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ATR72 - Sea collision

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ATR72 - Sea collision

Old 16th Jul 2020, 16:40
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There's a lot of talk about the fancy electronics, but....does no-one look at altimeters (baro and rad) anymore?
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Old 16th Jul 2020, 17:26
  #42 (permalink)  
 
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A non precision approach in zero VIS pushing down until you hit anything with a passenger load in your back asks for a criminal investigation.
They had a lot of luck to survive this.
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Old 16th Jul 2020, 19:01
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Hi ATC Watcher and parkfell, on first inspection, I totally see your point! However, the way I see it, in both cases, there is more to it than 2 PPLs going "rogue". Yes, we are not talking BA, Easy or anyone else - but there was more to these two than first meets the eye. There was a far more "professional" perspective to both events - which is why I brought them up as examples of "Western" rule-breaking.

Regarding RM of "Barton Birdwatcher" infamy, a quick scan of Companies House show him as a Director of the ex-Comed Aviation Limited, SICs for Scheduled Air Transport and for Non-scheduled Air Transport from 1982 until 2018. There's even a Comed thread on PPRuNe tho dealing with Flight Training. Comed also had a Bandeirante based at Blackpool (G-ONEW) - as well as a load of other stuff (something like 11 aircraft) again, the subject of another PPRuNe Thread - Comed Blackpool. Indeed, back in about 2001, Comed Aviation Limited flew scheduled daily flights to Belfast, Dublin and the Isle of Man until Comed went bust - https://www.lancashiretelegraph.co.u...boss-grounded/ ! And there's also Fly Bpl, yet another PPRuNe Thread - Fly Bpl - Is It The Beginning Of The End???! As you can see, this guy was not your average PPL cashing in on the unsuspecting "twitchers".

Re the Sala accident, the extensive PPRuNe Thread on that accident ( Cardiff City Footballer Feared Missing after aircraft disappeared near Channel Island ) is there and there is much discussion as to who organised what and in what capacity. In that case, DI was simply the pilot in a wider web of commercial intrigue which saw him "hired(?)" to fly the aircraft by 3rd parties (unclear exactly who did what, when and where - that's all gone a bit quiet). Anyway, those with time to spare can browse all 107 pages of that one. One health warning before you do, there's this blithering idiot called H 'n' H who appears frequently in the Sala Thread!!!! You have been warned!!!!!

But, you are both correct, both pilots were PPL-holders. Best I blither off
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Old 16th Jul 2020, 20:12
  #44 (permalink)  

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H n H

As someone who was born and bred in Cumbria, and learnt to fly at Carlisle in 1972, I became aware of RM and have “followed” his career.
It was common knowledge that he would stick his head well above the parapet often coming to the attention of Air Safety Enforcement (CAA).
A certain TEFLON effect?
That effect failed post COMED with the HMG banning him as a company director.
During his interview with Manchester’s finest, he claimed his crash landing was similar to ‘Sully on the Hudson’ and perhaps a film will eventually be made.

He was unaware that the CAA were the other side of the one way glass.
The subsequent court case and AAIB report on G-BAKH is a matter of public record.

As for the Sala accident, this matter is still active and I shall treat it as sub judice.
The relationship between Cardiff FC and one Mr Henderson, who it is alleged would fly their personnel and on this alleged occasion acted as ‘agent’ for the fateful flight ~ one of the many aspects under investigation.

Last edited by parkfell; 16th Jul 2020 at 21:30.
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Old 16th Jul 2020, 20:34
  #45 (permalink)  
 
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I agree that there is often too much finger pointing and "hang'em high" mob type culture with a lot of incidences, but this incident may actually deserve it. I fully accept every single one of us makes mistakes. We can forget a call due to distraction or fatigue, we can misjudge the effect of a tailwind in a descent and end up a bit high on final etc etc, incidents resulting from these types of human errors are beneficial to us all, because they can so easily happen and can catch us despite our best efforts. We read them and learn from them. My personal motto with incidences is I am far from perfect, so who am I to criticise?

However, there is a fine line between the above and deliberately deciding to go below minimums as this crew did. I accept others across the globe may have different 'styles' let's say, but at the end of the day this was an ATR, there are manuals clearly defining how this aircraft must be operated and it is up to the crew to adhere to those SOPs as best as they can. In this instance they made a conscious decision to flout these SOPs - to the detriment of the safety of the innocents sat down the back who naturally trust the pilots up front.

To bring an aircraft down to 50ft over the sea at 2km from the RWY, with pax on board, against all known SOPs is gross negligence, negligence because they knew what they were doing was wrong but neglected to care and did it anyway.

It is hard to gain any beneficial lessons from this incident because it is so far removed from how (I hope) most of us on here operate that it's difficult to draw any useful conclusions that we can apply to our own flying. I am rated on type, this has little to do with the type though. Switching off the GPWS, setting -1,200fpm at 400ft, flying along at 100ft over the sea etc requires no knowledge of the type to see it's wrong. The only thing maybe type related would be the fault given, but the MEL says it is a NO GO, I don't know what or who else they consulted before switching it off but it is misguided and in all fairness we don't need the MEL to tell us it is not allowed to fly into IMC with a faulty/switched off GPWS (if indeed it was faulty). Anyway I shouldn't think the MEL of any other type says you can fly in IMC with the GPWS switched off.

