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Missed approach instructions
There are criteria in ICAO 4444 which define when an aircraft should be instructed to go around, vs when it should be advised to go around. If the ATCO considers the aircraft is dangerously positioned, then it's an instruction; if he/she considers it to be in a position where a safe approach cannot be completed, then it's advice. Both of those hinge on understanding what the ATCOs involved were able to see, what they could deduce from that information, & of particular note, how much that differed from how they were used to seeing the aircraft fly it's approach. Without understanding how PIA normally fly, & how different this approach was, it's difficult to draw any conclusion as to whether the ATC reaction was appropriate or not.
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Sorry I did not listen to any of the tapes, have they been issued a landing clearance?
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Originally Posted by alfaman
(Post 10809498)
There are criteria in ICAO 4444 which define when an aircraft should be instructed to go around, vs when it should be advised to go around. If the ATCO considers the aircraft is dangerously positioned, then it's an instruction; if he/she considers it to be in a position where a safe approach cannot be completed, then it's advice. Both of those hinge on understanding what the ATCOs involved were able to see, what they could deduce from that information, & of particular note, how much that differed from how they were used to seeing the aircraft fly it's approach. Without understanding how PIA normally fly, & how different this approach was, it's difficult to draw any conclusion as to whether the ATC reaction was appropriate or not.
What was given by ATC in this case, were requests to change heading, which was refused by the PIC. This is the subject of the Pakistan CAA notice to PIA, headed "VIOLATION NON-COMPLIANCE OF ATC INSTRUCTIONS BY PIC PIA8303". Clearly at least one person at the CAA felt instructions were given to the PIC which were not followed, when they should have been, regardless of justification or outcome. Are the Pakistan CAA wrong? I was hoping someone could comment on that discrepancy rather than the hypothetical case. |
Originally Posted by FlightDetent
(Post 10809510)
Sorry I did not listen to any of the tapes, have they been issued a landing clearance?
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Originally Posted by donotdespisethesnake
(Post 10809528)
Not sure why people are highlighting a go-around request by ATC: none was given in this case so it is hypothetical.
What was given by ATC in this case, were requests to change heading, which was refused by the PIC. This is the subject of the Pakistan CAA notice to PIA, headed "VIOLATION NON-COMPLIANCE OF ATC INSTRUCTIONS BY PIC PIA8303". Clearly at least one person at the CAA felt instructions were given to the PIC which were not followed, when they should have been, regardless of justification or outcome. Are the Pakistan CAA wrong? I was hoping someone could comment on that discrepancy rather than the hypothetical case. 1 could see the aircraft on short final (there have been several opinions expressed as to the sight lines and distance from the tower to the threshold area of that runway). 2 was watching (in other words, actually saw v/s was in a position to see the aircraft). 3 was required by national and / or local procedures and directives to observe aircraft on final for issues such as gear being up. Second, re whether the heading of 180 degrees issued by ATC was a request (or a clearance) or an instruction. According to the audio available online, it was clearly an instruction (definitions as per ICAO Doc 4444) and something every controller knows by heart: the difference between a request, a clearance, and an instruction. With slight variations in wording in different jurisdictions, the definition of an ATC instruction is clear to all controllers (and hopefully also clear to all professional pilots). Basically it's a declarative statement from ATC requiring compliance (subject to captain's right to decline for immediate safety reasons, for which the captain would / should reply with something like: “Unable due xxx…). I’m not commenting on the reason for the instruction nor the appropriateness of the instruction; I’m simply clarifying that it was, as stated by the CAA, an ATC instruction. |
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I concur: there's also the aspect alluded to earlier in the thread, as to whether either the Tower or Approach ATCO should have initiated a go around, after the instruction to fly the heading was effectively ignored: my instinct is an instructed go around may well have been appropriate at any point from then on - but that's only based on what I've read, which probably doesn't paint the full picture, & the response from the crew put the ATC in an invidious position, unfortunately.
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I'm sorry, but as SLF I'm struggling to understand what the command and response is to ATC directives. ATC accepts the aircraft for landing, assigns a runway, etc. and directs the aircraft into the landing pattern. At what point does the PIC take over decisions as to whether the landing should continue? How can the pilot ignore specific (sounds to me) direction from ATC to take another heading and circle and decide on his own to continue the approach? Sure, the pilot is in command of his aircraft, but it would make a lot of sense to me that a command (turn left 180) is not a request but an order. Can the PIC just ignore direction from the ATC? Then what are the ATC there for? Don't they know much more than the landing aircraft as to what is happening around the airport?
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Normally follow ATC instructions
It would be reasonable (considering what we know) to think that the crew was under a lot of stress. ATC was doing its best and it is my opinion that they avoided making the situation worse with continuing instructions, considering the crew was already ignoring them.
