Halifax report coming May 18,2017

[Vsplat]

On 5/23/2017 at 10:00 AM, DEFCON said:

Do you guys read?

The TT on type is not low, but accumulating the time at a rate of 35 hours per month over 15 years is not exactly burning up the sky. You could compare the FO's time on the job to the Captain's; the disparity is more than obvious.

I'd bet the average A320 pilot time at AC probably averages somewhere near twice that amount of hard time.

Once you get by the need to circle the wagons, I'm sure some of you can at least acknowledge the fact that sitting as an FO on the 320 for 15 years at AC as everyone passes you by, including the subject Captain, would stand out to an observer and is a point worthy of investigative examination.

When you boil the entire matter down, although there are other related factors, the crash is a consequence of the crew's decision to allow the aircraft, for whatever the reason, to descend below the MDA without having the necessary visual clues. Blaming Airbus, automation, the airport factors and the weather etc. does not relieve a crew of its fiduciary responsibility.

DEFCON, that post is below your usual standard.

I don't know why you are so obsessed with the FO, but if you think that your read through of a sanitized report gives you insight beyond that of a two year investigation by professionals with unfettered access to information none of us have, then rather than calling our intellect into question, please feel tree to provide something more substantial than corrosive innuendo and extrapolation.

Vs

[DEFCON]

Vsplat

I do not have any kind of obsession with the FO. I only identified an anomaly, which several people attempted to rationalize. Did the investigators see the same thing and find answers that were satisfactory to them? Why you, especially you, would feel there's a need to turn said observation into a giant defence exercise escapes me. In the same vein, I don't know where in this thread it was that I questioned anyone's intellect? Perhaps you're too close to the fire this time to be completely objective?

And yes, I do feel the report came away a little light on the human factors aspects of the crash, but where otherwise do you think I was finding 'fault' with a report that's based on "a two year investigation by professionals with unfettered access to information none of us have"?

 

 

 

     

[Kip Powick]

3 hours ago, Vsplat said:

Kip, the AP disconnect rules I referenced come straight out of the FCOM/AOM.  Can't post them verbatim here. 

The MDA is not pulled from a database, it is a crew entry, so would reflect the additive. (BTW I think the TSB got that wrong, normally it is MDA + 50 feet then correct it all for temp)  I really can't answer for the TSB or what they said about autpilot engagement.  If it remained engaged more than 50 feet below the value set in the MCDU as MDA, that would require some further explanation. 

More likely to me is that this is unclear wording from the TSB.  As far as I can read, they don't reference the actual altitude where the autopilot disconnected, nor would they have that precisely, as there is some lag between data samples on the FDR.  50 feet in descent would be hard to pinpoint unless you got lucky with the sample rate.

FWIW

Vs

So  we can assume that the pilots wanted 813 feet as the calculated MDA (TSB report)

Therefore the altitude that should have been entered  for autopilot disconnect would be MDA plus 50 feet which makes autopilot disconnect at 863 feet

The TSB has the auto pilot disconnected at 30 feet above threshold altitude which would be 449 feet + 30 feet or 479 feet.

That would mean the aircraft descended 384 feet below the calculated autopilot disconnect altitude  on auto pilot...correct? (Calculations arrived at from TSB data)

You have to search for the data......, it is there.......,   and I am very surprised this "nugget"  is not written clearly in the report.

 

[Seeker]

DEFCON;

"I do not have any kind of obsession with the FO."  Hard to tell from the 6 or 8 posts where you've made reference to him.

"Why you, especially you, would feel there's a need to turn said observation into a giant defence exercise escapes me."  Ahhh, from your 6 or 8 posts about it perhaps?

"I don't know where in this thread it was that I questioned anyone's intellect?"  Maybe the part where you post - "Do you guys even read?

"where otherwise do you think I was finding 'fault' with a report that's based on "a two year investigation by professionals with unfettered access to information none of us have"?"  From these posts of yours;

1).  Competency may be a core issue here too, but it seems that the discussion of 'all' possible contributing factors falls into the pc realm, an apparent no go zone?

2).  Yes, he may just like the position, but the chance that's the reason he's in the seat is as remote a possibility as seeing a spotted tiger.

3).  Although I'm certain that any TSB investigator worth his pay would not have left this question open ended, for whatever the reason, the 1IC, or a higher authority decided to not include the details in the report.

As these things go, loose threads lead to questions.

4).  I'm sure some of you can at least acknowledge the fact that sitting as an FO on the 320 for 15 years at AC as everyone passes you by, including the subject Captain, would stand out to an observer and is a point worthy of investigative examination.

