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Thread: Air Niugini plane misses runway, lands in sea off Micronesia island

  1. #61
    Senior Member Gabriel's Avatar
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    Quote Originally Posted by Evan View Post
    He flew a 737NG into the water. How do you do that with an eye on the PFD?
    First of all, I didn't say that he had an eye on the PFD. Remove the parenthesis and my quote is:

    The fact that he stopped monitoring the instruments doesn't mean that he assigned that task to the FO.
    In other words, that you stop doing something doesn't mean that you assigned it to someone else or even that you expect that someone else will do it.

    Then, you have the parenthesis for ways to look at the PFD and still screw up:

    (or that he did keep monitoring them but disregarding the indication because he was either confused or, as you hypothesized, had other plans in mind)
    To clarify, "as you hypothesized" is that he intentionally kept going down in hope to regain the lost visual contact with the runway. As you said, a "dive and drive" attempt, gone wrong.

    And, the PFD is not one instrument, it is many. You can still have tunnel vision within the PFD, focusing only on few parameters of which there are many (airspeed, airspeed trend, altitude, altitude trend, vertical speed, attitude indicator, FD, glide slope, localizer, and flight mode annunciator among others like a red PULL UP text warning that was on during many seconds before the impact.

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  2. #62
    Senior Member Evan's Avatar
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    Quote Originally Posted by Gabriel View Post
    And, the PFD is not one instrument, it is many. You can still have tunnel vision within the PFD, focusing only on few parameters of which there are many (airspeed, airspeed trend, altitude, altitude trend, vertical speed, attitude indicator, FD, glide slope, localizer, and flight mode annunciator among others like a red PULL UP text warning that was on during many seconds before the impact.
    Yes, but obviously he was not tunnelling on any of these indications, because each and every one of them were telling of impending doom. GS off the scale, high sink rate, low altitude, low radio altitude... 117kts airspeed... He was tunneling out the window. (that little dot is black and white) He was certain he could find the runway with his eyes alone. The old Luke Skywalker routine: switch off the computer, ignore the warnings, use the force. Almost there... almost there... (watch my back R2)...

  3. #63
    Senior Member 3WE's Avatar
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    What in the hell are you guys arguing about?

    I take Evan's 'assignment' of the instruments in a gray fuzzy manner...

    Either the PF THOUGHT 'watch the airspeed' MEANT that the other guy would watch everything, or by not watching himself he 'THEORETICALLY' turned the instruments over to the other guy (which doesn't mean he did...)

    And, yeah, it took some big and DUAL screw ups.

    But hey, to hell with listening, let's argue.
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  4. #64
    Senior Member 3WE's Avatar
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    Quote Originally Posted by Evan View Post
    ***He was certain he could find the runway with his eyes alone. The old Luke Skywalker routine: switch off the computer, ignore the warnings, use the force. Almost there... almost there... (watch my back R2)...
    Gross over-statement...

    I'm sure he THOUGHT the runway would be right back...How is it you SEE the PAPI and then you don't see the PAPI

    How many rainy approaches had he made where you briefly lose contact, only to get it back?

    You make it sound like he paused to run the FCOM what NOT to do checklist...there was no DECISION nor CERTIANTY the runway would be back...just a lapse...mostly in CRM by BOTH pilots.
    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

  5. #65
    Senior Member Evan's Avatar
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    Quote Originally Posted by 3WE View Post
    Gross over-statement...

    I'm sure he THOUGHT the runway would be right back...How is it you SEE the PAPI and then you don't see the PAPI

    How many rainy approaches had he made where you briefly lose contact, only to get it back?

    You make it sound like he paused to run the FCOM what NOT to do checklist...there was no DECISION nor CERTIANTY the runway would be back...just a lapse...mostly in CRM by BOTH pilots.
    You still fail to understand the black and white things that make safe air travel possible. They lost visual contact below decision height, due to entering a prolonged area of precipitation. They were blind and unstable below decision height. That is a go-around. (that little dot is black and white). That is an IMC go-around (that big 'I" is for "instrument"). You lose visual briefly above DH and get it back? FIne. But below that, no coyboymanship allowed.

    It's almost like you need a lesson in the importance of this, like a real-life example of a pilot doing this and then, for instance, ending up in the water short of the runway. Oh, wait...

  6. #66
    Senior Member 3WE's Avatar
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    Quote Originally Posted by Evan View Post
    (that little dot is black and white)
    All words matter, Evan

    Quote Originally Posted by 3BS
    it took some big and DUAL screw ups.
    One guy...actually BOTH guys...should have been monitoring
    -The glideslope
    -The VSI
    -The Altitude
    -The view out the window
    -Whether they were above or below minimums
    -If Bitching Bob/Betty was unhappy
    -The airspeed (and a few other things)

    THEY didn't. (And yes, there's a period there).

