Airbus Within 6ft of the Ground nearly 1 mile Short of Runway

[FlightDetent]

BTW GetJet had some funny evolutions at MAD with a 737 as well.


fdr not sure what you mean. I was somewhat shocked the reaction at DDA=MDH+50 did not arrive. Unlike many other strange manoeuvres where I think - okay, they should know but no one really trains to proficiency on that - a simple absence of vis ref at decision was, I assumed, a wholly resolved issue since over two decades ago.

I can't fix or avoid the ATC mistakes on the next sector, but I better be sure to act faster on the throttles than 9 seconds.

observation 2, they call-sign was Red Nose xx11. Can't train the brainfarts out of humans, there goes the ATC's "1011" and a bit of understanding of the crew of not picking that up immediately.

Strangely they re-set it, whereas the Airbus has the means to pre-select QNH in 3 separate boxes before descent. A more conventional failure mode would be not to notice the instructed value was any different from the briefed one, so to speak make a second error which would negate the first one.

[The FUB]

"FAF altitude checks, MAP set."

Gross error of altimeter QNH should be evident.

[FlightDetent]

MSN 1087 / manufactured 1999. Not great, not critical.

additionally: Some bravely older A320 with QFE option need to set MDH (!) to the minima prompt when flying VNAV approach on QNH, in order to avoid undue AP disconncect. Some of the values just don't link properly inside the FMS. Another effect of that is the RA callout '100 above' and 'minumum' is also unuseable / missing (not rembeber which one).

Some operators "in the region of the parent AOC" believed that flying mixed configuration was prone to pilots getting overreliant on the auto-callouts and in turn presented a large risk on an old ship as explained above where no radio callouts would come. The solution was to deactivate the auto callouts on all airplanes for minima and 100 above in an attempt to drill the crews into observing the altimeters at all times.

Was this crew perhaps not ingrained with synthetic callouts from their previous life, so a deactivated (if) missing audio removed a useful trigger for them to GA swiftly?
Did the PM call Approaching and Minima at all?
What sort of ACMI suppliers do Norwegians hire (Go2sky non-RTO story, anyone)?
Is the EGPWS TCF not capable of picking this one?

Why cannot we yet, pretty please, get a rough GPS-alt vs. Baro-alt comparator for gross errors? In a form of "CHECK QNH REFERENCE" ??? Come on, it's 2022!

[A320LGW]

The incident at MAD was with Klasjet, not Getjet. Though they both belong to the aviasolutions group with questionable business practices.

As for level flight. Fair enough if they had no level offs below TL initially. After the GA though there was as someone has mentioned. I'd expect ATC to pick this 300ft deviation up and query it. But then again I'm not a controller ...

[paulross]

Originally Posted by Equivocal

That report makes rather startling reading with so many, some arguably minor, errors which very nearly led to the loss of the aircraft. My background is ATC and I am many years out of operational work, but the description of the ground-based aspects of this event are quite frightening to me. I may be living in a rose-tinted world when I think back to my operational days but I can't help thinking that almost every aspect of the event would have rung alarm bells - particularly the MSAW alert which I am sure would have had everyone running around double-checking the QNH in my day. And the idea that at 6ft RA there was no visual reference from the aircraft suggests that the weather (even the localised conditions included in the METAR) was less good than reported.

It does seem that ATC became aware that there was a problem and acted at the time. From page 4 of the report:"At 11:42:27 the LOC N controller switched ON the approach lights. Following the MSAW and the omission of switching ON the approach lights, the LOC N was replaced by his LOC-N assistant and a new LOC-N assistant took over."

The report also states (page 12) the expected ATC response to a MSAW, which includes QNH. Neither happened in this case.

[A320LGW]

The biggest mystery for me here is how a crew got as low as 6 feet/2 metres (!) above terrain and did not see it!!?? Whatever about visibility reductions, this is outlandish.

[tubby linton]

Originally Posted by A320LGW

The biggest mystery for me here is how a crew got as low as 6 feet/2 metres (!) above terrain and did not see it!!?? Whatever about visibility reductions, this is outlandish.

Children of the Magenta not looking out of the window?

[RatherBeFlying]

Harmonised Transition Altitude

In North America, it's 18,000 which gives time for ATC systems to spot a mismatch between cleared altitude and mode C readout. It seems more sensible to me to set the altimeter to ATIS once I receive it, than have an opportunity to forget to do it sometime later.

[Jonnyknoxville]

Originally Posted by AndiKunzi

They used LNAV/VNAV minima and obviously had no GP?

😂😂I hope your not in charge of an airliner

[vilas]

Dual language instructions always has the potential for an incident. It should be stopped.

[alf5071h]

FD #23
“… please, get a rough GPS-alt vs. Baro-alt comparator for gross errors?“
Yes !
The point of question #7 is that depending on the particular ‘TAWS’ vendor, (maybe software standard), some versions in association with GPS, external input or embedded in the Terrain System, will provide alerting.

Do operators understand the specifics of the equipment fitted in their aircraft or how with mixed fleets equipment fit varies ?

[DaveReidUK]

Originally Posted by alf5071h

Do operators understand the specifics of the equipment fitted in their aircraft or how with mixed fleets equipment fit varies ?

