Dangers of Unstable approaches - Getting the message across.
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Dangers of Unstable approaches - Getting the message across.
The media has revealed quite graphic photographs of the aftermath of the Garuda B737-400 accident under discussion in Rumours and News. Without pre-judging the investigation it does appear, however, to be the deadly result of an unstable final approach.
Visit any flight simulator training centre and chances are the briefing rooms are festooned with colourful flight safety posters. Cartoon characters in the posters warn of complacency, the perils of deviating from SOP, perhaps something on sterile cockpits, the captain's creed about flight safety. You name it but there will be professionally produced safety messages. There might even be a well designed depiction of the dangers of unstable approaches and with a cartoon captain in sunnies pressing on regardless.
Now we all know that these posters are there for show and perhaps to keep the regulator happy. The flight safety committee are just doing their job after all. But do we pilots ever carry those pretty colourful posters in our mind when we fly in bad weather or when we find ourselves on final high and fast because of our own incompetency or perhaps we were trying to please the hard working approach controller when he asks for a high speed below 10,000 or track shortening. In short are those posters a waste of paper?
Take cigarette advertising. In my country at least, the law requires cigarette packets to depict the horrible effect of smoking on the lungs and a picture of a blackened yukky looking lung or cancer ravaged mouth is part of the warning on the packets. "Smoking Kills" is the message on the cigarette packet. This may well frighten away the amateur smokers but the cigarette addicts still puff away regardless.
I wonder how effective it would be to have the professionals design a flight safety poster that displayed in all it's terrible clarity a photo of the burning wreckage of that Garuda Boeing with its scenes of passengers fleeing the flames. With it the flight safety message of the dangers of unstable approaches. No amusing cartoon characters - no warm and fuzzy principles of good CRM. Just a grim dose of reality. Would that not get through to the cowboys who see the hot and high approach as a challenge and not a deadly risk?
Visit any flight simulator training centre and chances are the briefing rooms are festooned with colourful flight safety posters. Cartoon characters in the posters warn of complacency, the perils of deviating from SOP, perhaps something on sterile cockpits, the captain's creed about flight safety. You name it but there will be professionally produced safety messages. There might even be a well designed depiction of the dangers of unstable approaches and with a cartoon captain in sunnies pressing on regardless.
Now we all know that these posters are there for show and perhaps to keep the regulator happy. The flight safety committee are just doing their job after all. But do we pilots ever carry those pretty colourful posters in our mind when we fly in bad weather or when we find ourselves on final high and fast because of our own incompetency or perhaps we were trying to please the hard working approach controller when he asks for a high speed below 10,000 or track shortening. In short are those posters a waste of paper?
Take cigarette advertising. In my country at least, the law requires cigarette packets to depict the horrible effect of smoking on the lungs and a picture of a blackened yukky looking lung or cancer ravaged mouth is part of the warning on the packets. "Smoking Kills" is the message on the cigarette packet. This may well frighten away the amateur smokers but the cigarette addicts still puff away regardless.
I wonder how effective it would be to have the professionals design a flight safety poster that displayed in all it's terrible clarity a photo of the burning wreckage of that Garuda Boeing with its scenes of passengers fleeing the flames. With it the flight safety message of the dangers of unstable approaches. No amusing cartoon characters - no warm and fuzzy principles of good CRM. Just a grim dose of reality. Would that not get through to the cowboys who see the hot and high approach as a challenge and not a deadly risk?
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Just my 2 pence...I don't think any pilot worldwide intend to do a hot'n high approach, it just happens, very suddenly. And it is usually when captain is PF and he/she gets a bright idea. If you're doing 300 kts at 10 miles, and being at 4000', then the appropriate thing to do is to level off/climb to missed approach altitude, call ATC and tell them you're doing a go-around and then ask for vectors for final again. Problem is, we're all trained to try to fix non-standard situations and this seem to be the reason why people choose to continue, and this is especially the case when something else is bothering them (you)...be it bad wx, personal problems, etc, etc.
A37575 “Would that not get through to the cowboys who see the hot and high approach as a challenge and not a deadly risk?“
This activity alone might help, but there also is a requirement for education to convince pilots of the need for their participation. A lack of knowledge or understanding has contributed to several recent worldwide accidents.
The FSF ALAR Tool Kit provides background information, checklists, and some cartoon posters, although these are culturally biased towards N America.
