Different Take on the HFX Crash of the AC 320

[Kip Powick]

Not sure if this has been posted before....Decent video except for some of the spelling

 

 

[blues deville]

I like the video and how well these can be produced now with such clear visual graphics and audio. Not sure where they received all of the details but perhaps it’s easy to find and accurate enough. 

The screen shot below is from the video and good dispatchers are worth their weight in gold. But sometimes statements like these can change the thought process and good decision making. So now rather than just diverting, there is the knowledge that someone else (company) just landed albeit on their second attempt. A sense of encouragement is added but also a challenge for most pilots and perhaps not always the best advice. Everyone has their own skill levels.

I did like the “lights off” selection but for me those conditions would also include strobes and sometimes the beacon too and nothing goes back on until a runway environment is positively identified. It can be difficult to see a minimum approach and runway light system and you don’t always have much time to decide what you are really seeing

Obviously their plan was to take a look, land or go to YQM. Too bad the path brought them in too early and the rest is history. 

[rudder]

A perfectly serviceable aircraft and a qualified crew had a CFIT landing event in YHZ - just like Jazz in CYAM and Asiana in KSFO.

Mistakes were made. Seemingly the common thread was the human component. But there were also procedural, technical, and regulatory shortcomings that contributed to the outcomes.

Hopefully all of the necessary changes have been made by the operators. However, Canada still lags behind the rest of the world in approach ban limitations on non-precision approaches.

[Southshore]

Help me here, Lucy. The wind that miserable night was right down 33. The approach was RNAV 33. 624 couldn't do that app cuz it's an old 320 with no GNS rnav app. So, with a perfect xwind they chose the LOC 05. Wx is going above and below limits for that app. but never goes below limits for the ILS 23. Why, if they were going to live with the big xwind for 05,not take the same xwind for the ils23 with real vertical guidance? 05 can be a real black hole in wx like that. Never have figured that out. L'il help?

[thor]

I don’t think that they could do the RNAV approach because they didn’t have GPS installed on the aircraft. 

[DEFCON]

Another poster previously indicated 320 crews are employing ipads  & phones to provide 'situational awareness'.

Did this crew use that technology to guide them through the approach?

 

 

[Kip Powick]

41 minutes ago, DEFCON said:

Another poster previously indicated 320 crews are employing ipads  & phones to provide 'situational awareness'.

Did this crew use that technology to guide them through the approach?

 

 

Not indicated in the TC Final report

http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2015/a15h0002/a15h0002.pdf

 

[boestar]

Not sure the crew ipads were deployed back then.

 

[DEFCON]

The FAF is defined on the approach chart. Maybe I'm missing something in the report, but it doesn't seem to tell us why the crew didn't verify their position using the approved navigational guidance? 

[DEFCON]

"Not sure the crew ipads were deployed back then."

Couldn't they have been using their own?

[Kip Powick]

14 minutes ago, DEFCON said:

The FAF is defined on the approach chart. Maybe I'm missing something in the report, but it doesn't seem to tell us why the crew didn't verify their position using the approved navigational guidance? 

Perhaps they were relying too much  on the automation.

From the report............

During the occurrence flight, as per Air Canada’s practice, once the FPA was selected and the aircraft began to descend, the flight crew did not monitor the altitude and distance from the threshold, nor did they make any adjustments to the FPA. The approach was considered stable and consistent with Air Canada’s training. The flight crew did not notice that the aircraft had drifted below and diverged from the planned VDAflight profile, nor were they aware that the aircraft had crossed the minimum descent altitude further back from the threshold.

 

and this...

Both flight crew members had detected ground lighting between the final approach fix and the MDA, which likely reinforced their expectation that they would acquire the required visual reference at the MDA and that a landing could be carried out successfully.

I'm sure all of us have experienced a similar scenario, that is during an approach  vertical visibility that gave us the expectation that it would be a "no problem" landing, and at minimums the "forward" visibility was actually  sketchy at best.

.

 

[DEFCON]

I agree Kip.

Never mind procedural, or SOP issues, this crash could have been prevented had a simple ancient technology known as VASI been available.

The crash demonstrates the industry's largest system weakness again imo; new generation crews are dangerously reliant on computer magic.

[boestar]

57 minutes ago, DEFCON said:

"Not sure the crew ipads were deployed back then."

Couldn't they have been using their own?

legally?  NO

 

[boestar]

3 minutes ago, DEFCON said:

I agree Kip.

Never mind procedural, or SOP issues, this crash could have been prevented had a simple ancient technology known as VASI been available.

The crash demonstrates the industry's largest system weakness again imo; new generation crews are dangerously reliant on computer magic.

if they didnt have visual reference to the runway lighting then what good would VASI have done.  it only works when you can see it.

 

[rudder]

3 minutes ago, boestar said:

if they didnt have visual reference to the runway lighting then what good would VASI have done.  it only works when you can see it.

 

There was VASI (or PAPI). 

