Inconceivable
huh
- Joined
- Jan 1, 2005
- Posts
- 578
This was passed on to me to be posted here. The pilot's named has been redacted by me. Remarks about other FOQA data have been removed.
A few thoughts for our younger pilots:
1. You can always count on the company to look out for themselves at your expenses. Always.
2. A little knowledge in the wrong hands can be dangerous. Nowhere is that more true then with your FAA POI.
3. What does ALPA do with my 2%? How about protect you from morons like these in management, training, the airport authority, and the FAA.
4. If something seems like a bad idea, ask why. If you don't like the answer, keep asking. Your career, or life, may depend on it. Seven and a half years ago I asked why we flew Ref+5 and couldn't get an answer. It took this to change it.
The author of the remainder is the Central Air Safety Chair at PCL. Read on:
As I sit here and type the report for the 4712 accident and think about some recent conversations with first officers I think we need to talk about the company landing standard of the first 1500' of the runway. This first part is background that almost none of you know.
Background
At 0443Z on April 12, 2007 N8905F operating as Flagship 4712 ran off the end of runway 28 in Traverse City. Some of the things that all came together to make this accident happen:
Pressure from the top of the management organization to achieve a high completion factor.
A forecast that did not include heavy snow.
No timely weather reporting available because the tower was closed.
"Whishy Washy" surface condition reports from the airport who didn't want to close the airport.
Pilot Fatigue
Improper procedures for computing Vref
The point that we need to focus on for this thread is the computation of Vref. Before the accident all of our landing performance was computed using Bombardier data except ... we always added 5 knots to Vref. Nobody ever took the time to correlate the effect of a measly five additional knots onto the published Vref speeds or how pilots would be able to fly it during difficult conditions.
The accident flight was just under 47,000 lbs and the speed card indicated 142 knots for Vref at flaps 45. As was company procedure the crew bugged and flew 147 (Vref+5) for the approach. The flight data recorder shows that when the airplane crossed the threshold for runway 28 it was at 148 knots. The whole approach the airplane is at 147 knots +/- 2 knots. That's pretty good considering the winds were strong that night and producing light turbulence as it crossed over the hilly terrain that surrounded the airport.
ALPA took the time to expand on the FDR data for the flair and touchdown. When you zoom into the landing you see that the airplane crosses the threshold at 50' agl and 148 knots (Vref+5). The power reduction is normal. At this point the airplane is held 10 feet (radar altimeter) over the runway with the nose pitched down about 2 degrees. If the airplane is pitched up to rapidly the airplane balloons back into the air. If he drops it nose first it's most likely the airplane would have slide off the side of the runway with catastrophic results. Don't forget there is a tail wind pushing the aircraft. So he holds the airplane at 10 feet and as airspeed decreases, pitch is slowly increased until the airplane is at only 2 degrees nose up (and the nose wheel is finally above the mains) and the airplane is quickly settled down onto the runway. If you're reading this ***** you're hot sh*t with the stick and rudder.
The airplane is too far down the runway and the runway is too slick. The airplane ends up off the end of the runway.
About 36 hours after the accident and many people had lots of time to think about what had happened that night, most if not all of the airport operations personnel stated in their interviews with the NTSB that they observed the airplane touchdown 3600' from the threshold of runway 28. Without any marks on the runway to confirm this their comments were noted but not taken to seriously and the NTSB decided to wait for the aircraft performance group to determine the exact touchdown point.
Some how the airports determination that the airplane touched down 3600' from the threshold makes it to our local office of the FAA. It wasn't a coincidence. The airport has been on the hot seat for several years and 4712 wasn't even close to being the first airplane to go off the end of the runway in TVC. There is some sort of relationship between the airport and our FAA and the information was given to them intentionally.
So our POI has this information that the airplane touched down 3600' from the threshold and gets crazy. There are meetings held with the company and the check airman, threats are made, everyone gets in a barrel and goes over the falls together and we had a 10 page thread on being disqualified if we didn't get the airplane into the 1500' zone. At the same time, and very quietly, our Vref bugging procedure is changed to use the published speed without adding five knots.
Fear is the worst possible motivator for safety and usually leads to new accidents and revolution against the tyrants.
A few months later two reports are issued by the NTSB. The first one is the performance factual report. I've uploaded this into the general documents section. On page 14 you can see that the computed touchdown point was actually 2300' from the threshold, not 3600'. Another report we have that I'll make available soon shows that at 142 knots instead of 147 knots, the airplane would have stopped before the end of the runway. ***** didn't blow the landing, he hit it dead on using the companies procedures.
