An old instructor once told me:

"You can play around with weather, and you can play around with fuel.

But NEVER play around with them together!!!"

NOsigbreak, listen to Backtrack.

Fact, the Captain DID fly again, subsequently retired on PHI and pension after some medical problems, related to a head injury in the incident. Good luck to him.

Fact. F/O is still flying.

I myself was in ALC earlier that same day, the CB's were huge and widespread. B***ard of a day, anywhere in that area.

Please can we stop the what ifs, so what hindsight is wonderful isn't it.

EGGW.

EGGW

Bad news. F/O HAS gone, as of a few days ago. Was due to be starting command course, so company (and everyone else) thought him able and capable enough. Great guy, and more able than me.

Will be missed. (and I'm not even looking at my roster!!)

Oh well, my info was correct last Wednesday. Thanks all the same. And good luck to him!!


EGGW.

Some posters seem to be apportioning some of the blame to the inexperience of the FO. Short of questioning the Cpts decision to do another approach what could the FO have done differently? IMHO he did his job well providing good support to the Cpt. The report mentions this by stating that the crew worked well as a team.

I cannot see why the controller gets criticised by some posters either. It is a small regional airport with limited facilities. She did her best within the resources available to her. Some posters have obviously not read the report. She sounded the alarm 40 seconds after the crash (the alarm did not work so she telephone the emergency services a few seconds later). Perhaps somebody in the ramp thought that the A/c had diverted, ATC and the emergency services didn't. It would be great if they had a fully working Heathrow airport everywhere we go, just for us, just for 20 aircraft a day three months of the year. Life is not like that. We as pilots must take all the factors influencing the flight into account.

It all turned to **** with that full nose down elevator. After that it was never going to be easy. Fatigue must have been a factor at that point

Can we now paste this thread into the one about 'overpaid bus drivers....'

The purpose of accident investigation is to find out what happened and why - NOT to apportion blame.

Pilots are human beings and by definition are capable of "error" but to blame any accident on the pilot is far too simplistic. Accidents are a product of the entire "system". Error chains can start anywhere and with this one it might be argued that such a chain started with the (permitted) FTL schemes that exist (this is no criticism of Britannia) or with a fuel policy which promotes "economy" rather than "safety".

I recall on one CRM course I attended the facilitator talked about the "poor judgement chain" - once one poor judgement is made then the probability is that more will follow at an ever increasing rate. I am not criticising the aircraft commander (there but fot the grace of God go I etc) but once the decision had been made to take only an extra 15 minutes holding then the odds were beginning to be stacked in the wrong direction. Poor judgements chains can only be broken by questioning their starting point and acting accordingly.

My experience is that crews are rarely given any training and guidance as to how much extra fuel to take when appropriate. As a training captain some years ago who often operated to GRO and the like I taught crews to look critically at the destination and alternate forecasts especially when either were close to minima and if there was any doubt to load more rather than less. I know that excess fuel carriage can be a contentious issue in some companies but such policies are, I repeat, part of the potential error chain. It is also important that crews understand the ramifications of terms such as TEMPO etc.

This type of accident could have happened to virtually any operator but we have to ask ourselves, as professional pilots, how WE as individual crew members in whatever role can prevent a similar accident in the future.

Seems Nosig Break was quite correct. Patronised or not.

Real shame about the First Officer, he was an excellent pilot. I too wish him well for the future.

Things have happened and only lessons can be drawn from these events.

Basic common sense tells you; if you have no visual cue’s to land from at the latest at DA or MAP, you make a go around!

But visual cues are not the only thing that may fail.

A thorough knowledge of ILS systems reveals that although LOC and G/S may well be centered it does NOT mean the Aircraft is within the limits or centered with the runway center line.

Some Airlines allow the F/O to continue an autopilot coupled approach (on the condition the LOC and G/S are centered) even if the Capt does NOT react at DA or MAP assuming incapacitation.

The logic behind this is that it is far safer to continue on the Autopilot than to carry out a missed approach with the autopilot by the F/O only.

Edited:

The logic behind this is that it is far safer to continue on the Autopilot and land than to carry out a missed approach with the autopilot monitored by the F/O only.

