A2’d…The NTSB prelim is something they toss together quickly before the hole even stops smoking. Yep, it leaves out a lot and they often contain errors. This one is no exception. The factuals released have all the usual group reports, charts, maps, tables, etc. I don’t have it in front of me, but the impact was almost dead on the centerline a little over one mile from the threshold (1.2 nm I think). According to the FDR and CVR, they configured before the FAF, crossed it, did around an 1100 fpm descent hitting MDA around two miles out, all SOP in the J32. The thing is they kept on going past MDA. Just a second or two after passing MDA, the CA saw the approach lights and the FO said “in sight…continue,” and they did, right into the trees. Along the way, the GPWS and radar altimeter alert systems in the ‘Stream were working properly (doesn’t seem like the new enhanced ones would have made a bit of difference in this case). The altimeters were set correctly and they were dead on the centerline.
The NTSB is (so far) doing a great job on this one because they picked up on the “continue” statement and pursued it. Although it doesn’t seem like they were going to stop right at MDA anyway (looking at the FDR), and may have intentionally gone a little lower than the 356 MDA with a 300 ceiling, they had armed the FD alt mode at MDA and probably did the CWS thing while ducking under some more, but upon seeing the ALS they cancelled the FD immediately after the FO said “continue.”
The ops group interviewed a bunch of pilots, check airmen, instructors, the POI, and his assistant (APOI). About half the group said it is SOP to leave MDA upon seeing (only) the ALS and going on down to 100 above TDZE. A few indicated concern about doing it too far out. The POI, who I think is the only one to nail it (using logic, not just spouting a reg word for word), said you can do that only if you also can see and intercept the VASI. The APOI got it assbackwards and said when you see the ALS at MDA, drop down to 100, then when you intercept the VASI, you follow it on down. Shoot, picking up the VASI at 100 feet means you are just off the end of the runway…when most guys (except lowriders) start going below the VASI to begin their “flare.” The APOI also claimed the TERPS assured obstacle clearance when you leave MDA out there if you see the lights. Say what????
The confusion doesn’t stop there. The NTSB says they showed the APOI a JEPP plate with an obstacle on final at 1027. I don’t see it on my copy, and Jepp says they don’t do that anywhere, but I do see one at 1059 on the NOS. Here’s the other mind-blowing quote: “He was asked if he was aware of an incident at IRK on the night before the accident when a Corporate Airlines crew had to climb to avoid colliding with a tree using the same approach procedures as the accident crew.”
I didn’t start this thread to speculate on this particular crash or second guess the NTSB, or the crew either, but this accident is illustrating what I think is a serious flaw in the system. The NTSB does a fine job, best in the world at it outside the military maybe, but their goal in investigating an accident, and what the airlines, manufacturers, safety people, lawyers, regulators, teachers and consultants like myself need to know about causation and how to act upon those factors is different, much broader and even deeper (another topic altogether). The NTSB “bluebook” is absolutely never the whole story and certainly not the end of it either.
What I am concerned about, professional interest aside, is for my own personal benefit, and maybe yours too. I wonder how many of my former students, whether when I was an active CFII or when I lecture, think seeing the ALS means go to 100 agl – period? I never taught it that way. When it did come up, like I said, it was in the context of deciding whether to miss or not. I’ve chased the rabbit on an ILS enough times that I don’t pucker up anymore doing it (still about the most clothed fun I can think of handflying one of those though). But on a non-precision approach, I have never given this (seeing ONLY the ALS and dropping to 100 above TDZE per 91.175) a thought…until now. Now I can’t get it off my mind, and what’s up with Jepp leaving that obstacle off of their plate?
PS – The NTSB is investigating this crash as a major, but they aren’t treating it like one in some respects, all at their option. It doesn’t look like there will be a public hearing, just the board meeting to adopt the final, and they didn’t post the docket – you have to call and ask for a copy (over 500 pages not counting pix and the FDR data) or you can get the CD. They will probably post a lot of it along with a few other goodies after the board meeting (later this year?), which will also be a webcast. They do all of them that way now.