Halifax crash report coming Thursday

[Commonwealth]

The report finds 14 causes and contributing factors. IMO, items 1 through 8 should be heeded by all cockpit crew members. There is much to learn for all of us. This crew had nearly 23,000 hrs of experience between them and the swiss cheese still lined up.

I'm not sure about this being a watershed moment, but I bet every CP and DFO in Canada will be looking over their procedures to see if their operation is vulnerable to an accident like this. My guess is that most operations likely are.

CW

[Cat Driver]

When did they change the rules for landing?

When I was flying IFR in IMC the approach plates had a minimum's for descending and at that point we had to have visual contact with the runway to descend any further or we did a missed approach.

If they had proper visual contact with the runway at the legal height and could see the runway it is not the fault of anyone except the pilots.

[Snagmaster E]

Figure 15 on page 50 says it all.

Basically the FPA mode achieves the desired descent angle in still air - works most of the time when the wind is not too strong.

One would have thought that FPA would be referenced to the touchdown point with GPS or IRS providing corrections. However the aircraft was not equipped with GPS.

The aerodynamicists will point out that FPA needs to be in the Earth Frame, not the Wind Frame.

The Airbus FPA mode is actually quite complex and not well understood. It is not geometric, but attempts to be by comparing barometric vertical speed changes to IRS computed ground speed. The wind is factored in through IRS ground speed calculations but obviously the calculation is not completely instantaneous.

The FPA is not referenced to the touchdown point and if the aircraft deviates from the appropriate glidepath it will not return to that glidepath. Instead it will only attempt to regain the selected flight path angle. For example, if the aircraft is disturbed (through external perturbations), 200 feet below the intended glidepath, the aircraft will attempt to regain the selected FPA and parallel the initial glidepath rather than climb up to correct for the disturbance.

Agreed. Nobody touched on this though: Report shows descent started 0.2 back from FAF, as opposed to over it, as it should be, and then was 0.3 back from profile MDA. Sooooo they were already 1216 further back upon beginning of descent. Where would that put you? They would have been past the threshold if they had started just over the FAF, assuming all things being equal. 608' is on the runway. Seems like that's an error on AC's SOP's, as it tells them to go down .3 before....It was low at the start.

[Cliff Jumper]

I'm confused. Maybe I read it too quick and missed something....

The report '#1 cause' somewhat hinges on the crew not cross checking their altitude vs distance, but doesn't suggest how they would do that with a cold temp correction to the FAF altitude. Were they supposed to add that correction to all the cross check points? Seems like that would skew the numbers, and you'd end up way to high.

Even if they had crossed checked (perfectly) using the chart in this case, it seems as though they wouldn't have noticed they were appreciably below published VDA until about ~1.3nm from the runway, with ~120 ft to go to MDA. Even then it was only about 50 feet low.

I'm not sure I want the PM to add the VDA section of the approach plate to his scan with 100 feet to go... maybe that's just me.

[BTD]

The crew believed they had the runway in sight. They didn't knowingly descend below the mda without the required visual reference. It is hard to tell from the report if they actually saw the runway environment or just believed they did.

The idea starting down .3 back is that it takes time for the aircraft to pitch over to aquire the FPA. Whether that is an appropriate amount or not can be debated, but those are the sops and the crew followed them.

[Commonwealth]

Many operators use 0.3 NM before the FAF to initiate descent when flying a SCDA approach. This is the case whether the approach is flown using FPA or V/S

[Cat Driver]

It is hard to tell from the report if they actually saw the runway environment or just believed they did.

Wow....

and we are supposed to fly with crews that can not figure out if they can see the runway or are imagining they can see it..

Good defense of that accident though, they were not sure so they just touched down to see if it was a runway or not.

[Cat Driver]

It is hard to tell from the report if they actually saw the runway environment or just believed they did.

Wow....

and we are supposed to fly with crews that can not figure out if they can see the runway or are imagining they can see it..

Good defense of that accident though, they were not sure so they just touched down to see if it was a runway or not.

