Bad Airmanship
 

Report: Air Nostrum CRJ2 at Barcelona on Jan 24th 2007, belly landing

:=

I wonder if the EGPWS had spoken Spanish would it have changed the outcome. As a native English speaker I cannot think that I would not have looked at the gear at least once if it was saying too low gear 15 times.

Amazed that a gear warning alert was ignored 15 times by two pilots!

Bad Airmanship is an understatement!!!

and

The report seems to indicate that they had already assumed the landing might be without flaps.

Wonder what happened in the last few moments...

Couldn't think for all of the noise. Seem to remember that happening to a Mirage driver landing at Tullamarine many years ago.

Don't be surprised at how anyone can be overloaded in the right circumstances.

As wiser men once said:

Something to think about...
 

I don't know what went through the minds of the Flightcrew. Being a Boeing pilot, I'm going out on a limb here assuming the GPWS system has similar callouts. I think that mabye the crew, knowing that they would be getting a "TOO LOW FLAPS" warning, disregarded the "TOO LOW GEAR" warning as it's substitute. You know, in this situation your "expecting that damm warning to go off", and being human, heard what they wanted to hear.
How many of us are guilty of that.

But for the Grace of God go I......
Fly safe

Que?? Si ! What??? :ok:

There's an (in)famous clip on Youtube showing a couple of guys doing a forced landing practice in a C172 or 182 RG. The camera guy is in the rear seat.

During the whole exercise you can hear the gear warning horn sounding right down to the point where they flare and touch the ground. :eek:

I have very nearly done it myself in similar circumstances. Concentrating very hard on the task in hand and the gear horn becomes just another noise in the background. :uhoh:

I think the crew got distracted by the flap problem so forgot the normal landing checklist. I admit I once through distraction found my self finding out at 200 ft where I always do visual gear, flaps, speedbrakes that the speedbrakes were not armed and noticed none of the before landing check had been done. Thank God I am a speed reader because in the flare everything was done.

They weren't as lucky to have a last chance personal visual scan in their landing to notice the problem. Warning horns when you know something is non standard can be ignored quite easily because you expect it may happen. They probably both thought it was a flap warning and didn't heed the gear warning. We all know it will never happen again. Remember "those that have and those that will"? Gear up landings for the new guys.

Limited experience
 

Report: Air Nostrum CRJ2 at Barcelona on Jan 24th 2007, belly landing
http://img188.imageshack.us/img188/4...onbelly.th.jpg

A reply to a forum attached to the above report suggests the captain had only 202hrs as captain while FO had only 200.

Sobering image

Yes, the brain can be a dangerous thing when it starts filling in the blanks for us or associates an observation with the wrong thing.

Was unfortunate enough to witness a tragic example some years back at a railway crossing with boom gates.
Police car came up to boom gates obviously in a hurry to get somewhere.
Driver looked at the stationary train at the platform still loading passengers, figured he'd get across comfortably and drove around the end of the boom gates to get across.

Express from the other direction cleaned him up.

I'm not familiar with this type, but with the 737NG right now.

Is it the case that, following the realization that a flapless landing will be necessary, that the crew cannot disable the "TO LOW FLAP" GPWS aural warning?

This is 'normally' done during the non-normal checklist as a result of the malfunction, is it not?

I would bet that, had the "TO LOW FLAP" GPWS warning been inhibited, the gear warning "TO LOW GEAR" would have been the trigger to do something!

Simply because, having inhibited the flap warning within the checklist, they would not have expected any warnings, and that warning aural may have woken them up to the oversight!

....or get a flight engineer!

Cheers...FD...:\

IIRC, it was the Capt of an Aerolineas Argentinas 747 on approach to EMAD more than 20 years ago who got the "whoop, whoop, Pull Up!"

Calla Te, Gringo! was his response just before they crashed short of the runway. (Shut up, Gringo!)

GB

Edit: OK, IRII, I recalled it incorrectly. It was Avianca. Thanks for the corrections following.

GrayBeard,

I have a feeling you are maligning Aerolineas Argentina incorrectly.

Was it not a different South American carrier whose commander immortalised that infamous remark?

BSD

(just another gringo!)

Be aware
 

An old saying was that there are those who have landed with the wheels up and those who are going to land with the wheels up.