    Instead, they took BASIC FUNDAMENTAL STUFF that applies to 172 driving every bit as much to 737 driving, and threw it out the window (pun was not intended, oh the ironing).

    I'll have to check my 172 FCOM for type specific procedures, but I believe you are generally supposed to go around if you are below minimums and don't see the runway.
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  7. #67
    Senior Member Gabriel's Avatar
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    Quote Originally Posted by Evan View Post
    ... the black and white things that make safe air travel possible. They lost visual contact below decision height, due to entering a prolonged area of precipitation. They were blind and unstable below decision height. That is a go-around. (that little dot is black and white). That is an IMC go-around (that big 'I" is for "instrument"). You lose visual briefly above DH and get it back? FIne. But below that, no coyboymanship allowed.

    It's almost like you need a lesson in the importance of this, like a real-life example of a pilot doing this and then, for instance, ending up in the water short of the runway. Oh, wait...
    I agree on the black-and-whiteness of this situation. It was a go-around, as clear as it gets. If you don't go around by this I don't know what you would go around for except an elephant on the touchdown zone.

    Now, there are some greyish options too, apparently...

    Not if the PAPI has suddenly disappeared into a rainy white void, as I think the case was here. Before disappearing, the PAPI told them they was a bit high (imprecisely). After the PAPI disappeared the PIC seems to have overestimated the correction, with nothing to gauge it by.
    Except, um... instruments. He seems to have assigned the instruments part entirely to his FO, who seems to have temporarily lost his voice. He seems to have been 100% focused on the task of regaining visual contact with the runway.

    If he was adamant about continuing (and thus a gambling man, gambling with the lives of others), I would have as least expected him to assign the visual contact part to his FO and concentrated himself at least partially on the instruments, not vice versa.
    Had he pulled that one off and not-died, he should be immediately sacked and his pilots privileges terminated for eternity in the whole universe. And also the FO, for not calling the go-around and initiating it by himself forcefully if needed, after what is evidently pilot (not-suddenly) incapacitation.

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  8. #68
    Senior Member Evan's Avatar
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    Quote Originally Posted by Gabriel View Post
    Had he pulled that one off and not-died, he should be immediately sacked and his pilots privileges terminated for eternity in the whole universe. And also the FO, for not calling the go-around and initiating it by himself forcefully if needed, after what is evidently pilot (not-suddenly) incapacitation.
    No argument. But I have the feeling he HAD pulled this one off before. Probably a few times.

    Who would blow the whistle? Not the pilot. Not his flunky sidekick. Can't ATC do that, if the flight clearly entered IMC below DH?

    I suppose there's some damn tradition against that?

  9. #69
    Senior Member 3WE's Avatar
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    Quote Originally Posted by Evan View Post
    ***Can't ATC do that***
    No.

    ATC has a very poor idea of what the pilots can or can't see out of the window.

    The visibility from the tower, the cockpit (and even from 23A) can be very different.

    Throw in all sorts of runway lighting systems and 'items consistent with the runway environment' and it gets MORE complicated.
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    Senior Member Gabriel's Avatar
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    Quote Originally Posted by Evan View Post
    No argument. But I have the feeling he HAD pulled this one off before. Probably a few times.

    Who would blow the whistle? Not the pilot. Not his flunky sidekick. Can't ATC do that, if the flight clearly entered IMC below DH?

    I suppose there's some damn tradition against that?
    Not the visibility part, but if they get GPWS warnings and an unstable approach below the DH or MDA and tey don't go around, FOQA should catch it.

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  11. #71
    Senior Member 3WE's Avatar
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    Quote Originally Posted by Gabriel View Post
    FOQA
    No habla acronymos muy bein.
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    Senior Member Gabriel's Avatar
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    Quote Originally Posted by 3WE View Post
    No habla acronymos muy bein.
    FLIGHT OPERATIONAL QUALITY ASSURANCE

    https://www.faa.gov/documentLibrary/.../AC_120-82.pdf

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    Quote Originally Posted by Evan View Post
    No argument. But I have the feeling he HAD pulled this one off before. Probably a few times.
    "Both pilots ignored the 28 EGPWS “Glideslope” aural caution alerts during the approach to Pohnpei during the previous sector on 27 September 2018"

    Section 3.1 (3) (h) of the report.

  14. #74
    Senior Member Evan's Avatar
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    Quote Originally Posted by Gabriel View Post
    FLIGHT OPERATIONAL QUALITY ASSURANCE

    https://www.faa.gov/documentLibrary/.../AC_120-82.pdf
    Is this program actually implemented? I only scanned the 78-page document, but it seems to be more of a proposal or the groundwork for setting such a program up.

