Automation Bogie raises it's head yet again
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In the modern world the political nations are governed by separation of powers. There are the executives, the lawmakers and the judges. (i will not contest the new power, the media, having a big impact as well).
In aviation there was a comparable set up with the company executives, the aviation authorities and the genuine postholders of safety within the company or some NTSB. (the unions also playing a part in it).
Today the company executives pay all of them and practically own them at least politically through economical blackmail. Rising big powers in Asia are set up in dictatorship countries anyway. The unions are almost eliminated and the media is so incompetent, that their impact is controllable. The big manufacturers play along, as it serves them well. The outcome is blatantly readable on more and more accident reports, but only for insiders, as it is well masked by the mighty interest groups.
It will not change, as it works nicely on the bonus side. Victims don't matter as long as the numbers stay below an unfortunately very high public trigger.
So brace for more automatic induced and low training enhanced accidents. The warnings on threads like this will only serve as cover-up in a future rude awakening.
For example:
" ... there were some voices among the professionals, but they should have stressed their point much stronger at that time, after all they were in charge of the final safety. So in effect the professionals bare the main responsibility for the present catastrophe, as the engineers and CEOs couldn't have fully known the impact of their actions ."
In aviation there was a comparable set up with the company executives, the aviation authorities and the genuine postholders of safety within the company or some NTSB. (the unions also playing a part in it).
Today the company executives pay all of them and practically own them at least politically through economical blackmail. Rising big powers in Asia are set up in dictatorship countries anyway. The unions are almost eliminated and the media is so incompetent, that their impact is controllable. The big manufacturers play along, as it serves them well. The outcome is blatantly readable on more and more accident reports, but only for insiders, as it is well masked by the mighty interest groups.
It will not change, as it works nicely on the bonus side. Victims don't matter as long as the numbers stay below an unfortunately very high public trigger.
So brace for more automatic induced and low training enhanced accidents. The warnings on threads like this will only serve as cover-up in a future rude awakening.
For example:
" ... there were some voices among the professionals, but they should have stressed their point much stronger at that time, after all they were in charge of the final safety. So in effect the professionals bare the main responsibility for the present catastrophe, as the engineers and CEOs couldn't have fully known the impact of their actions ."
Last edited by Gretchenfrage; 16th Jan 2011 at 04:56.
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Human Beings are inherently poor multi-taskers. We are also poor monitors. We are better monitors than multi-taskers. Automation can reduce the multi-tasking making the operation safer, but we need to train people to be better monitors so the automation can do whats its intended to do,make things safer; not complicate the situation. Complacency is similar to fatigue. You don't know you're introuble/tired until its often too late.
If humans are involved, mistakes will happen. Computers are programmed by humans.
As automation becomes more commonplace; we must always ask ourselves, is the automation doing what its supposed to do? We must always crosscheck the automation. Keep that scan going!
Edited on the advice of the next poster. Good catch, thats exactly right!?!:"+)
If humans are involved, mistakes will happen. Computers are programmed by humans.
As automation becomes more commonplace; we must always ask ourselves, is the automation doing what its supposed to do? We must always crosscheck the automation. Keep that scan going!
Edited on the advice of the next poster. Good catch, thats exactly right!?!:"+)
Last edited by Willit Run; 16th Jan 2011 at 22:26. Reason: improper punctuation
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Willit Run:
You ended the next to last sentence with a question mark. I don't believe that is what you intended. (?) 
Unless the crew fully understands the automation and all of its possible annunciations and nuances, they will not be successful (or valid) monitors in all circumstances.
The near loss of the 747 discussed earlier in this thread is a classic example. The autopilot gave a stark indication by attempting to do with aileron what needed to be accomplished with rudder, and the engine instrumentation gave indications, all of which were ignored.
I suppose the Boeing designers could have also been faulted for not having a full-time three axis autopilot on a modern design aircraft. (if my recollection is correct that it was a 747-400.)
As automation becomes more commonplace; we must always ask ourselves, is the automation doing what its supposed to do? We must always crosscheck the automation? Keep that scan going!
Unless the crew fully understands the automation and all of its possible annunciations and nuances, they will not be successful (or valid) monitors in all circumstances.
The near loss of the 747 discussed earlier in this thread is a classic example. The autopilot gave a stark indication by attempting to do with aileron what needed to be accomplished with rudder, and the engine instrumentation gave indications, all of which were ignored.
I suppose the Boeing designers could have also been faulted for not having a full-time three axis autopilot on a modern design aircraft. (if my recollection is correct that it was a 747-400.)