[Rockie]

All in all a disappointing report. No recommendations and no safety action taken by Transport Canada.

Basically back to our regularly scheduled programming.

[CpnCrunch]

Wow....

and we are supposed to fly with crews that can not figure out if they can see the runway or are imagining they can see it..

Good defense of that accident though, they were not sure so they just touched down to see if it was a runway or not.

They saw the approach lights, and the report calculated that the lights would have been visible from MDA. Perhaps you should read it.

[telex]

Did the airplane do exactly as commanded with the selection of the FPA?

It's a stretch to say "this slope" put them in the weeds. If anything, "this slope" added a buffer.

Cat Driver give your head a shake.

They were on the FPA "glide slope" saw the lights and continued. Turns out this slope put them into the weeds though... with the poor visibility on a black hole approach they didn't recognise the information provided to them was wrong until it was too late.

could they have done better? of course, but they were lead into a bit of a trap.

- inaccurate fpa guidance
- inadequate lighting
- lighting improperly set by the controller who was paying more attention to snow plows
- inadequate approach facilities
- inadequate guidance on minimum required visibilities

(note quoted post now deleted)

[Rockie]

In the absence of any recommendations by the TSB I'll make my own:

1. Eliminate the approach ban.

2. Make the published visibility dependent on the available approach lights as well as MDA height above threshold.

3. Modify the required visual reference to read the same as the US;

§91.175 Takeoff and landing under IFR.

(a) Instrument approaches to civil airports. Unless otherwise authorized by the FAA, when it is necessary to use an instrument approach to a civil airport, each person operating an aircraft must use a standard instrument approach procedure prescribed in part 97 of this chapter for that airport. This paragraph does not apply to United States military aircraft.

(b) Authorized DA/DH or MDA. For the purpose of this section, when the approach procedure being used provides for and requires the use of a DA/DH or MDA, the authorized DA/DH or MDA is the highest of the following:

(1) The DA/DH or MDA prescribed by the approach procedure.

(2) The DA/DH or MDA prescribed for the pilot in command.

(3) The DA/DH or MDA appropriate for the aircraft equipment available and used during the approach.

(c) Operation below DA/DH or MDA. Except as provided in paragraph (l) of this section or §91.176 of this chapter, where a DA/DH or MDA is applicable, no pilot may operate an aircraft, except a military aircraft of the United States, below the authorized MDA or continue an approach below the authorized DA/DH unless—

(1) The aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuvers, and for operations conducted under part 121 or part 135 unless that descent rate will allow touchdown to occur within the touchdown zone of the runway of intended landing;

(2) The flight visibility is not less than the visibility prescribed in the standard instrument approach being used; and

(3) Except for a Category II or Category III approach where any necessary visual reference requirements are specified by the Administrator, at least one of the following visual references for the intended runway is distinctly visible and identifiable to the pilot:

(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as a reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.

(ii) The threshold.

(iii) The threshold markings.

(iv) The threshold lights.

(v) The runway end identifier lights.

(vi) The visual glideslope indicator.

(vii) The touchdown zone or touchdown zone markings.

(viii) The touchdown zone lights.

(ix) The runway or runway markings.

(x) The runway lights.

[55+]

All in all a disappointing report. No recommendations and no safety action taken by Transport Canada.

Basically back to our regularly scheduled programming.

Perhaps one recommendation (if not in the works), no 1/2 sm vis credit via ops spec to any airline on NPA even with calculated vertical guidance to MDA without AN approach lighting system. Incidentally I did a fix displacement calculation (FAF DME) and it shows 0.32NM.

On a personal note, I hope both pilots fully recovered physically and emotionally from this accident and are back on full flight status.

[BTD]

It is hard to tell from the report if they actually saw the runway environment or just believed they did.

Wow....

and we are supposed to fly with crews that can not figure out if they can see the runway or are imagining they can see it..

Good defense of that accident though, they were not sure so they just touched down to see if it was a runway or not.

