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[Mushrif A 3]

Airline pilots 'not equipped' to land plane

 

 

 

Andrew Heasley

February 10, 2012 - 2:20PM

 

 

AirAsia X pilots flew so low into Gold Coast airport on two occasions that the safety margin from ground and other aircraft could no longer be assured, air investigators have found.

The pilots disregarded the safe minimum altitudes for no apparent reason, investigators from the Australian Transport Safety Bureau said.

The low flying meant the airliners strayed into non-controlled airspace used by other planes.

That the similar errors occurred on different flights with different air crew little more than three weeks apart highlighted systemic gaps in the airline's pilot training, the bureau found.

The flight incidents occurred in rain, cloud and low visibility, and involved multiple attempts to land.

The bureau found the pilots were probably not adequately equipped to handle non-standard landing approaches "other than autopilot managed mode".

In the first incident, on May 4, 2010, on approach to Gold Coast airport for their second attempt at landing, the pilots in their Airbus A330 with 258 passengers on board, sank below the safe minimum distance above the ground.

At 20 kilometres from the airport the plane was already at the minimum allowable level, but 900 feet lower than recommended.

At the lowest, the pilots flew 200 feet below the official minimum of 1500 feet — and were alerted by air traffic controllers to their low flying, but did not regain altitude — before ultimately abandoning the landing at 750 feet above the ground.

The pilots abandoned a third landing attempt, and finally diverted to land at Brisbane instead.

The descent "was conducted without apparent regard for the published segment minimum safe altitudes", investigators said, "... with the effect that separation from terrain (ie, the ground, obstacles) and other aircraft operating in non-controlled airspace was no longer assured".

Investigators said it was "not clear" why the pilots flew too low, but unfamiliarity may have been a factor, investigators said.

On the second flight carrying 260 passengers, on May 29, the pilots, about 19 kilometres from the same airport, began to fly under the recommended altitudes.

For four kilometres, the aircraft sank as much as 700 feet lower than the safe minimum altitudes, down to 1500 feet, before aborting the landing at 750 feet.

"It was apparent that the flight crews were not monitoring the ... [descent profile]...to ensure compliance with ... minimum safe altitudes," investigators said.

The similar breaches on both flights "indicated there may be systemic factor(s)" in the airline's training.

In response, the AirAsia X revisited its pilot and instructor training, putting all pilots through Gold Coast-specific simulator sessions, issuing revised charts and recommending a maximum of two missed landing attempts before diverting to another airport.

 

 

Read more: http://www.smh.com.a...l#ixzz1lyTnXFhK

 

Were these safety breaches reflective of pressures to contain costs, whether in training or flight diversions?

 

And in D7's response, it suggests that the issue was addressed via airport-specific re-training. But it makes you wonder if the same practice was done at other airports that D7 serves and the problem is more systemic.

Edited February 10, 2012 by Mushrif A

[Ganesh.r 0]

There is no ILS in OOL . You would have to look out the window to land.

Surprisingly other regional airport have in in Oz but not OOL

[alberttky 0]

There is no ILS in OOL . You would have to look out the window to land.

Surprisingly other regional airport have in in Oz but not OOL

 

Goes to show the reliance of pilots on ILS nowadays that without it they've forgotten how to fly a non-precision approach safely...

[Sandeep G 1]

Goes to show the reliance of pilots on ILS nowadays that without it they've forgotten how to fly a non-precision approach safely...

 

That's a very broad statement. You speaking in your professional opinion as a pilot to pass judgment on ALL pilots?

 

Back on Topic:

Similarly however, the TR grounding in Australia was the result of multiple violations in this same regard. However, in TR's case - IIRC - it was the same pilot who commited the same offence on multiple occasions, and the regulators discovered that not enough re-training nor grounding of the pilot had ever occured which was indicicative of a lapse in safety training standards at the airline - which led to the Grounding of the airline.