What helped me in my career was that the gear down action was always carried out prior to intercepting final and glide slope.

Tmb

The RAT
 

The picture shows the RAT has deployed. The landing deceleration was 1.16G. Not enough to shake the RAT loose. How come it's deployed?

Well, I guess the WOW switches were never activated ;)

(Not familiar with the CRJ, but on other types the RAT will deploy in case all AC buses fail with the aircraft being airborne)

Maybe a WOB switch would be helpful (weight on belly) :ugh:

Airmanship seems to have become a dirty word these days being replaced by SOPs.

I don't know the CRJ at all, but does the flapless landing QRH checklist include an item for 'gear down' expect EGPWS warnings somewhere?

202 hours as a captain and prepared to take off for a high probability flapless landing? What sort of command training did he/she have?
What worries me is the attitude!

Lots of theories as to why this would happen and what could have prevented it BUT ... we used to show a video during recurrent CFIT training of a 47 Classic (two pilots AND A FLIGHT ENGINEER) who misheard, and accepted, a clearance on a Non Precision approach to 400feet (instead of "cleared 2400 feet") and sat, fat, dumb and happy through EIGHT GPWS "Pull up" calls with no reaction and the last recorded remark before impact was ... "Oh ****". Combined crew flying hours totalled many thousands. :ugh:So ... any more helpful ideas as to how to prevent people doing what people have always done and will continue to do? :confused:
There is one which hasn't yet been mentioned and which will NEVER happen - institute an Aircraft Commander - an experienced type-qualified pilot on the jump seat who has no part in the physical flying of the aircraft but who is in overall command. NOTHING concentrates the mind in Flight Safety terms, as regards self-preservation, more than being responsible but NOT having control.:eek:

Yep ..I remember reading with horror about that Non prevision/non full procedure/modified by the crew to a straight in approach accident.
Correct me if I am wrong but was it not a long haul crew asked to do a ultra short empty positioning flight after a long haul day/night?
The all American crew on this flight and the all American crew of the AA B767
accident who also decided to modify a full procedure Non Precision approach into an attempted straight approach accident...
Plus the GF 320 Airbus accident which had 3 Arabic pilots in the cockpit also attempted to modify a full Non precision approach into a straight in accident all goes to prove the aircraft is no respect-or of nationalities and an unhurried full
procedures Non precision approach flown according to the approach plate can keep pilots out of a lot of trouble...and aircraft warnings and ATC high workload confusions largely avoided.
This gear up/ flap less incident picture reminds me of a Dan Air Comet that I saw at Newcastle similarly configured...I was told 22 qualified Comet pilots and the CAA pilots were on that "training flight". Fate is the hunter.

The shut up gringo incident/accident cos it was a very serious one I recall was Avianca not the other AA
PB

Calla Te, Gringo!
 

OK, IRII, I recalled it incorrectly. It was Avianca. Thanks for the corrections. My apologies to Aerolineas Argentinas.

GB

Seen that one many times as well Jack..................Flying Tigers Flt 66

On February 19, 1989, a Boeing 747-249F operating as Flying Tiger Flight 66 was flying an Non-directional beacon (NDB) approach to Runway 33 at Sultan Abdul Aziz Shah Airport, Kuala Lumpur, after having flown half an hour from an airport in Singapore. In descent, the flight was cleared to "Kayell" with a morse code of "KL" of which four separate points on the ground were commonly called by Malaysian ATC albeit with different frequencies. Two separate radio beacons where identically coded "KL" as well as the VOR abbreviation (Kuala Lumpur shortened to "KL") and the airport was also sometimes referred to as "KL" by local ATC (instead of the full "Kuala Lumpur"). The crew was unsure of which point they were cleared to. ATC then radioed to the flight, "Tiger 66, descend two four zero zero [2,400 ft]. Cleared for NDB approach runway three three." The captain of Tiger 66, who heard "descend to four zero zero" replied with, "Okay, four zero zero" (meaning 400 ft above sea level, which was 2,000 ft too low). Subsequent warnings triggered by the onboard Ground Proximity Warning System were cancelled as false alarms, and the aircraft hit a hillside 600 ft above sea level, killing all four people on board. The proper radio call from ATC, instead of "descend two four zero zero", should have been "descend and maintain two thousand four hundred feet". The First Officer had complained that he did not have an approach plate. The second officer was 70 years old and used a magnifying glass to see with. This accident created the GPWS escape maneuver which all airlines now use. The probable cause was the non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions.[1]

To the list of ad hoc modified NDB approaches that became CFITs can be added the Canadian Forces C-130 that flew into high terrain approaching Alert in 1991.