FFS

I imagine everyone of us who has ever seen the runway at minimums believes they have the runway in sight with no doubt. There would have been times in the last hundred years of flight that the crew saw what they thought was the runway but it actually wasn't. This crew conformed to the rules for the approach ban. Those rules are substandard relative to the rest of the world allowing for the visibility to be below what one could reasonably expect to positively identify the runway environment given the approach lighting on a specific runway.

That aspect is a regulation problem. The report gives no indication that the crew wasn't sure what they saw and decided to continue anyway. It does however go into great detail on the visibility and which lighting aides the crew could expect to see and at what distances.

At the end of the day the crew made some airmanship errors, but with the exception of leaving the autopilot on longer than allowed, operated within the sops their training and the information they had been given. They put the airplane where it end up, but they weren't helped out by any of the other players.

Cue response: back in the day we flew approaches to mins with only flare pots for lighting and we were fine.

Answer: Except for those who are dead

I respect your contribution to this board and the industry, but some posts come across with a malicious tone.

Let's try to find ways to make the industry safer. "Don't crash" is not an effective strategy,

[Flying Low]

Considering that seeing the approach lighting is considered the runway environment I understand the crew continuing. I am surprised that there was no training to cross check altitudes and distances. I'm not sure how accurate the distance would be non-GPS (a 320 person will have to speak up on that).

Seeing only the approach lighting does not generally give you much depth perception. I've seen approach lighting appear through fog that makes it look like it's just hovering there. On a precision approach this is not an issue; you see the lights and just continue down the glideslope knowing the runway will appear. On a non precision approach the lighting just confirms you are in the correct general area but gives you little to no information with respect to distance to the runway or height.

Several years ago a Jazz Dash-8 went off the end of North Bay's nice long runway for essentially the same reasons. They did an SCDA and ended up high on slope so when they broke out they saw the runway edge lights (no threshold lights) and decided to land having no idea most of the runway was behind them.

I've flown a lot of SCDA's but no FPA's, however, they are both "dead reckoned" descents using the best info you have when you make the calculations. They always need to be backed up with altitude/distance checks. A great last minute check is at 200' above touchdown zone. You should be 1/2 mile final so if you aren't seeing the threshold green lights then you are out of position (below planned slope) or the viz has gotten worse. Either one should be ringing alarm bells.

[TailwheelPilot]

Nobody touched on this though: Report shows descent started 0.2 back from FAF, as opposed to over it, as it should be, and then was 0.3 back from profile MDA.

It was not clearly stated, although it was touched on in the report. 1.17.1.3, second last paragraph on page 52 and 1.17.4 (specifically the last paragraph on page 53 and table 4 on page 54) highlight the differences between the Air Canada SOPs (which pilots had to reference) and the Air Canada and Airbus FCOMs (which the pilots did not have to reference).

Never flown an Airbus, but since they highlight the differences - preset the angle and then select FPA at FAF-0.3nm versus select FPA and fly it at 0.0 then set to 3.5 at FAF-0.3nm - there must be something to it. I am left thinking the FCOM procedure accounts for the smooth transition mentioned and you end up where you expect to be, whereas flying at FPA 0.0 then setting 3.5 at FAF-0.3nm will give a quicker response and lead to being under the desired approach path.

Not saying the pilots are not at fault, but how I read this the issue that started the chain was SOPs that did not match the FCOM. Air Canada missed the discrepancy. TC missed the discrepancy. Any one and everyone who read or was supposed to read the FCOM and SOP missed the discrepancy. Training followed the SOPs, not the FCOM. Line flying followed the SOPs, not the FCOM. The FCOM was correct, the SOPs were not. Not only is the sequence & timing to set and select FDA different, the items about checking your position and altitude were left out from the SOPs.

[atphat]

All in all a disappointing report. No recommendations and no safety action taken by Transport Canada.

Basically back to our regularly scheduled programming.

I agree. A wasted opportunity to make some much needed changes. Oh well. No one cares. Moving along.

