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

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

Old 13th Jul 2022, 07:08
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Airbus has the approach page in the FMGC which is filled out by the crew before every approach. One of the entries to be filled out on this page is the expected QNH, it is done during cruise from an automatic weather report.

Never understood why Airbus does not compare the QNH on this approach page with the QNH set in the FCU and give an alarm if off by more than 1. Can't be that difficult to construct such a feature.
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Old 13th Jul 2022, 08:25
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I think the main issue here is that we have crews flying around who are utterly reliant on the information given to them by outside agencies and the pretty pictures on the ND and PFD.

A miss set QNH can kill during an NPA as nearly demonstrated by this event. If a crew builds their SA from scratch in a robust manner they will pick up a mis set QNH by comparing it to the ATIS, by checking what the baro altimeter reads when the rad alt comes alive and latterly by realising they are too far from the field as they pass 500radio, 100 radio etc.

This crew was dependent on the pretty vertical profile displayed by the avionics which was incorrect.

Build your own SA, and place traps in your procedures to detect mistakes.

LD
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Old 13th Jul 2022, 08:58
  #63 (permalink)  
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Originally Posted by Eutychus
I may be SLF but I am also a professional interpreter and translator.
I appreciate the potential benefit of other pilots being able to listen in and spot errors, but I'm asking myself whether that actually happens and how often it is actually useful.
As the OP it was my intention to raise the very first gaping void in a cheese that has more holes in it than Garry Gilmore.

It's a fact. The use of two languages at CDG has already killed. Along with the apparent failure of the crew to deal with the resulting situation, It came within 6ft of killing again.

The appalling reality is, the Regulators were told in 1998, and, in the same year, an article in CHIRPS concerning the use of French at CDG it stated “I am sad to say, maybe show how a major incident is waiting to happen if French ATC continue to be constrained by Ministerial Order No 7.

One year later there was a fatal collision on the runway at CDG. The reason? A French a/c was cleared to take off in French while a British aircraft was cleared to line up in English.

This is not about bashing a country. Its about common sense . It appear "lessons have STILL not been learnt."

The ultimate 'well I did warn you years ago' can be found here.

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Old 13th Jul 2022, 09:09
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Hi John Tullarmarine, yes, your question about QNH cross checking already queried by me; post #5 And seemingly not performed by this crew. With horrible weather and the wipers going on fast, it would have been difficult to hear ATC clearly, hence it is very important to cross-check such things.

Regarding having the aircraft technology warn us about incorrect QNH. Yes, a possibility, but as above, we already have a proven way of cross-checking and double-checking the QNH, that has worked for many years. I am a fan of technology, but also believe that we should retain some element of pilot competence and error checking, with the pilots having a 3D model of their flight situation in their minds.

Re language and saying numbers digit by digit: That is so non-English speakers can hear standard English phrases and understand them, particularly when transmitted across an analogue voice radio link, which is subject to distortion, fading, noise etc. American ATC for example often say 'runway three' instead of 'runway zero three', and make other verbal short cuts. These are understood by local American pilots, but not necessarily by non-local, non-American pilots, whose first language is not English/American. Hence my question about how French ATC speak QNH in French. It is many years since I regularly flew in and out of CDG, and even when I did, my brain would not have listened closely to instructions given to others in French, so I don't know if ATC use digit by digit for QNH, or the short cut of 'mille un' etc. Having to say 'unité' instead of 'un' takes longer, at three syllables vs one, so 1011 spoken digit by digit in French would take a long time and at a very busy airfield such as CDG, having to say that over and over again; it must be very tempting to abbreviate. This in turn, might have caused confusion in the ATC's mind when they translated for the English speaking pilots.

Someone asked if anyone had ever corrected incorrect transmissions given to others. Yes, I did once, in the London TMA. It was busy - always is, but REALLY busy - and I picked up that another aircraft had responded to our descent clearance. I managed to tell ATC which aircraft had taken our clearance, and that we were maintaining (whatever) until we received further instructions. ATC were very grateful; as were we, and I am sure the other aircraft were too. Could have been very messy.

Another occasion, on our initial descent in Mexican airspace, ATC told us the QNH was '992'. This sounded very low to us and it didn't cross-check, so we queried it several times, without satisfactory resolution - the guy kept saying '992'. We were luckily in very empty skies with nothing around us, and not near the ground, so we continued cautiously with very heightened monitoring until we were handed over to the next controller. We worked out that the first guy was saying '2992', i.e. 29.92 mm/hg; equivalent to 1013 millibars, but he was saying it so quickly and cutting off the first '2' then emphasising the '....9 9 2' part, so the first '2' could barely be detected, and it sounded like a millibar QNH. Had the first controller said 'decimal' as he should have, we would have heard '....9 decimal 92' and would have realised the correct setting.
.
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Old 13th Jul 2022, 09:30
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Originally Posted by KRviator
Bollocks it isn't a dual language issue.
the whole point of the entire planet using English for aviation is to avoid mistakes and allow others to pick up on them should they occur.
May i suggest you travel a bit outside your confort zone and discover that 80% of the world airspace in not primarily English speaking., as to the reason you state to make English the common aviation communication language you obvioulsy do not fly IFR in busy airspace. . Anyway tthis incident is not a language issue, it is a combination of facts which started with an ATC error. giving the wrong QNH.
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Old 13th Jul 2022, 09:30
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Originally Posted by Youmightsaythat

