ATR72 - Sea collision
from avherald “Enroute at FL160 during the first sector the crew received a "TERRAIN" warning message on the EWD1 and an amber "TERRAIN FAULT" warning light. The warning indications disappeared after 6:38 minutes”
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swh
Off course there has been nuisance GPWS warnings. Like any system it is prone to error or malfunction. But your first thought can’t be an ASSUMPTION of a GPWS error. Just like Fire warnings. You can’t assume it’s erroneous just because you don’t see fire or smell smoke.
Act on the warning, and only subsequently establish the veracity of the warning.
Off course there has been nuisance GPWS warnings. Like any system it is prone to error or malfunction. But your first thought can’t be an ASSUMPTION of a GPWS error. Just like Fire warnings. You can’t assume it’s erroneous just because you don’t see fire or smell smoke.
Act on the warning, and only subsequently establish the veracity of the warning.
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For those interested an unofficial translation of the final report (which has so far only been published in French) can be seen at
2018 ATR72 struck water on app Al Hoceima Morocco | PicMA
This is a computer translation via Microsoft Translate and has not been edited or fully formatted. It does however provides more information than was available from sources noted here to date.
Other than for this item, PICMA.info has not been recently updated.
2018 ATR72 struck water on app Al Hoceima Morocco | PicMA
This is a computer translation via Microsoft Translate and has not been edited or fully formatted. It does however provides more information than was available from sources noted here to date.
Other than for this item, PICMA.info has not been recently updated.
Last edited by slast; 15th Jul 2020 at 16:02. Reason: typos
What the thunder is going on in aviation?
This was way way more than stupidity. This was criminal negligence. Maybe even attempted manslaughter.
What happened to "There's something not right here. Let's go around and check what we are doing".
How are people like this allowed anywhere near an aircraft, let alone the cockpit of one?
What happened to "There's something not right here. Let's go around and check what we are doing".
How are people like this allowed anywhere near an aircraft, let alone the cockpit of one?
OK, so we are probably seeing a bit of a change in slightly less of the "gung ho" types in the cockpit - but these have been simply replaced by far more of the "cut-throat commercial pressure" types, maybe not even in a flying role but who sit looking at, say, fuel bills and budgets. "Captain Snodgrass has done 2 go-arounds in the last 6 days! What's he playing at?" types. Does it happen? Not seen it myself - but I'll not relieve you of any money by betting on a certainty that that sort of stuff happens! After all, the "fuel monitor"s bonus is linked to them shaving x% off the fuel bill this year and people doing go-arounds are not helping him/her towards that bonus!
We all make mistakes in the paddock - and hopefully learn from them. Some are even forced into mistakes due to things like punishing Rosters (or over-zealous fuel monitors) but, even then, we should know better and say "No!" - easier said than done I know. Then there are also a whole raft of people who probably operate, routinely, out on the Prairie day-in and day-out as that is quite usual for them and their peers. Been doing it for years. We only see what makes the accident statistics. We never even hear of the routine level-busts, non-stable approaches and general flying mayhem. That said, flying is still incredibly safe - just that there may be quite a few more pilots related to cats out there than we think - just they will not know when Life #9 is now in operation.
Anyone into counting cats?
And, once you have done that for aircrew, you could start on ........ Engineering? ATC? Component suppliers? You know, at a personal level, it's far less stressful to look at the headline Safety figures rather than think too deeply about what contributes to those figures and, more importantly, what has nearly adjusted those figures but never been recorded (ie all the near-misses). How to solve it? Sheesh! Now there is a fortune to be made by the person who comes up with that "Holy Grail"!
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Anyone into counting cats? And, once you have done that for aircrew, you could start on ........ Engineering? ATC? Component suppliers? You know, at a personal level, it's far less stressful to look at the headline Safety figures rather than think too deeply about what contributes to those figures and, more importantly, what has nearly adjusted those figures but never been recorded (ie all the near-misses). How to solve it? Sheesh! Now there is a fortune to be made by the person who comes up with that "Holy Grail"!
And, once you have done that for aircrew, you could start on ........ Engineering? ATC? Component suppliers? You know, at a personal level, it's far less stressful to look at the headline Safety figures rather than think too deeply about what contributes to those figures and, more importantly, what has nearly adjusted those figures but never been recorded (ie all the near-misses). How to solve it? Sheesh! Now there is a fortune to be made by the person who comes up with that "Holy Grail"!
Other Cultures often adapt those rules. Morocco is one of them .
Just finished to read the original (French report ) If you know a bit the country you can see some lines and remarks made by the BEAM are painting the reality .
