Halifax crash report coming Thursday

[Cat Driver]

Thanks for the advice ditar, but I finally decided to quit flying because I have no need to, if I fly now we have pilots to fly the company airplanes and I just pick up the phone and book the flight.

What finally made me decide to not bother flying myself was I just could not justify getting medicals every six months with no real need to fly myself.

Of course you are correct, no one is immune to making mistakes and I made many during the fifty one years I flew for a living...I just never made one that serious ...maybe I was just lucky and decision making and cross checking had nothing to do with it but I am stuck with what I have and I am finished flying for a while.

We had a five day company meeting this week and the decision has been made to buy a Hughes 300 for the company to be kept at the corporate loge we operate in Desolation sound...I got my commercial helicopter license on the H300 in 1964 and just love the things so I definitely will be flying that but I do not need a medical to fly it because the company pilot will be with me.

Sorry I come across as such a know it all perfect a-hole but everyone has to be something.

Oh, I had some hard landings during my career but never over a thousand feet from where I was planning to land, but of course once again I am being unjustly critical of Air Canada and for that I apologize and will see if I can get some corrective training for that character flaw.

Any suggestions as to where I should go for such training?

[Big Pistons Forever]

Any suggestions as to where I should go for such training?

Ummmmm..... you could try ..*runners.com.......

[Cat Driver]

Ummmmm..... you could try ..*runners.com.......

Yes of course I can, I notice you are often mentioned there by some of the posters besides me.

[Jimmy2]

http://www.avherald.com/h?article=484c306e&opt=1

It took a year and a half for the Japanese to get their report done on a similar accident. An interesting read.

I like how the spell it out in black and white at the very top of their report. Probably not something you'd see in our reports. Certainly not this one. Sure there are contributing factors but it's like we dance around the obvious in order to not hurt feelings or take any kind of responsibility.

The PIC continued approaching without executing a goaround while the position of the Aircraft could not be identified by visual references which should have been in view and identified continuously at or below the approach height threshold (Decision Altitude: DA)

[confusedalot]

only skimmed through the report.

3.1.3, the crew did not notice they went through mda? what?

I'll buy all of the stuff about ground contact via ground lights and wanting to continue, but my gut tells me something is missing, procedure or not.

I dunno man.

Flame away.

[CpnCrunch]

I like how the spell it out in black and white at the very top of their report. Probably not something you'd see in our reports. Certainly not this one. Sure there are contributing factors but it's like we dance around the obvious in order to not hurt feelings or take any kind of responsibility.

The PIC continued approaching without executing a goaround while the position of the Aircraft could not be identified by visual references which should have been in view and identified continuously at or below the approach height threshold (Decision Altitude: DA)

Of course in this case the visual references were identified, so it's not the same at all...

[swordfish]

Flame away.

No need. See the following post....

[swordfish]

Here's what the report tells us, in simple language, after all the sticky parts have been wiped off, and all the cream & sugar has been adjusted by ACPA, Air Canada, Airbus Industrie, Halifax Airport Authority, Transports Canada, and all the other stakeholders who must have an opportunity to dilute its severity:

1. The crew failed to monitor the automation's flight path.
2. The crew blew through the MDA for 23 seconds, and continued descending to the ground while watching the autopilot do it.
3. The crew did not follow the AC SOP or the FCOM, ignored the CARs, and did not follow the AFM.
4. The crew allowed the automation to fly the aircraft, instead of the crew flying the plane.

I believe these can all be capitulated as "Pilot Error". The report does not mention this in the "Findings as to cause".

All the other trivia can be ignored. The light setting is of little consequence, because it was pitch black outside and both pilots could see them anyway. The red herrings about not monitoring the distance/altitude relationship is an unnecessary additional stress on the crew, and the plane is following a selected FPA. One issue I have with this is why doesn't the FPA correspond with the SCDA in the landing chart? If you enter your starting altitude, and your final altitude, can't the FMS take care of the altitude/distance relationship - regardless of the wind?

The rules about making an NPA don't change with the level of automation: if at the MDA you do not have the "landing environment" (and this is eloquently described in CARs with a good degree of latitude) visually established, you execute a missed approach. The same happens in a manually-flown approach. If you "level off" at the MDA to have a look-see for the airport, you are flying the aircraft way past its VNAV profile where the approach becomes unstable, and a safe landing is impossible.