    I also noticed that there is no FAILURE TO GO AROUND event. There are two GO-AROUND EVENTS (inquiring as to the reason for the go-arounds), a DESCENT BELOW MDA event, a HIGH DESCENT RATE event and a OPERATION BELOW GLIDESLOPE event. But the crime here apparently wasn't the decision to continue below DH (assuming the visual contact was initially established and there was nothing looming ahead that might obscure that visual contact). It was the failure to abandon the approach when the visibility was subsequently lost. They need to add that event. And possibly an IGNORANCE OF WARNINGS AND INSTRUMENTATION event and a GETTHEREITIS event...

    Also, the foundational idea of this as "de-identified aggregate information" to identify trends doesn't address the problem of confronting a specific pilot about his procedural violations. That behavior might be a trend within a company or a culture, but I think it is often just a trend within an individual. And that individual needs to be identified, re-educated or excommunicated.

  15. #75
    Senior Member Gabriel's Avatar
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    Quote Originally Posted by Evan View Post
    Is this program actually implemented? I only scanned the 78-page document, but it seems to be more of a proposal or the groundwork for setting such a program up.
    Yes, it is an ICAO requirement, except that ICAO requirements are not mandatory for member states.
    EASA adopted it and made it mandatory in Europe.
    The FAA adopted it as a voluntary process (the document that you skimmed through). However I believe that most airlines in USA including all major airlines adopted it in some way or another.

    I also noticed that there is no FAILURE TO GO AROUND event. There are two GO-AROUND EVENTS (inquiring as to the reason for the go-arounds), a DESCENT BELOW MDA event, a HIGH DESCENT RATE event and a OPERATION BELOW GLIDESLOPE event. But the crime here apparently wasn't the decision to continue below DH (assuming the visual contact was initially established and there was nothing looming ahead that might obscure that visual contact). It was the failure to abandon the approach when the visibility was subsequently lost. They need to add that event. And possibly an IGNORANCE OF WARNINGS AND INSTRUMENTATION event and a GETTHEREITIS event...
    It is not so easy.

    As far as I know, airlines in general do FOQA based on data downloaded from the airplanes (ACARS, QAR, etc...). Downloaded data is loaded in a database that looks for trends, spikes, and some specific critical single events can be flagged too. Loss of visibility, ignorance of warnings, monitoring of instruments and gettheritis is not sensed, measured, captured, recorded, downloaded, stored or analyzed.

    While the process includes pilot reports as a possible source of data, this source has demonstrated to be very unstable and unreliable, and under that condition false alarms of spikes and trends can show up frequently, misleading the improvement efforts (i.e. using resources to fix false alarms instead of real issues). As far as I know, responsible airlines do encourage pilots to report deviations, mistakes and other safety concerns with a no retaliation guarantee (against the pilot who reported the problem). But they keep that as a parallel process, no part of FOQA.

    Also the NASA administers database of pilot self-reporting of these kind of issues. The FAA uses the information to look for trends and the NASA de-identifies the incidents. Pilots reporting the issue are also safe-guarded of any retaliation by the FAA or their employees, but not the justice so if their act constitute a criminal negligence they can be prosecuted.

    Also, the foundational idea of this as "de-identified aggregate information" to identify trends doesn't address the problem of confronting a specific pilot about his procedural violations.
    That's true. Although it is my understanding that some airlines may make an exception to the de-identification for gross deviations that seen to be intentional and involve a serious disregard for safety. The crew involved can be de-identified but considered for a trend (like "PIC 12 + FO 17") and, depending on airline policies, the de-identification can be undone in extreme circumstances (for example, PIC 12 being involved in 5 cases in the last month of GPWS warnings below DH with no go-around executed).

    That behavior might be a trend within a company or a culture, but I think it is often just a trend within an individual. And that individual needs to be identified, re-educated or excommunicated.
    On the contrary, it is very rarely the trend within an individual person. Because these persons can't survive with such trends in a company with a strong safety culture. They either adapt to the culture, or leave, or are fired.

    Put this PIC in an American Airline flight and very likely what you'll have is the FO calling "we lost visual, go around; GPWS warning, go around, I have the plane, go around, flaps 15" and then filling a report on the incident. After that, if this PIC doesn't quickly adapt to AA's culture, he won't last.

    As a contrast, what we have here are 2 pilots (PIC and FO), below MDA, losing visual contact, ignoring more than a dozen GPWS warnings, allowing the sink rate to exceed the maximum allowed, allowing the glide slope to deviate more than 2 dots, and neither calling any of these issues, or calling a go around, or initiating a go around. And in the previous flight the same crew ignored 28 EGPWS warnings on the approach of the previous flight. And I bet you a jar of dulce de leche that the previous sector was not the first time that they did this, and that these were not the only pilots in the airline doing this.