The Domestic route network, local weather and lack of Nav infrastructure mean they have to "be flexible" as they say , but in this case we add the authority gradient , presence of a young female in the jumpseat, the relatively low experience FO being coached by an older CdB with lot of experience but on 737s.. where are using different routes and different airports .Perhaps the notion than an ATR can be flown like a light GA type., etc...The typical remark " we continue" (below minima) is heard all over the Southern Hemisphere , and even as North as in France until a few years ago ( e.g. Britair Brest CRJ100 /2003 ) Going below minima to have a look was probably done hundreds of time before by this CdB and it worked ... until now.
.
A remark from the flighglobal article. quoted above. The capt did not report a bird strike to ATC ( according the CVR) , a bit of extra sensationalism maybe , did not expect this from Flightglobal.
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The GPWS faulted in the first sector, fair enough. Post landing, why didn't they have an engineer come and inspect it? They continued the day in IMC with the GPWS switched off? I have a sore head trying to process that. I haven't got the MEL out but I would be shocked if it says anything else about going with GPWS off in IMC other than 'NO'.
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The GPWS faulted in the first sector, fair enough. Post landing, why didn't they have an engineer come and inspect it? They continued the day in IMC with the GPWS switched off? I have a sore head trying to process that. I haven't got the MEL out but I would be shocked if it says anything else about going with GPWS off in IMC other than 'NO'.
It appeared to have an erroneous fault at FL160 during cruise however functioned correctly during the approach:
One minute later, the TAWS alarms "TERRAIN AHEAD PULL UP" and "AVOID" TERRAIN" are triggered when the aircraft is 1760m from the runway threshold and 60ft at radio altitude. The PF then performs a change of trim to be pitched, and restores power. The lowest point reached is 45ft radio altitude. The aircraft then proceeded up to a height of 108 feet and maintained until the view of the runway and then resumed a descent to land.
the co-pilot's suggestion to stop the GPWS to avoid alarms during descent and approach, as they believed that those issued by this system during the first stage were untimely.
The whole thing is baffling.
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I apologise I missed that part...yeah sack him too but I bet they won't
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From the point of view that the crew were trying to do their best in the conditions, and attempting to manage the situation as they saw it. Trying to replicate that line of thought, there are aspects which are unclear or not understood after reading the report transcript (thanks Steve).
Re inhibiting 'EGPWS' (TAWS - T2CAS), is there any guidance on deselecting the terrain feature. The terrain aspects require accurate navigation, which if not available, give a 'terrain fault' alert; this appears to be an automatic inhibition (button-light for info only). Alternatively are there any recommendations to press the button; either for the alert, or only to be used in other situations, e.g. QFE approach. The crew appears not to have understood the interaction of the fault alerting and inhibit functions, and misguidedly switched all functions off. Did the crews backgrounds involve EGPWS vice T2CAS, inappropriate knowledge of fault switching / inhibit procedures; TAWS was serviceable for all flights, one leg suffered GPS degrade.
What are the visual requirements for this type of approach; 'contact with the airport environment' or seeing the runway. Continuing the descent with the sea in sight could be permitted until some later point (visual descent point ?).
After visual contact, would both pilots fly 'heads-up' as indicated in the report, reducing the need to scan Rad Alt or check altitude with distance for the procedure. A 'visual' descent over the sea in poor visibility, without horizon for pitch reference is an opportunity to misjudge the true height above the surface.
Does the design of approach procedures still allow level flight after MDA - contrary to the principle of continuous descent, and / or have visual minima where it may not be possible to see the runway at MDA (cf Zurich NPA CFIT many years ago), further encouraging 'dive and drive'. Again what procedures were the crew familiar with based on previous employment / training.
Re inhibiting 'EGPWS' (TAWS - T2CAS), is there any guidance on deselecting the terrain feature. The terrain aspects require accurate navigation, which if not available, give a 'terrain fault' alert; this appears to be an automatic inhibition (button-light for info only). Alternatively are there any recommendations to press the button; either for the alert, or only to be used in other situations, e.g. QFE approach. The crew appears not to have understood the interaction of the fault alerting and inhibit functions, and misguidedly switched all functions off. Did the crews backgrounds involve EGPWS vice T2CAS, inappropriate knowledge of fault switching / inhibit procedures; TAWS was serviceable for all flights, one leg suffered GPS degrade.
What are the visual requirements for this type of approach; 'contact with the airport environment' or seeing the runway. Continuing the descent with the sea in sight could be permitted until some later point (visual descent point ?).
After visual contact, would both pilots fly 'heads-up' as indicated in the report, reducing the need to scan Rad Alt or check altitude with distance for the procedure. A 'visual' descent over the sea in poor visibility, without horizon for pitch reference is an opportunity to misjudge the true height above the surface.