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Nope, it was a 747SP - manufactured in 1982, but definitely one of the older models.
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Originally Posted by RAT 5
I found it amazing that in the Cali B757 crash they tried to blame Jeppeson and Boeing. Incredible. It was a major human screw up, up front.
There is no "tried to". The named manufacturers were responsible for features of their products that demonstrably played a causal role in the accident. You may read about those features in the NSTB letter on the accident to the FAA. A Texas court later found those manufacturers partly responsible, because of the causal factors of the accident contributed by those features of their designs. The courts are, sometimes, able to follow careful causal arguments that don't rely on the gut reactions of casual observers, and pilots everywhere should be grateful for that.
Accident analysts look at all the factors. When you say "major human screw up", I take it you mean that the behavior of two pilots + controller was solely responsible for the accident, and that features of the nav database and FMC programming were not at all responsible. If that is what you are claiming, it is demonstrably mistaken: check out our causal analysis from 14 years ago at http://www.rvs.uni-bielefeld.de/publ...i_accident.pdf
If, rather, you are claiming something milder, such as "yes, features of those products did play a role, but the human-behavioral components on the day were so much more important causal factors", then you owe us a definition of what makes a "more important" causal factor and what makes a "less important" causal factor, and a demonstration that, according to your criterion, the features of the automation provided by those companies was unimportant. And while you do that, you can explain your disagreement with the NTSB and the Texas court along with it. Good luck with that.
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DozyWannabe:
Thanks for the correction.
In that case, the supposed "short stop" F/E was apparently asleep at the switch, too.
Nope, it was a 747SP - manufactured in 1982, but definitely one of the older models.
In that case, the supposed "short stop" F/E was apparently asleep at the switch, too.
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What he did not do was inform the captain that he'd ordered a restart of the engine when the aircraft was 11,000 feet higher than the maximum relight altitude - but I'm not sure if that was either a memory item for the FE, or in the QRH.
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While standards, professionalism and the career/job itself have changed almost singularly through the hands of non-aviation people who, among many things they must deal with to keep their enterprise going in a neoliberal political economy must eke out a profit for speculative and sometimes-fickle shareholders who reward slowly and punish quickly, do so by taking money from the only "flexible" source left ... where the effects of fiscal parsimony do not show themselves right away thus making them easy targets for bottom-line thinking and meetings with the CEO and COO.
The "neoliberal political economy - the set of notions de-regulating business to release it to free-market forces, the privatization of all services, including regulatory oversight, (SMS), which formerly came under government responsibility and which began in the US in the early 1970s and which effects and outcomes have been latent up until the mid-80's or so...
Many here "get it" and have already clearly stated that "automation" is not the problem - it is the belief by non-aviation people who have grown up in a software/microprocessor age and who manage the business of aviation but don't or can't manage "aviation" itself believing, for whatever reasons, that "these airplanes fly themselves", and that professional pilots are just expensive add-ons to the bottom line which can, and have, been cut.
I bang on about this a lot, but the whole "plane can fly itself, will pilots become obsolete?" spiel has only ever come from - and been propagated by - the press (and maybe a couple of sales guys who took things a little too far have said the former). Given the short shrift so many on here ascribe to the accuracy of reporting in aviation matters it really bothers me that some pilots on here seem to think that journalists are on to something in that case.
An MBA from Harvard or whereever does not teach someone about aviation - it teaches one about business principles in which the discourse is "profit, loss, and cost control".
We long ago lost the third crew member and our defence, based upon flight safety, was dismissed as "union featherbedding" - an effective if not rhetorical technique which easily convinced non-aviation, anti-union designers, manufacturers and airline managements.
The difficulty now emerging is for those who, despite the atrocious pay, the terrible working conditions and the constant dissing and lack of respect for what pilots do for aviation and for their companies, still choose to come into the profession, is that these changes are "normal", and, (like the Colgan First Officer), don't know what they dont' know about the profession and are not being mentored or taught by those who do know.
What I would envision within the severe limits of the present political economy is a hearty respect for what one's operations people are saying, first among those being the people at the pointy end of the airplane. SMS is about data, so staffing and resourcing programs which can tell non-aviation people just how close they're getting to the bone and where the risks and precursors to an accident are, is absolutely necessary notwithstanding that such programs and departments aren't traditional "profit-centers".
It got to the point about two decades ago where some middle managers started aping them, professing not to care about how the employees they were responsible for did their work, only that it was done. Some of those took it so far as refusing to listen to employees who tried to explain that their targets were unrealistic, and took it out on those employees when the wheels came off as predicted.