Another issue is that of extra fuel, 15 minutes is nothing!

If you take extra fuel, then you take plenty and not what I call some kind of psychological fuel of 15 min but at least 30 min if not 60 min.

Not so long ago there was a 757 cargo in LIME with TS all around the place and the same scenario nearly developed.

Again the crew took ONLY 15 min extra, all this causes a tremendous amount of stress and leads to errors.

Considering the small amount of extra burn due to the uplift there is no valid reason why this extra burn should not be considered as an insurance premium against tragedy.

It can only be explained as either reckless behaviour and/or bad company policy.

It is not a question of training but of common sense, only!

There are no clear criteria set out but if you check the WX and you see TS at your destination the you go and look how widely spread they are.

If it is confirmed that they are all over the place and not in a confined area only, then you know what your chances are.

Far too often, do we think that aviation is state of the art technology, perfectly regulated and controlled all this creates a blind confidence in the system.

Everybody with some years in the industry knows for a fact that it is far from perfect

I hope the guy did not leave because of the report being published. If so he probably didn't need the comments here

The practice of putting a student pilot in the right seat of a commercial jetliner is troubling and its implications need addressing.I dont agree with it and yet I know many airlines get away with it year after year.Aircraft are so reliable these days.Its not just that the poor guy is woefully unprepared for the huge workload and cognitive decision-making in the event of a LHS incapacitation.The real issue is that it creates a steep gradient between left and right seat.All US majors reject this model and for good reason.For CRM to function as IT WAS INTENDED WAY BACK WHEN,the gradient should be shallow enough to ensure that:
i)the "junior" pilot has a database of knowledge and experience which enables him/her to communicate any concerns about the flight.This communication can vary between timely and helpful advice to direct contradiction.
ii)the "senior" pilot,mindful of the experience of his/her colleague,will readily and confidently use and manage the resources of the right seat.
This model represents the perfect CRM model and I dont pretend that it exists in all US majors,but they certainly aspire to it.This model,when manifested in its purest form,will in fact perform miracles,as in the case of the DC-10 crash at Sioux city,where 182 people escaped certain death.
Increasingly,there seems to be a new model; communication of the type given in (i) is now based on the desire to conform to a politically-correct flightdeck(an anathema to pure CRM).Advocacy and assertion is there but now there's no database to back it up.Or alternatively,the communication is not forthcoming at all,because quite rightly,the first officer feels he/she is ill-equipped to advocate or assert anything.
Pilots wanted:college grad,3000 hours,1000 turbine,must have seen a bit of life.

Rananim

You have my blessing.

CRM has evolved into some talk show and has become a way to select pilots NOT on what they know “Database” but on the, are they “Nice” criteria like a kind of “Would I like to sit next to this guy for 8 Hrs”

For many years, models have been developed to select pilots and when Competent and Experienced recruiting staff uses it, they can get it right.

I prefer a young F/O with a solid educational background that challenges his Capt with questions over the one that is nice and that keeps quiet.

It keeps me up to speed, the flight is far from boring.

But the essence of the story is often: “How do you as a captain use your F/O as efficiently as possible” or in other words Crew Management. You can invite the F/O to get more involved yourself.

Certainly; when an approach gets difficult you want to use all resources and in my opinion in the case of this Gerona mishap “A MONITORED APPROACH”

"the "junior" pilot has a database of knowledge and experience which enables him/her to communicate any concerns about the flight."
Ranamim - did that include the Southwest that visited the gas station?
Yes we do it slightly different over here in Europe, but that does not mean either of us are getting it wrong. I have never had any problems flying with Cadets, if they are not happy with something they will always speak up.

Why oh why are people still going on about this??? It can be observed in the report that the F/O had a few hundred hours total time when he started flying for BY, BUT!!!!!! he had well over 1000 hours at the time of the accident, so why are people reffering to him as a low hour F/O??? He would have had 1-2 years experience! Where in the report does it comment on this??? If people want to discuss the pros and cons of low hour pilots please start another thread (or search for the past ones!) as people who have not read the report will start believing things that were not reported as factors!