Perhaps a refresh of this material is required, republished in local languages. Some of this has been done, see ALAR additional resources, with Spanish and Russian versions available.The conditions for, and the background to, a stabilized approach are in the ALAR Briefing Note 7.1
Similarly, language updates would be useful for briefings such as Managing Threats and Errors during Approach and Landing. This already uses a mixed text and graphic format that might go some way to meeting your request.
The main problem is to convince pilots that ‘it’ can happen to them, but all of us (humans, pilots) judge risks poorly. Thus the poster has to convince pilots of the risk; those tangible items that we deal with each day:- wet runway, tailwind, high speed.
Several of these issues are in the paper When a Runway is Not Long Enough to Land On.
Quotes:
1. The overrun accident risk was 55 times greater when the touchdown position was long.
2. The overrun accident risk increases by a factor of 10 when the landing was conducted on a wet or flooded runway, and by a factor of 14 when the runway was covered with snow, ice or slush.
3. In 15% of the 400 landing overrun accidents that were analyzed, there was late, or no, application of the available stopping devices.
This activity alone might help, but there also is a requirement for education to convince pilots of the need for their participation. A lack of knowledge or understanding has contributed to several recent worldwide accidents.
The FSF ALAR Tool Kit provides background information, checklists, and some cartoon posters, although these are culturally biased towards N America.
Perhaps a refresh of this material is required, republished in local languages. Some of this has been done, see ALAR additional resources, with Spanish and Russian versions available.The conditions for, and the background to, a stabilized approach are in the ALAR Briefing Note 7.1
Similarly, language updates would be useful for briefings such as Managing Threats and Errors during Approach and Landing. This already uses a mixed text and graphic format that might go some way to meeting your request.
The main problem is to convince pilots that ‘it’ can happen to them, but all of us (humans, pilots) judge risks poorly. Thus the poster has to convince pilots of the risk; those tangible items that we deal with each day:- wet runway, tailwind, high speed.
Several of these issues are in the paper When a Runway is Not Long Enough to Land On.
Quotes:
1. The overrun accident risk was 55 times greater when the touchdown position was long.
2. The overrun accident risk increases by a factor of 10 when the landing was conducted on a wet or flooded runway, and by a factor of 14 when the runway was covered with snow, ice or slush.
3. In 15% of the 400 landing overrun accidents that were analyzed, there was late, or no, application of the available stopping devices.
Precisely. The who need to heed it won't read it. I haven't seen any evidence of an endemic problem of
from where I sit. Are you are suggesting that most overrun accidents are caused by hot and high cowboys and not a whole bunch of other insidious, combining factors that suddenly creep up on an unsuspecting crew that may already be working overtime?
cowboys who see the hot and high approach as a challenge
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Many years ago while attending 727 recurrency school we had a cockpit voice recorder tape played that was taped during an high speed approach in a 727 that resulted in an accident.
When the instructor started playing the tape he did not tell us that the aircraft had crashed, he just told us to listen and that he would stop the tape from time to time and ask us our thoughts at that point.
There were about 20 or so pilots in the classroom, all 72 pilots, most of us with a lot of experience flying the 727.
At the start of the tape the captain and the FE were more focused on getting on the ground before the airport café closed and teasing the young FO.
The first real clue that something was not correct was when the captain called for gear down before extending any flaps or LEDs. As the noise in the cockpit raised drastically I realized that the aircraft was well above 200kts. Cutting the story to the end the flaps never passed 15 degrees down and the aircraft ran off the end of the runway resulting in many of the passengers being killed.
Anyone who has sat through that presentation will never forget just how badly a unstable high speed approach can end up.
I never have.
When the instructor started playing the tape he did not tell us that the aircraft had crashed, he just told us to listen and that he would stop the tape from time to time and ask us our thoughts at that point.
There were about 20 or so pilots in the classroom, all 72 pilots, most of us with a lot of experience flying the 727.
At the start of the tape the captain and the FE were more focused on getting on the ground before the airport café closed and teasing the young FO.
The first real clue that something was not correct was when the captain called for gear down before extending any flaps or LEDs. As the noise in the cockpit raised drastically I realized that the aircraft was well above 200kts. Cutting the story to the end the flaps never passed 15 degrees down and the aircraft ran off the end of the runway resulting in many of the passengers being killed.
Anyone who has sat through that presentation will never forget just how badly a unstable high speed approach can end up.
I never have.
