Report on incident in DUB 2007
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Report on incident in DUB 2007
Report out on the above.
Air Accident Investigation UnitFull List of Reports
I can imagine what the garbled part of the communication at 23.35:12 was!
Air Accident Investigation UnitFull List of Reports
I can imagine what the garbled part of the communication at 23.35:12 was!
Re “Captain was fired after this incident”.
If this is true then the action does little to further the cause of aviation safety.
The incident is an example of a threat (TEM terminology) which was not, or could not be detected. This is typical of the hazards associated with visual misidentification / illusion, and similar to several of the incidents described "here".
In these instances, both crew members can simultaneously suffer a failure in situation awareness, which does not enable or contribute to good cross monitoring.
Whilst the VOR could have been monitored more closely - SOPs were not followed, the report fails to identify why such a ‘failure’ (crew procedural violation) occurred. Similarly there is harsh wording about the crew’s failure to “comply” with the approach procedure – the crew did not check that the aircraft was following the procedure, … but why? Something we all might do when ‘visual’?
The report concludes the ‘probable cause’ as a crew decision failure with contributory factors; one of which was poor CRM. The report earlier defines CRM and crew responsibilities, and discusses error, but perhaps fails to support the conclusion of poor CRM, which IMHO together with the probable cause leaves the blame option open.
Was this aircraft fitted with EGPWS?
If so, at what altitude during this approach should an amber alert ‘Caution Terrain’ be given, together with the amber ND/radar display?
Was the EGPWS obstacle mode enabled?
Did the company SOP specify displaying the EGPWS map during the approach?
If this is true then the action does little to further the cause of aviation safety.
The incident is an example of a threat (TEM terminology) which was not, or could not be detected. This is typical of the hazards associated with visual misidentification / illusion, and similar to several of the incidents described "here".
In these instances, both crew members can simultaneously suffer a failure in situation awareness, which does not enable or contribute to good cross monitoring.
Whilst the VOR could have been monitored more closely - SOPs were not followed, the report fails to identify why such a ‘failure’ (crew procedural violation) occurred. Similarly there is harsh wording about the crew’s failure to “comply” with the approach procedure – the crew did not check that the aircraft was following the procedure, … but why? Something we all might do when ‘visual’?
The report concludes the ‘probable cause’ as a crew decision failure with contributory factors; one of which was poor CRM. The report earlier defines CRM and crew responsibilities, and discusses error, but perhaps fails to support the conclusion of poor CRM, which IMHO together with the probable cause leaves the blame option open.
Was this aircraft fitted with EGPWS?
If so, at what altitude during this approach should an amber alert ‘Caution Terrain’ be given, together with the amber ND/radar display?
Was the EGPWS obstacle mode enabled?
Did the company SOP specify displaying the EGPWS map during the approach?
Lighting issue at DUB
Surprised this hasn't been tagged yet, sounds like an event that could happen more often in many places.
Aircraft misguided by lights on a hotel.
Air Accident Investigation UnitFull List of Reports
Aircraft misguided by lights on a hotel.
Air Accident Investigation UnitFull List of Reports
JJ83, so in addition to reiterating the investigation’s conclusions (and similarly failing to provide any explanation / solution), you accuse the crew of being ‘stupid’.
The purpose of investigating such incidents is “…. the prevention of accidents and incidents” (ICAO Annex 13).
The report identifies preventative measures in the recommendations. Changing the Tower lighting addresses the obvious hazard; yet in acknowledging this, it might be construed that the crew’s decision based on what they saw was correct.
However, the apparent failure to following the VOR procedure or the operational SOP appears to be grouped in the recommendation to review CRM training. No evidence was presented relating to poor training; indeed the crew’s training was assessed as being satisfactory and met all regulatory requirements. If the investigation considered that the standard of CRM was insufficient, either a higher regulatory standard might be justified, or an explanation of why the crew did not exhibit their assessed standard on the day of the incident should have been given.
Lest I should be accused of being overcritical of the investigation, the Irish AAIU should be congratulated on addressing the difficult area of human factors, which is often avoided in such investigations.
IMHO a more considered view of the crew’s performance might come from a speculative review of the crew’s behavior including the possibility (probability) that the errors identified in hindsight (misidentification, violating SOPs) were to be expected in the situation and were within the limits of human performance.
Using James Reason’s view of accidents – latent factors and an unsafe act, the latent factor of the lighting was identified together with the act - human nature – believing what is seen; but for the procedural factors, only the unsafe act was mentioned.
The purpose of investigating such incidents is “…. the prevention of accidents and incidents” (ICAO Annex 13).