Typically, those that 'prefer' to argue about their revulsion at having 'young' inexperienced First Officers are the same ones that most Captains, young or old, experienced or inexperienced, can't stand spending long periods with on the flight deck. You only have to listen to Cap56 and you'd think he was an experienced jet CAPTAIN! :rolleyes: There can be little worse for anyone, Captain or First Officer to have to listen to someone pontificating from a position they don't have the credibility to claim to be coming from. A bit like listening to a "Jack of all trades, master of none"!

As has been pointed out already and suitably ignored by those that like the sound of their own voices, the F/O had two years of experience on the B757. Where he started from is irrelevant and yet we have 'pseudo experts' trying to tell us how terrible it is to have to fly with a cadet pilot. If the F/O had been only just released from line training, maybe, just maybe, there may have been a point to be raised but in this instance the F/O performed appropriately and according to the book.

So, would the pontiff (and I think we all know who we are talking about) please go back to lambasting other airlines about how to fly into Johannesburg on a hot night. The lecture on cockpit gradient (an inverse one in this case) would be better applied to a situation where an F/O was driving his Captain to distraction with his self deduced gospel about how he thinks it should all be done.

The Gerona accident was just that, an accident. It wasn't one single causal factor but a number of them, as in just about all accidents. We, as pilots hope to learn from them. Anyone who tries to use the information to pontificate about how it should be done will probably find themselves being knocked off their pedestals. This accident could have happened to any one of us, including the pontificators. Line up enough holes in the Swiss Cheese and, as we have learnt from this one, the brown stuff can and will hit the fan. Third night flight in a row is not where you want to be when you can see through the cheese.

Throughout this thread I've been wondering what the Captain and the FO thought of the final report and of the 20/20 hindsight comments hereon. I would only hope that the positivve comments of ex-colleagues outweigh, for them and by a long shot, the censure expressed by those who don't know them and weren't there. Particularly with regard to the FO, apparently leaving of his own accord shortly after the report was published, no indication as to whether he's off to another flying job, entering a new career or just contemplating the future. Whatever his course, best wishes.

It is interesting that the subject of low hour f/0's is being mixed in with the Girona topic.

This leads to the impression that the Girona f/o was in some way lacking. The majority of posters cannot know that.

My original post herein lambasted low hour f/o's straight from training school. OK, so I've flown with f/o's with over 10000 hours who should'nt be allowed in a cockpit, but they are few and far between. The big problem (and I am in a position to speak from experience) is low hour f/o's with little experience, maturity, humility and all of the other ingredients which go to make up a colleague who helps rather than hinders.

For goodness sake, some of the guys I've seen can't land the aeroplane anything but roughly on a calm, CAVOK day. Throw in some wind, heaven forbid a crosswind, and watch out!

The system needs sorting out by the CAA (wishful thinking, then).

Sorry to go off topic (or is it?). :hmm:

CAP 56 you must have had a different CRM experience to the one I have had. I was taught that the bottom line of CRM was flight safety.........being nice is nice, but flight safety takes precedence.

Very sensible and balanced editorial in Flight International this week, it's well worth reading and I have copied it below, the last sentence is particulary pertintent.


Sometimes an accident warrants examining because it is extraordinary. The Girona report needs study because it is ordinary

If Professor James Reason was looking for the ideal real-life example to demonstrate his famous "Swiss cheeses" model of what enables accidents to happen in a basically safe system, the just-published report on the September 1999 Boeing 757 accident at Girona in Spain has it all.

Now the investigators reveal a web of interacting forces, circumstances and influences, even including what secular insurers still call an act of God. Gamblers would call it a wild card.

It is worth using an event like Girona to examine whether, just sometimes, things like this are bound to happen and we have to accept it, or whether something could - or should - have been done that might have blocked the chain of events. Although this 757, with 245 people on board, careered off the runway at high speed with almost all its controls disabled or malfunctioning, only one person died as a result. Even the low toll in human life could be considered a matter of luck.

