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PHD. MBA. MHS. Type rated on A350, A330, B777, B747-400, B747-200, B757, B767, B737, B727. International Airline Pilot / Author / Speaker. Dedicated to giving the gift of wings to anyone following their dreams. Supporting Aviation Safety through training, writing, and inspiration. Fighting for Aviation Safety and Airline Employee Advocacy. Safety Culture and SMS change agent.

Monday, October 10, 2011

A330 Nightmare in the Making

Imagine flying into Shanghai. You’re in the weather converting feet to meters in unfamiliar environment. It’s the middle of the night. Fatigue tugs on your eyelids. You can see the many planes with the TCAS, you can hear them talking to ATC, but you have no idea what clearances they’ve received or where they’re flying to. Targets buzzing around like a swarm of bees.

ATC descends you to 600 meters. Quick check—2000 feet. They provide an intercept heading well inside of the final approach fix, which is 2900 feet. Then the pilot monitoring decides to help you - without your knowledge - by clearing the PPOS. (Present Position).

Your green line to the runway, on your map, disappears. The only green line is just in front of your plane but jetting off to the lefte

Your mind is traveling faster than the plane and you state, “Localizer captured. Glide-slope is armed and coming in nicely. Th green line is the missed approach. We don’t need the map. We’re good.”

But he says, “Don’t worry, I’ll fix it for you.”

Before you can yell stop, and quicker than the glide-slope can capture, it happens—Bells scream and lights flash, you’ve just gone through the glide-slope, the autopilot has disengaged and now you have no clue if the missed approach is in the box, or not. He’s taken out the approach in attempt to put it back in.

Quick response you re-engage the autopilot. You need everything you have to assess the situation and manage the plane. No time to spare. He has put the approach back in the box. You use vertical speed to fly down and capture the glide-slope, the most efficient option. "Course locked on, glide-slope captured, auto-thrust is engage, and our missed approach altitude is… It’s gone!” Okay… you remember … “213 feet.” Within seconds runway lights reach out through the fog… and you have a visual. But no automatic call-outs because you no longer have the MDA set.

You break out. “Runway in sight.” You glance at the altimeter—300 feet. Deep breath, and you disconnect the autopilot and land.

A nightmare in the making…

or a chapter in an aviation thriller?

What went wrong with this approach? Take a guess then join me on Thursday for the answer.

Enjoy the Journey!

XOX Karlene

32 comments:

  1. I'm a frequent flyer so this is really scary --but utterly gripping at the same time. I can't begin to guess what went wrong with the approach beyond two things: pilot fatigue and having the translate from meters into feet. I thought it was standardized in feet around the world, just as the air traffic language is English. I can't wait to know the solution!

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  2. excellent writeup , classic example of airbus pilot vs rookie airbus "oh it's doing that thing again" vs scarebus "what is it doing now" it happens on A320 too, if you are within 7NM FMGC logic presumes you have overflown the Airport & gives u missed approach track.

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  3. Seems to me like a pretty serious breakdown of cockpit communication. And one worth a pretty good debriefing post-flight to make sure it doesn't happen again!

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  4. Dear Karlene,

    Not sure if this is the direction you want to take, but I think that what went wrong is that the PF didn't abandon the approach, go missed and climb as soon as she lost solid situational awareness. Down in the weeds in the dark is no place to be wondering where you are.

    Regards,

    Frank

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  5. might seem to chapter in an aviation thriller,but also a real case, like those days where everything should goes wrong..

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  6. In response to Frank, I do agree with the safest course of action being to get out of there, but I do think it's worth giving it a chance. In an airline environment, you will burn a LOT of fuel and have people miss connections, etc. That being said, it's always good to take the safest course, and executing a missed could possibly be the best thing to do. I'm not familiar with Chinese airspace and procedures though. (soon to change!)

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  7. Hi Fred, No... there are a few locations in the world where it's not standardized. Most airlines have charts, and the A330 has a button that we select that will indicate meters. But, it's definitely one added distraction. Fatigue is always a factor. Thanks for the great comment.

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  8. Puneet, no kidding... "What's it doing now?" is the standard joke. Hopefully one day I'll know as much as my plane. But the Airbus may be awhile... she's smart.

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  9. Daniel, first comment... yes we need these type of situations to not occur. I think that an aviation safety forum when pilots can discuss scenarios such as this and we can learn from the "what ifs" is the best learning there is for safety.

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  10. Frank, you are so right! Had I been sitting in that jumpseat on such a scenario I, too, would have been saying... "Go Around!"

    But then...

    The safest course of action is just that. What is the safest action? Managing the plane to a safe landing... Or executing a missed approach?

    What is the pilot flying's situational awareness? Was the missed approach removed and what was the procedure? Did they know? We all depend on the airplane flying our missed... that we verified in the MCDU. Lots of traffic. Dealing with the language barriers, meters, and more than likely radar vectors through in an unknown environment... since very possibly the missed was removed, and or input incorrectly... and no time to verify. What was the fuel? How long until they could get back in for another approach?

    Situational awareness of terrain on final might have been the best there would be on that flight. But those are the decisions that each one of us have to make on every flight when we need to decided to go, or not go.

    So many factors to think about for sure.

    Thanks for the great comment!