The operations people are therefore facing the unenviable task of telling management things they don't want to hear, and if they are unlucky, reporting to the kind of manager who will threaten their job if they don't come up with something more palatable to the board. In an extended recession, the situation is even more perilous and it becomes a question of who is willing to stick their neck out and potentially risk everything for the sake of pointing out something is unsafe when there is a very real chance that they will simply be sacked and replaced by someone who is willing to do things the way the board wants, no matter how unsafe.
Then, even when the midden hits the windmill, the executives - who by and large negotiate their own contracts with clauses to deal with such things - simply take their six or seven figure golden parachute and leave the company. Most of them will find employment again in short order, and even if they don't the value of their severance pay alone will allow them to make investments that will keep them in a very comfortable lifestyle to the end of their days. Again, contrast this with the Japanese/Asian model where executives must take cuts in pay if the company fails to perform.
In short "Too Big To Fail" isn't new, it isn't just about banks and it's just about as corrosive a system as can be designed.
Now, I realise I've gone way over the bounds of an "Automation" topic, but I had to get this off my chest - thanks to PJ2 for providing the springboard.
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PBL:
That Texas jury was hoodwinked by deep-pocket-seeking plaintiffs' litigators.
Further, the NTSB has less than a sterling record of objective and competent analysis. And, Cali was not their investigation in any case.
My throat is sore from saying it over and over. :
These guys were trying to fly a non-LNAV VOR/DME combination arrival/IAP and throwing in an attempt at a short-cut in a non-radar environment. It would have been so easy to:
1. Gone to heading mode and raw data to sort things out.
(I believe AAL policy at the time required that one of them be in raw data mode.) (They finally did go to heading mode, but far too late.)
2. Have stopped a wild, excursion out of protected airspace while continuing a wild-a**ed descent with spoilers extended.
3. The course change was unwarranted on its face.
RAT 5, I am going to be somewhat more harsh than Dozy Wannabe, because the available information and analysis has been out there, in full view, on the WWW, for some 14 years now.
There is no "tried to". The named manufacturers were responsible for features of their products that demonstrably played a causal role in the accident. You may read about those features in the NSTB letter on the accident to the FAA. A Texas court later found those manufacturers partly responsible, because of the causal factors of the accident contributed by those features of their designs. The courts are, sometimes, able to follow careful causal arguments that don't rely on the gut reactions of casual observers, and pilots everywhere should be grateful for that.
There is no "tried to". The named manufacturers were responsible for features of their products that demonstrably played a causal role in the accident. You may read about those features in the NSTB letter on the accident to the FAA. A Texas court later found those manufacturers partly responsible, because of the causal factors of the accident contributed by those features of their designs. The courts are, sometimes, able to follow careful causal arguments that don't rely on the gut reactions of casual observers, and pilots everywhere should be grateful for that.
Further, the NTSB has less than a sterling record of objective and competent analysis. And, Cali was not their investigation in any case.
My throat is sore from saying it over and over.
:These guys were trying to fly a non-LNAV VOR/DME combination arrival/IAP and throwing in an attempt at a short-cut in a non-radar environment. It would have been so easy to:
1. Gone to heading mode and raw data to sort things out.
(I believe AAL policy at the time required that one of them be in raw data mode.) (They finally did go to heading mode, but far too late.)
2. Have stopped a wild, excursion out of protected airspace while continuing a wild-a**ed descent with spoilers extended.
3. The course change was unwarranted on its face.
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aterpster:
That's why the chart/FMS mismatch was considered a "contributing" cause rather than a "primary" cause (most of which were variations on loss of SA on the part of the crew).
Nevertheless, the mismatch did contribute and was proven to contribute. I don't mean to sound harsh, but the fact that you feel the flight crew should have done things fundamentally differently doesn't alter the situation.
One thing that we're skipping in this case, which relates to what PJ2 was saying regarding management pressure was that the whole reason they agreed to expediting the arrival was because they were concerned about delays - go back far enough and this crash was another example of the dangers of "Get-there-itis".
That's why the chart/FMS mismatch was considered a "contributing" cause rather than a "primary" cause (most of which were variations on loss of SA on the part of the crew).
Nevertheless, the mismatch did contribute and was proven to contribute. I don't mean to sound harsh, but the fact that you feel the flight crew should have done things fundamentally differently doesn't alter the situation.
One thing that we're skipping in this case, which relates to what PJ2 was saying regarding management pressure was that the whole reason they agreed to expediting the arrival was because they were concerned about delays - go back far enough and this crash was another example of the dangers of "Get-there-itis".