This aircraft set off from the UK for Girona, knowing its destination and all its alternates were affected by a band of stormy, frontal weather - but it was the type that might delay a landing until a storm cell passed rather than prevent it. The captain loaded an additional 15min of fuel above standard company diversionary minima to allow for this. On calling Girona it was clear that a storm cell was close to the airfield, but it was dark and its precise location was not communicated. The wind - not strong - had shifted from southerly to northerly, so the captain decided on a runway 02 non-precision approach rather than a precision approach on to 20 with a tailwind. The trouble with 20 is that it has a strong downslope - just above the International Civil Aviation Organisation recommended maximum. And the runway - adequate but not generously long at 2,400m (7,900ft) - was going to be wet, so the captain opted for the risk of a non-precision approach rather than the alternative risk of a tailwind landing on runway 20. He also took over as the pilot flying at that point. But the VOR/DME approach did not go well, the tower/approach controller advised during it that the storm cell was now over the airfield, and the captain carried out a go-around. Meanwhile, the wind was shifting again to southerly, making an ILS to runway 20 plausible for the second attempt. Then the aircraft flight management system advised the crew they were approaching company fuel minima, so the captain was under pressure to make a decision whether to divert or not. It was dark, turbulent and the rain over the airfield was "torrential", but had they diverted to any of the alternates it might have been the same. As they established on the ILS for runway 20, the "must land" mindset would have been a tempting one to adopt. The approach was turbulent and not stable relative to the glideslope, but the runway lights were visible before decision height and, despite a sink-rate warning from the ground proximity warning system on short final, the captain clearly thought the landing could be safe.

Then fate played the wild card. The runway lights went out for 11s just as the captain needed them to judge the final descent and flare. The report says a contributory factor in the very hard, nose-down landing that followed was "the effect of shock or mental incapacitation on the pilot flying at the failure of the runway lights, which may have inhibited him from making a decision to go-around". Most pilots have experienced an unexpected loss of visual contact with runway lights at the last moment - usually due to a patch of fog caused by a local micro-climate effect - but by the time the pilot has registered the loss of contact the lights usually reappear again.

A pilot is "the system's goalkeeper", and this one got past the 757's crew. So where else did the defences fail? Girona, with its steeply sloping runway, is scarcely perfect, but that was a known part of the risk management calculation. With hindsight, 15min of extra fuel was not enough. A recommendation that go-around manoeuvres below decision height should be a mandatory part of recurrent training seems useful because it would help pilots override a "must land" mindset. Another recommendation - that more precise real-time weather information should be immediately available to controllers - would have helped the captain with decision making. There's plenty else - the report is a gift for nitpickers.

The Girona report should be required reading for airline and airport safety committees, because there is no "silver bullet" solution for this one. It was an ordinary situation that got out of hand, and all operators can face challenges like these at any time.

Very sobering indeed.

I would be very interested to read Appendix 3 to see how many hundreds of others would have ended up in the same position, albeit in the sim.

Goes to show just how few holes there are in the Swiss cheese to line up these days... courtesy of the beancounters.

'The only time you have too much fuel is when you are on fire' was one of the first rules of flight planning ...back in the days when flight crew had complete control of the safe operation of an a/c.

Huh?
 

...back in the days when flight crew had complete control of the safe operation of an aircraft."

Hmmm, the license these flight crew held certainly required the full authority for carrying more fuel, yet the Captain chose not to do so.

Quite frankly, having operated into Girona more than a few times (yes, at night, stormy weather etc), it would seem that the operating crew in question stuffed it up rather badly...a lesson for all, to actually pay attention to what the hell they are doing.

A bit more experience in the RHS wouldn't hurt either.

Huh? Again
 

It might seem like that to you. But the Flight Editorial provides a wiser perspective on the events. One needs to have a bit of imagination to see how one can quickly find oneself up to one's ears in unexpected troubles.

Perhaps persuading yourself that it could not happen to you just represents a failure of imagination, rather than an affirmation of the skills you demonstrated in successfully getting yourself in and out of Girona on several occasions?

You make a good point, atse, but then again the photo of the concerned aircraft off the side of the runway clearly showing the damage done, really says it all.