Does the design of approach procedures still allow level flight after MDA - contrary to the principle of continuous descent, and / or have visual minima where it may not be possible to see the runway at MDA (cf Zurich NPA CFIT many years ago), further encouraging 'dive and drive'. Again what procedures were the crew familiar with based on previous employment / training.
Indeed but most of us here were raised and trained in a western culture and our manuals and rules designed originally with anglo-saxon rationale. We are judging those safety events on our western rational minds
Other Cultures often adapt those rules. Morocco is one of them ........
Other Cultures often adapt those rules. Morocco is one of them ........
Hell, we even have quite a bit of deviation within that "western" standard in the, erm, West - thinking of the recent ATP Thread and, as someone else mentioned, the "Barton Birdwatchers" saga - even though that was a light single with a PPL operating what was deemed a commercial flight https://www.cps.gov.uk/north-west/ne...mercial-flight - or the Emiliano Sala crash which seems to have been masterminded by those who should be aware of what was expected of them and their pilot.
Where other cultures apply their norms to adapt the "western" standard, things inevitably happen differently. In many cases, such new norms (near-vertical gradients between the boss (Capt) and the lackey (P2)) have existed for 1000's of years so a few CRM courses is not going to change much when the whole of society operates on a fundamentally different basis. Therein lies my comment re the Holy Grail re finding a "one size fits all" solution.
No answers, just more questions I'm afraid!
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Doubtful they had an engineer at AHU as it's a tiny station.
It appeared to have an erroneous fault at FL160 during cruise however functioned correctly during the approach:
This is the most shocking part. I don't see how it was 'untimely' when triggering at 60ft radio altitude almost 2km from the runway. It appears he wasn't concerned about the error during cruise, but rather the correct warning during a dangerous approach.
The whole thing is baffling.
It appeared to have an erroneous fault at FL160 during cruise however functioned correctly during the approach:
This is the most shocking part. I don't see how it was 'untimely' when triggering at 60ft radio altitude almost 2km from the runway. It appears he wasn't concerned about the error during cruise, but rather the correct warning during a dangerous approach.
The whole thing is baffling.
I want to know why a GPWS master caution went off before all the drama and if so did they attribute the warnings on final approach to that master caution they had previously encountered and therefore dismissed them? This could be significant as it indicates they saw absolutely nothing wrong with driving along at 100ft nearly 2km from the runway and in their minds meant there shouldn't have been any warnings, making them switch them off later on.
I have had this exact fault once and it was on the ground after push back. We taxied back onto the stand and the flight was subsequently cancelled. We had realised ourselves we couldn't go anywhere (MEL) and even the arrival of the engineers couldn't fix it. The fact they sought self diagnosis in this manner is incredible, not even a phone call back to Casablance? Most peculiar.
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For all we know the captain could be trying to pin this one on the FO to make himself look less bad, with a career at RAM he probably has all the contacts in the airline and CAA needed to do so.
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Thanks to this IATA analysis, we're hearing about them. Unstable approaches are running at 3X the pre-pandemic rate.
What could explain this, other than stress?
http://www.flightglobal.com/safety/u...139309.article
What could explain this, other than stress?
http://www.flightglobal.com/safety/u...139309.article
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@A320LGW :
It is explained in the final report. ( bad GPS)
No chances with the conclusions of that report . Anyway the airline disciplinary part is long gone . this was a 2018 event remember.
I want to know why a GPWS master caution went off before all the drama
For all we know the captain could be trying to pin this one on the FO to make himself look less bad
de minimus non curat lex
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The event was 2018. Captain “retired”, now aged 63.......and the FO..?
We know that the UK CAA took action against Emerald for two similar events on the same day at the IOM on the VOR/DME 08 approach.
The ATP crew with the recent dodgy crosswind landing at BHX are no longer employed ~ PPRuNe thread comment.
To have been a “fly on the wall” during the investigation interviews.......probably enough material for a complete CRMI conference.
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Hot 'n' High: Thanks for the Barton Birdwatcher link. I had forgotten that one ..a copy of the Malibu Sala story .But those were amateurs trying to do like professionals. In this case, or the PIA Karachi one, we have professionals flying like amateurs.
Passing a safety audit in some places is just like teenagers preparing for an exam . make sure everything is OK on the day , learn by heart or write down somewhere accessible the answers to pass the test, and when it is done and the auditors.examiners are back home , go back as you were doing before.
