NTSB Final Report on Corporate Airlines 5966

[LowlyPropCapt]

I think everyone is right on why this event happend... It is both fatigue AND poor airmanship. The two go hand in hand.

We have all been there... Late night, last leg. Tired as hell. Doing the approach and we dip a little below MDA, but so what, it's only a little, I can see the approach light anyway. Fatigue breeds complacency the same way that doing the same legs in the same airplane, day in and day out, can make us a little sloppy. Professionalism mitigates this to some extent and it seems this crew was caught lacking on that night. It could happen to anyone of us if we are not very careful.

On another note, this accident prompted me to ask my FO's whether they could initiate a decent from MDA with only the ALS in sight. To a man, they all said "YUP! Down to 100 feet above TDZE." Shows a lack of quality IFR training, if you ask me.

 

[CA1900]

On another note, this accident prompted me to ask my FO's whether they could initiate a decent from MDA with only the ALS in sight. To a man, they all said "YUP! Down to 100 feet above TDZE." Shows a lack of quality IFR training, if you ask me.

Why? They're absolutely correct:


Section 91.175: Takeoff and landing under IFR.

...
(c) Operation below DH or MDA. Except as provided in paragraph (l) of this section, where a DH or MDA is applicable, no pilot may operate an aircraft ... at any airport below the authorized MDA or continue an approach below the authorized DH unless—
(1) The aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuvers...
(3) Except for a Category II or Category III approach... at least one of the following visual references for the intended runway is distinctly visible and identifiable to the pilot:
(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as a reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.
[etc...]

 

[Paul R. Smith]

On another note, this accident prompted me to ask my FO's whether they could initiate a decent from MDA with only the ALS in sight. To a man, they all said "YUP! Down to 100 feet above TDZE." Shows a lack of quality IFR training, if you ask me.

I'm making some popcorn for this one.

In other news...Heard a stinker that Regions is going to fly out of CLE for CAL whether its express or connection is above my paygrade but either way...sheesh.

 

[onionluvr]

You can't descend below MDA or DH unless you have the required in flight visibility. That includes if you are using only the ALS.

 

[onionluvr]

"Fatigue-related training"?!! I have been off for a few days and I have been getting over 8 hours of "fatigue-related training" each night. It's very effective. I recommend it.

 

[LowlyPropCapt]

Onionluvr hit the nail on the head, With the ALS, you don't have the required in flight visibility to descend below MDA.

The other reason why that is not a good idea? How do you know that you will clear the terrain and towers below you if you dip below MDA at the first sign of the approach lights? Many of the FO's I fly with think that the numbers in parenthesis on the profile view indicate hieght above terrain... They don't as you well know. You only know your HAT, so your actual terrain clearence is really unknown, for the most part. Having the approach lights in sight on a non-precision approach and initiating a descent based upon that is stupid, regardless of how you read 91.175. This would get you killed at many of the airports I fly into on a regular basis.

 

[CA1900]

You can't descend below MDA or DH unless you have the required in flight visibility. That includes if you are using only the ALS.

I know that. That wasn't the question.

 

[Andy Neill]

The lesson learned that I have used in my readings of this accident (both the initial information when the crash happened and the subsequent reports) has been the value of a PDP (which another thread has pointed out is the more correct term for what many of us refer to as a VDP).

The approach they were shooting that night was the LOC/DME RWY36 if I recall correctly. The plate shows a HAT for the MDA at 356'. The PDP would have been about 1.2 miles away from the runway or 2.9 miles beyond the FAF.

The captain called the field in sight (I believe the captain DID see the field lighting) and, while LEGAL to depart MDA, it would have been safer to maintain MDA until the PDP. As it was, the aircraft impacted 13 seconds after the captain's call indicating below MDA when the call was made or a descent rate in excess of of 1200 fpm (not stabilized) or some combination of the two. Had they stayed at MDA, they probably would have had to miss since they likely would have re-entered IMC. The impact point was short of the PDP.

 

[CA1900]

Onionluvr hit the nail on the head, With the ALS, you don't have the required in flight visibility to descend below MDA.