Yes, Girona has some of the same problems that many Spanish airports have...poor atc communication, rather nasty weather at times, high ground nearby, sub-standard lighting...but in the end it is the Commanders responsibility to factor all these in, and if the picture is not pretty, then immediate diversion becomes necessary.
If you don't have the fuel for same, due to poor planning in the beginning, or waiting too long to make that diversion decision, then the picture becomes very nasty indeed.

Many pilots (and especially, airlines) can learn valuable lessons from this very unfortunate accident.
Wonder if they will?

The point I was making 411A is that the photo of the aircraft is a photo of an outcome, the end of a process. It is singularly inappropriate to judge culpability by the outcome. It may appear reasonable to do so, but it just ain't so. (You quickly end up in a position where the worse the outcome, the more the culpability ...).

Even in your response where you say I make a "good point" you quickly revert to the attribution of crew error with implicit backwards reasoning along the lines of:

- Bad things happened,
- The captain's responsibility is not to have bad things happen,
- Therefore, pilot error

All I can say is Fatigue was a major factor in this accident!

1998 at Britannia was a turning point, a lesson in how not to run an airline.

441a : How many times have you diverted? And I don't mean on Microsoft flight sim!

Still trying (with ´Big Tudor) manfully to try and drag this away from the vulture mentality into looking at Danny´s fatigue points.

Good idea in my book, and one of the things I started discouraging some years ago was the dialling-up of the ground frequency (if any) on finals, which could pre-condition the ´land´ mental picture. Leaving the radar frequency in place is better.

Can we now leave THIS crew alone - please, or are we all going to conduct our own ´accident investigation´ here over and over again?:(

I heard that there were 3 aircraft in the hold that night who were diversions from BCN (The nominated diversion for the Britannia flight).
Does that change your opinion about them commiting?

I think we could go round in circles for ever on this one but a couple of comments:-

>a) A sufficient quantity of fuel is carried for the intended flight with a safe margin for contingencies.<

It is surely the aircraft commander who makes the decision to ensure a "safe margin".

>c) The uneconomic carriage of fuel is minimised.<

Emphasis on the word "uneconomic".

>If you were operating under this fuel policy how might it affect your daily decisions, year in year out, on how much extra fuel to carry? <

I hope that as an aicraft commander it would never influence my decision to carry any extra amount of fuel I deem necessary for safe flight. Further there must surely be other instructions in the fuel policy that the aicraft commander has the overriding authority as to how much fuel to depart with?

I cannot understand why various posters are being so defensive about this aspect. Surely it is a fact that more fuel should have been carried on this flight? Why dodge the issue? You only need to eliminate one of the holes in the cheese model to avoid an accident.

Accidents are caused by a chain of events that were able to happen because some defences failed. Mentioning a specific defence (ie. crew experience, CRM, fuel etc..) is not meant to single out a cause, it's just to poit to were defences failet to meet their objective.
By law it's so easy, the commander shall...... So it's all his/her responsibility nowhere however does JAR-OPS say that the company must make shure commanders take their responsibilities. Worse even in many occasions the company consider a pilot who is willing to take a risk (read breake a rule) a better pilot because it helps the company to acieve their goal which is making money.
Detailed discussions into the amound of fuel required is in my opinion bs. we should discuss how to deal with commercial pressure, and how to regain captains authotity because that is were the risk starts.

Troubles

I worked for an airline that had a set of, I think it was six, corporate objectives. The first was that "the company should operate to standards of safety that tolerate neither accident or incident". It is obvious commonsense that if there is only one corporate objective in an airline it would have to be about safety.

Once you have established such an objective all sorts of things flow from it if is going to be achieved. The Captain's authority over the preparation for the flight and the management of the flight are just two examples.

I am not going to pass any judgment about the Girona crash because all the issues would appear to be in the accident report. But I would like to see the corporate objectives for the business as a whole. I was told some years ago by a senior director in the Thomson organisation that thre role of Britannia was very clear. It was to be the mass trassport system for Thomson Holidays.

Some years later I was headhunted to run a shipping business. I did not get the job and I was given some feedback on why. It was apparently because I answered one of the questions at the interview in the wrong way. I was aked what I would do on my first morning there. I answered that in addition to meeting the key people who would be reporting to me I would need to study the accident handling procedures so that I would know what I was required to do if there was any incident or accident on my first day there. I was told in the feedback that I should have talked about profit instead.

