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-   -   PIA A320 Crash Karachi (https://www.pprune.org/rumours-news/632693-pia-a320-crash-karachi.html)

Rossair 24th May 2020 08:29

Unless I have missed it, there is an important Safety Management issue here that has not been mentioned :

WHAT ABOUT O F D M. ?

Is there a culture of consistent monitoring of OFDM in PIA ?

I am sure that if crews were aware that all unstable approaches would be subject to a subsequent review, this type of flying would be extremely rare.

A simple short training video to be shown to pilots explaining why unstable approaches are dangerous and that the Safety Department will find out about every one. You cannot hide them.

Such a video would cost very little to make.

In my book, the senior flight operations management are just as culpable as the crew. They should have made OFDM effective.

Monitoring frontline operations is a key part of Safety Management Systems. in many different industries. Most organisations doing this have avoided fatal accidents for many years.

Incidentally, these organisations have also found that their monitoring systems have made them more efficient as well as safer.




Ollie Onion 24th May 2020 08:31

No, both the Air France and Jetstar aircraft previously commenced the GA procedure above DA. Pilot selected TOGA and didn’t check FMA’s. Positive Climb and Gear up called do to the initial pitch up with application of thrust. Since GA mode wasn’t engaged in both instances the aircraft then pitched down and accelerated towards the ground with GEAR UP as the aircraft tried to get back onto the G/S, the pilots realised something was wrong and manually took over selecting TOGA and pulling up, they both came within 38’ RA of a wheels up landing, in this case if the pilots were slow in deselecting TOGA they would have pitched up manually the speed would of bleed off and they would have floated down the runway and possibly touched down like the EMIRATES did, at some point TOGA was selected and the aircraft did commence a climb but only after scraping the pods. To believe ANY crew. could fly an approach with no gear and be so unaware of the warnings they continued it all the way to the ground is just too much of a stretch.

etrang 24th May 2020 08:37


Originally Posted by Ollie Onion (Post 10791644)
Because ATC just watched them do a belly landing and may have assumed a problem.

And why would the pilot confirm?

voiceinurheadset 24th May 2020 08:37


Originally Posted by Ollie Onion (Post 10791644)
Because ATC just watched them do a belly landing and may have assumed a problem.

approach controllers do not necessarily have a RW view . They can be located in the same building as Tower or can be miles away . I dont know how it works in Karachi.
A Tower controller has RW view from beginning till end and saw whatever happened on the RW . After going around Crew switches to an APP controller freq who may be sitting in a different building and have not yet been informed of what has just happened on the RW. All depends how quickly info was passed .
I would really like to know what was happening 5-10 min before * being established at 3500’ 5 miles gear up ‘ to paint a better pic .

silverstrata 24th May 2020 08:40


Originally Posted by Dropp the Pilot (Post 10791519)
"Training for positive rate/climb is based on a positive V/S trend and increasing RA."

Two wrong
statements in less than twenty words. Neither of these things are "positive rate".

The ONLY measure for positive rate is a sustained and progressive increase in the altitude displayed on the altimeter.
.

Well said.
And yet there are STILL airlines out there, that call positive rate instead of positive climb.

In addition to your reasoning, inertial vertical speed indicators will show a false positive rate of climb, on rotation.

Silver


andrasz 24th May 2020 08:43


Originally Posted by Ollie Onion (Post 10791686)
...at some point TOGA was selected and the aircraft did commence a climb but only after scraping the pods. To believe ANY crew. could fly an approach with no gear and be so unaware of the warnings they continued it all the way to the ground is just too much of a stretch.

From the posted video (that was apparently released by Pakistani CAA) it is clear that there were two brief ground contacts with the engines, roughly 8 seconds apart. If the G/A would have been initiated before the first touch-down, there would have been only one. The evidence strongly suggests that TOGA was only selected after the first ground scrape with the engines. To repeat the famous quote, once the impossible had been eliminated, what remains, no matter how improbable, must be the truth...

Dan_Brown 24th May 2020 08:44


Originally Posted by Rossair (Post 10791681)
Unless I have missed it, there is an important Safety Management issue here that has not been mentioned :

WHAT ABOUT O F D M. ?

Is there a culture of consistent monitoring of OFDM in PIA ?

I am sure that if crews were aware that all unstable approaches would be subject to a subsequent review, this type of flying would be extremely rare.

A simple short training video to be shown to pilots explaining why unstable approaches are dangerous and that the Safety Department will find out about every one. You cannot hide them.

Such a video would cost very little to make.

In my book, the senior flight operations management are just as culpable as the crew. They should have made OFDM effective.

Monitoring frontline operations is a key part of Safety Management Systems. in many different industries. Most organisations doing this have avoided fatal accidents for many years.

Incidentally, these organisations have also found that their monitoring systems have made them more efficient as well as safer.

What are ICAO Doing about certain issues that may or may not relevant to this accident. When i operated in an A**** country years ago, we had to be cleared by the company Dr. to fly. For example, If someone hadn't been taking on water for a long period during the stifling heat of the day, they would often have a breath the could peel paint. This was ignored in most cases.

ICAO people are put in these countries to monitor these situations. What are they doing apart from enjoying their big fat UN salaries?

Not rocking the boat, thats for sure.

EDLB 24th May 2020 08:45

Hope we get soon a good accident report. This does boil down to a CRM failure we should learn from. The picture from the cockpit window under Cavoc conditions must have been so wrong on the approach, that there has to be an interesting story, why they continued the approach. A few minutes more on a circle or go abound would have saved all lives. So what is it, that has prevented this course of action? My suspicion is, that human, cultural, and airline management factors play the main role here.