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When is it we screw up? ****ty weather with poor vis? naaa....perfect clear weather, a bit behind shedule, an unexpected short cut during the app and you end up being hot and high. Problem is, we are not trained for it. We only get told what to do. If at 10 miles, high speed and too high do the G/A. How many of you have acually practised that situation in the sim (not the G/A alone) Everbody should be allowed to try a couple of rushed approaches every OPC just too feel the situation rather then get told about it... 
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Everbody should be allowed to try a couple of rushed approaches every OPC just too feel the situation rather then get told about it...
He then points out to pop-eyed students that under similar conditions it may be their fate if they elect to try and salvage an unstable approach. Some may argue that is negative teaching. Maybe so - but the silence is deafening after the aircraft finally stops...
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Hear Hear!
That sounds like a very useful exercise, Tee-emm, and not just for trainees. Mindsets need to be changed on the subject of rushed approaches, of which we have all been guilty at one time or another.
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I wonder how effective it would be to have the professionals design a flight safety poster that displayed in all it's terrible clarity a photo of the burning wreckage of that Garuda Boeing with its scenes of passengers fleeing the flames.
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There's a very good 'chase plane' animation of the AA Little Rock accident at
http://www.ntsb.gov/Events/2000/AA14..._boardmtng.htm
............ problem is - I've just discovered, with my machine it doesn't want to open. You may be luckier. I've got it on hard drive at 2M, Windows Media, if the link is stuffed and anyone wants it.
http://www.ntsb.gov/Events/2000/AA14..._boardmtng.htm
............ problem is - I've just discovered, with my machine it doesn't want to open. You may be luckier. I've got it on hard drive at 2M, Windows Media, if the link is stuffed and anyone wants it.
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The depressing thing about reading accident reports is the sameness of them all. ie No one has invented a new way to have an accident. The safety people will never be out of a job and their never ending problem is how to get the message across. How many of you find yourself relearning lessons that had been learnt in the past, since foregotten, only to have it reappear from left field and leave you with a palpitating heart. Being human, all of us are subject to any number of influences which may impact on our performance at any given point in time. Bill Gates cant get Windows to work. What chance do you think there is of getting 100% performance out of 100% of the people 100% of the time. Anyone who feels it cant happen to him may be in for a very rude shock. If you have never had a heart thumping experience perhaps it was your naivete or inexperience that didnt allow you to recognise what was happening and the Gods smiled on you and said "We'll let him off this time". The unfortunate fact of our existance upon this good earth is that there will always be accidents (else they could stop building trauma centres in the hospitals). An ICAO official some years ago when a zero rate in some aviation accident statistic had been reached was asked by a reporter "I guess you'll be breaking out the champagne then?". His reply was "No. We cosider it to be a statistical abberation that we dont expect to ever see repeated again". The industry as a whole has an outstanding record of which we can all be proud, but that doesnt mean we can rest on our laurels and not strive for that elusive zero rate inspite of the ICAO assessment.
Sorry for the drivel.
Sorry for the drivel.
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drivel - don't think so - I think it's quite a valid commentary Brian.
mingalababya - while I think I'd agree with the principle. I think the appearance of that particular image is a bit bloody unfair - to say the least. For the obvious reason that no-one yet knows the full circumstances of exactly what happened - let alone if a go-around was even possible or advisable - with reference to discussion elsewhere and facts yet to be established.
But then again - we already know about similar "campaigns" and their effects (or lack thereof) for everything from AIDS/Safe sex to drink driving. For some, human nature seems to dictate that nothing impresses the importance of a message to them other than the proverbial "
hitting the fan" for real - unfortunately.
I wonder how effective it would be to have the professionals design a flight safety poster that displayed in all it's terrible clarity a photo of the burning wreckage of that Garuda Boeing with its scenes of passengers fleeing the flames. Like this one perhaps? (Not mine .. but saw it on an Indo pilots' forum)
But then again - we already know about similar "campaigns" and their effects (or lack thereof) for everything from AIDS/Safe sex to drink driving. For some, human nature seems to dictate that nothing impresses the importance of a message to them other than the proverbial "
hitting the fan" for real - unfortunately.
Last edited by theamrad; 10th Mar 2007 at 00:51. Reason: typo (again!)
A common discussion at the Rotorheads Forum revolves around the question that challenges the methods and objectives of current training programs and the repeated refusal to utilize technology by the Helicopter industry to mitigate the fallibility of the human portion of the accident chain.
Is that not a consideration in the current approach to training in the fixed wing part of the industry? Think back to the American crash resulting from the use of rudder causing excessive loads on the tail assembly.....could there have been a simple technological system in place to warn the crew of such a situation.