5).  Seeing that one of the crew only averaged 35 hours a month over 15 years in the right seat of one type in a fast moving upgauging / upgrading environment is unusual to say the least and worthy of examination.

[Vsplat]

Kip, AP disconnects 50' below MDA .  Not sure about the rest of your calculations. 

Edited to correct, checking Airbus FCOMs, the auto-disconnect of the AP is not on all serial numbers or approach modes.  Without knowing specifics, it may be that this particular serial number, when flying selected FPA mode, did not have auto-disconnect enabled.

Vs

[Kip Powick]

35 minutes ago, Vsplat said:

Kip, AP disconnects 50' below MDA .  Not sure about the rest of your calculations. 

 

Vs

Sorry....50 feet below......OK

 

 

 

Sorry about the 50 feet... Changes the autopilot on distance to 334 feet....

 

 

 

 

[Vsplat]

Kip, I did a bit of looking.  I don't know the mod status of the aircraft involved.  Indeed, AP auito disconnect at MDA-50 feet is not fitted on all serial numbers or modes. 

It may be, and again with deference to the TSB, that in the absence of FINAL APP mode, an aircraft already in an FPA descent with AP on could continue in descent below MDA without the autopilot kicking off.  Some aircraft will flash an FMA warning, others will simply carry on silently.

Not sure this clears it up, again, not sure what the mod status of that aircraft was.

Vs

[Kip Powick]

I think we can all agree, there is certainly a lack of clarity as well as a lack of continuity in the report. Sort of like life

We all know TSB is not going to redo or reopen the investigation just because a few AEFers have questions that they think the TSB should have foreseen and preempted them with answers..........

Have a nice week.

[Kip Powick]

38 minutes ago, blues deville said:

Does the TSB report make any reference to which seat was PF or PM? Can't seem to find that info.

AC624 was airborne at 2205 on 28 March 2015.^Footnote4 The captain occupied the left seat and was the pilot flying (PF), while the first officer occupied the right seat and was the pilot monitoring (PM). This was the first time these pilots had flown together.

[Vsplat]

7 hours ago, DEFCON said:

Vsplat

I do not have any kind of obsession with the FO. I only identified an anomaly, which several people attempted to rationalize. Did the investigators see the same thing and find answers that were satisfactory to them? Why you, especially you, would feel there's a need to turn said observation into a giant defence exercise escapes me. In the same vein, I don't know where in this thread it was that I questioned anyone's intellect? Perhaps you're too close to the fire this time to be completely objective?

And yes, I do feel the report came away a little light on the human factors aspects of the crash, but where otherwise do you think I was finding 'fault' with a report that's based on "a two year investigation by professionals with unfettered access to information none of us have"?

Defcon, I think seeker has captured the specifics, I won't hammer further.  I will speak to your comment directed at me personally.

First off, I don't think we disagree that there were opportunities missed in this report.  After this long a wait, frankly I expected more too. 

Am I defensive of the crew?  You bet your butt I am.  But you will recall from my other posts on the forum that I have been just as adamant regarding the crews of other airlines whose misfortunes have been discussed here.  It's not an AC thing.  It is a pilot thing. And yes, I am old fashioned, getting older fashioned by the day if the mirror tells me anything.

What I read in your posts about the FO suggests that you are frustrated with the gaps in the report, in fairness about more than just the FO.  While it is natural to want to bridge the gaps with theory, I draw a line between theories about facts and those about people, especially those who are living with the memories of an event like this one.  It is just my opinion, but strongly held, that they deserve understanding and a bit of elbow room, especially here, on a forum of fellows.

The report notes both crew were qualified and fit.  They followed SOP.  There is nothing, and I repeat, nothing in the report that suggests crew experience or currency undermined their compliance with SOPs.  That, to me, is a summative statement.  Far from taking the interpretation that something got missed, it says to me that, having looked at everything, there was nothing remarkable about the crew's ability to do the job, so rather than distract from the meat of the findings, no more space will be devoted to the matter.

Do I have questions left unanswered having read the report?  You bet I do.  But you and I have kicked this can around the block enough to know there are better ways to get answers than to float theories about real people on a forum.

I know this won't settle the matter, but I felt I owed you a response.

Vs

[Kip Powick]

OK...I am confused...VSplat said that......

