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Canada Rouge at Montego Bay
With respect to the crew, who I am sure didn't set off that morning to (almost) wreck an aircraft, this could be another reminder to the pilot community to stay sharp at the pointy end, hopefully endorsed by a supportive training department. Notwithstanding the balls up of an approach, it's the last couple of hundred feet which are really interesting. Touchdown at 108 KIAS, 15,3 deg AoA, 125 ft past the threshold, at 3,12 G with a last second attempt to save it with full thrust. We all know which accident it resembles, in this case they just had enough energy to make it to the runway.
Report: Canada Rouge A319 at Montego Bay on May 10th 2014, hard landing at +3.12G |
My guess: PF "forgot" that he already disconnected A/THR.
Fly NPA with managed speed and autothrust ON. Makes life easy. |
Most AB pilots will recognise what was going on there. Once the AB starts to "run amok " best disconnect everything & hand fly it.if you can't get it stable go around. But as discussed many times on these forums if you are not happy with your ability. Thrust to toga & go around level off & start again. Mind you some go arounds end up just as bad, but at least you should be a bit further away from the ground.
When I say run amok = self induced. |
I was a bit alarmed to read this
- Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach. Surely this is exactly the sort of thing simulator checks are for. I mean an unstable approach should always be followed by a go around should'nt it otherwise you end up where these guys did or worse. And if its a predictable occurrence then they should get the training on how to handle it. A view from down the back but it really struck me as an odd statement |
Toronto Montego Bay is not a short flight. One can surmise the beginning of this swiss cheese was not reviewing the NOTAMS en-route before staring the briefing. For me that is unprofessional. Missing it before flight is one thing; missing it during the flight is not good.
Reading AV's a/c it said they were 9.9 degrees attitude near the ground. I am not an AB pilot, but in B737, at that attitude, the touchdown/runway is out of sight. You can see a lot of sky and not much ground. That in itself is a clue that all is not good with your world at that moment, and continuing might not be the best option. IMHO all this talk about automation and this & that over complicates the more simple fact that if you can not see the target you are unlikely to hit it. They were very lucky not to plant it short of the tarmac. 125' is not much. Back to the 2nd slice of cheese; it does seemed to have been rushed. the PM was playing with the flaps like it was a manual gear shift, without PF realising. Not good. Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach. As a result, the occurrence flight crew did not recognize the multiple deviations in airspeed and thrust or the deficiencies in coordination and communication, and they continued the approach well beyond the stabilization gates. I find this unrealistic. Every airline I've flown with had stabilised criteria. They were written down and made perfect common sense. If the parameters didn't past the test you were considered unstable. KISS. To design a simulator scenario to demonstrate unstable parameters, so the crew can experience them, is IMHO extremely difficult. They experience the stable criteria every day. If it's different and outside limits then you are unstable. To have to train with professional crews seems unrealistic. It seems we are going to have to train crews how to do it correctly, and then let them see how it is if they screw up. Given the vast variety of possibilities we shall be flying the sim more than the real a/c. |
@ pac britanica
I was a bit alarmed to read this - Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach. Surely this is exactly the sort of thing simulator checks are for. I mean an unstable approach should always be followed by a go around should'nt it otherwise you end up where these guys did or worse. And if its a predictable occurrence then they should get the training on how to handle it. A view from down the back but it really struck me as an odd statement http://www.bst-tsb.gc.ca/eng/rapport...8/a14o0218.pdf Findings as to risk 1. If operators do not provide adequate simulator training for flight crews to recognize an unstable approach, then there is a risk that flight crews will continue an approach when it is unstable, which may lead to a landing incident. |
Rat 5
thnaks for the explanation -as I said I dont have a flight deck view and if it is ahrd to program a sim for these conditions I guess why they do not do it. So presumeably the SOP is if the following criteria including speed/R o D/ flap settings etc are not met then you are unstable and must go around-it just struck me as odd -perhaps its the phraseology- that after numerous recent accidents/incidents related to unstable approaches that it appeared was not something that was being coverd in training |
(Not) Recognizing unstable approach on THAT profile is a matter of medical, not remedial / insufficient SIM training.
