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PIA A320 Crash Karachi

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PIA A320 Crash Karachi

Old 13th Jun 2020, 16:28
  #1201 (permalink)  
 
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At this point, do we really need the info from the FDR and the CVR ? I fear that many will suffer from neck injuries when the final report comes out ! ( from shaking their head)
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Old 14th Jun 2020, 01:54
  #1202 (permalink)  
 
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For those wondering how did it happen a review of Garuda GA200 might be in order,the 737 touched down at an airspeed of 221 knots, 87 knots faster than landing speed for 40 degrees flap and ran off the end at 110 knots, though they did have the gear down in this case.
1.Absorption. A state of being so focused on a specific task that other tasks are disregarded.

2.Fixation: A state of being locked onto one task, or one view of a situation, even as evidence accumulates that attention is necessary elsewhere, or that the particular view is incorrect.

3.The ‘tunneling or channelizing’ that can occur during stressful situations, which is an example of fixation. Note: The term ‘fixation’ has been chosen to describe the PIC’s state of alertness, which provides a clearer idea of ‘being locked onto one task’, than ‘absorption’. Several ‘findings’ support this ‘tunneling or channelized’ condition, for example:

•The PIC’s attention became fixated on landing the aircraft. The concept of fixation is reinforced because he asked the copilot a number of times to select flaps 15 and asked if the landing checklist had been completed.

•The PIC did not respond to the 15 GPWS alerts and warnings and the two calls from the pilot monitoring to go-around. The PIC did not change his plan to land the aircraft, although the aircraft being in unstabilized condition. The other tasks that needed his attention were either not heard or disregarded. The auditory information about other important things did not reach his conscious awareness.

•The PIC said ‘The target is 6.6 ILS, we will not reach it’. The PIC flew an unstabilized approach. He also realized the abnormal situation when he commented ‘Wah, nggak beres nih!’ (‘Oh, there is something not right’). So, the PIC’s intention to continue to land the aircraft, from an excessively high and fast approach, was a sign that his attention was channelized during a stressful time.

•The PIC also asked several times for the copilot to select flaps 15. During interview he said to investigator that ‘his goal was to reach the runway and to avoid severe damage’. He ‘heard, but did not listen to the other voice (GPWS), and flaps 15 and speed 205 was enough to land’. The PIC experienced a heightened sense of urgency, and was motivated to escape from what he perceived to be a looming catastrophe, being too high to reach the runway (09 threshold). He fixated on an escape route, ‘which seem most obvious’, aiming to get the aircraft on the ground by making a steep descent. His decision was flawed, and in choosing the landing option rather than the go around, fixated on a dangerous option.

•The PIC was probably emotionally aroused, because his conscious awareness moved from the relaxed mode ‘singing’ to the heightened stressfulness of the desire to reach the runway by making an excessively steep and fast, unstabilized approach.

Hazardous States of Awareness
Inattention, or decreased vigilance, is often cited in ASRS reports, and has been a contributor to operational errors, incidents, and accidents. Decreased vigilance manifests itself in several ways, which can be referred to as hazardous states of awareness. These states include:

•Absorption is a state of being so focused on a specific task that other tasks are disregarded. Programming the FMS to the exclusion of other tasks, such as monitoring other instruments, would be an example of absorption. The potential for absorption is one reason some operators discourage their flight crews from programming the FMS during certain flight phases or conditions (e.g., altitude below 10,000 feet).

•Fixation is a state of being locked onto one task or one view of a situation even as evidence accumulates that attention is necessary elsewhere, or that the particular view is incorrect. The ‘tunneling’ that can occur during stressful situations is an example of fixation. For example, a pilot may be convinced that a high, unstabilized approach to landing is salvageable even when other flight crew members, air traffic control, and cockpit instrument strongly suggest that the approach cannot be completed within acceptable parameters. The pilot will typically be unaware of these other inputs and appear to be unresponsive until the fixation is broken. Fixation is difficult to self-diagnose, but it may be recognizable in someone else.

•Preoccupation is a state where one’s attention is elsewhere (e.g., daydreaming). Decreased vigilance can be caused or fostered by a number of factors, including:

•Fatigue, which has been the subject of extensive research and is well recognized as a cause of decreased vigilance.

•Underload, which is increasingly being recognized as a concern. Sustained attention is difficult to maintain when workload is very low.

•Complacency. Automated systems have become very reliable and perform most tasks extremely well. As a result, flight crews increasingly rely on the automation. Although high system reliability is desired, these high reliability effects flight crew monitoring strategies in a potentially troublesome way. When a failure occurs, or when the automation behavior violates expectations, the flightcrew may miss the failure, misunderstand the situation, or take longer to assess the information and respond appropriately. In other words, over reliance on automation can breed complacency, which hampers the flight crew’s ability to recognize a failure or unexpected automation behavior.
http://knkt.dephub.go.id/knkt/ntsc_a...%20Release.pdf
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Old 14th Jun 2020, 13:30
  #1203 (permalink)  
 
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Originally Posted by bud leon View Post
That's precisely my point and one incident that I was referring to. Cultural issues are always raised in a negative context when a non-western incident occurs but rarely if ever when a western incident occurs.
I suggest you look at some of the comments that have been made about Air France and their record.