The report identifies preventative measures in the recommendations. Changing the Tower lighting addresses the obvious hazard; yet in acknowledging this, it might be construed that the crew’s decision based on what they saw was correct.
However, the apparent failure to following the VOR procedure or the operational SOP appears to be grouped in the recommendation to review CRM training. No evidence was presented relating to poor training; indeed the crew’s training was assessed as being satisfactory and met all regulatory requirements. If the investigation considered that the standard of CRM was insufficient, either a higher regulatory standard might be justified, or an explanation of why the crew did not exhibit their assessed standard on the day of the incident should have been given.
Lest I should be accused of being overcritical of the investigation, the Irish AAIU should be congratulated on addressing the difficult area of human factors, which is often avoided in such investigations.
IMHO a more considered view of the crew’s performance might come from a speculative review of the crew’s behavior including the possibility (probability) that the errors identified in hindsight (misidentification, violating SOPs) were to be expected in the situation and were within the limits of human performance.
Using James Reason’s view of accidents – latent factors and an unsafe act, the latent factor of the lighting was identified together with the act - human nature – believing what is seen; but for the procedural factors, only the unsafe act was mentioned.
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Serious MD-83 incident at Dublin
The Irish AAIU have released their report on a serious incident that happened at Dublin in August 2007 involving a Flightline MD-83 from Lisbon. Among the contributing factors was poor CRM of the flightcrew, who did not follow company SOPs.
Serious Incident: McDonnell Douglas MD-83, G-FLTM, Santry Cross near Dublin Airport, 16 August 2007: Report No 2009-010
21 April 2009
SYNOPSIS
The aircraft departed Lisbon with the Co-pilot as Pilot Flying (PF). The flight progressed without incident until commencing its approach to Dublin Airport. The approach was made at night; the weather and visibility were good. Due to scheduled maintenance on the main runway (RWY 10-28), RWY 34 was in use for landing. The flight was cleared by Air Traffic Control (ATC) to carry out a non-precision approach to RWY 34. During the approach, at approximately 5 nautical miles (nm) from touchdown, the aircraft began to deviate left of the approach course. This deviation was due to the Flight Crew mis-identifying the lights of a hotel at Santry Cross as those of the runway approach lighting system on RWY 34. The aircraft continued to descend below the Minimum Descent Altitude (MDA) without proper visual identification of the runway in use, and continued to descend to an altitude of 580 ft above mean sea level (AMSL) before executing a go-around.
At the point the go-around commenced, the aircraft was approximately 1,700 ft from the building and 200 ft above it. On the instructions of ATC the aircraft turned right and climbed to a safe altitude. The aircraft subsequently landed without further incident. There were no injuries.
Full report here Air Accident Investigation UnitFull List of Reports
Serious Incident: McDonnell Douglas MD-83, G-FLTM, Santry Cross near Dublin Airport, 16 August 2007: Report No 2009-010
21 April 2009
SYNOPSIS
The aircraft departed Lisbon with the Co-pilot as Pilot Flying (PF). The flight progressed without incident until commencing its approach to Dublin Airport. The approach was made at night; the weather and visibility were good. Due to scheduled maintenance on the main runway (RWY 10-28), RWY 34 was in use for landing. The flight was cleared by Air Traffic Control (ATC) to carry out a non-precision approach to RWY 34. During the approach, at approximately 5 nautical miles (nm) from touchdown, the aircraft began to deviate left of the approach course. This deviation was due to the Flight Crew mis-identifying the lights of a hotel at Santry Cross as those of the runway approach lighting system on RWY 34. The aircraft continued to descend below the Minimum Descent Altitude (MDA) without proper visual identification of the runway in use, and continued to descend to an altitude of 580 ft above mean sea level (AMSL) before executing a go-around.
At the point the go-around commenced, the aircraft was approximately 1,700 ft from the building and 200 ft above it. On the instructions of ATC the aircraft turned right and climbed to a safe altitude. The aircraft subsequently landed without further incident. There were no injuries.
Full report here Air Accident Investigation UnitFull List of Reports
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At the point the go-around commenced, the aircraft was approximately 1,700 ft from the building and 200 ft above it.
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Why does a hotel look like a runway?
This sounds like a knock knock joke. Why is a hotel lit up in the vicinity of an airport in such a way that it may be mistaken for a runway? Is there no local authority planning for the arrangement of lighting of buildings near airports. OK vmc conditions were in operation at the time of the incident but had the visibility been marginal it could have happened to any crew.
I hope this long delayed report has caused some head scratching at the local authority if they ever get to read it.