Homebrew1 24th May 2020 08:45


Originally Posted by Ollie Onion (Post 10791609)
I think the chance of continuing below 750’ RA with the TO LOW GEAR warning sounding down to a height low enough to impact the engines is almost to hard to believe. It is more likely with those rates of descents and speeds that the gear was out early to even make it onto GS.

I'm on the bus and should probably know this but would the Master Warning sounding due to flap overspeed from the unstable approach, over ride the "Too low gear" from the EPGWS? In other words, could there have been no "too low gear" warning sounded as the Ding ding ding Master warning got aural priority?

voiceinurheadset 24th May 2020 08:49


Originally Posted by arvindasija (Post 10791607)
He suggested a heading even when the pilot was established on final, during the first approach.
......
The trainee, with whatever limited wits ( and vocabulary) repeated the availability of both runways. The availability of the runways had probably been conveyed to him by the tower controller and the trainee radar controller has repeated the same twice.

1. At 3500’ ~ 5 miles gear up one can hardly be properly established. Thats why he offered heading to lose that altitude which should have been around 2000’. Even with pilots report of “established“ I'd be somewhat alert tbh
2. it doesn't take a trainee to repeat smth after a Sup or a Tower controller. Easily happens to many controllers under stress . Yes , even to most skilful ones. Saw it many times in different radar rooms around the world. People’s reactions to a stress can be unexpected at time. I once saw a person 30+ years of experience putting the headset down in emergency and getting up from working position.

macdo 24th May 2020 09:06


Originally Posted by Homebrew1 (Post 10791701)
I'm on the bus and should probably know this but would the Master Warning sounding due to flap overspeed from the unstable approach, over ride the "Too low gear" from the EPGWS? In other words, could there have been no "too low gear" warning sounded as the Ding ding ding Master warning got aural priority?

Entirely plausible that the crew were overloaded by the multiple warnings aural and visual in addition to the mounting stress of the cocked up approach. And being received by people who are not native English speakers. Amazing what humans can filter out in extreme circumstances. Aural inputs being one of the first to go.

Superpilot 24th May 2020 09:21


Two wrong statements in less than twenty words. Neither of these things are "positive rate".

The ONLY measure for positive rate is a sustained and progressive increase in the altitude displayed on the altimeter.

No where did I say they were "positive rate". I said most training I've seen in the simulator teaches the PM to look for those two parameters before calling the words. I completely agree, they're not the ONLY criteria.

mr ripley 24th May 2020 09:41

Re Belly landing quote from ATC?
How about, because the pilot has just announced both engines have failed, thus ATC thinks they are going to do a crash landing.

metro301 24th May 2020 10:08


Originally Posted by Homebrew1 (Post 10791701)
I'm on the bus and should probably know this but would the Master Warning sounding due to flap overspeed from the unstable approach, over ride the "Too low gear" from the EPGWS? In other words, could there have been no "too low gear" warning sounded as the Ding ding ding Master warning got aural priority?

Too low gear will have priority. Will an over loaded non native english speaker hear it?

AmarokGTI 24th May 2020 10:13


Originally Posted by krismiler (Post 10791031)
Pilots are conditioned that once a go-around has commenced, that’s it forget about landing so the option of putting it back down may have been unconsciously rejected by the crew.

check out VH-ODI report from this week

krismiler 24th May 2020 10:39

Even one warning during an approach is bad enough and suggests that a go-around would be a good idea.

Multiple warnings would surely remove any doubt about continuing to land and are best prioritised and delalt with once a safe flight path has been established and the missed approach procedure complied with.

Fear of loss of face from going around may well have played a part, culturally it may only be acceptable for the senior pilot to decide whether to continue, and unsolicited advice from a junior would be regarded unfavourably. When CRM is really bad it might even cause the senior pilot to feel he has to prove a point and establish his authority.

With engine bypass ratios becoming higher and ground clearance being reduced, has adequate consideration gone into the location of vital components such as pumps, gearbox’s and supply lines ? Whilst space is obviously constrained, having vital systems in a vulnerable position should be avoided.

Greek God 24th May 2020 10:51

With regard to this particular event and many more I have long wondered why Towers (especially at major airports) do not seem to have continuous CCTV coverage of every approach and threshold.

Also, in the absence of any notified emergency, should it not be SOP that the ATCO called a GA for a commercial airliner on short final with no gear?

Right Way Up 24th May 2020 11:02

An approach with the gear possibly left up from 3500 ft at 5nm. Would be very interesting to see their speed over the threshold.

DaveReidUK 24th May 2020 11:18


Originally Posted by krismiler (Post 10791804)
With engine bypass ratios becoming higher and ground clearance being reduced, has adequate consideration gone into the location of vital components such as pumps, gearbox’s and supply lines ? Whilst space is obviously constrained, having vital systems in a vulnerable position should be avoided.

The ability to go flying again immediately after you have scraped all your engines along the runway with no gear down probably isn't very high up the designer's list of "what if" scenarios.

RVF750 24th May 2020 11:45


Originally Posted by Greek God (Post 10791815)
With regard to this particular event and many more I have long wondered why Towers (especially at major airports) do not seem to have continuous CCTV coverage of every approach and threshold.

They probably do but being official would be for the investigation and not released into the public domain. (unless someone leaks them). Or the system was broken.


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