..... autopilot disconnect is inconsequential.  It self cancels at 50' below MDA, which for this airline, is set 50' above published minimum to ensure the aircraft doesn't descend below MDA in the event of a go around

Based on that statement, the autopilot disconnect is set for 50 ft ABOVE the MDA....so my calculations are correct. The autopilot would be set to disconnect, for this approach at 863 ft MSL

However, if the aircraft in question was not fitted with the self-cancel, would it not still be incorrect to do the approach and let the aircraft descend on auto pilot  to the altitude it did???

 

Not beating a dead horse...just want to know if it is permissible to do a FPA approach and allow the aircraft to go past MDA on auto pilot or should it be disconnected and hand flown at MDA??

[DEFCON]

Thanks Vsplat. Truth be known, I didn't intend to capture you in my blanket comment with respect to 'reading'.

Seeker ... good effort, but your defence skews the context of my remarks all to hell. 

 

[Vsplat]

kip, I think the TSB has answered your question.  SOP would be to disconnect no lower than corrected MDA.  Their report indicates when they believe it was actually disconnected, which seems not to line up with our expectations at this point.  I watched the press briefing where they addressed this pretty well, I thought.  I think that briefing is still available as a link somewhere.  The memory I took from it, perhaps incorrectly, is that, in the TSB's view, the AP simply continued on the trajectory the crew themselves would have chosen had they been hand flying, so that aspect was not pivotal.

Bottom line, for a whole host of reasons, the crew lost situational awareness at some point during final approach and thought they were somewhere other than where they truly were.  It took a number of conjoint threats to defeat them, the removal of any one might have made the difference.  Again, my paraphrasing, so look to the TSB document and briefing for more,

Vs

 

[Kip Powick]

OK ...understand...I'm disappointed with the written report and perhaps that is because I am looking at it strictly from a pilot's POV.

There is a company FCOM and SOP  and the question is, (and here the TSB falls flat), what is the expected and detailed procedure for this approach and particular type of approach.

The TSB should have then spelled out clearly where there were distinct deviations from the SOPs/FCOM that resulted in the accident.

The reader should not have to flip back and forth in an effort to find the relevant data and then attempt to put it all together and have to inquire from others who are more conversant with the SOPs and FCOM, for the information.

Personally I think the report is barely acceptable, and could have been written with more continuity and clarity..Over two years and we still have to dig for the information. And finally, the TSB's mandate to include material that is totally irrelevant to the actual sequence of events that led to this  accident does little to enhance the overall document...it is more of a distraction from the serious information that operators want to know.

That non relevant information could have been added as an addendum, not included in the middle of an accident report.

Thanks for the chat and now I'm gone

[Zan Vetter]

The autopilot only disconnects at pilot-entered minimums automatically in FINAL APP mode (ie. a managed approach). This was a coupled/selected approach (coupled to LOC, with vertical profile selected by the crew via FPA mode). A/P would not disconnect automatically. The autopilot remaining engaged below mins is contra the SOP. Was that intentional, task saturation, or something else isn't addressed in the report. 

 

 

 

[Zan Vetter]

That's why np approaches are published with a min visibility. In Canada, at the time of this accident, airlines were permitted to halve that value. I'm quite sure that at the charted visibility for that approach, nobody would have seen anything. 

You appear to be saying they didn't see enough, left the autopilot on to push it a little further, and shoulda gone around. Ok, you win. I'm not perfect, so I'm saying I can see myself in their shoes, following all the same steps, getting to minimums and seeing what I think are approach lights, and then realizing too late that I'm not where I want to be. I don't think I'll ever do that, I doubt any pilot does! It's enough to give humble pilots nightmares. Perhaps we don't need to key on the autopilot or what pilots may or may not have seen, we need to key on the fact that if the worldwide industry standard for non precision approach visibility (ie. charted) was also the law in Canada, we wouldn't even be having this discussion.

If you re-run that ILS feasibility study with charted mins for the LOC only approach, I bet it becomes a lot more feasible. 

Too many limits in Canada are viewed merely as the starting point for exemptions. 

[Homerun]

2 hours ago, Kip Powick said:

OK ...understand...I'm disappointed with the written report and perhaps that is because I am looking at it strictly from a pilot's POV.

There is a company FCOM and SOP  and the question is, (and here the TSB falls flat), what is the expected and detailed procedure for this approach and particular type of approach.

The TSB should have then spelled out clearly where there were distinct deviations from the SOPs/FCOM that resulted in the accident.

The reader should not have to flip back and forth in an effort to find the relevant data and then attempt to put it all together and have to inquire from others who are more conversant with the SOPs and FCOM, for the information.