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Sum Ting Wong, and Wi Tu Lo revisited
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RAT5,
I'm not sure how NOTAMs are presented at your company, but in the companies at which I've worked, it's EXTREMELY easy to miss a NOTAM. An out of service ILS will be buried in a mix of taxiway closures and defective windcones. It's about time some human factors analysis goes into the NOTAM presentation. In a world where we're getting paperwork on tablets, why can't we adjust the formatting of NOTAMs to something like this? -Runway Closures- RW 22R CLOSED from 22 Dec 2016 to 26 Dec 2016 -Inoperative Navaids- ILS RW07 I-SIA ots from 22 Dec 2016 to 26 Dec 2016 -Taxiway closures- taiway B closed btwn B6 and B7 from 22 Dec 2016 to 26 Dec 2016 -Other stuff- RW 8R windcone unlit taxiway D non-std markings btwn D2 and D5 !DTW 01/440 (KDTW A0750/17) DTW RWY 27L PAPI OUT OF SERVICE 1701110628-1701131800EST !DTW 01/439 (KDTW A0747/17) DTW RWY 27L FICON 10 PRCT WET OBSERVED AT 1701110551. 1701110551-1701120551 !DTW 01/438 (KDTW A0746/17) DTW RWY 21L FICON 10 PRCT WET OBSERVED AT 1701110551. 1701110551-1701120551 !DTW 01/437 (KDTW A0745/17) DTW RWY 22L FICON 10 PRCT WET OBSERVED AT 1701110550. 1701110550-1701120550 !DTW 01/436 (KDTW A0741/17) DTW RWY 04L/22R CLSD 1701110513-1701111030 !DTW 01/435 (KDTW A0740/17) DTW RWY 03L/21R CLSD 1701110513-1701111030 !DTW 01/433 (KDTW A0736/17) DTW TWY ALL FICON WET OBSERVED AT 1701110138. 1701110138-1701120138 !DTW 01/432 (KDTW A0737/17) DTW TWY W HOLD PAD AT RWY 03R CLSD 1701110137-1701120133 !DTW 01/430 (KDTW A0733/17) DTW RWY 21R FICON 5/5/5 100 PRCT WET OBSERVED AT 1701110128. 1701110128-1701120128 !DTW 01/429 (KDTW A0732/17) DTW RWY 22R FICON 5/5/5 100 PRCT WET OBSERVED AT 1701110128. 1701110128-1701120128 Software filters would also help. If 22R is closed, I don't want to be reading notams pertaining to approaches or departures for that runway. Surely such things aren't considered scifi in 2017? |
The official report said that even though the PM called "Autothrust", the PF didn't reply, and the landing checklist wasn't done. It's pretty reasonable to assume that the PF thought the AT was on. At 1427:42, the PF stated that the aircraft was too high and that he was correcting, then stated that the autothrust was off. The PM did not hear the statement that the autothrust was off. At 1427:52, the PM initiated the callouts associated with the landing flap selection portion of the final approach and landing check. The PM called out “autothrust,” which is the first callout item. The PF did not immediately respond, but shortly afterward he initiated a dialogue regarding the FAF and the missed-approach altitude, interrupting the checklist. |
It's about time some human factors analysis goes into the NOTAM presentation.
Spot on. Absolutely, and better filtering. there is far too much spurious stuff that masks the important bits. It's interesting that so much HF research is done on the actual operation of the a/c and all its systems. Here is an item (NOTAMS) that might seem trivial yet often proves to be the start of events. Is this not a very suitable issue for the national union technical committee to make up with the relevant authority? Knowing what approaches are available is a critical as knowing the weather because they go in combination. This has become more important in recent times. When I worked with flight dispatchers who gave preflight briefings this type of item was highlighted. Later, a dispatcher may not brief but would still 'marker highlight' important items in the NOTAMS. Now, in more & more cost cutting, everything is crew self brief in a reduced pre-flight planning report time. You have to print your own nav plans, check the a/c HIL's, print & check the weather, check...check....and still make the slot, but don't rush. Oh Please! |
RAT5, I have to agree with you. I stopped flying way back in '04, and even then there was too much information covering the really important bits. I can only imagine that it's got worse. Add to that the time constraints where there is only about five minutes to check everything before having to head off to security etc.
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It really is needle in a haystack stuff with twenty odd pages of trivia like crane positions for example which personally are for me not terribly high priority. Then you have coded validity times, e.g. the ILS is out of service from 30 Aug to 10 Dec but coded in numbers, while there are pages of the Greeks or the Turks saying they do not recognise things each other are doing. Surely some form of prioritisation listing ops critical data together with opening hours of alternates could be contemplated? It does not however excuse this truly alarming performance by two experienced pilots.
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You should see the Indian airports, with four or five pages of arse covering irrelevance. They should be told to sort it out or be isolated, nothing in, nothing out.
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I would imagine that a lot of the problem is in the arse covering - anyone who replaces the current NOTAM presentation with a new format will be immediately put up against the wall if the algorithm used misses something that is, after an incident, deemed important.