Tiger 66 Malasian ATC's fault - I don't buy it for a second.
 

Dave Clark Fife.

I take issue with this statement of yours: “The probable cause was the non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions”. I followed your link; and don’t believe what Wikipedia and the Aviation Safety Network have the final say on cause. It would be similar to saying the KLM-Pan Am Tenerife accident was caused by “antiquated tower/ATC equipment”. Well yes there is an element of truth in that statement, but to walk away believing ATC was the only cause is to miss much of what that accident can teach the aviation community.

Tiger 66 taught me to pay attention to the NOTAMS and the paperwork. The ILS was NOTAMED out of service. The captain and crew set up and briefed (poorly) an ILS that was not available to them and never was.

When Malasian ATC corrects them that the approach in use is an NDB approach not the ILS they have some non-complimentary comments regarding the ATC specialist’s family origins. Being an U.S. citizen I find myself as patriotic, flag waving and pro-American as most. However pinning Tiger 66’s demise on Malasian ATC offends my even greater commitment to the “truth”.

It’s not the Malasian ATC controller’s fault that English uses “To”, “Too”, and “Two”. The clearance was to descend to 2400; the captain and FO responded descend “to” 400. So yes there are some phraseology problems. Notice the FAA changed the read back/hear correctly rule about two years ago. Now if you misunderstand and read back the incorrect clearance, and ATC does not catch your error, the fault lies with the pilots (not ATC).

And then there is the little matter of descending down to 400’ to intercept. You and I know an ILS will take you down to about 200’. What non-precision NDB approach in SE Asia would you intercept at 400’? Further, whose responsibility is it to have situational awareness concerning airport elevation, and surrounding terrain when you are running around the clouds close to the ground in a Boeing 747? I would be looking at the people in the left and right front seat (and on the panel). 400’ AGL for an intercept to a non-precision NDB approach does not pass the “reasonability” test! Most/many MDA’s on NDB approaches are above 400’. If memory serves me correctly they crashed into a 600’ +/- hill a few miles short of the runway. Using a 3:1 ratio if you are at 600’ (about where they died) you should be somewhere around 1.8 NM from the airport – they were so far out of those parameters it should have made the hair on the back of their necks stand out. In fact it did.

Listen/read what the FO is saying during the time leading up to this accident. He is extremely uncomfortable with how the flight is progressing. He is hinting/questioning clearances and is out of his comfort zone. The Captain doesn’t seem to really care and seems to ignore his partner’s obvious discomfort.

And then there is the matter of the ground proximity alerter issuing warnings. Warnings ignored. “Wait we are at 200’ RA” (words to that affect) !!@$%##!!! – Bang and it is over. I think the wreckage burned for 2 or more days.

FlightSafety has a good analysis of this accident. I have spent many hours going over the material for my own education. This accident taught me to read and understand the NOTAMS, pay attention to my crew members and the importance of keeping situational awareness. Unfortunately none of those are anything new in aviation. In this case 4 people died in the jet. To infer that they died because an Malasian ATC specialist used non-standard phraseology is to miss the vastly more important lessons that cry to be learned from this accident. And I don’t care what Wikipedia says.

Too Low - Gear
 

An early poster suggested that if the "Too Low; Gear" warning had been in Spanish, the accident might have been averted.

Surely there is a simpler solution. "Too Low; Gear" and "Too low: Flap" both have the same number of syllables. In years past, the RAF determined an unmistakeable instruction from the bomb aimer. To turn to port, the command was "Left, Left" ie two syllables. To turn to starboard, the command was "Right," just one syllable.

Why not change the warnings to: "Too Low, Flap" and "Too Low, Landing Gear." The disparate number of syllables should then alert the ICAO Level 2 English speaker to the imminent danger!
Remember, ICAO Level 4 is only a requirement for international flights.