 

I'm suprised this news has come up again WRT D7 - thought it was very old news and had been written up before... I wonder if it's bad press for the benefit of an up and coming carrier? Pure speculation of course..

[Naim 6]

"RT: @azranosmanrani: mean-spirited media. Old issue. Audit done and cleared. Tough airport because no ILS which they now realise they need to install"

[Ahmad M 1]

Trained properly there should be no problem landing at a non ILS airport. A Non Precision Approach on the A330 is almost as simple as an ILS Approach. Mr Azran is actually insulting his pilots by saying that. Maybe training just to the minimum standard is not good enough....

 

 

 

Goes to show the reliance of pilots on ILS nowadays that without it they've forgotten how to fly a non-precision approach safely...

 

Have you done a sim check with any airline recently? Don't be to quick to generalize.

[flee 5]

ATSB Report: http://atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-027.aspx

 

"RT: @azranosmanrani: mean-spirited media. Old issue. Audit done and cleared. Tough airport because no ILS which they now realise they need to install"

Why should D7 CEO bitch about it? The media was merely reporting on the official ATSB investigation that was released on 10 Feb 2012.

 

It was good that no fatalities resulted from the problems encountered landing at OOL.And the positive that came out was that D7 had to provide better training for their pilots.

[Mushrif A 3]

"RT: @azranosmanrani: mean-spirited media. Old issue. Audit done and cleared. Tough airport because no ILS which they now realise they need to install"

 

Azran should also complain about the ATSB making public its official report that was released this month. Dont just shoot the messenger. Otherwise, it seems to suggest that Azran would rather sweep the matter under the carpet, or continue the practice of being economical with the facts/ truth (just like ticket prices, which was blamed on "IT issues")

[Waiping 12]

They know OOL does not have ILS when they choose to fly there, no?

[alberttky 0]

Have you done a sim check with any airline recently? Don't be to quick to generalize.

 

I've just completed my IR renewal recently.

 

As a HPL instructor I follow these areas very closely. I have no doubt that all professional pilots are trained properly. And we know the saying "practice makes perfect". The reality is how many non-precision approaches do airline pilots do versus precision approaches, whether it be in sim or in the aircraft? After doing so many ILS approaches, the brain is more or less "programmed" that all approaches are ILS until they encounter one that is not, at which it takes a while to readapt to something outside the norm. Some pilots have no problem doing that, others need more time. Unfortunately when you're doing an approach at +/- 150 KTS there really is not much margin.

 

There have been numerous articles written on the reliance on automation and how the sheer amount of technologies in the cockpit today has, to some degree, compromised flying skills. Some examples are listed below. While ILS is a landing aid, most pilots in commercial airliners tend to rely on AP to capture the ILS and fly just before reaching minima and disconnecting the AP. They do it day in and out and I believe the one of the few rare occassions where pilots are able to hand fly the entire approach on raw data is during their sim checks, whether precison or non-precision.

 

It could happen to any pilot, including myself.

 

http://expertaviator.com/2011/08/08/how-reliance-on-automation-has-decreased-our-flying-skills/

 

http://aviationknowledge.wikidot.com/aviation:automation

 

http://theworldlink.com/news/local/article_a75ecdb6-d333-11e0-b6a9-001cc4c03286.html

[Mike P 0]

When they mentioned standard, is it standard only in Australia? or Is it standard globally?

[Sandeep G 1]

 

 

I've just completed my IR renewal recently.

 

As a HPL instructor I follow these areas very closely. I have no doubt that all professional pilots are trained properly. And we know the saying "practice makes perfect". The reality is how many non-precision approaches do airline pilots do versus precision approaches, whether it be in sim or in the aircraft? After doing so many ILS approaches, the brain is more or less "programmed" that all approaches are ILS until they encounter one that is not, at which it takes a while to readapt to something outside the norm. Some pilots have no problem doing that, others need more time. Unfortunately when you're doing an approach at +/- 150 KTS there really is not much margin.