Similar to comments about other high incident areas.

You seem to be emotionally over-reacting, which is part of the problem to begin with.

Objective discussion is more applicable, which is exactly what is done with accidents such as Tenerife and United 173(incidents discussed which led to the post I quoted).

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Old 16th Jun 2020, 13:34
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For those wondering how did it happen a review of Garuda GA200 might be in order,the 737 touched down at an airspeed of 221 knots, 87 knots faster than landing speed for 40 degrees flap and ran off the end at 110 knots, though they did have the gear down in this case.


That Garuda debacle and other similar tragic accidents could easily have been averted if the copilot had the moral courage to force a go-around at any time on the approach by simply calling aloud "GO AROUND - GEAR UP - and simultaneously selected gear up. Even the most culturally mad captain would not deliberately land gear up just to make a point.
In 1982 a Japan Airlines DC8 was deliberately flown into Tokyo Bay by its Japanese captain killing several passengers . The CVR revealed a frantic call by the copilot pleading with the captain not to kill him. The captain survived and was found to be insane. He was jailed and released in later years. See:
https://en.wikipedia.org/wiki/Japan_Airlines_Flight_350
Culture has a lot to answer for in some societies

Last edited by sheppey; 16th Jun 2020 at 13:51.
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Old 16th Jun 2020, 13:50
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Originally Posted by sheppey View Post
That Garuda debacle and other similar tragic accidents could easily have been averted if the copilot had the moral courage to force a go-around at any time on the approach by simply calling aloud "GO AROUND - GEAR UP - and simultaneously selected gear up. Even the most culturally mad captain would not deliberately land gear up just to make a point.
"Wait.... what did you say??"

And...... sliding along the runway....
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Old 16th Jun 2020, 14:11
  #1206 (permalink)  

de minimus non curat lex
 
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Originally Posted by sheppey View Post
That Garuda debacle and other similar tragic accidents could easily have been averted if the copilot had the moral courage to force a go-around at any time on the approach by simply calling aloud "GO AROUND - GEAR UP - and simultaneously selected gear up. Even the most culturally mad captain would not deliberately land gear up just to make a point.
The culture stems from the top of the airline management and emanates down all the way to the ‘shop floor’.

It would be interesting to analyse previous worldwide events, say in the last 10 years, to determine if had the first officer ‘piped up’ ( and probably complied with the SOPs ) the accident would have been averted, and avoiding mention of “Swiss cheese”. Probably research for a prospective PhD student?

Culture invariably plays a part in all accidents; those aspects which inhibits the SOPs from being carried out is a mission which all training departments need to adopt to eradicate, and eliminate “SKYGODS”. Without that commitment avoidable accidents will not diminish.
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Old 16th Jun 2020, 17:46
  #1207 (permalink)  
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Re "culture stems from the top...all the way to the 'shop floor' ." Indeed it does and this is true of any & all human organizational behaviour. Take a look at Flight Safety Foundation Human Factors & Aviation Medicine, Vol.37 No.2, Mar/Apr 1990 entitled Orchestrating the Human Symphony in Flight Operations, authored by John Nance and still available @ https://flightsafety.org/hf/hf_mar-apr90.pdf

Whether a country, a band, a family, a classroom or an airline, people take their cues as to what is acceptable and legitimate from whoever is at the top; - from the behaviour and standards they demonstrate and what they tolerate and what they won't. That's where to put resources and that's also where to nip things in the bud, if that is the desire or the need. There are plenty of examples of this principle in our midst these days.
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Old 16th Jun 2020, 19:05
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Best Captains CRM course I ever attended (with one of the best CRM instructors I’ve ever known) started with the following written on the board at the front of the room:-
“Don’t be a dick.”..........Discuss!

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Old 17th Jun 2020, 01:37
  #1209 (permalink)  
 
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Originally Posted by parkfell View Post
Gary

Was the landing clearance issued by approach radar (coordination with the aerodrome controller)?
Slightly odd phraseology?
The veracity of this transcript needs to be confirmed perhaps?

This will have been a salutary lesson for the unfortunate approach controller who I suspect will be somewhat more assertive when a blatantly obvious anomaly occurs in future.