I wonder just how many airlines would have a similar view.

BOAC

It would appear that your are striving in vain. It seems strange that the fatigue aspect of the incident is being overlooked by the majority of posters, especially since there have been numerous threads on this BB recently about his very subject, some quite voiciferous. We appear to be concentrating on how much fuel the commander chose to carry and how much more we would have uplifted in the circumstances. Did fatigue play a part in the commanders decision on fuel, one wonders? If the commander had uplifted more fuel would the outcome have been any different?
There are plenty of scary comments about flying when fatigued, but what about the implications of planning when fatigued? It is said that familiarity breeds contempt, what happens when familiarity is coupled with fatigue, especially when reading met briefings prior to a flight. What do you think when you read an all too familiar TAF for an airfield of TEMPO VRB20 TSRA OVC500? Do you take in what the TAF is telling you or is it pushed to one side with an confident look and a "Been there in worse" thought?

I don't think anyone has mentioned the one conclusion that was, I believe, the cause of this becoming an accident rather than just a landing incident.

This is the poor construction of the dog box, which caused thrust to be applied leading to the aircraft departing the clearway. The conclusion was that if the dog box construction was more robust the aircraft would have come to rest within the airport perimeter with little further damage to the aircraft. This is not the first time that this has happened to a B757 yet Boeing do not seem to have any thoughts on rectification of this problem.

The conclusion in 2.2.2.3 that the cockpit gradient didnt play a role in the crash is frankly suspect.By advocating the use of a monitored approach(a procedure designed to combat adverse cockpit gradient) in its recommendations,the report seems to be contradicting itself.
Disappointingly,the report didnt discuss what role the first officer had in the decision to take only 15 minutes extra fuel.Also no broader discussion on the general fuel policy adopted by the company.Did an in-house fuel league table exist whereby pilots compete for brownie points?What effect did the fuel status have on the captain's decision NOT to go-around when it was mandatory to do so.

Rananim No there isn’t a fuel league table in operation at BY. If the crew identifies a reason to load more fuel than CMR, then they are free to do so.

So hands up amongst the real pilots in this thread who hasn't on some occassion thought to themself,"Sh1yte,I wish I'd loaded more gas!!" ??

It will be a big day for passenger aviation in Europe when there is a hull loss + widespread death at any well known airline. If the subsequent report blames fatigue - even obliquely - there will be hell to pay. The whole health and safety mafia will feel mandated to get into aviation and fatigue is their easiest and most powerful entry point.

Doctors, lorry drivers, train and tube operators, Air Trafficers; all are required by law to work fewer hours with more rest than the pilots of airliners. The logic and the media impetus from mass funerals will be overwhelming.

Which leaves one frustrated that the authorities do not prempt and prevent the whole sorry scenario. Lets face it - the industry is overdue for another big one in Europe after many close calls.

Cheers

WWW

You cannot be serious!
 

I have been following the thread closely, from the outset, and measuring the replies without further comment since my own.

However, I do feel the need to ask readers what they feel about the one insert by WWW - and I add this:


WWW

You cannot be serious - surely!?

Are you telling readers, that YOU would take only 15 minutes extra fuel had you been the Commander of that flight?

I wonder how many readers with real airline Command experience would support your veiw of that RAMP fuel decision?


The "poor facilities" you mention - are you talking about NAV aids, or those engaged after the sad event.

I'm glad you engaged your imagination on this one; for I hope never to fly with you in the LHS if you opt and contend it reasonable to carry such fuel loads in those conditions.
Seems the lessons about WX and options have been lost on some F/O's.

TG

was the fuel uplift a contribution to the accident?????

The accident investigators seem to think it was a factor...

"REC 31/04 - It is recommended that the Operator should review its Flight Planning and Clearance Procedures in order to take into consideration probable meteorlogical conditions at the destination and alternate airports, including thunderstorms"

PHX

The SIDS, STARS, likely routings, winds aloft, estimated weight vs reality, all these things we know not. The Skipper may have thought himself likely to have quite a bit more than 15mins.

Pointless speculation really.

Cheers

WWW