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DozyWannabe:
No, I don't see you as being too harsh. You and I have a different view of the facts.
The four probable causes makes it quite clear the Colombia investigators reached the same operational conclusion that I did. I have no quarrel with their probable causes. But, in the area of contributing factors I believe they were expecting more of 1995 FMS databases (i.e., be the "same" as the paper chart) than was realistic. In fact, the same circustances exist today in many, if not most FMSes: select either direct-to a downstream waypoint or VTF, and "poof" the legs page no longer resembles the paper (or electronic) chart.
Also, as discussed in the report, no doubt that "get there itis" really had this crew hooked. Nonetheless, had they been sufficiently sharp to have simply reverted to raw data, they could have been quickly back on track and had sufficient distance remaining to the airport that a speed-brake assisted descent would have gotten them down in time for a landing on Runway 19.
From the Colombian report:
3.2 Probable Cause
Aeronautica Civil determines that the probable causes of this accident were:
1. The flightcrew's failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation.
2. Failure of the flightcrew to discontinue the approach into Cali, despite numerous cues alerting them of the inadvisability of continuing the approach.
3. The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids.
4. Failure of the flightcrew to revert to basic radio navigation at the time when the FMS-assisted navigation became confusing and demanded an excessive workload in a critieal phase of the flight.
3.3 Contributing Factors
Contributing to the cause of the accident were:
1. The flightcrew's ongoing efforts to expedite their approach and landing in order to avoid potential delays.
2. The flightcrew's execution of the GPWS escape maneuver while the speedbrakes remained deployed.
3. FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing.
4. FMS-generated navigational information that used a different naming convention from that published in navigational charts.
aterpster:
That's why the chart/FMS mismatch was considered a "contributing" cause rather than a "primary" cause (most of which were variations on loss of SA on the part of the crew).
Nevertheless, the mismatch did contribute and was proven to contribute. I don't mean to sound harsh, but the fact that you feel the flight crew should have done things fundamentally differently doesn't alter the situation.
That's why the chart/FMS mismatch was considered a "contributing" cause rather than a "primary" cause (most of which were variations on loss of SA on the part of the crew).
Nevertheless, the mismatch did contribute and was proven to contribute. I don't mean to sound harsh, but the fact that you feel the flight crew should have done things fundamentally differently doesn't alter the situation.
The four probable causes makes it quite clear the Colombia investigators reached the same operational conclusion that I did. I have no quarrel with their probable causes. But, in the area of contributing factors I believe they were expecting more of 1995 FMS databases (i.e., be the "same" as the paper chart) than was realistic. In fact, the same circustances exist today in many, if not most FMSes: select either direct-to a downstream waypoint or VTF, and "poof" the legs page no longer resembles the paper (or electronic) chart.
Also, as discussed in the report, no doubt that "get there itis" really had this crew hooked. Nonetheless, had they been sufficiently sharp to have simply reverted to raw data, they could have been quickly back on track and had sufficient distance remaining to the airport that a speed-brake assisted descent would have gotten them down in time for a landing on Runway 19.
From the Colombian report:
3.2 Probable Cause
Aeronautica Civil determines that the probable causes of this accident were:
1. The flightcrew's failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation.
2. Failure of the flightcrew to discontinue the approach into Cali, despite numerous cues alerting them of the inadvisability of continuing the approach.
3. The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids.
4. Failure of the flightcrew to revert to basic radio navigation at the time when the FMS-assisted navigation became confusing and demanded an excessive workload in a critieal phase of the flight.
3.3 Contributing Factors
Contributing to the cause of the accident were:
1. The flightcrew's ongoing efforts to expedite their approach and landing in order to avoid potential delays.
2. The flightcrew's execution of the GPWS escape maneuver while the speedbrakes remained deployed.
3. FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing.
4. FMS-generated navigational information that used a different naming convention from that published in navigational charts.
Last edited by aterpster; 16th Jan 2011 at 23:16. Reason: correct accident report format
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I flew into San Salvador the night of the Cali crash and my FO was concerned about our VMC circling approach. There was no moon so even in clear conditions you could not see terrain. I flew the Cali flight the next several months after checking out in the 757. I always flew the whole ILS approach after what happened. One night they cleared me for the 19 straight in approach and I declined it because so many had died doing it even though I could see the runway with calm winds. It just didn't seem right to do an easy approach that had proved fatal to so many. Situational awareness was their problem. They went heads down and forgot to fly the airplane. They turned east because of the Bogota R outer marker showed up first on the FMC. I don't know why they didn't notice the left 90 degree turn putting them into the mountains. Yes it was pilot error that was helped by computer generated data. It should have never happened with a crew paying attention to the store.