 

There have been numerous articles written on the reliance on automation and how the sheer amount of technologies in the cockpit today has, to some degree, compromised flying skills. Some examples are listed below. While ILS is a landing aid, most pilots in commercial airliners tend to rely on AP to capture the ILS and fly just before reaching minima and disconnecting the AP. They do it day in and out and I believe the one of the few rare occassions where pilots are able to hand fly the entire approach on raw data is during their sim checks, whether precison or non-precision.

 

It could happen to any pilot, including myself.

 

 

Thank you for your clarification. Where do you teach BTW? Whilst we do rely on automation, it is usually governed by company policies and with good reason, which I'm sure your links to articles above will reiterate, to increase situational awareness in the flight deck amongst all tech crew. The use of Autopilot could have in fact saved the D7 pilots from making this mistake in the first place.

 

Hand flying skills are important and we actually tend to handily approaches including intercepts in low workload environments more so FOR precision approaches.

 

Briefs and running through all SOPs before will always increase the chances of a successful approach, and it's such cockpit discipline that will save lives.

[Ahmad M 1]

The flight to OOL is at least 8 hours long and normally 1 hour before landing the pilots should have completed their approach briefing already, so no question why they shouldn't be mentally ready for the non precision approach. Anyways the report was for flying below safe altitude and not the approach procedure itself, you can only speculate why they did what they did. One tend to think that they were trying too hard to land the aero plane, schedule before safety. My hope is that I'm totally wrong.

[alberttky 0]

Thank you for your clarification. Where do you teach BTW? Whilst we do rely on automation, it is usually governed by company policies and with good reason, which I'm sure your links to articles above will reiterate, to increase situational awareness in the flight deck amongst all tech crew. The use of Autopilot could have in fact saved the D7 pilots from making this mistake in the first place.

 

Hand flying skills are important and we actually tend to handily approaches including intercepts in low workload environments more so FOR precision approaches.

 

Briefs and running through all SOPs before will always increase the chances of a successful approach, and it's such cockpit discipline that will save lives.

 

No doubt automation is necessary to improve situational awareness. But with anything in aviation, it is a compromise. While automation is good, studies have shown that too much reliance on automation has resulted in deteoriation of flying skills in the long run, be it intentional or unintentional. So when pilots are faced with something not commonly encountered (e.g. non-precision approaches), things MAY get haywire. I stress that not all pilots face the same situation, othewise every flight to OOL would have been a violation.

 

So how many non-precision approaches do you guys do versus ILS?

[alberttky 0]

Anyway I'm always a bit sceptical about reading from the media. Best to read the report from the experts.

 

http://www.atsb.gov....7/ao2010027.pdf

 

By the way you may want to see what others are saying...

 

http://www.pprune.org/dg-p-reporting-points/476813-atsb-report-airasia-x-gold-coast-approaches.html

Edited February 11, 2012 by alberttky

[Arthur Van Straten 0]

@Albertky

 

You are right, Read the report.

Here is an excerpt.

 

"In response to this incident, the aircraft operator made a number of changes to flight crew procedures when conducting instrument approaches. The operator also modified the recurrent simulator training program to include more complex non-precision instrument approaches."

 

Begs the question though. Is, was, there complacency in the operators way of doing things? And they only found out now, ?

Horse, stable, bolted, springs to mind.

 

Now, before some wisecrack comes back here and says that they are still way better than Lionair, lets call a spade a spade.

 

Cheers

Art

[Aaron Goh 1]

guys guys chill, they probably just misread the chart and descended earlier rather than the specified fix. have u guys even seen OOL VOR app chart? at least they did the right thing by going around. lets not get onto manual vs automation ok?

Edited February 11, 2012 by Aaron Goh

[alberttky 0]

guys guys chill, they probably just misread the chart and descended earlier rather than the specified fix. have u guys even seen OOL VOR app chart? at least they did the right thing by going around. lets not get onto manual vs automation ok?