Last edited by A320LGW; 16th Jul 2020 at 21:53.
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Old 17th Jul 2020, 09:00
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I am not entirely convinced that the captain did know what he was doing. According to the report he had just under 200 hours on type, so in most European airlines would have been barely out of line training. The co-pilot was also low time but significantly more experienced on the ATR than the captain. They may (if my French is up to scratch) have switched off the GPWS due to poor system knowledge and nuisance warnings earlier rather than simply a desire to bust minimums. It would be interesting to know the captain's previous history and why he switched to the ATR at age sixty. Given the focus on dubious qualifications and Parker pen hours following the Pakistan crash it is reasonable to be sceptical, particularly given how close they got to crashing. The overconfidence displayed however is all the more remarkable give the pilot's low experience and the technical failure, if we are being charitable about why they switched off the GPWS.
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Old 17th Jul 2020, 09:37
  #47 (permalink)  
 
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Can I just confirm what we think actually happened? I have tried to read the machine translation of the report but it is not easy going and I might have got confused.

I think they were flying a VOR/DME approach and saw nothing at minima, so they went down to a lower minima? They still saw nothing so selected V/S down of more than 1000' per minute and eventually hit the sea a couple of km out?

On the VOR/DME approach plate there must be a table of altitudes versus DMEs for cross checking? Does anyone have a copy of the plate available?

Thanks
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Old 17th Jul 2020, 10:10
  #48 (permalink)  
 
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Originally Posted by lederhosen
They may (if my French is up to scratch) have switched off the GPWS due to poor system knowledge and nuisance warnings earlier rather than simply a desire to bust minimums.
I did consider this, but then again, that doesn't answer for the fact they did go below minimums. This is obviously a rule that applies from a C172 to an A380, you don't go below minimums without visual reference. We aren't even talking about a cheeky delayed 'looking out' ... ..... 'visual', in fact what they did to was quite extraordinary. I see this and the GPWS confusion as 2 entirely separate issues, one does not simply lead to the other.
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Old 17th Jul 2020, 12:24
  #49 (permalink)  
 
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A320LGW, et al; recent posts.
re 'you don't go below minimums without visual reference.'

My earlier post #13, asked if operational procedures would allow the crew to continue the approach with the sea in sight at MDA; check ICAO approach procedures, charted procedures, operators specific procedures (local authority).

If the crew's understanding was that contact with 'the airport environ' (or similar wording used in some documents) was allowed, then they could continue the approach having the sea in sight. But would this be a continuous descent approach - encouraged for safety, and better enabled by GPS; or would the aircraft have to fly level until the runway was seen - where the aircraft would have to fly a steep (unstable) approach. (Catch 22)

The inappropriate conclusion of 'deliberate' might reflect ambiguity in rules or guidance; what are operators allowed to do, what interpretations are made, or what happens in real operations. (Work as done vs work as imagined; viewpoint - crew, operator, regulator, investigator, Pprune Pundits)

Thus the crew - from their point of view, may have been able to continue the descent, but with additional risk from increased workload - maintain visual and accurately checking the vertical path, and awareness of height illusion when flying over a horizonless seascape. (Risk mitigation, but from whom; crew first or last, operator, regulator, industry, … point of view)
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Old 17th Jul 2020, 13:09
  #50 (permalink)  
 
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My interpretation of the report is that the captain (non flying) was pushing the nose down (without saying I have control) while the co-pilot was pulling the other way. The captain appears to have lost situational awareness, was not monitoring the instruments and was interfering with the controls in an extremely unhelpful and inappropriate manner. They were over the sea so the mindset would appear to have been that there were unlikely to be any obstacles, while disregarding the fact that it might well be difficult to judge height over the water visually, particularly at a high rate of descent. There was the thread about the Westjet 737 which got very low over the sea and of course those about the Air Niugini and the Lionair 737s that actually did crash on similar non precision approaches. So this is by no means an isolated incident.
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Old 17th Jul 2020, 13:44
  #51 (permalink)  
 
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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.[img]images/smilies2/icon_rolleyes.gif[/img].
According to the CVR transcript in Annex 2 indeed not, however elsewhere in the main body of the report ...

Page 30 under "La Troisième Etape (TNG-AHU)" does mention a birdstrike in connection with the go-around call (4th bullet from bottom), which afterwards in a phonecall had been "precised" by the commander by stating the water had been hit before initiating the go-around (last bullet on same page).

For completeness and to be fair to Flightglobal.