Are we fixated upon checking to a satisfactory accomplishment of the maneuver and overlooking other more critical aspects of training designed to take us beyond merely meeting a minimum standard on specified maneuvers and procedures etched in stone in the form of checklists and SOP's?
Is that not a consideration in the current approach to training in the fixed wing part of the industry? Think back to the American crash resulting from the use of rudder causing excessive loads on the tail assembly.....could there have been a simple technological system in place to warn the crew of such a situation.
Are we fixated upon checking to a satisfactory accomplishment of the maneuver and overlooking other more critical aspects of training designed to take us beyond merely meeting a minimum standard on specified maneuvers and procedures etched in stone in the form of checklists and SOP's?
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Isn't supervision the key here? At our airline, we run a FOQA program and they very clearly define what constitutes an unstable approach.
Our airline also has a "no-fault" policy for go-arounds (although reporting of a go-around is still required). However, if they see a tape of an unstable approach that did not end in a go-around, the pilots find themselves in hot water from the Company.
It's working here.
Our airline also has a "no-fault" policy for go-arounds (although reporting of a go-around is still required). However, if they see a tape of an unstable approach that did not end in a go-around, the pilots find themselves in hot water from the Company.
It's working here.
It happened with two highly-experienced pilots in a transport jet on a very short runway in California. The airline is known to hurry between airports and on taxiways a bit, or so they say.
Where is the motivation to cut corners these days?
In contrast to airlines which cultivate good morale and a team spirit, at my company these days we have no more incentive, financial or otherwise, to decrease our "comfort level" more than a tiny bit. Never mind with standby/reserve pilots flying all the time with ever-present fatigue as their constant companion-at least for several months in a row.
The only truly measurable incentives go into the already grotesquely bloated pockets of Upper Mgmt.
So risk your job and your career (it is nice landing jets on paved runways in the 'first world'...) for THEM?
For example?
A 744 pilot for a 'freight airline' told me confidentially that at least one crew had diverted from a route into Narita near a typhoon-but they could have safely continued to their destination. Incentives are quantifiable and produce many long-term dividends (no pun intended)-but crew decisions can be subjective.
Clear, arrogant contempt
from above creates a lack of 'team spirit' and is costly.
Where is the motivation to cut corners these days?
In contrast to airlines which cultivate good morale and a team spirit, at my company these days we have no more incentive, financial or otherwise, to decrease our "comfort level" more than a tiny bit. Never mind with standby/reserve pilots flying all the time with ever-present fatigue as their constant companion-at least for several months in a row.
The only truly measurable incentives go into the already grotesquely bloated pockets of Upper Mgmt.
So risk your job and your career (it is nice landing jets on paved runways in the 'first world'...) for THEM?
For example?
A 744 pilot for a 'freight airline' told me confidentially that at least one crew had diverted from a route into Narita near a typhoon-but they could have safely continued to their destination. Incentives are quantifiable and produce many long-term dividends (no pun intended)-but crew decisions can be subjective.
Clear, arrogant contempt
from above creates a lack of 'team spirit' and is costly.
Last edited by Ignition Override; 10th Mar 2007 at 05:15.
C-P
I have heard that tape, too. At the beginning, I could not believe a professional crew was doing it, but OTOH, I had seen crews approaching that level of silliness until someone said...STOP! Amazing, really. Good lesson in that presentation.
GF
I have heard that tape, too. At the beginning, I could not believe a professional crew was doing it, but OTOH, I had seen crews approaching that level of silliness until someone said...STOP! Amazing, really. Good lesson in that presentation.
GF
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I'm employed by a UK regional operator; we normally fly 4 sectors daily - as two rotations out of 'home base', normally Captain will be PF on #1 and #4. The introduction of Flight Data Monitoring surprised us all by revealing that most FDM 'events' occur on sector 2 (and then secondly, on sector 4). In this company at least, it appears that home base familiarity has a lot to do with the number of FDM events (of which unstable approaches are just one example).
Would that not get through to the cowboys who see the hot and high approach as a challenge and not a deadly risk?
Sometimes you, despite all sorts of proactivity, are put in a situation where the total energy of the aircraft is more than you would wish at some point on the approach. If there is a way of recovering from this without unduly increasing risk levels or upsetting passengers, then why not? What is truly dangerous is the fixated must-get-in-itis, with no thought applied to what the limits are to your actions in trying to get the aircraft onto the concrete. Or not knowing when an approach has become irrecoverable and DOING something about it.