Red on Blue ???
 

Minor(?) nitpick, Northbeach ...
Kuala Lumpur is in Malaysia, north of Singapore, while Indonesia is South ...
Not that that negates the rest of your argument ...

I find it difficult to believe that nobody in the tower looks out of the window at landing aircraft to see that three greens are what the drivers should be seeing.

Northbeach.........................it wasn't 'my' statement just a simple cut and paste from a site on the web. If you have any issues or complaints then please direct them in that direction. With all due respect, not being the author means I have no control over the content


[/quote]And I don’t care what Wikipedia says.[/quote]

So why bother haranguing me then??

I just re-read the AvHerald article the OP linked to, and can't see where "too low FLAPS" was heard on the CVR.

It strikes me as poor engineering if the crew would be unable to dismiss a "nag" once the problem had been understood and dealt with.


and then

.

I wonder if this would have helped - seems all the gear warnings are indeed the same # of syllables.

Quick question: Level 4 is only required for int'l flights, but how much proficiency training/testing is done for "talking" cockpits?


Another quick question:

Is there a similar horn warning for flaps on this frame - mistaken identity of warning?

ICAO Level 1 Arithmetic
 

Rottenray
Can't you count? "Too Low Flap" is three syllables
"Too Low Landing Gear " is five!

The accident usually associated with the 'shut up gringo!' call is Avianca 11 operating CDG-MAD on November 27, 1983.

However, the published CVR transcript has no mention of the legendary last words:

http://www.fomento.es/NR/rdonlyres/D...66/Anexo_A.pdf

Another CFIT accident sometimes claimed to have the exclaimation was Avianca 410 CUC-CTG on March 17, 1988. It was a 727 doing a high speed climb into the haze in mountainous terrain, with the FO flying and the captain chatting over his shoulder with a jumpseat rider.

I first recall hearing about this callout a couple of decades ago at the Pan Am training center in MIA. PAA trained Avianca's 747 and 727 crews in those days I believe.

just a brief reading reminds me of how hard it is to be a good pilot/airman.

descend to/two/too 400? in the usa the proper phrase is: descend and maintain xxx

being of the air is much too hard to teach...piloting is one thing...but being of the air is something else. and too hard to describe here.

Neptunus Rex, I think you should recheck youre own math. There are a few more syllables in those phrases. Remember Rule 452 from the Rules of Flying;

Rule 452: If you're going to be pedantic always make sure you're right first! :ok:

Does the CRJ have an EGPWS flap override switch?
Or was there failure to use the abnormal checklist which could have prevented the flap calls with a switch operation, leaving the relevant gear call with some precedence?

Select EGPWS off … don’t even think about it ... ever. TAWS ‘Saves’.

is that proper FAA terminology, or ICAO? Just like "taxi into position and hold" is FAA but different in ICAO

Dave Clarke fife,

A perfect example of a confusing presentation. Your original post had all the hallmarks of being your own work leading to the response from Northbeach.

I have long thought that the use of the phrase, "....descend to....." and similar is confusing and have tried to avoid it in my own RT use preferring something like, "Leaving 5,000 on descent 2,500" and similar.

I remember hearing an audio tape of the Tiger 66 during my ATPL theory course and thinking the same as Northbeach along the lines of, "what crew could possibly think a non-precision approach starts at 400'". The only possibility I could think of was that they were at the end of a long flight and fatigue had set in.

As to the gear warnings, I don't think it would matter how many syllables it was. The problem comes when the attention is firmly fixed on the task in hand and the mind starts excluding other senses as a distraction. I suspect this crew were concentrating so hard on the problem of the flaps and the approach that the gear warning was excluded from their loop. Perhaps if a visual stimulus cannot be provided an alternate aural warning is required to break through the concentration set of the pilots, something along the lines of "Hey effwit, lower the effing gear" in a very loud voice.

In Australia the tower, both military and civil, is required to transmit "Check gear" to landing military aircraft. Perhaps it should be required where an aircraft is making a non-normal approach.

The CRJ has a Flap Override switch that will make the GPWS not generate the "Too Low Flaps" message exactly for that purpose. It is part of the checklist.

Nic