The evidence will likely conclude that the controller's turn instruction was the a far superior choice. Crew ignoring aircraft generated warnings is a matter for the accident investigation. Crew occasionally do ignore a heading like those that might take an aircraft into a thunderstorm, or hit high ground or another aircraft. The protocol seems to be a call like "unable, require right turn to avoid CB", except in China where it seems sometimes ATC thinks it is essential to take that risk. |
Originally Posted by Winemaker
(Post 10809799)
I'm sorry, but as SLF I'm struggling to understand what the command and response is to ATC directives. ATC accepts the aircraft for landing, assigns a runway, etc. and directs the aircraft into the landing pattern. At what point does the PIC take over decisions as to whether the landing should continue? How can the pilot ignore specific (sounds to me) direction from ATC to take another heading and circle and decide on his own to continue the approach? Sure, the pilot is in command of his aircraft, but it would make a lot of sense to me that a command (turn left 180) is not a request but an order. Can the PIC just ignore direction from the ATC? Then what are the ATC there for? Don't they know much more than the landing aircraft as to what is happening around the airport?
Now back to the subject, ATC should have given the reason as to why they wanted pilots to turn heading left180. Pilots' tunnel vision at that point resulted in them not querying as to why left heading. I know the fact that in pilots minds they knew the intention as to why they were instructed to fly the heading. But being given a reason as to why the heading, verbally, would click more to pilots' minds. Again the final decision is always Captain's. After all ATC have never flown the machine who are they to judge what's happening in the cockpit. |
I just realized that in all the posts, no one has mentioned the possibility of fumes in the cockpit and perhaps the crew was unaware and not 100%.
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Because no one can be bothered to try and make up excuses for this level of incompetence.
At this level, fumes may have helped them more.... |
ATC Instructions
Winemaker ~ suggestions to the anomalies which you ask about
I have posted other answers to questions raised on this thread trying to explain the relationship between the crew and ATC. On another thread an Italian B.737 at Bristol UK was instructed to G/A as the approach was unstable (decidedly “iffy”). As usual, the UK AAIB left “no stone unturned”. So taking each of your points in turn: 1. Within controlled airspace, radar control applies and in essence the crew complies with ATC instructions, unless it is not safe to do so, or a new accord is reached. A new radar heading towards a thunderstorm would be declined. Ultimately it is aircraft commander in charge, not ATC. I have ignored TCAS protocols. 2. Without reading the transcripts I cannot be certain, but the new heading 180° to fly was an instruction, which the aircraft commander foolishly declined ~ the aircraft had established on the localiser. He cannot just ignore ATC instructions. He needs to explain why ~ in this case established on the localiser. See my recent post about the boy scout and the ‘old dear’ crossing the road concept. 3. Yes, ATC should have perfect knowledge (situational awareness) as to what is occurring. I don’t think there was any conflicting traffic in this case? What approach radar observed was the aircraft too high and too fast on the approach, and recognising this gave a delaying manoeuvre instruction (new heading 180°). If a sooner intervention has occurred before localiser established, then I suspect that there would have been a greater chance of compliance with the ATC instruction. Pure speculation on my part. 4. Now comes the delicate bit. Sensitive areas. In common with all parts of the world, it is possible that “cultural aspects” played a part in these events. 5. What is a mystery at present ~ why the crew continued what was an extremely unstable approach and didn’t G/A no later than 1000’RA ? Interim report due to be published 22 June. There is enough material for a complete conference for psychologists who specialise in CRM, & those who teach it to crews & junior birdmen. An interesting topic for TRUCE for the ATCOs? |
[Apologies - I made an editing error in cleaning up the formatting of the original and originally put "Tower ATC" instead of the correct "Approach ATC"]
It's worth repeating the ATC transcript of the first landing phase (NB, the only transcript I have seen start here, clearly halfway through a conversation): Pilot: Sir, we are comfortable now and we are out of 3500 for 3000, established ILS 25L Approach ATC: Copy that. Turn left heading 180 Pilot: Sir, we are established on ILS 25L Approach ATC: Sir, you are 5 miles from touchdown, re-cleared passing 3000 for ILS Approach ATC: Pakistan 8303 clear to land on ILS 25L Pilot: Roger Pakistan 8303 Whether or not the 180 heading was an ignored / refused / challenged instruction or not, the approach controller undoubtedly then immediately gives a altitude change on the existing heading and a landing clearance. |
(Former Mil ATCO) If I was giving an 'unusual' instruction, such as the "heading 180º" in this instance, I would always try to supplement it with a reason. I suspect most ATCOs here would do similar ... time permitting, of course.
At a pinch, my stated reason might even be spurious to achieve the desired safety aspect. "Traffic sequencing" usually worked well. |
Originally Posted by Gary Brown
(Post 10809094)
Though it's worth mentioning, in this general context, that anyone can read the detailed and complete CVR transcript from AF447 many times over, in French or in good translation, and while you can be sure what happened, why it happened will forever remain baffling.