Personally I think the report is barely acceptable, and could have been written with more continuity and clarity..Over two years and we still have to dig for the information. And finally, the TSB's mandate to include material that is totally irrelevant to the actual sequence of events that led to this  accident does little to enhance the overall document...it is more of a distraction from the serious information that operators want to know.

That non relevant information could have been added as an addendum, not included in the middle of an accident report.

Thanks for the chat and now I'm gone

Kip, the only deviation from SOP that I see is keeping  the autopilot connected below MDA.  Are you trying to say this resulted in the accident?

As an aside, the autopilot would have continued to fly the selected FPA.

[Kip Powick]

2 minutes ago, Homerun said:

Kip, the only deviation from SOP that I see is keeping  the autopilot connected below MDA.  Are you trying to say this resulted in the accident?

As an aside, the autopilot would have continued to fly the selected FPA.

Absolutely not.....I feel that leaving the A/P on was a "contributing" link in the chain.

In my book during a NP one does not descend below MDA until the guaranteed landing environment is visual..I feel the lights are a guide in an NP, they are not the landing environment.

[Specs]

Any chance the report might have been prepared in such a way as to obscure TC's shortcomings in oversight?

[Vsplat]

kip. it is important to note that, at the time of the accident, "lights only" was a valid call.   Like so many accidents, the crew had sufficient confidence in what they saw to conclude they had met the criteria to enter the visual segment.

The AP angle really doesn't factor in here, at least from what I see,  I don't know anyone at this end of the industry who would intentionally abuse it to push below minima, particularly on a night such as that one.  While we are left to form our own conclusions as to why the AP was not cancelled on time, the most common conclusion, including that directly provided by the TSB, is that the extended use of the AP below the expected altitude did not change the threat level faced by that flight.

To say the crew should have gone around based on what they saw, knowing all of what is now known is, well, hindsight...

Vs

[Kip Powick]

To say the crew should have gone around based on what they saw, knowing all of what is now known is, well, hindsight...

You addressed your last post to me so......perhaps you read something in my last comment that is really not there. 

I did not say the crew should have gone around....................................

I merely stated what my parameters are for flying  an NP approach.

[Seeker]

10 hours ago, DEFCON said:

 

Seeker ... good effort, but your defence skews the context of my remarks all to hell. 

 

Really?  They are cut-and-paste from your own posts,  If you want I could copy your entire posts but I think the context is clear enough.  Sometimes the truth hurts - best to just accept it.

[Vsplat]

2 hours ago, Kip Powick said:

To say the crew should have gone around based on what they saw, knowing all of what is now known is, well, hindsight...

You addressed your last post to me so......perhaps you read something in my last comment that is really not there. 

I did not say the crew should have gone around....................................

I merely stated what my parameters are for flying  an NP approach.

The weeds are starting to get pretty thick.

The crew applied the SOP.  They clearly thought they had the required visual reference as set out in the SOP .  They discussed it. 

To suggest that a personal standard of visibility would then be applied is really opening the pandora's box of intentional non-compliance with SOP. 

The causal factors are set out in the report and the network laid out the way it is, likely on purpose.  The 'lights only' SOP is gone, the minimum visibility requirements have been improved, other changes have been put in place so, hopefully, another crew does not arrive to see a compelling, but incorrect, visual reference.  Those are all good solutions.  Applying a personal standard to an SOP operation, well, not so much.

Vs

[DEFCON]

Seeker

Your post destroyed the context of my original post.

Let me ask you a question;

Is it your position that accident investigators should not undertake an in depth exploration of everything related to each of the crew members qualifications, experience and personal history. 

In my mind, accident reports are supposed to answer the questions Seeker, not leave loose threads hanging.

 

 

  

[Seeker]

17 minutes ago, DEFCON said:

Is it your position that accident investigators should not undertake an in depth exploration of everything related to each of the crew members qualifications, experience and personal history.

Of course that's not my position.  I believe the investigators did undertake the "in depth exploration of everything related to each of the crew members qualifications, experience and personal history" and found nothing significant or worth mentioning in that area.  You, OTOH, seem to believe you're found some secret hidden factor and for post after post kept repeating the same thing.

You're right about one thing though, there are unanswered questions, just not the ones you think.  The unanswered questions are about ATAC's lobbying of the regulator to allow reductions to the minimum approach visibility in direct opposition to accepted industry safety standards in other jurisdictions and, the use of AIFs for cosmetic and ego-boosting by airport authorities instead of for infrastructure.  You might want to ask about the effect of airport rents on the financial resources of the airport authorities while you're at it.