Rant over
woodsy
I hope this long delayed report has caused some head scratching at the local authority if they ever get to read it.
Rant over
woodsy
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They went around from 580' AMSL. Dublin airport, as I recall, is 325 AMSL, and the hotel well may have been above the level of the airport. Hence the 200' clearance. Personally, I used to try and miss sticky uppy pieces of the land scape by something more than 200' vertical seperation.
They went around from 580' AMSL. Dublin airport, as I recall, is 325 AMSL, and the hotel well may have been above the level of the airport. Hence the 200' clearance. Personally, I used to try and miss sticky uppy pieces of the land scape by something more than 200' vertical seperation.
Discussion on the safety and human factors aspects of this incident is running here:- http://www.pprune.org/safety-crm-qa-...ml#post4878565
One question asked (as yet unanswered), was if the aircraft was fitted with EGPWS. Presuming that it was then at what altitude would an alert be given?
I think that the incident provides a salutary lesson, particularly with the similarities of those incidents described in TAWS Saves.
One question asked (as yet unanswered), was if the aircraft was fitted with EGPWS. Presuming that it was then at what altitude would an alert be given?
I think that the incident provides a salutary lesson, particularly with the similarities of those incidents described in TAWS Saves.
dontdoit, to avoid being labeled in the same manner as you address the incident crew, I suggest that you read the report in detail and the link to similar incidents above.
Then reflect on the behaviors reported, consider the incident crew’s perspective, and the human issues which you or anyone else might encounter in similar circumstances.
Then reflect on the behaviors reported, consider the incident crew’s perspective, and the human issues which you or anyone else might encounter in similar circumstances.
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dontdoit, Who are you flying for now, so I can go and fly with someone else? 
Ever hear of the saying "There but for the grace of God go I"? Or you one of those chaps whose only mistake was the time you thought you made a mistake?
Ever hear of the saying "There but for the grace of God go I"? Or you one of those chaps whose only mistake was the time you thought you made a mistake?
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At a final approach speed of 130kts, they were less than 8 seconds from the hotel......I'm sure guests in the top floor got a fright as the go-around was initiated! 
As the report states, if the crew had bothered to read the NOTAM beforehand then this in all probability wouldn't have happened. They were lucky this time..
As the report states, if the crew had bothered to read the NOTAM beforehand then this in all probability wouldn't have happened. They were lucky this time..
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I disagree,a change of runway is something we deal with on a regular basis.Ok,the notams should have been read to avoid a double brief,but even if they had read the notes,does that mean they wouldnt make the same mistake?
Althought initially high,my reading of the report is that they stabilised in good time.
The nighttime photos are frightening,I empathise with this crew I have to say,a very human error,and lets be honest we have all had our moments.
34 at Dublin is always least favored by pilots and ATC,the FAF distance makes it look like you got oodles of time,but the VOR is away out in North Co.Dublin.
I was amazed they got planning for this particular eyesore of a hotel,taller than any other structure within a close radius of the airport.There is a mention of planning guideline rules regarding structures in the report.And a suggestion that rules were not followed,I wonder if that will be followed up?Probably not.
Althought initially high,my reading of the report is that they stabilised in good time.
The nighttime photos are frightening,I empathise with this crew I have to say,a very human error,and lets be honest we have all had our moments.
34 at Dublin is always least favored by pilots and ATC,the FAF distance makes it look like you got oodles of time,but the VOR is away out in North Co.Dublin.
I was amazed they got planning for this particular eyesore of a hotel,taller than any other structure within a close radius of the airport.There is a mention of planning guideline rules regarding structures in the report.And a suggestion that rules were not followed,I wonder if that will be followed up?Probably not.
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A nasty 'event'.
Thanks to PPRNkof for posting the link to the report or we might have missed it. This thread has finished up in a typical PPRune 'Pickle', and in defence of PPRNkof I would point out that it would have been quite hard to find the original thread - you'd need to be really clever - like some of our contributors on the closed thread. It is a pity the responsible mod did not do that homework himself and add the post to the old thread which would have then popped up very neatly in R&N. However - I think this forum is just fine for it now. I've no doubt PPRNkof considers him/herself fully chided.
Thanks to PPRNkof for posting the link to the report or we might have missed it. This thread has finished up in a typical PPRune 'Pickle', and in defence of PPRNkof I would point out that it would have been quite hard to find the original thread - you'd need to be really clever - like some of our contributors on the closed thread. It is a pity the responsible mod did not do that homework himself and add the post to the old thread which would have then popped up very neatly in R&N. However - I think this forum is just fine for it now. I've no doubt PPRNkof considers him/herself fully chided.