Apropos that, Airhub operates four A320s with YoM ranging from 1999 (the incident aircraft) to 2010, according to their website.

[tubby linton]

The year of manufacture is not relevant, it is the mod state of the aircraft that is important.

[WideScreen]

Originally Posted by FlightDetent

......
Why cannot we yet, pretty please, get a rough GPS-alt vs. Baro-alt comparator for gross errors? In a form of "CHECK QNH REFERENCE" ??? Come on, it's 2022!

I am glad, you raise this item. This event (and many, many others) do scream for an E2GPWS or EGPWS-NG, or what-ever. GPWS is a kind of static virtual 2-D vs. height "where am I". EGPWS effectively creates a dynamic multidimensional "virtual-path", where it is safe to fly. The E2GPWS would add the GPS version of the approaches, down to acceptable Terra-Tarmac-Touchdown-Zones, and produce warnings, when the factual GPS flight path goes outside that "cone" (low/high/left/right). The closer the airplane gets to the GPS ground, the smaller the cone size will be.

Of course, there are a lot of "but's", though such a feature working properly, would (have) save(d) quite a few potential and real mishaps. This would be relevant, not only for this case, though 2 times the near accident with an A380 (Moscow/New York), the ACT/Bishkek, the PIA touch-and-go on engine pods at Karachi, all the Asian water touch-downs just short of the runway, and a lot more. Not to say, it gives quite a solid checkmark for being stable at 1000 ft (or at least in the approach cone).

[FullWings]

Originally Posted by A320LGW

The biggest mystery for me here is how a crew got as low as 6 feet/2 metres (!) above terrain and did not see it!!?? Whatever about visibility reductions, this is outlandish.

That surprises me as well. From the report they said they never saw anything, but even in fog you’d expect to see something at 6R. Daytime as well but heavy rain with the wipers on. I suppose the 6R was reached at a high pitch attitude during the GA, so you’re looking at somewhere between 50’ and 100’ AGL - still one would have thought something would be visible, especially as you’re supposed to be visual below MDA!

Apparently no RAD ALT calls apart from 2,500’ and 1,000’ which kind of makes sense, because getting 50 30 20... on an NPA with no visual reference is definitely attention getting.

[DaveReidUK]

Originally Posted by tubby linton

The year of manufacture is not relevant, it is the mod state of the aircraft that is important.

Indeed it is.

With Airhub's four aircraft having originated variously from Iberia, Jazeera and Indigo (two of them CFM-engined and two IAE) I wouldn't put any money on their respective mod states being remotely consistent.

[tubby linton]

The origin is irrelevant, it is the current state of the aircraft and the only organisation that will know that is Airbus .The mod stae will depend on whether the mods are mandated or the operator decided to upgrade the aircraft. I worked for an airline that had CFM A320s. IAE A321 with numerous differences.There were even differences between the type of CFM56 and whether they had sharklets, gps etc etc. The airline borrowed from a flag carrier a differences sheet which was part of the pre-flight briefing to brief the crew what they were going to operate. I can also think of another large operator that has a mixed single aisle fleet with seven distinctly different sub types.

[Equivocal]

Originally Posted by paulross

It does seem that ATC became aware that there was a problem and acted at the time. From page 4 of the report:"At 11:42:27 the LOC N controller switched ON the approach lights. Following the MSAW and the omission of switching ON the approach lights, the LOC N was replaced by his LOC-N assistant and a new LOC-N assistant took over."

Fully accepted. It is the nature of such reports that some information that is available to investigators may not be included. It would be interesting to know how long after the first event that the original LOC N was replaced and why - simply omitting to switch the lights on seems unlikely to be a suitable justification. But if the significance of the QNH was recognised as a potential contributing factor, I would expect the correct value to be stressed somewhere before the second approach was commenced and, as someone else pointed out, there was likely a period of level flight during which the discrepancy between assigned level and mode C could have been checked - and back in my day, in an incident with which I was involved that bears some similarity, it most certainly was! There are many other 'ground-based' questions which could be investigated, and I hope that they will form part of the final report

[A320LGW]

Originally Posted by tubby linton

Children of the Magenta not looking out of the window?

I myself am probably a child of the magenta line, but even I have not (knowingly) achieved this, to date at least.

Good point RE pitch attitude at the time and that may explain it. I was also watching in a sim recently and saw 2 pilots staring aggressively at their instruments below DA with the runway perfectly visible, but neither looked up to see it. Instructor not impressed. That may have happened here.

I'm surprised there isn't passenger footage or scare articles. I'd have thought even the most fashionably aircraft unaware passengers would know that being so low without tarmac beneath them wasn't normal.

[CVividasku]

Originally Posted by Uplinker

I am wondering how 1001 and 1011 are spoken in French by French ATC; 'mille une' and 'mille onze' perhaps? instead of 'une zero zero une' or 'une zero une une'. This could have led to confusion in the ATCs mind; not realising the mistake when translating to English.
.

Indeed.
"Mille un" and "mille onze" which is much easier than "un zero zero un".
Similarly I don't understand why in english we couldn't use "thousand one" and "thousand eleven" which is much clearer than a jolt of zeros and ones.

Separation number by number is only used as a way of disambiguation, in a very slow manner.