I'm not sure I agree with that. I've had many an approach with a ragged ceiling where I can see the approach lights (and the terrain) plain as day, but the runway is still obscured. Going down another 100' gives me a clear view of the runway, and is perfectly legal per 91.175.

The other reason why that is not a good idea? How do you know that you will clear the terrain and towers below you if you dip below MDA at the first sign of the approach lights?

You're reading more into it than I said. I don't go down to 100 feet at the "first sign of the approach lights." But there are specific situations, such as the one above, where it's the safe and prudent thing to do. Blindly dropping down as soon as you see the approach lights? No! And that's not what I said.

Having the approach lights in sight on a non-precision approach and initiating a descent based upon that is stupid, regardless of how you read 91.175. This would get you killed at many of the airports I fly into on a regular basis.

Same here. But it has nothing to do with "how I read 91.175." FAA (lawyers) wrote it, and it's not ambiguous in the least. If they require MDA until you see the runway, then they should split the section in two: One for precision approaches (DA), and one for non-precision (MDA).

 

[FCPhotography]

Do you think the average citizen would feel comfortable going to work for 9 hours, then going to a kid's soccer game. Then take all the kids out to dinner for a pizza party. Now, 14 hours later let's take your family and all the kids on a 2 hour car drive in fog.......Not me.

This happens ever day in an airplane and the public doesn't even think twice about it.

 

[onionluvr]

I know that. That wasn't the question.

I'm not sure what you are asking then.

It sounded like you were implying that you can go below DH or MDA to 100' above TDZE; as long as you have the approach lights in sight. That is only partially correct.

In order to descend to 100' above touchdown using only the approach lights you still must have the required inflight visibility for the approach. That doesn't necessarily mean that you will be able to see the runway, but you need enough visual cues to indicate that you have the inflight visibility needed.

An example would be on an ILS where you need 1/2 mile visibility. If you get to DH and can see a strobe or two from the ALS, you cannot conitnue to 100' above touchdown. You must have enough of the ALS system in sight that would indicate you have the 1/2 mile visibility required.

I aplogize ahead of time if this isn't the question you are asking, but I figure it is still worth mentioning. I didn't learn this until a couple years ago (long after I got my instrument rating). Up until then I was always under the impression that any part of the ALS gave you the go ahead to continue down to 100' above TDZE. I don't think I'm the only one who got an intstrument rating and came away with that impression.

 

[Amish RakeFight]

Based on a transcript of the cockpit voice recorder, investigators also found that Sasse and his co-pilot, Jonathan Palmer, 29, "lacked a professional tone" in the cockpit. A steady stream of quips, laughter and more than 45 expletives distracted the crew from focusing on the flight, investigators said.

"The discipline in that cockpit didn't seem to exist, which really created an environment for mistakes to be made," said NTSB Acting Chairman Mark Rosenker.

"This was extremely disappointing to hear what we heard on that cockpit voice recorder," said Rosenker, who described the recording as one of the most unprofessional he's ever heard.

....as far as the conversations being unprofessional in the cockpit during the flight....I don't think that what they said was any more unprofessional (that make sense?) than any that I have had in the cockpit in the past as well.....fact of the matter is.....13 people were killed....

So while flying at night after many, many duty hours in IMC conditions after several legs, down to, and below minimums with trusting souls on board, you engage in this type of unprofessional behvior as well, and on a regular basis. So all of that cursing and unprofessionalism that took place prior to the crash is not anything abnormal for you. Just another day flying the line. You admit to being just as bad as they were that particular night. Unbelieveable you would admit such a thing.

I would hope you mature and reconsider that maybe you should be a little more professional and curse maybe half as much and be a little more professional on your future trips. Do you think many of your passengers or CP would like to know you are just as caviler as these pilots.

There's something wrong with you if you don't see that this kind of conversational banter had no impact on the crash of this Jetstream and its passengers.

 

[Andy Neill]

How about bringing into the context of this event? The captain saw the approach lights more than a mile away with published minima at 400-3/4. They were legal to descend to 100' above touchdown.

 

[81Horse]

No -- you have to continuously be in a position to make a normal landing. You can't descent below MDA until you intercept a normal glidepath -- and, it should go without saying, you must also be within the circling radius defined by the visibility and speed criteria.