And even if the algorithm is perfect, if someone presenting the data to it (I don't know how these are generated) is imperfect then you will get imperfect results. Garbage in, Garbage out. So from a purely technical point of view, I can see huge benefit in having something that parses or sorts the messages , but from a liability point of view I can see why no-one would want to do it... -edit- I am an IT guy, this kind of stuff interests me, dealing with interactions between humans and machines . Where do the NOTAMS come from - are they public info that anyone can grab , any time? Is there a better thread for this discussion |
There appears to be a drift away from the subject in hand here.
Let's put it bluntly, that this crew messed up big time and were lucky to walk away from it unscathed; forget there not being an ILS and all the NOTAMS. What were they doing allowing themselves to get into such a dangerous and unstable position. The Capt seems pretty experienced on type, and the FO was not so much so on type, but had a significant number of hours. When one of them saw that they were digging a hole for themselves, they should have gone-around and not persevered putting the lives of those who trust in them at risk. This crew should be ashamed of themselves. |
And so back to a regular question -
Why are airline pilots so reluctant to go around ? Lack of practice ? Fear of being asked why ? Commercial pressures ? Coming from an african bush background every approach was a potential go around, mainly due to errant wildlife and it happened on a regular basis, a few times a month so we were always ready. |
Most modern aircraft CAN be a handful on a go-around. Can't find it at mom but in the early days of the A320 at LTN one went around & if I remember got to 13000 ft before the crew got it under control. (G/A alt = 3000ft). I had one almost get to the stall (into VLS) on an automatic go-around. (I disconnected & flew it before anything serious happened). This is not a AB Boeing thing as Boeing have had their fair share.
So I believe a lot of pilots subconsciously resist go arounds. The crew in question had already "lost it" so going around probably didn't enter their conscious thought. |
The PF probably intended to land with A/T off but was habitually conditioned to having A/T on (AC Rouge SOP strongly recommends A/T on from takeoff to landing). The PM probably thought A/T was on and did not monitor the speed. |
NOTAMs, Go-arounds etc. aside..
There was a point, although a tad late, when this aircraft was 'in the slot' for landing. From that point this incident resembles the Asiana very much. Thrust idle, speed drops, pitch increases... until impact. Even in an Airbus proper pitch+power isn't too much to ask for, is it? Someone pointed out, they probably 'forgot' that A/THR wasn't there to save them. Probably true, but did they get so confused when the A/THR failed to respond that they didn't do it themselves? Is it not time for regulators to mandate that crew is comfortable with all modes of operation? In the process, ban the "Maximum use of automation" quote from all Operations Manuals. That could be a starter for a cultural change that takes time to change. |
It will drift off the thread, but the question was asked. Gehenna asked, and has the correct attitude. I used to beat into my students that every takeoff was an RTO until V, and every approach was a GA until TR's were selected. GA training in the sim is very little of training and more tick in the box stuff. An ATC wave off at 50' is a non event. An automatic GA at 30' LVO is a non event. A W/S ahead GA is a non event. When it goes wrong is when it is rushed and complicated. One airline in my portfolio had such a rushed 2 engine GA SOP, with lots of mouth music and actions close to the ground, that it was so easy to make a real mess; and often it was. Take it slowly & relaxed, but expedite. Treat it like a takeoff, that manoeuvre we do every day. (Why oh why did B737 reinvent the acceleration to be via the flap lever and not the MCP window????? And why retract the flaps at 400'???????) Don't panic with fire walled thrust levers and lots of screaming.
If a GA is the default of any approach it should never be a surprise. It should be a simple manoeuvre. So why is it messed up so often? 1. It is often rushed and SOP complicated. 2. It is not the same sequence as a normal takeoff. 3. It is seldom trained in recurrency. I still remember the most important learning experience of my commercial apprenticeship. An IMC GA at Le Bourget as a young biz-jet RHS'er. & a CAVOK GA as F/O in B732 due to wind shifts on short finals and a subsequent long landing on a short runway. Both were a huge learning experience and both were a non event due to the character in LHS. Other opinions and solutions invited. |
I, for one agree with the last part of 172 driver's post.
There are far too many accidents and incidents where some degree of automation between "maximum" and "none" is involved. This is the area where there are dragons. Most of us can monitor an autoland, and most of us can fly it around just like a real one. |
If the crew think "we've got this", then they see no reason to perform a go around. I think the problem is that it can very difficult to take a mental step back, and objectively assess your own performance. Ideally, the PM performs this role, but the PM can be as much "in the loop" as the PF. This psychology affects all teams of people, in any discipline. People assigned to monitor can become too closely involved in the execution of the task.