I have been in so many places ( for ATC business) and watched and flew on so many of these" flexible " air operations. A good example , a small airline in a small poor Asian mountainous country operates Beech 1900s domestically for years , all VFR. Tourism grew and they bought a few ATRs 42 and 72s . They fly those VFR only , with a portable Garmin 196 screwed on the glare shield, just like the Beech were operated. It works..until now at least.
Similar situations in Africa and Latin america.
The world is much wider than FAA/EASA...
Passing a safety audit in some places is just like teenagers preparing for an exam . make sure everything is OK on the day , learn by heart or write down somewhere accessible the answers to pass the test, and when it is done and the auditors.examiners are back home , go back as you were doing before.
I have been in so many places ( for ATC business) and watched and flew on so many of these" flexible " air operations. A good example , a small airline in a small poor Asian mountainous country operates Beech 1900s domestically for years , all VFR. Tourism grew and they bought a few ATRs 42 and 72s . They fly those VFR only , with a portable Garmin 196 screwed on the glare shield, just like the Beech were operated. It works..until now at least.
Similar situations in Africa and Latin america.
The world is much wider than FAA/EASA...
de minimus non curat lex
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Hot 'n' High
The difference here was that the two light aircraft crashes were rogue British PPLs carrying out commercial flights.
The ATR ‘stone skimming’ event was carried out on a commercial flight by pilots holding professional licences and duly authorised to operate the flight.
Culture played a significant part in all three events ~ a blatant disregard for the rules and regulations.
The PPL holders knew what they were doing was illegal and didn’t give a toss, with the PA46 pilot & passenger dead.
The ATR event was “pony express” mentality (by the Captain) which nearly ended in disaster.
I had thought about mentioning the “Swiss Cheese” model. However, the mince had consumed all that cheese, before it appeared on the table !
The Trick Cyclists would have a field day.
The difference here was that the two light aircraft crashes were rogue British PPLs carrying out commercial flights.
The ATR ‘stone skimming’ event was carried out on a commercial flight by pilots holding professional licences and duly authorised to operate the flight.
Culture played a significant part in all three events ~ a blatant disregard for the rules and regulations.
The PPL holders knew what they were doing was illegal and didn’t give a toss, with the PA46 pilot & passenger dead.
The ATR event was “pony express” mentality (by the Captain) which nearly ended in disaster.
I had thought about mentioning the “Swiss Cheese” model. However, the mince had consumed all that cheese, before it appeared on the table !
The Trick Cyclists would have a field day.
Last edited by parkfell; 16th Jul 2020 at 09:32. Reason: insert ~ Swiss cheese
Learning from what we don't know.
From the number of posts concluding 'blame and train' or prosecute individuals there should be greater concern about the effectiveness of HF training, what is taught, remembered, how applied. The opinions are without justifying evidence, only based on outcome - valueless; should all adverse outcomes suffer the same critique and action - who judges.
We learn little from this approach, apart from the frailty of human behaviour and inability to identify the limits of performance (the posters suffer the same weakness, particularly with hindsight).
In addition, there is an apparent lack of technical knowledge about the aircraft, operation, situation, the context.
Mea culpa; but with a little research, a pilots guide for TAWS re post #31 ATR72 - Sea collision - Terrain inhibit (one function) vs TAWS Inhibit (all functions) can be viewed @ http://uaecis.com/files/T2CAS/T2CAS%...ide%20Rev4.pdf 2008, see sections 9-10.
Example of inappropriate use in incident 8 in the ICAO link in GPWS-GS Button callouts A319/320
Also, if the earlier Terrain Fault annunciation was due to GPS, this was for info only; except checking GPS might have identified an aspect which would suggested not using GPS for navigation or the approach.
What might we learn from this accident;- how do we learn from what we don't know.
Ask questions, seek answers; never assume, nor allocate blame unless we were there.
We learn little from this approach, apart from the frailty of human behaviour and inability to identify the limits of performance (the posters suffer the same weakness, particularly with hindsight).
In addition, there is an apparent lack of technical knowledge about the aircraft, operation, situation, the context.
Mea culpa; but with a little research, a pilots guide for TAWS re post #31 ATR72 - Sea collision - Terrain inhibit (one function) vs TAWS Inhibit (all functions) can be viewed @ http://uaecis.com/files/T2CAS/T2CAS%...ide%20Rev4.pdf 2008, see sections 9-10.
Example of inappropriate use in incident 8 in the ICAO link in GPWS-GS Button callouts A319/320
Also, if the earlier Terrain Fault annunciation was due to GPS, this was for info only; except checking GPS might have identified an aspect which would suggested not using GPS for navigation or the approach.
What might we learn from this accident;- how do we learn from what we don't know.
Ask questions, seek answers; never assume, nor allocate blame unless we were there.
