to be as bad as the BFU.

Deeply incompetent, at best.
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Old 28th Mar 2020, 22:40
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Originally Posted by Kit Sanbumps KG View Post
JW, those images show that the radar vectored approach was significantly above the glideslope, in contravention of ICAO etc. The BFU note the ‘on-board entertainment music’ and show us the dimensions of an A350, as if we needed them, and say nothing at all about the ATC aspects. I also found the ‘seizing’ of the recorders unnecessarily dramatic.

But to look at that and say the crew ‘cocked it up’ is to be as bad as the BFU.

Deeply incompetent, at best.
Yes, the aircraft was above the glideslope, but from the report it is unclear who is responsible for that. They were assigned 3000' and told to expedite descend, so maybe the crew had been slow to descend earlier or maybe the altitude assignment had been late. Impossible to tell with the info we have.
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Old 29th Mar 2020, 00:51
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Originally Posted by hans brinker View Post
Yes, the aircraft was above the glideslope, but from the report it is unclear who is responsible for that. They were assigned 3000' and told to expedite descend, so maybe the crew had been slow to descend earlier or maybe the altitude assignment had been late. Impossible to tell with the info we have.
Yep. Very important facts, I agree.
As already mentioned, there are completely irrelevant facts in the report, like dimensions of the plane, blah, blah, but this isn*t unusuale.
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Old 29th Mar 2020, 01:10
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Originally Posted by Jwscud View Post
It’s just a rubbish interim report. A graph of altitude versus time with the runway on it isn’t really very useful. Altitude versus DME? Position clearances were given?

This crew were clearly high and cocked it up. No hint is given as to how/why that occurred in this report.
One can only wonder if this report was written to satisfy the ICAO demand for a preliminary report within 30 days, something about which some people on here are extremely pedantic
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Old 29th Mar 2020, 09:30
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Originally Posted by Kit Sanbumps KG View Post
JW, those images show that the radar vectored approach was significantly above the glideslope, in contravention of ICAO etc. The BFU note the ‘on-board entertainment music’ and show us the dimensions of an A350, as if we needed them, and say nothing at all about the ATC aspects. I also found the ‘seizing’ of the recorders unnecessarily dramatic.

But to look at that and say the crew ‘cocked it up’ is to be as bad as the BFU.

Deeply incompetent, at best.
The aircraft ended up in an Undesirable Aircraft State - Mitigated by the crew by a go around. This is so far the only real "fact" we have.
ATC can definitely be a contributing factor, but it is very unlikely to be the root cause.
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Old 29th Mar 2020, 09:33
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Ah, the fallacy of the 'root cause'... https://www.safetydifferently.com/wp...Processing.pdf
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Old 29th Mar 2020, 09:48
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Originally Posted by Kit Sanbumps KG View Post
Ah, the fallacy of the 'root cause'... https://www.safetydifferently.com/wp...Processing.pdf
There are some very interesting point in the article you have linked, but in the end I believe it all depends on how "deep" You go when looking for the root cause of an event. I 100% agree it is definitely too easy to hammer the crew as they are ultimately responsible for the safe conduct of the flight and this is where the real just culture should come in, trying to understand what led a competent crew to end up in that situation and fix it, and the root cause could definitely be within the system and not the crew.
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