[Rockie]

Never flown an Airbus, but since they highlight the differences - preset the angle and then select FPA at FAF-0.3nm versus select FPA and fly it at 0.0 then set to 3.5 at FAF-0.3nm - there must be something to it. I am left thinking the FCOM procedure accounts for the smooth transition mentioned and you end up where you expect to be, whereas flying at FPA 0.0 then setting 3.5 at FAF-0.3nm will give a quicker response and lead to being under the desired approach path.

There is no difference between the two methods, they both account for a small inertia delay so that by the time the descent point is crossed the airplane is starting down on the correct path. Either way has been used for years by multiple companies with no problem.

The problem is that it is a non-precision approach with no vertical guidance. While it is unquestionably safer to fly it as a SCDA it denies the crew the time necessary to make a proper determination of aircraft position and trajectory at MDA. This forces them under the Canadian approach ban rules to make a snap assessment at minimums (with half the charted visibility) and either continue to land or go-around. It's a recipe for failure without the charted visibility.

Monitoring the altitude/range past the FAF could be useful, but don't forget this was in winter and the altimeter was subject to cold temperature errors making the charted altitudes wrong anyway. And even if the crew detected a difference there's nothing they could do about it because we cannot change the FPA beyond the FAF (for good reason). All it would do is alert the crew that they may not be in a position to land, which they have to be ready for regardless because it's a non-precision approach.

[rookiepilot]

I know nothing about airline ops, but..

"Non precision approach."

It is simply bizarre to me at major Canadian airports -- a small list to be sure -- we still don't have precision approaches to each runway, and GPS / LPV equipment in at least all jet equipment.

Spend the friggin money, people.

Third world.

[Black_Tusk]

Hehe LPV in jets. What do you think it is, 2017?

[Black_Tusk]

This forces them under the Canadian approach ban rules to make a snap assessment at minimums (with half the charted visibility) and either continue to land or go-around. It's a recipe for failure without the charted visibility.

The nice thing about doing an actual step down like many 703 operators do is you level off, and you either see the runway or you don't. MAP? Go around. Simple, easy and pretty much fool proof.

[RVR6000]

The crew also requested multpile times with Tower light setting '5'. The tower forgot to set it, they were busy coordinating snow removal. There is a 70% intensity difference between setting 5 and setting 4.

[Old fella]

I know nothing about airline ops, but..

"Non precision approach."

It is simply bizarre to me at major Canadian airports -- a small list to be sure -- we still don't have precision approaches to each runway, and GPS / LPV equipment in at least all jet equipment.

Spend the friggin money, people.

Third world.

I have an outdated(2013) CAP 7 Atlantic and there is a published GPS for runway 05 with LPV portion down to 720ft(257) and visibility of 1 mile. I assume the AC A320 fleet do not have the avionics to do these approaches that's why they did the LOC, but I stand corrected on the A320 equipment.

[BTD]

This forces them under the Canadian approach ban rules to make a snap assessment at minimums (with half the charted visibility) and either continue to land or go-around. It's a recipe for failure without the charted visibility.

The nice thing about doing an actual step down like many 703 operators do is you level off, and you either see the runway or you don't. MAP? Go around. Simple, easy and pretty much fool proof.

Apparently Not.



http://www.skybrary.aero/bookshelf/books/811.pdf

Under Statistical Data

57% of CFIT accidents during approach and landing were found to be during non precision step down type approaches.

https://flightsafety.org/fsd/fsd_nov-feb99.pdf

6. Among occurrences where data were available, three-fourths of the accidents happened where a precision approach aid was not available or not used.

[Rockie]

I have an outdated(2013) CAP 7 Atlantic and there is a published GPS for runway 05 with LPV portion down to 720ft(257) and visibility of 1 mile. I assume the AC A320 fleet do not have the avionics to do these approaches that's why they did the LOC, but I stand corrected on the A320 equipment.

All AC fleets can do RNAV approaches to LNAV/VNAV minimums except for the non-GPS 320's. The company is in the process of upgrading the 320 fleet now. Some fleets can do RNP (AR) approaches, but none can do LPV approaches because no AC aircraft are equipped with WAAS.