    Watch the movie Whisky Romeo Zulu (based on a true story, available in Amazon Prime and YouTube)) and observe how a company culture is stronger than an individual. This works both for good and for bad.

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    Quote Originally Posted by Gabriel View Post
    Put this PIC in an American Airline flight and very likely what you'll have is the FO calling "we lost visual, go around; GPWS warning, go around, I have the plane, go around, flaps 15" and then filling a report on the incident. After that, if this PIC doesn't quickly adapt to AA's culture, he won't last.
    The point you're making about the power of company culture vs procedure is definitely thought-provoking. For what it's worth, I found this in the Air Niugini Standard Operating Procedure Manual:

    "When a crew member notices a significant deviation from standard procedures during a normal flight regime, he should communicate this immediately to the crew member flying. If he does not receive a response to his challenge either verbally or by corrective action, he should immediately repeat the challenge. If there is still no response to the second challenge, then he should take over the control of the aircraft and restore a safe flight condition while he obtains assistance to determine the cause of the problem. All crew members are to be aware of this challenge and response philosophy. If they are challenged, they must be prepared to respond immediately, either verbally or by taking corrective action" (Section 2.5.1)

  17. #77
    Senior Member 3WE's Avatar
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    Quote Originally Posted by flashcrash View Post
    I found this in the Air Niugini Standard Operating Procedure Manual
    I've become a grumpy old man.

    Yes, I'm sure that IS in their manual.

    And, yes it SHOULD be done.

    But the fact that someone wrote a bunch of stuff in a manual versus how you actually do it in the real world while balancing common sense, the written procedure and true right and wrong is why Evan and I argue all the time.

    And none of what I say or you say or Evan and Gabriel says, or the manual says means anything if they simply blow off what's in the manual (or get in the habit of effectively flying blind below minimums with apparently inadequate attention to the altimeter reaching zero.)

    Or if there's a culture that the manual is only suggestions...
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    Senior Member Gabriel's Avatar
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    Quote Originally Posted by flashcrash View Post
    The point you're making about the power of company culture vs procedure is definitely thought-provoking. For what it's worth, I found this in the Air Niugini Standard Operating Procedure Manual:

    "When a crew member notices a significant deviation from standard procedures during a normal flight regime, he should communicate this immediately to the crew member flying. If he does not receive a response to his challenge either verbally or by corrective action, he should immediately repeat the challenge. If there is still no response to the second challenge, then he should take over the control of the aircraft and restore a safe flight condition while he obtains assistance to determine the cause of the problem. All crew members are to be aware of this challenge and response philosophy. If they are challenged, they must be prepared to respond immediately, either verbally or by taking corrective action" (Section 2.5.1)
    That something is in a SOP, procedure, manual, training verbiage or policy doesn't mean AT ALL that it is what is being done or that it is part of the culture.

    Watch the movie that I recommended to Evan.

    Culture is how we behave normally in our daily life / work, especially when we are not doing something for the culture.

    EDIT: I made this post before reading 3WE's answer. Spot on!

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  19. #79
    Senior Member Evan's Avatar
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    Quote Originally Posted by Gabriel View Post
    On the contrary, it is very rarely the trend within an individual person. Because these persons can't survive with such trends in a company with a strong safety culture. They either adapt to the culture, or leave, or are fired.
    Or crash, then get fired. I think you are right that it is often a culture at fault, but there are also instances of a certain pilot who just can't be bothered with 'nanny-state' safety procedures because he has stupendous airmanship and doesn't need them (see: Cowboy). If he is accompanied by a culture that tends to embrace the cockpit gradient philosophy (see: Asia), he can get away with a lot.

    Watch the movie Whisky Romeo Zulu (based on a true story, available in Amazon Prime and YouTube)) and observe how a company culture is stronger than an individual. This works both for good and for bad.
    Is there a subtitled version out yet? The film chronicles an extreme example of broken safety culture (dispatching aircraft with no functioning primary instrument) that hopefully no longer exists. But who knows. There's always AirAsia.

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    Quote Originally Posted by Gabriel View Post
    That something is in a SOP, procedure, manual, training verbiage or policy doesn't mean AT ALL that it is what is being done or that it is part of the culture. Watch the movie that I recommended to Evan.
    Saw it in Paraguay in 2006. Great movie. Purpose of the post was to demonstrate the size of the discrepancy between culture and written procedure, reinforcing your point. Hence the phrase “culture VS procedure”. That said, culture notwithstanding, both pilots were ultimately judged against that specific procedure, as the report demonstrates.

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