This is not about bashing a country. Its about common sense .
The problem is that complex systems tend to be more and more counter-intuitive rather than easily analysed in terms of "common sense".

I can easily see how use of more than one language in ATC could lead to some disasters. What is not so easy to see is what the best way of mitigating that might be, bearing in mind that the solution needs to ensure other, more serious disasters will not ensue as a result.

Supposing English is implemented as the only ATC language at CDG. A quick Google suggests that a large proportion of flights in and out of CDG are domestic. My guess (and it is a guess) is that many of the pilots in question will be French native speakers flying only or mostly domestic routes (I don't know enough about rostering to be sure). With the best will in the world, it's very difficult to remain fluent in a non-native language when living and working in your native country. Communication in French will always have the edge for those operating mostly in a dominantly French-speaking general environment. Would communication between Sully and ATC have been so fluid in such a short space of time if both he and ATC had been obliged to communicate in a non-native language? I think not.

If I'm flying into CDG with a French pilot up front I'd feel much safer with French being an approved ATC language than knowing it was prohibited. Of course my perception may be wrong, but I'll need some convincing!
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Old 13th Jul 2022, 09:32
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Very, VERY worrying and lots of comments - but #26 and #27 say it all !
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Old 13th Jul 2022, 09:36
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One year later there was a fatal collision on the runway at CDG. The reason? A French a/c was cleared to take off in French while a British aircraft was cleared to line up in English.
Again not factual. find an read the officilal accident repport before posting statements like this. One in a long list of possible contributing factors was not the cause of this accident.
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Old 13th Jul 2022, 09:42
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Originally Posted by ATC Watcher
Again not factual. find an read the officilal accident repport before posting statements like this. One in a long list of possible contributing factors was not the cause of this accident.
You are correct the 'official; report did not highlight this as being a serious problem. Now I wonder why that might be? Can I suggest you look at the FACTS of the crash. When you have, get back to me and tell me that this wasn't a major factor.
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Old 13th Jul 2022, 09:50
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Originally Posted by Uplinker
Hence my question about how French ATC speak QNH in French. It is many years since I regularly flew in and out of CDG, and even when I did, my brain would not have listened closely to instructions given to others in French, so I don't know if ATC use digit by digit for QNH, or the short cut of 'mille un' etc. Having to say 'unité' instead of 'un' takes longer, at three syllables vs one, so 1011 spoken digit by digit in French would take a long time and at a very busy airfield such as CDG,
French officilal phraseology spells numbers in full . here the QNH would have been mille onze. English phraeology spells all numbers digit per digit , one-zero-one- one, No French controller mixes this up,
For "one" in the French phraeology we use "unite" instead of "un" (1) this is to avoid the mix up with vingt ( 20) sounding the same. One othert hing to remember is that in France , like in many other countries, the French Phraseology is the one to be used, English is secondary and must be used if you do not have a French language endorsement on your licence. In addition most GA airports in France are French language only.

Last edited by ATC Watcher; 13th Jul 2022 at 10:08. Reason: typo
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Old 13th Jul 2022, 10:04
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Originally Posted by Youmightsaythat
You are correct the 'official; report did not highlight this as being a serious problem. Now I wonder why that might be? Can I suggest you look at the FACTS of the crash. When you have, get back to me and tell me that this wasn't a major factor.
You mean your FACTS ? Not the ones established by my colleagues after months of invstigation and intervewings the pilots and the controllers involved ? It feel a bit like arguing with a pro Trump replubican Senator.
By the way the Shorts Captain statement was relatively clear, , very sadly he committed suicide 6 months later. A second victim of this tragic accident.
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Old 13th Jul 2022, 10:34
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Regarding having the aircraft technology warn us about incorrect QNH. Yes, a possibility, but as above, we already have a proven way of cross-checking and double-checking the QNH, that has worked for many years. I am a fan of technology, but also believe that we should retain some element of pilot competence and error checking, with the pilots having a 3D model of their flight situation in their minds.
100% agreed. Technology would have trapped this error slightly further back, but ultimately it shouldn’t be happening in the first place.

My operator highlighted this very risk in training a few years ago and we reproduced pretty much this exact scenario. Instructor froze the sim at minima and then set VMC conditions. It’s sobering just how close to the ground you get and with a 10hPa discrepancy it’s quite easy to justify it in your head (terrain under approach path, temperature etc etc) when the rad alt gives the 2500 call out.