 

[onionluvr]

How about bringing into the context of this event? The captain saw the approach lights more than a mile away with published minima at 400-3/4. They were legal to descend to 100' above touchdown.

Unfortunately, legal doesn't always mean safe. IMHO I don't think it should be legal to use the approach lights in this manner with a non-precision approach. It can be done safely with proper situation awareness and technique, but I think safety margins are severely diminished. At least with a precision approach there is GS information to back you up.

I also don't think it should be legal for any crew to be in a situation where they have to make these types of decisions after six legs and a 14+ hour duty day. But what do I know?

 

[LowlyPropCapt]

No -- you have to continuously be in a position to make a normal landing. You can't descent below MDA until you intercept a normal glidepath -- and, it should go without saying, you must also be within the circling radius defined by the visibility and speed criteria.

...Which underscores the importance of precomputing a VDP if one is not provided on the plate for the approach. Before it, you can't come down. After it, probably not depending on the descent rate required to make the touchdown zone.

In the context of this accident, it would appear that the crew in question left MDA too early. But as the above posters have alluded, this was just the final link in a long chain of causation. FAA regulation/oversight, corporate policy, training, CA inability to run a disciplined flight deck, failure to plan the approach, fatigue and a multitude of other factors caused this (and every) accident. To pin the blame on one or two factors is wrong.

 

[Andy Neill]

Unfortunately, legal doesn't always mean safe.

That's why I said in my previous post:
The captain called the field in sight (I believe the captain DID see the field lighting) and, while LEGAL to depart MDA, it would have been safer to maintain MDA until the PDP.

 

[CA1900]

I'm not sure what you are asking then.

I was responding to LPC's assertion that his FOs believing they can go down to TDZE+100, with just the approach lights in sight, showed "a lack of quality IFR training." That's all.

Obviously there's more to it, as you point out (including flight visibility), but his blanket statement is what I disagreed with.


In any case, I'm a big believer in calculating a planned visual descent point if the chart doesn't already have a VDP charted. Coming down before that point isn't safe, I agree.

IMHO I don't think it should be legal to use the approach lights in this manner with a non-precision approach.

On that I completely agree. I think there should be separate language for precision and nonprecision approaches.


EDIT:

...Which underscores the importance of precomputing a VDP if one is not provided on the plate for the approach. Before it, you can't come down.

You beat me to it, LowlyPropCaptain.

 

[81Horse]

IMHO I don't think it should be legal to use the approach lights in this manner with a non-precision approach.

The FAA doesn't think so either; it's not legal.

I also don't think it should be legal for any crew to be in a situation where they have to make these types of decisions after six legs and a 14+ hour duty day. But what do I know?

You know more than the FAA on this subject; flight/duty regs in their present form are criminal -- IMO.

As a previous poster noted, it's not reasonable to expect the pilot to recognize his/her own fatigue-degraded performance and judgment. It's easy to say someone should just call in tired -- but that's a very hard call to make in the real world (for many reasons).

 

[masedogg19]

So while flying at night after many, many duty hours in IMC conditions after several legs, down to, and below minimums with trusting souls on board, you engage in this type of unprofessional behvior as well, and on a regular basis. So all of that cursing and unprofessionalism that took place prior to the crash is not anything abnormal for you. Just another day flying the line. You admit to being just as bad as they were that particular night. Unbelieveable you would admit such a thing.

I would hope you mature and reconsider that maybe you should be a little more professional and curse maybe half as much and be a little more professional on your future trips. Do you think many of your passengers or CP would like to know you are just as caviler as these pilots.

There's something wrong with you if you don't see that this kind of conversational banter had no impact on the crash of this Jetstream and its passengers.

Wow....someone's making some pretty big assumptions now.....you have obviously never had casual, friendly conversations with crewmembers that sometimes have cursing in them....it's not about what was said in this incident...it's when it was said that is what they are referring to....I am not condoning this use of a non-sterile cockpit below 10K....but above that (and if in cruise flight with plenty of time), if I'm comfortable with who I am flying with and know that they are the same with me...I'll talk about whatever the hell I want to and say what I want within certain limits