 

Sorry buddy... MSA is published for a reason. I don't suppose management will take it lightly to pilots with thousands of hours in their logbooks carrying hundreds of lives at the back "misreading the charts". Oh by the way, 4 pilots misread the chart??? C'mon....

 

I suppose one question people might ask is: did the FOs for both flights knew they busted the MSA? If so, what did they do about it?

 

There's nothing wrong with the OOL VOR app chart.

 

Yes you're right. They jolly well did the right thing by going around.

Edited February 11, 2012 by alberttky

[Sandeep G 1]

 

 

Sorry buddy... MSA is published for a reason. I don't suppose management will take it lightly to pilots with thousands of hours in their logbooks carrying hundreds of lives at the back "misreading the charts". Oh by the way, 4 pilots misread the chart??? C'mon....

 

I suppose one question people might ask is: did the FOs for both flights knew they busted the MSA? If so, what did they do about it?

 

There's nothing wrong with the OOL VOR app chart.

 

Yes you're right. They jolly well did the right thing by going around.

 

My, my.. Albert, tone it down.. We're not denying you are right. I for one don't appreciate your blanket call that all pilots are not up to mark when it comes to flying during any phase of flight.

 

We are glad that in the D7 instances, the flights landed safely wherever it may be at OOL and BNE and the pax are safe - furthermore that the lessons are learned.

 

As to your earlier qu, not many NPA's as oppose to PA's..but we prepare whenever we go somewhere we know the chances of an NPA'S are high.

 

 

[alberttky 0]

My, my.. Albert, tone it down.. We're not denying you are right. I for one don't appreciate your blanket call that all pilots are not up to mark when it comes to flying during any phase of flight.

 

We are glad that in the D7 instances, the flights landed safely wherever it may be at OOL and BNE and the pax are safe - furthermore that the lessons are learned.

 

As to your earlier qu, not many NPA's as oppose to PA's..but we prepare whenever we go somewhere we know the chances of an NPA'S are high.

 

I appreciate your opinion and I do apologize if you feel offended in anyway. I just have a very strict view on safety, and you do agree as a professional pilot that it shall never be compromised in any way. I don't mean all pilots are not up to mark but you'll just never know. Murphy's Law do prevail sometimes. Just ask one of the SQ 777 Training Captain.

 

Yes the lesson is indeed learned and I hope there will be no more instances like these, be it D7 or any airlines.

[flee 5]

We should keep in mind that this report closes the investigation of the 2010 incidents: http://atsb.gov.au/media/3543827/ao2010027.pdf Since then, there has been no recurrence and it would appear that the measures taken by D7 re their pilot training have been effective.

 

While I agree that safety is paramount for commercial airlines, it should be noted that those weaknesses in D7 have been fixed. I think that with their pilots becoming more experienced on the A330 aircraft (many were promoted from A320s in D7's early days), the days of bad airmanship should be well behind them.

 

Also do remember that the pilots did redeem themselves by making the decision to go around and land in BNE instead. The passengers and aircraft were safe.

[BC Tam 2]

Yes the lesson is indeed learned and I hope there will be no more instances like these, be it D7 or any airlines.

Sad fact (of life) is that such instances WILL recur, may or may not be D7

[michgyver 0]

Malaysia Airlines’s safety performance versus Air Asia’s safety performance

 

 

 

 

 

 

 

 

4 Votes

 

Mohamadon Abdullah a.k.a. Dr. Don, one of MAS pioneer leaders has recently wrote his testimonial about Malaysia Airlines’ history and achievement in YB Wee Choo Keong’s blog. Here’s Dr. Don’s testimonial about Malaysia Airlines and what he doubts about Air Asia’s capability and the insult of appointing Mat Salleh’s consultant and Advisor who knows nothing about the history of Malaysia Airlines.