We set QNH on the standby altimeter during cruise and independently check it against the ATIS, and then verify it again when ATC clear us to an altitude. But then I keep an eye on the rad alt too.
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Old 13th Jul 2022, 10:50
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My facts? Do you really want to go down the rabbit hole of French Investigations?

Originally Posted by ATC Watcher
You mean your FACTS ? Not the ones established by my colleagues after months of invstigation and intervewings the pilots and the controllers involved ? It feel a bit like arguing with a pro Trump replubican Senator.
.
Well I suppose when your argument begins to look a little frayed its time to resort to insults.
Still not convinced about the issue?

​​​​​​​Literally a few months after the Concorde crash I was behind an Italian aircraft at the holding point. A KLM aircraft had just landed. He reported that he had blown a tyre, in English. Immediately after acknowledging this the controller cleared the Alitalia to line up and take off.

​​​​​​​The Italian pilot immediately refused this clearance and informed ATC they would remain at the holding point. ATC queried the reason. The Alitalia commented replied that the KLM had reported a blown tyre and there was likely debris on the runway. Now, can you imagine if that had been a French aircraft that had shead a tyre. If you still can't see there is a problem then there is not much more I can say.
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Old 13th Jul 2022, 11:00
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How on Earth are the French allowed to remain in EASA/ICAO with such unsafe rules? A global industry requires a global language. If Napoleon had tried a bit harder that language might have been French, but he didn't so here we are...
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Old 13th Jul 2022, 11:20
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Originally Posted by Youmightsaythat
​​​​​​​The Italian pilot immediately refused this clearance and informed ATC they would remain at the holding point. ATC queried the reason. The Alitalia commented replied that the KLM had reported a blown tyre and there was likely debris on the runway. Now, can you imagine if that had been a French aircraft that had shead a tyre. If you still can't see there is a problem then there is not much more I can say.
Seeing a problem is not the same thing as identifying an appropriate solution, and may not be the same thing as seeing the predominant problem.

In the case you relate above the first question in my SLF mind is the grounds on which ATC cleared an aircraft for takeoff when they had been informed of FOD on the runway. That issue remains the same however recent another FOD event or the language of the ATC conversation.

On the incident referred to in the OP, I think there's little disagreement that language may have played a role, but a lot more disagreement about how big a hole in the cheese that was compared to the others, and how that particular factor should best be mitigated. Short of requiring all pilots and ATC everywhere to conduct all communications in a given language (would you personally accept any language other than English?), the use of more than one language cannot be excluded entirely, and I'm far from convinced that implementing such a measure would be safer overall than educating those involved about the limits of language-based communication and the need for greater awareness when not communicating in one's native language.

Some of the best-paid jobs I get are ones untangling disputes caused by people believing they understood each other adequately in what was a non-native language for at least one of the parties. Fortunately none of them so far were in the aftermath of situations requiring split-second decisions...


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Old 13th Jul 2022, 11:22
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Sure the French colleagues operating at CDG all have ICAO ELP 4+.

I still think the mixed languages were irrelevant to the situation as it unfolded here.

The proposed safeguard is the Incident aircraft picking on the 4the transmission about the different QNH.

They seem to have been too deep in a hole of their digging at that point. For sure they did not pick it from the 3rd transmission (EZY read back, proper English I would suppose).

Blame the French for language problem other time, blame the French for useless MSAW intervention. Over here the lingo did not play a role nor would have changed the outcome, your honour.

- - -
Would it not be ironic if one of the GetJets pilots was actually a native French speaker?

​​​​
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Old 13th Jul 2022, 11:39
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Am I the only one thinking my iPad would have had a screen full of red if I tried this?
Also are radar altimeters no longer a thing?
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Old 13th Jul 2022, 12:58
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Highly probable that the wrong QNH might have been passed to the French crew as well if in English.
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Old 13th Jul 2022, 13:08
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As noted above in various posts, the issue of pilots being able to maintain their situation awareness by monitoring all relevant transmissions to and from other aircraft is a significant defence in closing the holes. When CPDLC was being introduced, the fact that pilots would be operating in their own non-RT silo was raised as a risk-assessment hazard requiring mitigation. Incidents since then have shown that the hazard still exists.
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Old 13th Jul 2022, 14:37
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Detent.

This is multi point mistake, but to say mixed languages isn't a factor is frankly bollox. Haven't read the report, but were the crew on day 5 and on the edge of FTLs? Was the latest METAR accurate and up to date? Do we know the techlog status etc etc

I do know that the LTMA controllers are very careful to speak super clear and be mindful if a pilot is not an English speaker, as are the Dutch and the Germans. Try ORD on a bad stormy night and that's a different ball game.

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