ATSB unable to understand why AirAsiaX pilots
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ATSB unable to understand why AirAsiaX pilots
Cikey February 10, 2012 – by Ben Sandilands
Students of sloppy standards and crashes caused by pilots who press on regardless should find the ATSB report into two examples of really poor flying at the Gold Coast airport by AirAsiaX in May 2010 a fascinating read.
The good news is that after being caught out the Malaysia flag carrier changed its procedures and instructed its pilots as to follow the published Australian requirements for approaching this particular airport in bad weather, without descending too steeply, or disregarding safe mininum altitudes, which are there to stop them hitting the mountain ridges of the Gold Coast hinterland.
Actually, the ATSB was a bit less blunt than the above, but this is a post about air safety breaches, written in plain english, and with a view to stopping practices that could scatter hundreds of dead across the landscape which the rules are there to keep jets from hitting.
On 4 May 2010 an AirAsiaX Airbus A330-300 with 258 passengers, nine cabin crew and two pilots made three missed approaches to a Gold Coast airport the pilots couldn’t see through the cloud and rain, after which they landed the jet at nearby Brisbane airport.
On 10 May 2010 a different AirAsiaX crew in the same A330 landed safety at the Gold Coast airport with 260 passengers and the same head crew for the cabin crew and pilots on board, after one non-compliant missed approach in similarly poor visibility.
These were pilots that fly single aisle A320s and twin aisle A330s in the same roster period. The jets are very similar in flight operations, but not identical, and not all Airbus users with such mixed fleets accept the premise that their pilots should mix ‘n match their duty time on the two models.
In its report the ATSB details all of the missed approaches in clinical detail.
This is an extract from the 4 May missed approaches, with emphasis added to show that at times the flights were above the required altitude, below the required altitude, and in breach of the published approach procedures.
When the aircraft was about 5 DME(9 km) from the Gold Coast Airport, and 2,500 ft above mean sea level (AMSL), the aircraft was above the recommended descent profile for that approach. With the selected flightpath angle (FPA) of -4.9°, the aircraft was descending at a rate of about 1,300 ft/min. The flight crew continued descent until the aircraft was about 1,000 ft at 1 DME (2 km). At that point, a landing was not possible and they initiated a missed approach.
The crew was radar vectored at 2,500 ft for a second VOR approach to runway 32. Subsequently, the crew was cleared to make a pilot intercept of the final approach track and to conduct the approach.
The crew used the autopilot in selected mode to fly the approach. At 11 DME (20 km) they commenced descent, selecting an FPA of ‑3°. At that point, the aircraft was below the recommended descent profile and was descending below the procedure’s segment minimum safe altitudes.
Approaching 7 DME (13 km), the flight crew reduced the FPA to achieve level flight at 1,300 ft. At about the same time, the aerodrome controller advised the crew to check their altitude and that the radar lowest safe altitude in that area was 1,500 ft. The controller cleared the crew for further descent in accordance with the runway 32 VOR procedure. The aircraft remained below the segment minimum safe altitude until reaching 5 DME (9 km). Soon after, the controller provided the crew with surface wind information and cleared the aircraft to land.
At about 4 DME (7 km) and 1,300 ft, the crew reselected an FPA of ‑3° to commence the final descent to 750 ft, which was the minimum descent altitude (MDA). The aircraft reached the MDA at 2 DME (4 km) but low cloud, rain and reduced visibility prevented the crew from landing and they commenced another missed approach.
The flight crew then conducted a runway 14 VOR approach. Again, due to weather, they were unable to land the aircraft and conducted a missed approach and diverted to Brisbane, Qld. The aircraft landed at Brisbane at 0823.
In its account of the 10 May missed approaches the ATSB says
The flight crew conducted a Runway 32 VOR approach but were unable to land due to reduced visibility in low cloud and rain. Following a missed approach, the crew conducted another Runway 32 VOR and landed.
For both approaches, the crew commenced descent from 2,500 ft at about 10 DME (19 km), which was below the recommended descent profile. During each of those approaches, when between 9 and 7 DME (17 and 13 km), the aircraft was below the procedure’s segment minimum safe altitude.
Both approaches were conducted in selected mode, with the vertical navigation of the aircraft initially conducted in ‘open descent’. In open descent, engine power reduces to flight idle and the aircraft descends at the FPA required to maintain the selected airspeed. The aircraft reached 1,500 ft by about 8 DME (15 km), recording a maximum FPA of ‑5.6° and a rate of descent of about 1,500 ft/min.
From 1,500 ft, the descent to the MDA was conducted using a selected FPA of ‑3°, in accordance with the published procedure.