Last edited by bubbers44; 17th Jan 2011 at 00:32. Reason: spelling
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Bubbers 44 has hit the nail on the head....it is discipline. It is knowing that their is a ''shortcut" and not taking it because there can be a fatal flaw when things aren't perfect.
Going to an airport you've never been to? Take the full ILS and don't just head for the nearest airport.
Ask for a radar point out even on a beautiful day.
And, a real killer, ask for progressive taxi instructions if the airport has construction or something odd going on.
And I think the biggest one...if the weather is bad, always wait 15 minutes. If it gets worse, you are vindicated. If it gets better, you were just waiting for a better ride for the passengers.
Going to an airport you've never been to? Take the full ILS and don't just head for the nearest airport.
Ask for a radar point out even on a beautiful day.
And, a real killer, ask for progressive taxi instructions if the airport has construction or something odd going on.
And I think the biggest one...if the weather is bad, always wait 15 minutes. If it gets worse, you are vindicated. If it gets better, you were just waiting for a better ride for the passengers.
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terpster,
it is likely we are not going to agree on the Cali analysis, but at least we could agree on what the criteria for a proper causal analysis are, and hammer out the differences.
That is all ad hominem stuff.
Further, I refute your suggestion that the people I know at the NTSB who were involved with that analysis are neither competent nor objective. The mystery of the left turn was solved by the NTSB investigator who found the non-volatile FMC memory amongst the rubble (that is the same guy who solved the TWA800 case, BTW. Just to have those two on the resume is a good lifetime's work, in my opinion). The human factors work was undertaken by the same investigator who introduced the questions about biorhythms and alertness physiology for the very first time in any accident investigation into the 1985 China Air Lines upset over the Pacific, which I regard as a milestone in accident investigation.
However, we both know that that ad hominem commentary is not your real argument. You real argument is more careful. Our argument is contained in the paper I referenced.
BTW, the conclusions to which the NTSB came are not necessarily the same conclusions to which the Colombian investigators came; as you say, it was Colombia's show. And citing the list of causes as listed in the accident report neglects the unfortunately pervasive fact that the causal reasoning in most accident reports is nowhere near rigorous (read: there are mistakes in that reasoning in at least half of the reports we have analysed). You are not arguing with the report when you are arguing with me: you are arguing with our work, not theirs.
You have a list of causal factors which make your throat sore I do not disagree that those were causal factors. What I would like to know is what criteria you are using to rule out the other demonstrable causal factors. You are picking and choosing and I want to know how and why.
Further, I want to know what exactly is wrong with the causal analysis we presented a decade and a half ago in that paper. I don't see any mistakes in it. If you can't find mistakes in it, they you haven't refuted it adequately just by saying you disagree.
PBL
it is likely we are not going to agree on the Cali analysis, but at least we could agree on what the criteria for a proper causal analysis are, and hammer out the differences.
Originally Posted by aterpster
That Texas jury was hoodwinked by deep-pocket-seeking plaintiffs' litigators.
Further, the NTSB has less than a sterling record of objective and competent analysis. And, Cali was not their investigation in any case.
My throat is sore from saying it over and over. :
Further, the NTSB has less than a sterling record of objective and competent analysis. And, Cali was not their investigation in any case.
My throat is sore from saying it over and over. :
Further, I refute your suggestion that the people I know at the NTSB who were involved with that analysis are neither competent nor objective. The mystery of the left turn was solved by the NTSB investigator who found the non-volatile FMC memory amongst the rubble (that is the same guy who solved the TWA800 case, BTW. Just to have those two on the resume is a good lifetime's work, in my opinion). The human factors work was undertaken by the same investigator who introduced the questions about biorhythms and alertness physiology for the very first time in any accident investigation into the 1985 China Air Lines upset over the Pacific, which I regard as a milestone in accident investigation.
However, we both know that that ad hominem commentary is not your real argument. You real argument is more careful. Our argument is contained in the paper I referenced.
BTW, the conclusions to which the NTSB came are not necessarily the same conclusions to which the Colombian investigators came; as you say, it was Colombia's show. And citing the list of causes as listed in the accident report neglects the unfortunately pervasive fact that the causal reasoning in most accident reports is nowhere near rigorous (read: there are mistakes in that reasoning in at least half of the reports we have analysed). You are not arguing with the report when you are arguing with me: you are arguing with our work, not theirs.