Dr. Don’s testimonial:-

MAS Corporate Safety and Security record has been excellent since 01 October 1972. Its Cockpit Resource Management (CRM) Programme has been internationally recognized since late 1980s. Asiana Airlines adopted MAS CRM. When MAS was established way back on 3rd April 1971, MAS litreally started from Ground Zero. However through the commitment of people like Tan Sri Saw Huat Lye, Tan Sri Abdul Aziz Abdul Rahman, Mr. Lee Shu Poh, Allahyarham Tuan Hj. Sidek Alwi, Dato’ Resham Singh and many others, developed the Airline to be a major Player in the Aviation Industry. All this was possible unfer the Chairmanship of Allahyarham Raja Tun Mohar Raja Badiozaman.

Not many realized that MAS started its operations on 1st. October 1972, three months ahead of schedule. That was really Malaysia Bolih. Yes, this was history.

Whilst I appreciate that we must look forward, but once in a while we must look back at the past. It is just like driving a car, once in a while in moving forward, we must look at the rear view mirror, just to be safe. The Five Objectives established by the Founding Fathers are now somewhere buried in the archives. But these Five Objectives were the driving force of the Pioneer Group and is still relevant. MAS is an Engine of economic growth for Malaysia. Not many people appreciate the contributions made by MAS to the people of Malaysia. As a simple example, MAS produced approximately 25,000 sticks of satay per day. To some, so what? But do you know where the satay sticks come from? It was not from Tokyo or London but from Ulu Yam, in Selangor. What about the development of Human Capital? MAS has over the years developed Malaysian expertise in Aviation Industry especially in the technical areas.

What has Air Asia done in this area? If one tourist visit Malaysia and fly MAS, Can you imagine how much they contribute to the Country? Tourism Malaysia states that each Tourist spend at least RM 600 per day, can you imagine how much can 25 million tourists spend in a day in Malaysia (RM 600 x 25,000,000 per day).

Who do you think will benefit from this tourist spend? Today, are we saying that Malaysia do not have expertise in the Aviation Industry? What about those people I mentioned.? Do we really need a foreigner to be an Advisor to MAS when we have our own people who have years of experience in the Aviation Industry? No point in gloriously giving accolades to someone, being a Member of the Board of Directors for the last ten years, to justify his appointment in MAS? Where was he when MAS went through Y2K, September 11, the introduction of Cockpit Resource Management (CRM) or for that matter where was he when MAS was formed? Did he really contribute to MAS Safety record or is he reaping the fruits of past labors?

There are Malaysians who have contributed to the development of MAS. Ignoring these people, to me, it is an insult to us Malaysians, after 55 years on Independence. MAS provided its expertise in setting up of Jet Airways, supported Asiana Airlnes in their B777-200 introduction and Korean Air etc. Are we saying that Malaysians are incompetent, that we have to look for foreign expertise? Sad…..sad….sad. Is this is not a National Tragedy?

Is this not a National Tragedy? Well said Dr. Don and let us look at Air Asia’s performance for the past decades;

The chick below will show you whether Air Asia can performed safely or not.

Hi, there, my name is Miss Air Asia and here below is the photographic evidentiary affidavit which will prove my Air Asia most recent record of safety performance where our low fares value has added the “refined experience” in aircraft skidding during landing that led to one of our AirBus aircraft crash-landed in Kuching International Airport. However, this fatal accident was totally covered up for our Air Asia’s bosses.

So where is the safety guaranteed when flying with Air Asia? Honestly, we in Air Asia cannot guarantee your safety because we are operating a low cost airlines. Fair?

Well! Our boss, Tony Fernandez said he knows Malaysians very well and if that we fared our prices a little lower, Malaysians are willing to risk their lives and the above is the exemplary of our guarantee service when flying with us, Air Asia.

 

Here’s another performance by “Air Asia B O L E H” where it has been investigated by the Australian authority for another two more hazardous incidents occurred outside Malaysia which they cannot cover up for the reason the bribery concept isn’t availed for Tony Fernandez and his gangsters in that country.