Trained procedures and SOPs help the crew to assess their performance, but when you go outside that envelope you can also lose the awareness and ability to recognise that you are dangerously outside the envelope. |
Ideally, the PM performs this role, but the PM can be as much "in the loop" as the PF. This psychology affects all teams of people, in any discipline. People assigned to monitor can become too closely involved in the execution of the task.
Trained procedures and SOPs help the crew to assess their performance, but when you go outside that envelope you can also lose the awareness and ability to recognise that you are dangerously outside the envelope. You may be correct, but 2 comments on your points. 1. PM, if a recent cadet F/O, creates a steep cockpit gradient. Having said that, in today's new world the LHS might well be a cadet captain as well. That brings in its own problems in a critical situation. Pilots, especially new F/O's, have it drummed into them to 'advocate their position' and not be afraid to question and speak up. Easy to say. However, wth a low experience base it can cause hesitation to speak up because their 'envelope of experience' or 'comfort zone' is so small. It is easy to become outside it, but are you sure there is danger. 2. That brings us to the point about 'dangerously outside the envelope'. I've been through TR courses on many Boeing a/c in many companies. What has been noticeable, sadly, is that since the rapid growth of the new airlines, IMHE, the envelope experienced under training is very small; well within the the boundaries of the a/c design. They have been taught, even restricted by SOP's and philosophy, to operate within such a very tight box that is astonishingly easy to stray outside, either by lack of attention, outside elements including ATC or Mother Nature, or non normals or a combination of some of those. The scenario is perfectly manageable by a well trained crew, but to the many who have been drilled in the world of automation first and factory fed rigid system they become a fish out of water in search of a paddle. Years ago we were taught, extensively, how to fly the a/c, then how to operate it according to SOP's and then how to manage it under normal & non-normal conditions. We were encouraged and expected to maintain those skills every day. Our abilities, based on knowledge & gained experience, was huge compared to many of today's crowd. Sad but true, but not universal. I speak to friends in different national carriers who fly B747 B777 A320 A330. They can pole it around onto visual approaches & short finals as they see fit and circumstances allow. The maintain their learnt & developed competence every day: and there are some destinations where those skills are vital. I have trained pilots, for some operators, on base training where the standard circuit used as part of their licence & type rating is not allowed on the line; and even extended visual circuits manually flown are discouraged. Go figure. There is such a diversity of standards and philosophy amongst operators that finding a common solution to these reoccurring problems will be nigh impossible. During all this discussion I know of some operator's TR syllabi where the amount of manual flying in the sim as been reduced. Go figure, again! |
Rat5 kindly explained why the scenario described isnt easily replicated in sims in answer to my comment about being surpised at the Transport Canada comment about Rouge crews not receiving training for these situations. But I ams urprised at the numebr of coments ehre that suegst go arounds are not that common on sim checks and given the equal number fo comments about them being potentially tricky (and recent accidents in Go Around/Missed Approach situations Is till find it odd that it doesnt get that much sim time when it appears much more common that engine outs at V!. Clearly the later is very demanding and requires immediate and correct response but it seems to go back to the prop era when it wasn't the rarity it is now but a common occurrence and with aircraft with very limited performance compared to todays mature jets
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Pressing the Approach
1 Attachment(s)
The attached file shows how easy it is to Press the Approach.
This was a NASA study which give solutions. |
My word Britanica that was a challenging read, though I suspect either typing on a small screen or a few glasses of wine are to blame :}
Very interesting reading overall. My airline encourages manual flying withing the bounds of "appropriate" conditions and has a seemingly benign but effective reporting system, where crews aren't generally called into question for a go-around decision due instability/other. That being said the "culture" of the airline is towards keeping it well within the bounds of automatics+vectors+ILS. Flying manually with A/THR off isn't so common, nor are visual approaches (partly due to ever restrictive noise control). I don't think I've ever seen a raw data non-precision approach on the line. Flying a manual/visual approach and messing it up (that is, go-around, nothing heroic) would be intensely embarrassing I would expect, almost a sort of bravado gone wrong, thought in other flying environments it would be considered more as a fact of life when flying a plane. Hard to pin down why, but I'd say we're in ever more dangerous territory with regards to decaying flying skills and automatics mis-management, and unfortunately in this automation no-man's land we're risking slowly re-enforcing the idea that we might be better replaced with computers entirely. |
Flying a manual/visual approach and messing it up (that is, go-around, nothing heroic) would be intensely embarrassing I would expect, almost a sort of bravado gone wrong, thought in other flying environments it would be considered more as a fact of life when flying a plane. On a (somewhat) lighter note, maybe it's time we reverse years of tradition, and let the FO fly in more challenging situations, as the CA has been the PF for the past few incidents on approach. After all, it's probably easier for the CA to see the big picture when he's PM. |
Being unstable and landing is completely unacceptable . At most operators these days you are fired for doing it.