Later in its analysis of these incidents, the ATSB says of 4 May stuff up:
The descent from 2,500 ft to 1,300 ft at the selected flight path angle (FPA) of -3° was continuous and was conducted without apparent regard for the published segment minimum safe altitudes. That resulted in the aircraft operating below the segment minimum safe altitude prior to the aircraft reaching the final approach fix at 5 DME (9 km), with the effect that separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.
It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach. Being above the recommended flightpath on the first approach might have influenced the crew to descend earlier to avoid being similarly high during the second approach. Unfamiliarity with the conduct of non-precision approaches, and especially those that incorporated intermediate segment minimum safe altitudes, was another possibility.
It also says of the 29 May instances:
In both approaches on 29 May 2010, the crew initiated descent at about 10 DME (19 km) and before the aircraft had intercepted the recommended descent profile for the non‑precision approach. Those descents were conducted without apparent regard for the published segment minimum safe altitudes. As a result, separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.
It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach and descended below the segment minimum safe altitudes. However, unfamiliarity with the conduct of VOR approaches that included intermediate segment minimum safe altitudes was again a possibility.
One possibility that the ATSB doesn’t canvas is that the crew didn’t read the navigational notes or had no intention of paying any attention to them, preferring to press on regardless.
AirAsiaX did respond fully to these incidents with comprehensive safety actions.
Action taken by the aircraft operator
In response to these occurrences, AirAsia X developed a simulator training session that specifically targeted the Gold Coast approaches and emphasised the preference for pilots to conduct managed approaches. All flight crews were required to complete this training prior to further operations into the Gold Coast.
In addition, AirAsia X:
Issued a ‘flight operations circular’ advising that open descent mode should not be used when performing an instrument approach.
Issued revised Gold Coast approach charts.
Implemented additional training and checking of crews operating to the Gold Coast.
Implemented a policy recommending a maximum of two approaches before diverting to an alternate airport.
Reduced the incidence of mixed-fleet flying such that pilots only fly either the A320 or the A330/A340 during a roster period.
Implemented an instructor standardisation and enhancement program.
During the press conference earlier this week at which AirAsiaX rival Scoot announced its plan to fly to the Gold Coast from June, Queensland Premier Anna Bligh confirmed that an ILS system to improve bad weather access to the airport would be installed there sometime this year.
Comments (3) | Permalink
Students of sloppy standards and crashes caused by pilots who press on regardless should find the ATSB report into two examples of really poor flying at the Gold Coast airport by AirAsiaX in May 2010 a fascinating read.
The good news is that after being caught out the Malaysia flag carrier changed its procedures and instructed its pilots as to follow the published Australian requirements for approaching this particular airport in bad weather, without descending too steeply, or disregarding safe mininum altitudes, which are there to stop them hitting the mountain ridges of the Gold Coast hinterland.
Actually, the ATSB was a bit less blunt than the above, but this is a post about air safety breaches, written in plain english, and with a view to stopping practices that could scatter hundreds of dead across the landscape which the rules are there to keep jets from hitting.
On 4 May 2010 an AirAsiaX Airbus A330-300 with 258 passengers, nine cabin crew and two pilots made three missed approaches to a Gold Coast airport the pilots couldn’t see through the cloud and rain, after which they landed the jet at nearby Brisbane airport.
On 10 May 2010 a different AirAsiaX crew in the same A330 landed safety at the Gold Coast airport with 260 passengers and the same head crew for the cabin crew and pilots on board, after one non-compliant missed approach in similarly poor visibility.
These were pilots that fly single aisle A320s and twin aisle A330s in the same roster period. The jets are very similar in flight operations, but not identical, and not all Airbus users with such mixed fleets accept the premise that their pilots should mix ‘n match their duty time on the two models.
In its report the ATSB details all of the missed approaches in clinical detail.
This is an extract from the 4 May missed approaches, with emphasis added to show that at times the flights were above the required altitude, below the required altitude, and in breach of the published approach procedures.
When the aircraft was about 5 DME(9 km) from the Gold Coast Airport, and 2,500 ft above mean sea level (AMSL), the aircraft was above the recommended descent profile for that approach. With the selected flightpath angle (FPA) of -4.9°, the aircraft was descending at a rate of about 1,300 ft/min. The flight crew continued descent until the aircraft was about 1,000 ft at 1 DME (2 km). At that point, a landing was not possible and they initiated a missed approach.
The crew was radar vectored at 2,500 ft for a second VOR approach to runway 32. Subsequently, the crew was cleared to make a pilot intercept of the final approach track and to conduct the approach.