MPN11 ~ I concur.
SOP in Pakistan.
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Old 17th Jun 2020, 14:47
  #1210 (permalink)  
 
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Wiz: Which part of the quote are you saying is "SOP in Pakistan"? An honest question out of interest.
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Old 18th Jun 2020, 10:44
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. Probably 8303 could have opened full power before touch down ...jet engines take long to spool up...and in the process could have led to more touch downs....of course we should wait for the official report.....
They crossed the RW threshold 75kts faster than approach speed. Had opened throttle and pulled up he would have reached 500 ft just by dropping that speed and TOGA power comes up in 9seconds it's not too long.
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Old 18th Jun 2020, 23:26
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What would have been interesting from a HF point of view is why the crew were so committed to getting on the ground from a spectacularly bad approach, then as soon as they hit the ground (I won't assume to call it a landing) they were then equally committed if not more so to getting the thing back into the air!
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Old 19th Jun 2020, 01:28
  #1213 (permalink)  

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Originally Posted by Lookleft View Post
were then equally committed if not more so to getting the thing back into the air!
and even with the abundance of speed and lift available exactly for that, swept the tarmac yet twice more.

Come to think of it, perhaps they tried to stay on the ground and only abandoned that plan after the third touch, lacking the deceleration (no spoilers, no brakes) and trying not to overrun.

I probably could imagine someone not lowering the gear in the heat of such moment, and then letting the fact escape alongside the landing C/L.,

The excess speed, however, most likely over the limit for any certified landing flap - i.e. either without the landing flap out or inside the red barber pole and possibly both, is still beyond understanding.
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Old 19th Jun 2020, 23:15
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FD,
Long before the engines scrape the crew had already well and truly lost the plot. They were obviously not adequately engaged in flying the aircraft so everything becomes understandable.
I don't think it will be a particularly difficult job for the crash investigators to find the likely human factors and possible crew/company understandings that resulted in the accident. Included in the considerations and the accident report should be:
  • crew desire to follow traditions
  • crew actual rest and actual sleep
  • crew sign on time and 3 hour departure delay at Lahore
  • midday temp 42C at Lahore, ambient conditions where crew were waiting, crew health
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Old 20th Jun 2020, 03:54
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Originally Posted by FlightDetent View Post
and even with the abundance of speed and lift available exactly for that, swept the tarmac yet twice more.

Come to think of it, perhaps they tried to stay on the ground and only abandoned that plan after the third touch, lacking the deceleration (no spoilers, no brakes) and trying not to overrun.

I probably could imagine someone not lowering the gear in the heat of such moment, and then letting the fact escape alongside the landing C/L.,

The excess speed, however, most likely over the limit for any certified landing flap - i.e. either without the landing flap out or inside the red barber pole and possibly both, is still beyond understanding.
My educated guess is that they gave the stick a yank and this deflected the elevator up, immediately producing a force down. While this also produces a pitch moment and eventually causes an increase in the angle of attack of the wing, instantaneously the angle of attack of the wing won't change, so over the short interval it pushes the plane down. A similar thing happens with boats alongside docks. Using hard rudder to turn the bow away from the dock just shoves the boat into the dock.

Had they lowered the flaps a small amount to complement the elevator that would have increased the lift without a change in AoA and gotten them away from the runway to where they could fully use elevator, but it was far too short an event for the crew to work this out after they had managed to get themselves into this situation to begin with.

Anyone have access to a dynamics simulator that can confirm or deny?
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Old 20th Jun 2020, 08:54
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One of the best examples of 'taking the lead fro the top' is the way that newspapers are run. The behaviour at the top influences the risks they will take on the lowest rung.

The force of social conditioning that prevents a FO from taking control (Gear/Toga/ATC call out) in 2020 is beyond words.
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Old 20th Jun 2020, 09:19
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Originally Posted by FlightDetent View Post
.............
I probably could imagine someone not lowering the gear in the heat of such moment.........
To a degree, but well before the flare on an A320, you would have had GPWS mode 4A shouting "TOO LOW GEAR. TOO LOW GEAR" audio, with a RED master warning, AND a bloody great big RED down arrow lighting up next to the gear lever. Or would all of that be inhibited if the gear lever had been put down above 260kts?

I will be fascinated to read the CVR to find out how they got themselves into this situation.
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Old 20th Jun 2020, 09:38
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Reply

PAXboy

Excellent summary, quite agree.
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Old 20th Jun 2020, 18:09
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Originally Posted by Uplinker View Post
To a degree, but well before the flare on an A320, you would have had GPWS mode 4A shouting "TOO LOW GEAR. TOO LOW GEAR" audio, with a RED master warning, AND a bloody great big RED down arrow lighting up next to the gear lever. Or would all of that be inhibited if the gear lever had been put down above 260kts?

I will be fascinated to read the CVR to find out how they got themselves into this situation.
Per a previous post, the "TOO LOW GEAR" alert would have been inhibited due to their airspeed - instead they would have gotten the GPWS alert - which could well have simply been dismissed as a nuisance since they were attempting to land.
Given all that apparently transpired during their initial approach - mistaking a 'Too Low Terrain' as a nuisance indication is actually one of the more understandable mistakes they made.
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Old 21st Jun 2020, 01:58
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Obviously doing a landing checklist must be just an option in this airline.
After all, it is cluttered up with all that irrelevant stuff like GEAR - DOWN, 3 GREENS.
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