<end quote>
Fly safely.
A few thoughts for our younger pilots:
1. You can always count on the company to look out for themselves at your expenses. Always.
2. A little knowledge in the wrong hands can be dangerous. Nowhere is that more true then with your FAA POI.
3. What does ALPA do with my 2%? How about protect you from morons like these in management, training, the airport authority, and the FAA.
4. If something seems like a bad idea, ask why. If you don't like the answer, keep asking. Your career, or life, may depend on it. Seven and a half years ago I asked why we flew Ref+5 and couldn't get an answer. It took this to change it.
The author of the remainder is the Central Air Safety Chair at PCL. Read on:
As I sit here and type the report for the 4712 accident and think about some recent conversations with first officers I think we need to talk about the company landing standard of the first 1500' of the runway. This first part is background that almost none of you know.
Background
At 0443Z on April 12, 2007 N8905F operating as Flagship 4712 ran off the end of runway 28 in Traverse City. Some of the things that all came together to make this accident happen:
Pressure from the top of the management organization to achieve a high completion factor.
A forecast that did not include heavy snow.
No timely weather reporting available because the tower was closed.
"Whishy Washy" surface condition reports from the airport who didn't want to close the airport.
Pilot Fatigue
Improper procedures for computing Vref
The point that we need to focus on for this thread is the computation of Vref. Before the accident all of our landing performance was computed using Bombardier data except ... we always added 5 knots to Vref. Nobody ever took the time to correlate the effect of a measly five additional knots onto the published Vref speeds or how pilots would be able to fly it during difficult conditions.
The accident flight was just under 47,000 lbs and the speed card indicated 142 knots for Vref at flaps 45. As was company procedure the crew bugged and flew 147 (Vref+5) for the approach. The flight data recorder shows that when the airplane crossed the threshold for runway 28 it was at 148 knots. The whole approach the airplane is at 147 knots +/- 2 knots. That's pretty good considering the winds were strong that night and producing light turbulence as it crossed over the hilly terrain that surrounded the airport.
ALPA took the time to expand on the FDR data for the flair and touchdown. When you zoom into the landing you see that the airplane crosses the threshold at 50' agl and 148 knots (Vref+5). The power reduction is normal. At this point the airplane is held 10 feet (radar altimeter) over the runway with the nose pitched down about 2 degrees. If the airplane is pitched up to rapidly the airplane balloons back into the air. If he drops it nose first it's most likely the airplane would have slide off the side of the runway with catastrophic results. Don't forget there is a tail wind pushing the aircraft. So he holds the airplane at 10 feet and as airspeed decreases, pitch is slowly increased until the airplane is at only 2 degrees nose up (and the nose wheel is finally above the mains) and the airplane is quickly settled down onto the runway. If you're reading this ***** you're hot sh*t with the stick and rudder.
The airplane is too far down the runway and the runway is too slick. The airplane ends up off the end of the runway.
About 36 hours after the accident and many people had lots of time to think about what had happened that night, most if not all of the airport operations personnel stated in their interviews with the NTSB that they observed the airplane touchdown 3600' from the threshold of runway 28. Without any marks on the runway to confirm this their comments were noted but not taken to seriously and the NTSB decided to wait for the aircraft performance group to determine the exact touchdown point.
Some how the airports determination that the airplane touched down 3600' from the threshold makes it to our local office of the FAA. It wasn't a coincidence. The airport has been on the hot seat for several years and 4712 wasn't even close to being the first airplane to go off the end of the runway in TVC. There is some sort of relationship between the airport and our FAA and the information was given to them intentionally.
So our POI has this information that the airplane touched down 3600' from the threshold and gets crazy. There are meetings held with the company and the check airman, threats are made, everyone gets in a barrel and goes over the falls together and we had a 10 page thread on being disqualified if we didn't get the airplane into the 1500' zone. At the same time, and very quietly, our Vref bugging procedure is changed to use the published speed without adding five knots.
Fear is the worst possible motivator for safety and usually leads to new accidents and revolution against the tyrants.
A few months later two reports are issued by the NTSB. The first one is the performance factual report. I've uploaded this into the general documents section. On page 14 you can see that the computed touchdown point was actually 2300' from the threshold, not 3600'. Another report we have that I'll make available soon shows that at 142 knots instead of 147 knots, the airplane would have stopped before the end of the runway. ***** didn't blow the landing, he hit it dead on using the companies procedures.
<end quote>
Fly safely.