You have a list of causal factors which make your throat sore
I do not disagree that those were causal factors. What I would like to know is what criteria you are using to rule out the other demonstrable causal factors. You are picking and choosing and I want to know how and why. Further, I want to know what exactly is wrong with the causal analysis we presented a decade and a half ago in that paper. I don't see any mistakes in it. If you can't find mistakes in it, they you haven't refuted it adequately just by saying you disagree.
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Nonetheless, had they been sufficiently sharp to have simply reverted to raw data, they could have been quickly back on track
A quick 30 second switch-over to the VOR/ILS HSI mode - coupled with an RMI reading and a DME reading, would have proved instantly where they were in relation to the MSA. But we regularly saw crews so rusty on basic radio navigation aid position fixing techniques, that it became readily apparent they did not know - or had forgotten - how to interpret their basic nav instruments.
So whatever raw data they had available, and in theory were supposed to be monitoring, meant nothing.
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PBL:
Link me to your paper and I will read it carefully.
My issue is squarely with relating their misuse of the FMS, auotflight, and navdata becoming in any way a liability for anyone other than American Airlines, and only in the context of their agents' inept operation of the flight. The analysis of the FMS was fine to point out limitations of which the crew should have been aware. But, some of those limitations still exist today; hopefully all crews understand them better.
I was a "pioneer pilot" on the 767 having started training in 1983 and flew it unil April, 1986. We reverted to raw data periodically as a matter of staying proficient in all of the options.
Further, I want to know what exactly is wrong with the causal analysis we presented a decade and a half ago in that paper. I don't see any mistakes in it. If you can't find mistakes in it, they you haven't refuted it adequately just by saying you disagree.
My issue is squarely with relating their misuse of the FMS, auotflight, and navdata becoming in any way a liability for anyone other than American Airlines, and only in the context of their agents' inept operation of the flight. The analysis of the FMS was fine to point out limitations of which the crew should have been aware. But, some of those limitations still exist today; hopefully all crews understand them better.
I was a "pioneer pilot" on the 767 having started training in 1983 and flew it unil April, 1986. We reverted to raw data periodically as a matter of staying proficient in all of the options.
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PBL:
Just after the Colombians made a preliminary press release, I opined about the accident on my web site. A few months later I wrote an aritcle about the accident for the Air Line Pilot Magazine:
Here is the opinion part of my posting on my web site some 15 years ago:
MY OBSERVATIONS AND COMMENTS ABOUT THE ACCIDENT:
The instrument approach from the north at Cali, and its essentially identical terminal arrival procedure, proceed via a dogleg approach course. This approach course begins at Tulua VOR and proceeds down a canyon that just has room for standard instrument flight rules (IFR) terminal and approach procedural airspace. The majority of the instrument approach procedure can be flown at as low as 5,000 feet, msl, in a canyon with terrain rising steeply to 13,000 feet to the east, and over 6,000 feet to the west.
The non-radar services provided by the Cali ATC controller were completely correct and in accordance with accepted international standards. Further, the controller knew that it was essential that AAL 965 begin the approach at its mandated beginning: the Tulua VOR. This is evidenced by his repeated requests for a Tulua mandatory position report.
Although it would have been helpful had the flightcrew had intimate familiarity with the terrain along the approach course, such knowledge was not essential to the safe use of the approach procedure. Instead, the crew should have been conditioned to know that an approach without an ATC-provided radar vector must be flown in its entirety. In this case, that meant starting the approach at Tulua VOR without exception.
However, pilots trained in the United States, and who generally fly in the United States have, as a group, been lulled into generally thinking in terms of instrument approaches in a radar-driven ATC environment. Plus, to move traffic, the FAA itself encourages shortcuts with a wink and an approving nod, so to speak. Air carrier simulator and ground school training deals with radar vectors to the approach's final approach course as a matter of routine.
Further complicating the mix are the area nav systems on modern airline aircraft, which make it easy and tempting to always cut the corner, and go: direct, direct. This is fine in a radar enroute environment, but it killed the crew and passengers of AAL 965. Imaginary TERPs containment areas prior to the final approach segment are routinely breached during non-radar operations within the United States. This is because of inadequate training and understanding by pilots, ATC controllers and, today, most of FAA's management, about the essential requirements to fly the entire instrument approach procedure with absolute compliance. Usually, the transgression is forgiven, because there are no rock walls in the area beyond the protected airspace. But, the rocks can exist, as they do north of Cali Airport. As the United States pushes forward with GPS approach procedures, we will see more approaches hugging the canyon walls, so to speak. Yet, the FAA seems oblivious to the problem.