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Old 18th Jul 2020, 07:47
  #52 (permalink)  
 
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..........that it might well be difficult to judge height over the water visually, particularly at a high rate of descent.............
............awareness of height illusion when flying over a horizonless seascape.......
I don't know about other pilots, but when I fly visually, I still refer to my flight instruments: Thrust, speed, altitude, Rad Alt, V/S, and pitch - and gear and flap status, as well as looking out the window.

Does the ATR not have a Rad Alt? I am sure it has at least two altimeters.


Regarding the bird strike, please check my schoolboy French, but I think bird is "oiseau", and water is "eau". Could this have been a mis translation or a misheard word?. "We have hit the water" might have been heard or written as "we have hit the bird"?
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Old 18th Jul 2020, 09:31
  #53 (permalink)  
 
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It certainly does, the ATR has all the bells and whistles, except for autothrottle!
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Old 18th Jul 2020, 11:38
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Required visual reference

alf5071h

In nearly all these types of events (and unfortunately a lot of the comments) there seems to be a basic ignorance of the meaning of instrument approach minimums, required visual reference, and what is needed to continue below DH or MDA.

ICAO Annex 6 is what governs the minima and they are based on a very specific requirement. Whatever the visibility, if you have not been able to confirm the aircraft's position and velocity in relation to the desired flight path from the external cues BEFORE you reach DH/MDA, you must go around. If you don't adhere to that, every aspect of the underlying safety assumptions is undermined.
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Old 18th Jul 2020, 16:47
  #55 (permalink)  

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Originally Posted by A320LGW
It certainly does, the ATR has all the bells and whistles, except for autothrottle!
1. They (Captain essentially) blatantly and recklessly disregarded what any sensible crew would do.

2. Once below DA, the Workload went significantly UP, and the Situational Awareness plummeted.
Failed to appreciate the Rad Alt, and for that manner the Altimeters.

3. They would both have got one hell of a fright when sea contact was made.
Just what the CCM and the passengers thought, and what they were eventually told or learnt sometime later has not been disclosed.

4 Had any Brits been on board then the Daily Mail / Sun would have been hot on the trail.

Still hard to believe such an event occurred.

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Old 18th Jul 2020, 17:08
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Thanks Steve, #54
I agree with all of your points; however its the unusual regulation or its interpretation that might lead us astray, e.g.

"10. other visual references specified in the operations manual."

AMC1 CAT.OP.MPA.305(e) - Commencement and continuation of approach,
https://www.easa.europa.eu/sites/def...rch%202018.pdf page 157 / 158

And within that, weak knowledge within the regulatory authorities - your ' a basic ignorance of the meaning of instrument approach minimums, required visual reference, and what is needed to continue below DH or MDA.'

It has not been established which particular regulation the operator was using, nor the interpretation of this or any rules from previous employment, however misguided that might be.
Even so, flight over featureless sea with minimum horizon has significant risk.

Last edited by alf5071h; 18th Jul 2020 at 17:18.
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Old 18th Jul 2020, 19:21
  #57 (permalink)  

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When I flew the C 130 for Her Majesty, our minimum height over the sea was 250'. That was set on the rad alt, and a warning light came on if the reading was below that. Three crew facing forward. The captain flew it, with the co-pilot and engineer's eyes glued to the rad alt. Any deviation below 250' would elicit an immediate "height" call. What this crew did was outside limits and dangerous, but if you are going to do it, set the rad alt at say 150' (which should clear any fishing boats) and have the PM glued to that instrument. I don't think they used it at all; nor the DME.
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Old 20th Jul 2020, 06:40
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Originally Posted by Uplinker
Regarding the bird strike, please check my schoolboy French, but I think bird is "oiseau", and water is "eau". Could this have been a mis translation or a misheard word?. "We have hit the water" might have been heard or written as "we have hit the bird"?
On the bottom of page 30 it says "Le CDB confirme avoir fait part de cet événement, par «Air Safety Report» et par téléphone, au management de RAM EXPRESS en tant qu’impact d’oiseau, mais qu’il a rappelé ensuite pour préciser que «l’eau aurait été touchée avant la remise des gaz».

Which translates to: the PIC confirms that he has informed the management of RAM Express of the event as a bird strike, via Air Safety Report and via telephone, but that he later phoned back to clarify that the water had been contacted before the go-around.
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Old 20th Jul 2020, 16:03
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The inquiry doesn't seem to have picked up on an interesting detail. They make the obvious CRM point that the cross-cockpit gradient was steep, with the Captain on 13,487 hours and the F/O on 1,063. They don't say anything about the fact that there was also a steep cross-cockpit gradient in the other direction with regard to hours on-type - the F/O had 815 hours on the ATR-72, over 4 times as many as the Captain, who had 193 (and some more on the ATR-42 30 years earlier). The combination of a Captain with lots of experience in general, but not much on the specific aircraft, and an F/O with little experience in general but much more on the specific type, sounds about as bad as it could be.
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Old 20th Jul 2020, 16:24
  #60 (permalink)  
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Joe_K

More "Would/Could have been contacted" Than "Had been contacted before the go-around"

Sounds like a bad face covering attempt.
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