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  11. Fabian, exactly. And like I say... truth is scary than fiction far too often. Some days are just better than other.

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  12. Karlene, does your airline have such a forum or anything where you can discuss a situation like this? Would be nice to have a place to see if anyone else had similar scenarios or suggestions. Could possibly be divided into individual fleet types and then scenarios very applicable to all pilots. It might be important to stress that the replies need to be constructive as I know many pilots that would be quick to pass judgement...

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  13. Daniel, you will soon be familiar. Not sure what your new airline has in place, but there are some things you can do when flying down there. Having a chart with equivalent meters to feet is the best.

    My decision making on the missed is can the plane be landed safely. You're right... so many decisions go into that process on the missed. I wrote my thoughts above to Frank.

    The only decision for the "missed" or divert, I don't take into account is passenger misconnect. Divert... if it's a safe action I will account for passenger service, but...


    Passengers will be angry if they are delayed, if they miss their connect, or are canceled... anything that ruins their day.

    But this is like tough love for our kids. I know more than the average passenger on what will keep them safe.

    They may be angry, it may cost the company money, but the passengers will be alive to complain about their inconvenience. And I will be alive to go to that hearing to tell why I did what I did.

    I'm a proponent of ruining a passengers day if it will keep them alive. I want to go home to my family too.

    Thanks for the great comment and opening some excellent discussion.

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  14. Daniel, we don't have anything like that. Unfortunately. I wish we did. I think every airline can learn from these sort of mistakes.

    Northwest used to take scenarios like this and we made videos. Then during our recurrent training we watched the video as a crew and discussed the biggie of the year. It was excellent! We all heard the actual details ... not the on-line rumors... and then pick it apart as to what we could do differently.

    If you could take what NWA did and implement that at your airline... good stuff!

    Denial is not the best course of action... learning moments so others won't repeat is the answer. This is the reason I am part of
    http://www.flightpodcast.com/
    We interview pilots from major incidents, hear what happened and then discuss.

    Thanks for the comment!

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  15. Wow, your life is like a thriller! I can't imagine the adrenaline rush of something like that. You are kind of my hero. :)

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  16. Such decisions are so much simpler for a private pilot coming in at under 100 mph with no passengers to worry about. My hat's off to all you pros. You earn what they pay you.

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  17. Karlene, I completely agree with you, I meant that passengers were just one more consideration, but when deciding to go around, especially in a situation like this, it isn't something to even think about. Without question better late than never. I will have to take a look at that website. I don't believe this company does either.

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  18. Heather... no heroes. This story is just an example of what's happening out there that we can all learn from.

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  19. Thank you Dave! Unfortunately the industry is shifting and squeezing the pilots tight. Many losing pensions, lost pay, work rules changing... lots of distraction out there.

    I hope we can shift back to better pay and work-rules so our pilots can focus on their job and not worry about the life on the ground at home.

    Thanks for your comment and support.

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  20. Daniel, you are so right. They are a consideration. But, one that I try to put out my mind in crisis. Save the plane, save the passengers. So if I'm thinking about the plane then I have one less worry.

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  21. when you are climbing from takeoff to cruise altitude, do you insert the wind information at each waypoint, or is this done during preflight?

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  22. Jet Airliners, we don't normally enter winds. It's automatically uploaded. Not that we can't... we can. And that can could be during preflight or enroute. When new winds are uploaded enroute, we insert.

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  23. Terrifying but you pulled through! I bet adrenaline was pumping yet you stayed calm and knew exactly what to do.

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  24. Thanks Angela. One thing about writing... we can make the story end happily ever after. Or however we want it to end. :) Thanks for the comment!

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  25. so does the wind data get uplinked?

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  26. Kar, I was flying out of Seoul Korea when the copilot switched my course/VOR without informing me!! Yikes, heading north of out South Korea would be terrifying!!! ATC caught the error as I was still questioning it (both tired, all night freight) but cockpit communication and situational awareness are critical to have. Copilot was a pro, and usually right on - he couldn't apologize enough, but I knew it was my "fault" as captain - to "see and know all". :)

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  27. Great post and great discussion.
    In my airline, there is a "no blame policy" regarding go-around's. You do have to write a report, but nobody will blame you for that.
    This said, they've found that 87% of our pilots do not go around when not fully stabilized by the 1000ft call.

    I believe it is very hard to judge such a situation with so few details, seating in a comfy seat in a calm environment.

    I often find ATC to be the greatest source of distraction during the approach and landing, especially in some of the few countries using dual language communications (such as Spain, France, Italy, Germany, ...).

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  28. Kath... Silly girl. Nobody "sees and knows all." There are some things you can't do anything when the other pilot pushes buttons and tunes radios. We're all in this together. We just need to do the best to make sure the cockpit is open to communication and we set our expectations for a safe flight. Thanks for the comment.
    PS... Scary no kidding! Not the place you want to be flying.

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  29. GC232... Thanks for the excellent comment. Yes, so easy to sit in the comfort of our living room judging. But hopefully we can learn. There are so many possibilities for something to fall through the holes... ATC is one of them. Our task is to stop it before it turns into a situation that we can get out of.

    I think every company should have a no blame go-around policy. That is the last thing a pilot needs to be thinking.

    Thanks for the great comment.

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  30. Jet Airliner... how about you email me with these questions? Thanks.

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