ALPA's Charting and Instrument Procedures Committee (CHIPs) has been urging the FAA for over three years to publish first-rate, instructional and directive information about all the critical nuances of proper flying of the full instrument approach and IFR departure procedures. These efforts have gone nowhere with a unresponsive FAA. Further, the CHIPs Committee forced the FAA to issue a legal interpretation that, excepting a radar vector, an instrument approach must begin at the appropriate feeder fix or initial approach fix (IAF). But, the FAA refuses to publish this requirement in the Aeronautical Information Manual, much less widely disseminate comprehensive guidance to the aviation community. Because of lack of FAA leadership, it is probably a rare air carrier recurrent training program that addresses these IAF issues at all.
Further, the FAA, in a rush to develop 500 new GPS instrument approach procedures, is creating deadly gaps in these new instrument procedures by violating their own criteria. Instead of always tying the beginning and end points of these new instrument approach procedures to the published enroute airway structure, they are leaving deliberate gaps for pilots and air traffic controllers to try to work through. Also, these approach procedures are often designed to encourage shortcuts around required segments, because of lack of flexible design of individual approach procedures.
The FAA is now pointing the finger at American Airlines' training when, instead, they should be pointing the finger at themselves. Like the cancer that had grown in the ATC system that resulted in the TWA 514 crash at Dulles Airport on December 1, 1974, a similar FAA-induced infection can be seen in the recent crash at Cali.
The crew obviously lacked recent, good training on the essential requirement to begin the approach at the IAF. Instead, they took full "advantage" of their modern glass-cockpit, area nav system, and simply punched in the approach fix nearest the airport which, in this case, was a stepdown fix in the final approach segment of the approach. This confusion and lack of essential understanding was compounded by this stepdown fix (ROZO) being the name of the arrival procedure. Thus, the crew established a flight track that, although it converged with the instrument approach criteria's mandated protected airspace, it was outside of that minimal airspace, which resulted in the airplane literally scrapping the canyon wall.
In conclusion, I submit that more professional flight crews than not would have made a similar fatal mistake had they been in this situation. This can be directly laid at the door of an unresponsive, disjointed FAA.
Just after the Colombians made a preliminary press release, I opined about the accident on my web site. A few months later I wrote an aritcle about the accident for the Air Line Pilot Magazine:
Here is the opinion part of my posting on my web site some 15 years ago:
MY OBSERVATIONS AND COMMENTS ABOUT THE ACCIDENT:
The instrument approach from the north at Cali, and its essentially identical terminal arrival procedure, proceed via a dogleg approach course. This approach course begins at Tulua VOR and proceeds down a canyon that just has room for standard instrument flight rules (IFR) terminal and approach procedural airspace. The majority of the instrument approach procedure can be flown at as low as 5,000 feet, msl, in a canyon with terrain rising steeply to 13,000 feet to the east, and over 6,000 feet to the west.
The non-radar services provided by the Cali ATC controller were completely correct and in accordance with accepted international standards. Further, the controller knew that it was essential that AAL 965 begin the approach at its mandated beginning: the Tulua VOR. This is evidenced by his repeated requests for a Tulua mandatory position report.
Although it would have been helpful had the flightcrew had intimate familiarity with the terrain along the approach course, such knowledge was not essential to the safe use of the approach procedure. Instead, the crew should have been conditioned to know that an approach without an ATC-provided radar vector must be flown in its entirety. In this case, that meant starting the approach at Tulua VOR without exception.
However, pilots trained in the United States, and who generally fly in the United States have, as a group, been lulled into generally thinking in terms of instrument approaches in a radar-driven ATC environment. Plus, to move traffic, the FAA itself encourages shortcuts with a wink and an approving nod, so to speak. Air carrier simulator and ground school training deals with radar vectors to the approach's final approach course as a matter of routine.
Further complicating the mix are the area nav systems on modern airline aircraft, which make it easy and tempting to always cut the corner, and go: direct, direct. This is fine in a radar enroute environment, but it killed the crew and passengers of AAL 965. Imaginary TERPs containment areas prior to the final approach segment are routinely breached during non-radar operations within the United States. This is because of inadequate training and understanding by pilots, ATC controllers and, today, most of FAA's management, about the essential requirements to fly the entire instrument approach procedure with absolute compliance. Usually, the transgression is forgiven, because there are no rock walls in the area beyond the protected airspace. But, the rocks can exist, as they do north of Cali Airport. As the United States pushes forward with GPS approach procedures, we will see more approaches hugging the canyon walls, so to speak. Yet, the FAA seems oblivious to the problem.