The Australian Transport Safety Verdict :

The AirAsia jet, “descended to a height where there was no longer separation assurance from the ground and from planes operating outside controlled airspace.”

- Australian Transport Safety Bureau.

(Copied from airasiaannus.blogspot.com)

For us laymen, that means AirAsia was precariously close to both the ground and to any civilian aircraft that may have strayed into its path. No longer was separation from the ground

assured

means – but for the grace of God, it could easily have crashed. If you’re hard pressed to imagine any of this, cast your mind back to the Charlton Heston movie classic ‘Airport 1975′. That’s what generally happens when commercial airliners come into contact with light aircraft in mid air.

So what could be the root cause? Please memorize this “citing” by the International Investigators

-

Pilot training was cited as a major factor in the incidents. According to today’s The Australian, Investigators said the crew were “probably not adequately equipped to manage the approach in other than autopilot managed mode”. In essence, theses guys were on their P-Plates, flying you and your family. To be more accurate, they were in the middle of a lesson, with an obviously bungling ‘instructor’ that allowed this to happen.

What International Reporter has to say about AirAsia’s Pilot training?

Chan Sue Ling of Bloomberg reported thus :

Some airlines aren’t waiting for qualified talent to walk in the door. Singapore Airlines and Air Asia, based near Kuala Lumpur, have each set up their own tuition-free training academies.

Singapore Air’s flying school turns out about 150 cadet pilots a year, while AirAsia’s facility trains as many as 500 annually.

People, 500 pilots annually versus 150 for respected carrier – Singapore Airlines. That is really Air Asia B o L e H…….you gotta be kidding! Quantity versus Quality by retarded leaderships……and retarded leaderships never passed! Agreed?

Flying with Malaysia Airlines, your safety as passengers and flight crew are guaranteed 100% because it is an organized “Legacy Airlines” as compared to a Low Cost Airlines.

But nowadays, can AJ and Danny Rash Dan guaranteed the safety for Malaysia Airlines under the ruling of Air Asia board of directors camouflaging as board of directors of Malaysia Airlines?

Malaysia Airlines has lost its first class platinum customers since the collaboration between MAS and Air Asia took effect last year because of Air Asia’s past track record – bad paymaster and aircraft crashed landing for more than 5 times.

Would you like to know who are the platinum customers that have left Malaysia Airlines for Singapore Airlines?

It is the Sultan of Pahang and his entourages.

So MAS has since lost a yearly RM2 million or more revenue. Sad…sad…sad…as quoted by Dr. Don, it is indeed a National Tragedy to have Air Asia KAMBING (coming) on board Malaysia Airlines.

The airasiaannusblogspot.com wrote :

Is this lax attitude toward safety/remuneration – not to mention their attitude to maintenance leading to airlines such as AirAsia and MAS becoming a very real risk to fly?

Mr Ozman-Rani shows that AirAsia are deceptive spin doctors who will stop at nothing to wriggle out of acknowledging responsibility. Do you trust them?

In time, these bent politicians and puppets like Fernandes will be brought to justice. In the meantime, they are gaining a stronger stranglehold of the Malaysia Airlines board of directors by the day; a previously upstanding, safe and professionally run

airline will soon be in tatters if Malaysia doesn’t wake up.

The evidence has clearly shown to us before our eyes that MAS/AirAsia Collaboration Agreement is only SAVING AIR ASIA. How to save Air Asia? The Collaboration Agreement is to improve the Air Asia group’s earnings. CLEAR!

Well..Mr. Prime Minister, you gotta move faster before this burns your entire team. Whether people choose Barisan National again or not, it’s all depending on your decision made for Malaysia Airlines.

Malaysia must wake up now and you, the Prime Minister must wake up and stop listening to your crooked mentor – Tun Dr. Mahathir. Some people said Anwar Ibrahim has two faces, well, we say Tun Dr. Mahathir has four faces.