I believe the TSB has missed an essential element of this accident: the stress and stressors the crew were subjected to. Any NPA in minimum conditions (and particularly THOSE conditions of the accident flight) are very stressful requiring multiple monitoring and cross-checking parameters. You are absolutely loaded to the hilt during these approaches. Of course this stress heightens the intensity of the crew's focus on the flight. But does the automation result in complacency at the same time?

We have here a crew EACH with about 6000 hrs on the type, and it is an established fact that you lose your manual flying proficiency flying these automated aircraft, unless you make a practice of hand-flying an approach every so often, but I believe approaches to hard minimums are required, by the SOP, to be flown by the autopilot.

[goldeneagle]

Of course in this case the visual references were identified, so it's not the same at all...

That's the crux of it though, in this case the visual references were NOT identified. If they had been, then the aircraft would not have touched down a long ways short of the runway.

Folks can spend endless hours splitting hairs about SOP etc etc etc, but, there is a bottom line truth in this case. The aircraft was on a non precision approach, and descended below the MDA without the required visual reference. That is the short story final answer. Two well qualified folks up front, busted minimums and bent the airplane because of it.

All the other blah blah blah about sop, manuals, etc etc etc, just skirting the issue and manufacturing excuses. But in the end, they went well below the MDA and did not have a runway in sight. If this was a navajo up north that landed a thousand feet short after busting minimums, folks here would be first in line to crucify the pilots, the operator, and anybody else involved.

[swordfish]

Exactly. I don't see those words in the report. Can you add them please as a postscript, goldeneagle...?

[Jean-Pierre]

I can't help but think they were trying to 'homebrew' an ILS using FPA and letting the autopilot take them below MDA with the belief the runway will appear in front of them. The error in the FPA caused that point to be much earlier than the runway though.

[Rockie]

As all you experts point out the crew descended below MDA and touched down short of the runway...clap the dust off your hands because we're done here right? Except what you don't consider and disappointedly neither does the report is why. You also make pronouncements on the aircraft systems without understanding them.

There are human factors at play here exacerbated by a regulatory environment that sets not just this crew up for this kind of accident but you as well.

But no, let's pin it all on the crew....

[PositiveRate27]

Anyone who looks at this and just writes it off as "two lazy airline pilots mailing it in and screwing the pooch" is missing the huge red flag that should be a warning to all of us.

Quoted from PPRUNE : "I am reminded of comments after Gemini 8 "The crew reacted as they were trained, and they reacted wrong because we trained them wrong" - the most sobering part for me is that the crew flew the approach as per SOP, were slightly late picking up how wrong the visual picture looked in $h!t weather and ended up drilling it in."

The crew should not be absolved of all responsibility. It's their job as pilots to always return the aircraft to a runway safely, but they were very much hung out to dry by their procedures and training. The same could happen to any of us and to deny that is to deny the concept of human factors. Everyone is human. Let's not pretend we never lose the big picture and it couldn't happen to us.

Stay vigilant chaps.

PR

[rookiepilot]

As all you experts point out the crew descended below MDA and touched down short of the runway...clap the dust off your hands because we're done here right? Except what you don't consider and disappointedly neither does the report is why. You also make pronouncements on the aircraft systems without understanding them.

There are human factors at play here exacerbated by a regulatory environment that sets not just this crew up for this kind of accident but you as well.

But no, let's pin it all on the crew....

I thought the crew are the ones responsible for my safety, when all is said and done.

Seems with incidents like Asiana, there is no "issue" "pinning it" all on the crew.

I remember Asiana's CEO apologized. AC has not only tried to blame Airbus et all, but done everything in its power to obstruct a well deserved passenger lawsuit.

Someone is responsible, it isn't airbus. This could have easily been an accident with all on board killed. Let's not forget that.

[goingnowherefast]

I can't help but think they were trying to 'homebrew' an ILS using FPA and letting the autopilot take them below MDA with the belief the runway will appear in front of them. The error in the FPA caused that point to be much earlier than the runway though.

If they were trying a "homebrew" ILS, why did they wait until moments before impact to attempt a go around? Just doesn't make sense.

My understanding is that they saw something at minimums, mis-interpreted it as it looked similar to what they wanted to see, therefor they kept going down. By the time they realised it wasn't the runway, it was too late. Hence the conclusion that the lighting available was inadequate for the visibility required on the approach (approach ban).