ALPA's Charting and Instrument Procedures Committee (CHIPs) has been urging the FAA for over three years to publish first-rate, instructional and directive information about all the critical nuances of proper flying of the full instrument approach and IFR departure procedures. These efforts have gone nowhere with a unresponsive FAA. Further, the CHIPs Committee forced the FAA to issue a legal interpretation that, excepting a radar vector, an instrument approach must begin at the appropriate feeder fix or initial approach fix (IAF). But, the FAA refuses to publish this requirement in the Aeronautical Information Manual, much less widely disseminate comprehensive guidance to the aviation community. Because of lack of FAA leadership, it is probably a rare air carrier recurrent training program that addresses these IAF issues at all.
Further, the FAA, in a rush to develop 500 new GPS instrument approach procedures, is creating deadly gaps in these new instrument procedures by violating their own criteria. Instead of always tying the beginning and end points of these new instrument approach procedures to the published enroute airway structure, they are leaving deliberate gaps for pilots and air traffic controllers to try to work through. Also, these approach procedures are often designed to encourage shortcuts around required segments, because of lack of flexible design of individual approach procedures.
The FAA is now pointing the finger at American Airlines' training when, instead, they should be pointing the finger at themselves. Like the cancer that had grown in the ATC system that resulted in the TWA 514 crash at Dulles Airport on December 1, 1974, a similar FAA-induced infection can be seen in the recent crash at Cali.
The crew obviously lacked recent, good training on the essential requirement to begin the approach at the IAF. Instead, they took full "advantage" of their modern glass-cockpit, area nav system, and simply punched in the approach fix nearest the airport which, in this case, was a stepdown fix in the final approach segment of the approach. This confusion and lack of essential understanding was compounded by this stepdown fix (ROZO) being the name of the arrival procedure. Thus, the crew established a flight track that, although it converged with the instrument approach criteria's mandated protected airspace, it was outside of that minimal airspace, which resulted in the airplane literally scrapping the canyon wall.
In conclusion, I submit that more professional flight crews than not would have made a similar fatal mistake had they been in this situation. This can be directly laid at the door of an unresponsive, disjointed FAA.
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Tee Emm:
If so that was grossly inexcusable. This was not an RNAV IAP. They had no need to use RMIs. They had just passed the IAF (ULQ) and when confusion ensued, a switch to raw data VOR/DME and selecting the 202 Radial would have been all they needed to do. There was no need to use RMIs or do fix positioning.
This is the VOR/DME chart they were using:
http://tinyurl.com/4jcxrld
So whatever raw data they had available, and in theory were supposed to be monitoring, meant nothing.
This is the VOR/DME chart they were using:
http://tinyurl.com/4jcxrld
Last edited by aterpster; 17th Jan 2011 at 16:34. Reason: correct "past" to "passed"
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the 4 dimensional mind
when I first read about flying , thinking in three dimensions was part of the equation...up/down, left right/ forward back....but we must add time into that process, so, let's say 4 dimensions.
I think modern automation reduces the mind's capability to think in 4 dimensions. Whether really good pilots know it or not, they are working all the time in 4 dimensions.
Using RMIs is sort of tough and your must project your position upon a chart for terrain reference/safe altitudes.
Are our minds becoming weaker? I think so. Or if not weaker, more clouded by gadgets instead of using the imagination to know where we are in 4 dimensions.
When I was first learning to fly in California, USA...a number of radar mistakes lead airplanes into the sides of mountains. when I first flew to one of these airports, I insisted on flying the entire procedure as published...it added quite a bit of time to the flight, but I knew where I was every step of the way...right down to minimums.
Anyone here think flying is easy? Well, it isn't...if you aren't firing on all 8 cylinders of the mind, you aren't doing your job.
I think modern automation reduces the mind's capability to think in 4 dimensions. Whether really good pilots know it or not, they are working all the time in 4 dimensions.
Using RMIs is sort of tough and your must project your position upon a chart for terrain reference/safe altitudes.
Are our minds becoming weaker? I think so. Or if not weaker, more clouded by gadgets instead of using the imagination to know where we are in 4 dimensions.
When I was first learning to fly in California, USA...a number of radar mistakes lead airplanes into the sides of mountains. when I first flew to one of these airports, I insisted on flying the entire procedure as published...it added quite a bit of time to the flight, but I knew where I was every step of the way...right down to minimums.
Anyone here think flying is easy? Well, it isn't...if you aren't firing on all 8 cylinders of the mind, you aren't doing your job.