Problem is that with the reported visibility they would not have seen it at the MDA. As a matter of fact, they would not have seen it until very short final.

TC needs to harmonize the approach ban visibility for non-precision approaches with the standards in the rest of the world.

If that has been the case, this approach never would have been commenced and never would have been continued.

Thankfully, the smarter CDN operators have established their own visibility requirements which are far more restrictive (and sensible).

Another black eye for TC and this Minister.

[DEFCON]

I generally agree with Rudder above.

Maybe I need to re-read the report, but I don't recall a VASI being part of the equation?

And perhaps I'm taking the report the wrong way, but had the crew maintained the MDA as the approach requires instead of following the flawed FDA data into terrain the crew would have either seen a vasi, or missed the approach.

Regardless, approach lights alone don't give much direction in the way of vertical guidance until it's too late.

In this example it seems to me that the pilot's perspective on those lights provided the visual cue that the ac was way too low and led to the initiation of the miss.

 

[J.O.]

10 minutes ago, rudder said:

Another black eye for TC and this Minister.

The problem is hardly new - it existed when "this Minister" was still employed by the Canadian Space Agency. Multiple past efforts to modernize approach ban limits have been lobbied into oblivion by industry groups. The ridiculous "level of service" debacle that came out about 10 years ago was a backhanded way for the then Director General to push a more conservative methodology on the industry. Unfortunately he did nothing to mandate airport operators to bring their equipment up to modern standards.

Airbus has consulted heavily with industry and has put a ton of work into their FCOM SOPs. If those SOPs had been used, I believe this accident would have been prevented. Just because you can doesn't mean you should.

[AIP]

Or what if a few dollars were spent on a glideslope for the localizer on 05.

This thread probably wouldn't be needed if that were the case.

When are the airports, and local airport authorities going to be called out ???

Does Nav Canada get some blame here as well ??  

[Seeker]

I don't see anything new about this effort.

The airport authorities are too cheap to spend money on proper navigation and lighting equipment - "we'll just leave it to the pilots to handle."  Transport did make an effort to help when they instituted the whole "approach ban" requirements.  ATAC immediately lobbied for exemptions (which they got) making the whole thing moot, and an exercise in frustration, for every commercial pilot in Canada.  It's an embarrassment that the major airport in eastern Canada doesn't have a CAT II on every runway or, at the very least just a basic ILS.  In fact, every airport with scheduled service in Canada should be equipped with ILSs on every runway.  Yes, I know the airport authorities are hoping that RNAV approaches will provide everything they need for free but an ILS, and especially the CAT II,  is still the gold standard.

So, what do we have:  a couple of well-intentioned, conscientious,  professional pilots flying an airplane with substandard avionics, doing a cobbled together approach to an airport with marginal lighting in very poor weather conditions, under an exemption the the visibility rules the that entire rest of the planet uses!  They apparently thought the lights they saw at MDA were runway lights and continued.  Far too easy to point at the pilot's error - to find the real cause you got to follow the chain of events much further back.  The accident report is/was complete waste of tax dollars (that's just my humble opinion) - completely glosses over the implications of the approach ban waivers achieved by ATAC's lobbying (and the governments error in allowing them in the first place), completely glosses over the failure of the airport authority to properly equip the airport with navigation equipment and lighting and completely glosses over other errors I won't get into.

 

edit - I see, after posting this, that AIP posted some of the same thoughts.

[rudder]

More proof that the pilots are the last line of defense.

”minimums”...... Go Around.

nuf said.

[DEFCON]

I've gone back to the report and stand corrected; VASI was available and operational, but probably not useful at strength 4 that night.

If you step back and look at the event from a distance it does look like the crew flew into a trap of sorts created by government, pier pressure maybe, but mostly because of the emphasis the industry places on getting the job done.

All that aside, the crew remains the master and final link in the accident chain regardless.

 

  

[blues deville]

Re: VASIs. Where they not buried in the snow and therefore totally useless?

[Kip Powick]

17 minutes ago, blues deville said:

Re: VASIs. Where they not buried in the snow and therefore totally useless?

I don't think they have VASI on that runway, only PAPI

The runway is serviced by a precision approach path indicator (PAPI) that projects a 3° slope and is suitable for aircraft with an eye-to-wheel height of 45 feet. The PAPI is located on the left side of the runway, approximately 1300 feet from the threshold.

At the time of the occurrence, the PAPI was on setting 4 and had been on this setting since the morning of the previous day.

 

[blues deville]

Okay thanks Kip my mistake. I thought there was something in the report about them being covered in snow. I guess not. 

[canadairguy]

18 hours ago, seeker said:

The airport authorities are too cheap to spend money on proper navigation and lighting equipment - "we'll just leave it to the pilots to handle."  

I'm sorry, seeker, but I don't think that it's the airports that are too cheap.  A modern aircraft arriving at Halifax that night would have flown an RNAV approach to LPV minimums, rather than a non-precision approach.  It was 2015, after all.  Are there still aircraft in the fleet incapable of flying RNAV approaches?