Late configuration , getting behind , pulling ALT, ... What was the PM doing ?! Simple go around would have avoided all of this! Raw data NPA with auto thrust off very rare ! What's the point ? Why are we only hearing about this now ? Are the TSB and AC hand in hand ? |
Why are we only hearing about this now ? Are the TSB and AC hand in hand ? Aviation Investigation Report A14F0065 - Transportation Safety Board of Canada |
Raw data NPA with auto thrust off very rare ! What's the point ? |
You didn't hear about it because you didn't look for it. |
Originally Posted by pfvspnf
(Post 9638074)
Raw data NPA with auto thrust off very rare ! What's the point ?
That wasn't the case here, but it's hardly a crime. |
Ive done it too in VMC, but it includes a thorough briefing including the approach strategy, missed approach procedure and threat and error management.
The fact that they didnt respect the stabilization criteria and a TSB report that took so long to come out indicates something very wrong with the system. is the final report out on the halifax incident? |
In B732 days the visual approach into the Greek & Canary islands was the norm. It was a non event. Mk.1 eyeball and naff all inside the cockpit to help. Sometimes the visual ended up intercepting an ILS, or VOR, or NDB. Sometimes there was a DME as well. Sometimes not, but a CDA idle thrust approach was also the norm for such an arrival. Or even a cloud break procedure to visual low level manoeuvring.
28 years ago I joined an outfit that had upgraded from a basic needles & dials Boeing to an EFIS Boeing. We were arriving downwind to TFS, which had an ILS and was severe clear. The basic idea was to steam in right-hand downwind and with finesse and dexterity arrive via short finals over the sea to meet the runway at the correct spot at the correct speed. The new to type F/O started constructing an LNAV circuit. After a WTF are you doing moment there followed a discussion about how he was going to fly this visual circuit. His idea of VNAV/LNAV FD did not match mine, but hey, if the kid wants to do that then it was too late to argue and disturb his equilibrium and dent confidence. I just felt saddened. The older of us switched it all off and rolled it in for a 3-4nm final spooling up around 1000'. 28 years later there are some operators that have an SOP of constructing an OM or 4nm point on finals and entering SPD/ALT data to give LNAV/VNAV guidance, and you can't intercept closer than 5nm. Full approach profiles, if no vectors, with full automatics, are the norm. Hence the decline & dilution of basic piloting skills. If they are not trusted to fly the most basic of profiles, and thus lose handling skills, what would you expect when a GA is required and it is SOP to be flown completely as a manual manoeuvre? So if the GA is screwed up where is the root cause? It is lack of manual flying skills due to company culture; followed up by lack of recurrency training of GA's. One reason for not favouring manual visual approaches is the increase in GA's due to unstable & messed up approaches. So rather than train and maintain the skill of a manual approach the manoeuvre is removed which leads to another manoeuvre for which the skill has also been forgotten. Chicken & egg. |
Some airline cultures involve a "please explain" for a missed approach and some pilots think that a missed approach is an admission of failure to perform.
Respectable airlines do not request an explanation. Of course, many questions follow a busted aircraft. |
@IcePack
There's actually some thought going on on the certification/design side of the world to address the issue of GA with the high thrust levels (and other issues) on modern aircraft. Restricting the T/W achieved on a GA is one concept (like the Boeing two-press TOGA idea) |
Love the bureaucrats. If they'd only briefed the go-around or missed approach procedures, or called stable, this all might have been prevented.
How about getting guys to do basic automation off flying? All of the nonsense generated by mode confusion would have never occurred with a simple switch to basic, low automation mode, flying. And it's obvious, just like in the Korean Air 777 crash in KSFO, that neither pilot ever checked the N1's below 500'. Never. Or else they would have called out the inappropriate power setting. It gets tiring reading these reports, over and over again. "Did you ever check your power setting?" "Did you ever set up a basic, non automation mode, and fly the airplane like it's been done for the majority of the time since the Wright brothers first flew?" The answers to both questions are no. Until the industry gets their head around this issue we'll have to keep hoping it just doesn't happen more often. |
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