The crew used the autopilot in selected mode to fly the approach. At 11 DME (20 km) they commenced descent, selecting an FPA of ‑3°. At that point, the aircraft was below the recommended descent profile and was descending below the procedure’s segment minimum safe altitudes.
Approaching 7 DME (13 km), the flight crew reduced the FPA to achieve level flight at 1,300 ft. At about the same time, the aerodrome controller advised the crew to check their altitude and that the radar lowest safe altitude in that area was 1,500 ft. The controller cleared the crew for further descent in accordance with the runway 32 VOR procedure. The aircraft remained below the segment minimum safe altitude until reaching 5 DME (9 km). Soon after, the controller provided the crew with surface wind information and cleared the aircraft to land.
At about 4 DME (7 km) and 1,300 ft, the crew reselected an FPA of ‑3° to commence the final descent to 750 ft, which was the minimum descent altitude (MDA). The aircraft reached the MDA at 2 DME (4 km) but low cloud, rain and reduced visibility prevented the crew from landing and they commenced another missed approach.
The flight crew then conducted a runway 14 VOR approach. Again, due to weather, they were unable to land the aircraft and conducted a missed approach and diverted to Brisbane, Qld. The aircraft landed at Brisbane at 0823.
In its account of the 10 May missed approaches the ATSB says
The flight crew conducted a Runway 32 VOR approach but were unable to land due to reduced visibility in low cloud and rain. Following a missed approach, the crew conducted another Runway 32 VOR and landed.
For both approaches, the crew commenced descent from 2,500 ft at about 10 DME (19 km), which was below the recommended descent profile. During each of those approaches, when between 9 and 7 DME (17 and 13 km), the aircraft was below the procedure’s segment minimum safe altitude.
Both approaches were conducted in selected mode, with the vertical navigation of the aircraft initially conducted in ‘open descent’. In open descent, engine power reduces to flight idle and the aircraft descends at the FPA required to maintain the selected airspeed. The aircraft reached 1,500 ft by about 8 DME (15 km), recording a maximum FPA of ‑5.6° and a rate of descent of about 1,500 ft/min.
From 1,500 ft, the descent to the MDA was conducted using a selected FPA of ‑3°, in accordance with the published procedure.
Later in its analysis of these incidents, the ATSB says of 4 May stuff up:
The descent from 2,500 ft to 1,300 ft at the selected flight path angle (FPA) of -3° was continuous and was conducted without apparent regard for the published segment minimum safe altitudes. That resulted in the aircraft operating below the segment minimum safe altitude prior to the aircraft reaching the final approach fix at 5 DME (9 km), with the effect that separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.
It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach. Being above the recommended flightpath on the first approach might have influenced the crew to descend earlier to avoid being similarly high during the second approach. Unfamiliarity with the conduct of non-precision approaches, and especially those that incorporated intermediate segment minimum safe altitudes, was another possibility.
It also says of the 29 May instances:
In both approaches on 29 May 2010, the crew initiated descent at about 10 DME (19 km) and before the aircraft had intercepted the recommended descent profile for the non‑precision approach. Those descents were conducted without apparent regard for the published segment minimum safe altitudes. As a result, separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.
It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach and descended below the segment minimum safe altitudes. However, unfamiliarity with the conduct of VOR approaches that included intermediate segment minimum safe altitudes was again a possibility.
One possibility that the ATSB doesn’t canvas is that the crew didn’t read the navigational notes or had no intention of paying any attention to them, preferring to press on regardless.
AirAsiaX did respond fully to these incidents with comprehensive safety actions.
Action taken by the aircraft operator
In response to these occurrences, AirAsia X developed a simulator training session that specifically targeted the Gold Coast approaches and emphasised the preference for pilots to conduct managed approaches. All flight crews were required to complete this training prior to further operations into the Gold Coast.
In addition, AirAsia X:
Issued a ‘flight operations circular’ advising that open descent mode should not be used when performing an instrument approach.
Issued revised Gold Coast approach charts.
Implemented additional training and checking of crews operating to the Gold Coast.
Implemented a policy recommending a maximum of two approaches before diverting to an alternate airport.
Reduced the incidence of mixed-fleet flying such that pilots only fly either the A320 or the A330/A340 during a roster period.
Implemented an instructor standardisation and enhancement program.
During the press conference earlier this week at which AirAsiaX rival Scoot announced its plan to fly to the Gold Coast from June, Queensland Premier Anna Bligh confirmed that an ILS system to improve bad weather access to the airport would be installed there sometime this year.
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