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Gary
Was the landing clearance issued by approach radar (coordination with the aerodrome controller)? Slightly odd phraseology? The veracity of this transcript needs to be confirmed perhaps? This will have been a salutary lesson for the unfortunate approach controller who I suspect will be somewhat more assertive when a blatantly obvious anomaly occurs in future. MPN11 ~ I concur. |
@ parkfell
Apologies - that's my error in cleaning up the formatting of the transcript - that should of course be Approach ATC. And I'll correct that. |
@ uncle dicky
Yes - completely my error in cleaning up the format of the transcript. I'll correct. |
At this point, do we really need the info from the FDR and the CVR ? I fear that many will suffer from neck injuries when the final report comes out ! ( from shaking their head)
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For those wondering how did it happen a review of Garuda GA200 might be in order,the 737 touched down at an airspeed of 221 knots, 87 knots faster than landing speed for 40 degrees flap and ran off the end at 110 knots, though they did have the gear down in this case.
1.Absorption. A state of being so focused on a specific task that other tasks are disregarded. 2.Fixation: A state of being locked onto one task, or one view of a situation, even as evidence accumulates that attention is necessary elsewhere, or that the particular view is incorrect. 3.The ‘tunneling or channelizing’ that can occur during stressful situations, which is an example of fixation. Note: The term ‘fixation’ has been chosen to describe the PIC’s state of alertness, which provides a clearer idea of ‘being locked onto one task’, than ‘absorption’. Several ‘findings’ support this ‘tunneling or channelized’ condition, for example: •The PIC’s attention became fixated on landing the aircraft. The concept of fixation is reinforced because he asked the copilot a number of times to select flaps 15 and asked if the landing checklist had been completed. •The PIC did not respond to the 15 GPWS alerts and warnings and the two calls from the pilot monitoring to go-around. The PIC did not change his plan to land the aircraft, although the aircraft being in unstabilized condition. The other tasks that needed his attention were either not heard or disregarded. The auditory information about other important things did not reach his conscious awareness. •The PIC said ‘The target is 6.6 ILS, we will not reach it’. The PIC flew an unstabilized approach. He also realized the abnormal situation when he commented ‘Wah, nggak beres nih!’ (‘Oh, there is something not right’). So, the PIC’s intention to continue to land the aircraft, from an excessively high and fast approach, was a sign that his attention was channelized during a stressful time. •The PIC also asked several times for the copilot to select flaps 15. During interview he said to investigator that ‘his goal was to reach the runway and to avoid severe damage’. He ‘heard, but did not listen to the other voice (GPWS), and flaps 15 and speed 205 was enough to land’. The PIC experienced a heightened sense of urgency, and was motivated to escape from what he perceived to be a looming catastrophe, being too high to reach the runway (09 threshold). He fixated on an escape route, ‘which seem most obvious’, aiming to get the aircraft on the ground by making a steep descent. His decision was flawed, and in choosing the landing option rather than the go around, fixated on a dangerous option. •The PIC was probably emotionally aroused, because his conscious awareness moved from the relaxed mode ‘singing’ to the heightened stressfulness of the desire to reach the runway by making an excessively steep and fast, unstabilized approach. Hazardous States of Awareness Inattention, or decreased vigilance, is often cited in ASRS reports, and has been a contributor to operational errors, incidents, and accidents. Decreased vigilance manifests itself in several ways, which can be referred to as hazardous states of awareness. These states include: •Absorption is a state of being so focused on a specific task that other tasks are disregarded. Programming the FMS to the exclusion of other tasks, such as monitoring other instruments, would be an example of absorption. The potential for absorption is one reason some operators discourage their flight crews from programming the FMS during certain flight phases or conditions (e.g., altitude below 10,000 feet). •Fixation is a state of being locked onto one task or one view of a situation even as evidence accumulates that attention is necessary elsewhere, or that the particular view is incorrect. The ‘tunneling’ that can occur during stressful situations is an example of fixation. For example, a pilot may be convinced that a high, unstabilized approach to landing is salvageable even when other flight crew members, air traffic control, and cockpit instrument strongly suggest that the approach cannot be completed within acceptable parameters. The pilot will typically be unaware of these other inputs and appear to be unresponsive until the fixation is broken. Fixation is difficult to self-diagnose, but it may be recognizable in someone else. •Preoccupation is a state where one’s attention is elsewhere (e.g., daydreaming). Decreased vigilance can be caused or fostered by a number of factors, including: •Fatigue, which has been the subject of extensive research and is well recognized as a cause of decreased vigilance. •Underload, which is increasingly being recognized as a concern. Sustained attention is difficult to maintain when workload is very low. •Complacency. Automated systems have become very reliable and perform most tasks extremely well. As a result, flight crews increasingly rely on the automation. Although high system reliability is desired, these high reliability effects flight crew monitoring strategies in a potentially troublesome way. When a failure occurs, or when the automation behavior violates expectations, the flightcrew may miss the failure, misunderstand the situation, or take longer to assess the information and respond appropriately. In other words, over reliance on automation can breed complacency, which hampers the flight crew’s ability to recognize a failure or unexpected automation behavior. |
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