 

Plane Talking ATSB unable to understand why AirAsiaX pilots

 

by throttlejockey » Sun Feb 12, 2012 11:55 am

Cikey..February 10, 2012 – 12:58 pm, by Ben Sandilands

 

Students of sloppy standards and crashes caused by pilots who press on regardless should find the ATSB report into two examples of really poor flying at the Gold Coast airport by AirAsiaX in May 2010 a fascinating read.

 

The good news is that after being caught out the Malaysia flag carrier changed its procedures and instructed its pilots as to follow the published Australian requirements for approaching this particular airport in bad weather, without descending too steeply, or disregarding safe mininum altitudes, which are there to stop them hitting the mountain ridges of the Gold Coast hinterland.

 

Actually, the ATSB was a bit less blunt than the above, but this is a post about air safety breaches, written in plain english, and with a view to stopping practices that could scatter hundreds of dead across the landscape which the rules are there to keep jets from hitting.

 

On 4 May 2010 an AirAsiaX Airbus A330-300 with 258 passengers, nine cabin crew and two pilots made three missed approaches to a Gold Coast airport the pilots couldn’t see through the cloud and rain, after which they landed the jet at nearby Brisbane airport.

 

On 10 May 2010 a different AirAsiaX crew in the same A330 landed safety at the Gold Coast airport with 260 passengers and the same head crew for the cabin crew and pilots on board, after one non-compliant missed approach in similarly poor visibility.

 

These were pilots that fly single aisle A320s and twin aisle A330s in the same roster period. The jets are very similar in flight operations, but not identical, and not all Airbus users with such mixed fleets accept the premise that their pilots should mix ‘n match their duty time on the two models.

 

In its report the ATSB details all of the missed approaches in clinical detail.

 

This is an extract from the 4 May missed approaches, with emphasis added to show that at times the flights were above the required altitude, below the required altitude, and in breach of the published approach procedures.

 

When the aircraft was about 5 DME(9 km) from the Gold Coast Airport, and 2,500 ft above mean sea level (AMSL), the aircraft was above the recommended descent profile for that approach. With the selected flightpath angle (FPA) of -4.9°, the aircraft was descending at a rate of about 1,300 ft/min. The flight crew continued descent until the aircraft was about 1,000 ft at 1 DME (2 km). At that point, a landing was not possible and they initiated a missed approach.

 

The crew was radar vectored at 2,500 ft for a second VOR approach to runway 32. Subsequently, the crew was cleared to make a pilot intercept of the final approach track and to conduct the approach.

 

The crew used the autopilot in selected mode to fly the approach. At 11 DME (20 km) they commenced descent, selecting an FPA of ‑3°. At that point, the aircraft was below the recommended descent profile and was descending below the procedure’s segment minimum safe altitudes.

 

Approaching 7 DME (13 km), the flight crew reduced the FPA to achieve level flight at 1,300 ft. At about the same time, the aerodrome controller advised the crew to check their altitude and that the radar lowest safe altitude in that area was 1,500 ft. The controller cleared the crew for further descent in accordance with the runway 32 VOR procedure. The aircraft remained below the segment minimum safe altitude until reaching 5 DME (9 km). Soon after, the controller provided the crew with surface wind information and cleared the aircraft to land.

 

At about 4 DME (7 km) and 1,300 ft, the crew reselected an FPA of ‑3° to commence the final descent to 750 ft, which was the minimum descent altitude (MDA). The aircraft reached the MDA at 2 DME (4 km) but low cloud, rain and reduced visibility prevented the crew from landing and they commenced another missed approach.

 

The flight crew then conducted a runway 14 VOR approach. Again, due to weather, they were unable to land the aircraft and conducted a missed approach and diverted to Brisbane, Qld. The aircraft landed at Brisbane at 0823.