What I don't get is why everybody is hung up on the plane reaching MDA earlier than expected. You reach MDA you level off or go missed. Doesn't matter if it's 1 mile from the runway or 5 miles from the runway. They weren't where they expecting to be, but they still saw something when they got there, just happened to be easily confused with what they were expecting.

[rudder]

This one is simple - under a different regulatory environment (approach ban), this approach would never have been commenced. No approach - no accident.

Not complicated.

[55+]

[quote="PositiveRate27"]Anyone who looks at this and just writes it off as "two lazy airline pilots mailing it in and screwing the pooch" is missing the huge red flag that should be a warning to all of us.


Your commentary has merit in my view. Why, let me say this as a former IAP designer. We are permitted by criteria to give a 1/2 mile visibility credit on a NPA procedure if the runway to which the procedure is setup for has a High Intensity Approach Lighting System however the published visibility cannot be lower than 1sm under any circumstances. That's why regardless of the HAT no published NPA here has a published visibility less than 1sm. Question is, why is an airline given an ops spec for a REDUCED vis on a NPA IAP with an AO apch lighting system such as rwy 05 in Halifax. Shouldn't it have been aircraft equipment specific and runway environment aka lighting. I understand from the report issues on lighting have been addressed(AC requested) and airport authorities have complied. Isn't that an admission something slipped through the cracks regardless of what many here think of flight crew action or inaction.

[Rockie]

I thought the crew are the ones responsible for my safety, when all is said and done.

No. So too is the company, the manufacturer and the regulator. All have their part to play and in this circumstance the regulator set the conditions for this accident to happen, a fact completely ignored in the report.

It's difficult for me to see how Airbus did anything wrong here, the airplane did what it's designed to do. Don't be distracted by AC suing Airbus as anything but expected Corporate and legal department strategies.

I'm sure the crew will in the future have much higher personal criteria for continuing below MDA. Air Canada already does. Airports have committed to improving their lighting. Now all that's required is for TC to do their part.

[CpnCrunch]

That's the crux of it though, in this case the visual references were NOT identified. If they had been, then the aircraft would not have touched down a long ways short of the runway.

Well, both pilots thought the "lighted facility" they saw was the runway or approach lighting. The report doesn't seem to make clear what exactly this "lighted facility" at 0.7nm from the threshold actually was, but presumably it wasn't the ODALS as that only extends 1500ft (0.25nm).

[rookiepilot]

I thought the crew are the ones responsible for my safety, when all is said and done.

No. So too is the company, the manufacturer and the regulator. All have their part to play and in this circumstance the regulator set the conditions for this accident to happen, a fact completely ignored in the report.

How is the manufacturer remotely responsible for this accident?

Did they forbid AC from installing WAAS in their aircraft, for example? That's money.....

[Rockie]

Read my post.

[pelmet]

I admit that I have not read the report.

I have a question....Did the crew have the required visual references at the MDA?

If they did, did they have any VASI/PAPI to follow down?

There have been plenty of non-precision approaches in the past where an aircraft was too high or too low and the flightpath had to be adjusted. What happened here?

[CpnCrunch]

I admit that I have not read the report.

I have a question....Did the crew have the required visual references at the MDA?

If they did, did they have any VASI/PAPI to follow down?

There have been plenty of non-precision approaches in the past where an aircraft was too high or too low and the flightpath had to be adjusted. What happened here?

From what I can tell (skimming/searching the report) they thought they have the runway lights or approach lights, but what they saw wasn't actually the runway or approach lights (because they were too far away). I don't think the report says what those lights actually were. Perhaps Aerotech business park, which is 0.7nm from the threshold.

[swordfish]

But no, let's pin it all on the crew....

That's where it belongs. The contributory elements, while interesting, do not detract from the responsibility, that literally thousands of other crews exercise every day - and have been doing so since the A320 started flying....without driving the aircraft into the ground.

It is the crew's responsibility to manage the automation, not the other way round, and not Airbus's.

[NewCommercialPilot]

It's been more than 15 years since my last flight on an Airbus product (310/320/330) but my recollection of using the FPV is that it wasn't a fixed path in space, as you have all pointed out. It was an aid to making a constant descent non-precision approach. The responsibility still lies with crew to identify the runway. While there were obviously contributory factors that dark windy night in YHZ, at the end of the day, we either have the required visual references at MDA, or we do not.

I'm with Cat Driver on this one. Nothing in automation land has changed our responsibilities once we close the door and start the engines.

My sympathy is with the crew, but that only goes so far.