 

In its account of the 10 May missed approaches the ATSB says

 

The flight crew conducted a Runway 32 VOR approach but were unable to land due to reduced visibility in low cloud and rain. Following a missed approach, the crew conducted another Runway 32 VOR and landed.

 

For both approaches, the crew commenced descent from 2,500 ft at about 10 DME (19 km), which was below the recommended descent profile. During each of those approaches, when between 9 and 7 DME (17 and 13 km), the aircraft was below the procedure’s segment minimum safe altitude.

 

Both approaches were conducted in selected mode, with the vertical navigation of the aircraft initially conducted in ‘open descent’. In open descent, engine power reduces to flight idle and the aircraft descends at the FPA required to maintain the selected airspeed. The aircraft reached 1,500 ft by about 8 DME (15 km), recording a maximum FPA of ‑5.6° and a rate of descent of about 1,500 ft/min.

 

From 1,500 ft, the descent to the MDA was conducted using a selected FPA of ‑3°, in accordance with the published procedure.

 

Later in its analysis of these incidents, the ATSB says of 4 May stuff up:

 

The descent from 2,500 ft to 1,300 ft at the selected flight path angle (FPA) of -3° was continuous and was conducted without apparent regard for the published segment minimum safe altitudes. That resulted in the aircraft operating below the segment minimum safe altitude prior to the aircraft reaching the final approach fix at 5 DME (9 km), with the effect that separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.

 

It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach. Being above the recommended flightpath on the first approach might have influenced the crew to descend earlier to avoid being similarly high during the second approach. Unfamiliarity with the conduct of non-precision approaches, and especially those that incorporated intermediate segment minimum safe altitudes, was another possibility.

 

It also says of the 29 May instances:

 

In both approaches on 29 May 2010, the crew initiated descent at about 10 DME (19 km) and before the aircraft had intercepted the recommended descent profile for the non‑precision approach. Those descents were conducted without apparent regard for the published segment minimum safe altitudes. As a result, separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.

 

It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach and descended below the segment minimum safe altitudes. However, unfamiliarity with the conduct of VOR approaches that included intermediate segment minimum safe altitudes was again a possibility.

 

One possibility that the ATSB doesn’t canvas is that the crew didn’t read the navigational notes or had no intention of paying any attention to them, preferring to press on regardless.

 

AirAsiaX did respond fully to these incidents with comprehensive safety actions.

 

Action taken by the aircraft operator

 

In response to these occurrences, AirAsia X developed a simulator training session that specifically targeted the Gold Coast approaches and emphasised the preference for pilots to conduct managed approaches. All flight crews were required to complete this training prior to further operations into the Gold Coast.

 

In addition, AirAsia X:

 

Issued a ‘flight operations circular’ advising that open descent mode should not be used when performing an instrument approach.

Issued revised Gold Coast approach charts.

Implemented additional training and checking of crews operating to the Gold Coast.

Implemented a policy recommending a maximum of two approaches before diverting to an alternate airport.

Reduced the incidence of mixed-fleet flying such that pilots only fly either the A320 or the A330/A340 during a roster period.

Implemented an instructor standardisation and enhancement program.

 

During the press conference earlier this week at which AirAsiaX rival Scoot announced its plan to fly to the Gold Coast from June, Queensland Premier Anna Bligh confirmed that an ILS system to improve bad weather access to the airport would be installed there sometime this year.

Edited February 13, 2012 by michgyver

[flee 5]

Sad fact (of life) is that such instances WILL recur, may or may not be D7

Unfortunately, we cannot eliminate human error. Even SQ's superbly trained pilots managed to crash a B747 in Taipei some years ago. Having said that, flying is still a lot more safer than driving on Malaysia's roads!

[JuliusWong 0]

Unfortunately, we cannot eliminate human error. Even SQ's superbly trained pilots managed to crash a B747 in Taipei some years ago. Having said that, flying is still a lot more safer than driving on Malaysia's roads!

I like your last statement: Malaysian road!~~~ "Like"