Trouble in the Cockpit: Execuflight 1526 Part One

9 Feb 18 23 Comments

On the 10th of November 2015, Execuflight flight 1526 was a British Aerospace HS 127-700A chartered for a flight across Ohio from Dayton-Wright Brothers Airport in Dayton to Akron Fulton International Airport.

The British Aerospace 125 is a twin-engine mid-size corporate jet, designed by de Havilland as a small business jet (under the much cooler name of the DH125 Jet Dragon) and originally produced by Hawker Siddeley. The aircraft has been used by the RAF as a navigation trainer and by the USAF as a calibration aircraft. The series 700 has variants including a military version for RAF liaison aircraft and a maritime patrol aircraft with search radar and cameras.

N237WR photographed 5 August 2013 by Cfichad49

The BAe 125 registration N237WR was equipped with a cockpit voice recorder but no flight data recorder; it’s not required for aircraft that have fewer than 10 passenger seats. N237WR was configured with eight passenger seats. This means that the re-creation of the flight is based solely on the sounds audible in the cockpit voice recorder and external information. Unfortunately, the quality of the CVR recording was bad. The pre-start checks include a quick test but only to make sure that it is physically working, not to check the recording levels. As it happens, an FAA inspector did a ramp check on the aircraft but, as there was no power, he couldn’t check the CVR.

The aircraft was booked for a 7-leg charter spanning two days, using the same crew for each leg. The trip began the day before, on the 9th of November 2015 at 06:50, when the aircraft departed Fort Lauderdale with seven passengers on board. They stopped at St Paul, Minnesota; Mooline, Illinois and St Louis, Missouri before ending their day at 19:55 in Cincinnati, Ohio.

The following day, they departed Cincinnati and arrived at Dayton after a half-hour flight. At Dayton, the captain filed an IFR flight plan departing 13:30 for Akron, Ohio. The flight plan showed a 34-minute flight cruising at 17,000 feet with a cruise speed of 382 knots. The captain filled both wing tanks and, at 13:49, he sent a ‘doors closed’ text message to the operator. Air Traffic Control issued their IFR clearance to Akron Fulton International Airport and, at 14:13 EST, the flight departed on runway 20.

They contacted Indianapolis Air Route Traffic Control Center (ARTCC) and the controller cleared the flight to its cruising level of 17,000 feet and to Akron via the HUUVR intersection.

Execuflight had an informal practice that the captain would act as Pilot Flying on any flights carrying “revenue passengers”; however on this day, the first officer was the Pilot Flying and the captain was the Pilot Monitoring.

As they prepared for the approach, the flight crew attempted to pick up the weather information at Akron. They didn’t tune the radio correctly and instead of Akron’s status, they received the weather for Fairfield County Airport in Lancaster, about 108 miles southwest of their destination.

After noting the (incorrect) weather, the first officer, who as the Pilot Flying would normally handle the approach briefing, said, “I’ll let you brief it to me.”

They discussed the localiser 25 approach at Akron. Here’s the key information for that approach.

  • Final Approach Fix (FAF) minimum crossing altitude: 2,300 ft above mean sea level
  • Minimum Descent Altitude (MDA): 1,540 ft above mean sea level
  • Touchdown zone elevation (TDZE): 1,067 feet
  • The minimum descent height above the runway 25 TDZE: 473 ft
Instrument approach chart for the localizer approach to runway 25 at Akron Fulton
International Airport at the time of the accident.

Review of the instrument approach chart for the localizer 25 approach at AKR showed that the FAF was located at 4.8 nm DME, and the missed approach point was at 1.1 nm DME.

The Indianapolis ARTCC controller cleared the flight to cross the HUUVR intersection at 9,000 feet and then asked them to change frequency to Cleveland ARTCC. The crew checked in with Cleveland and then returned to their discussion of the localiser 25 approach. Before they could finish, a passenger came forward from the cabin to speak to the crew.

The flight was descending through 13,500 feet and the captain told the passenger that he could stay for a couple minutes but then he had to leave because “we cannot be distracted”.

I’m including as much as possible of the transcript of the cockpit conversation, with parentheses used to mark where the words were not clearly audible in the CVR playback and might be wrong. The only other real information we have is the radar returns, from which we can extrapolate the speed and descent of the aircraft as it approached Akron.

First Officer: Okay, so we go down twenty three then down to… (what’s the minimums)?
Captain: four seventy three.

They discussed the missed approach and then the cloud cover. At Fairfield County Airport, the clouds formed a broken ceiling of 1,100 feet above the ground and an overcast cloud layer at 1,800 feet above the ground.

First Officer: The minima for this approach [is] fifteen twenty… Which is ground? Where is the ground? Five oh one, right?

From the accident report:

The MDA for the localizer performance version of the AKR RNAV GPS 25 approach was 1,520 ft msl, and the height of the MDA above the TDZE for the lateral navigation version of the approach was 501 ft.

What this means is that the chart showed two ways of looking at the same approach. One had 1,520 feet above mean sea level as the MDA (Minimum Descent Altitude). The second showed 501 feet above the ground as the MDA: in other words, one was the altitude and one was the height. The elevation of the airfield was just over 1,000 feet above mean sea level, so there’s a difference of just over 1,000 feet between the two figures, even though effectively they are used for the same thing: the specified altitude or height below which the flight crew should not descend without being in sight of the runway.

Forgive me for going over this at length but I find this usage of MDA to be deeply confusing. We’ve had some discussions in the comments about Minimum Descent Altitude vs Minimum Descent Height and I have to admit, it’s making my brain ache to read this report which repeatedly refers to height as altitude in the context of the MDA. Certainly, it seems like this is a poster-child for why it is important to specify, even in acronyms, whether you are discussing altitude above the airport (above mean sea level, or QNH in the UK where I trained) or height (above the ground, or QFE in the UK).

From a personal point of view, if I were the Pilot Flying and mixing up 1,520 feet above mean sea level and 501 feet above the ground in a single conversation about the MDA, it probably means I’m already halfway to becoming a crash statistic myself.

First Officer: Which is ground? Where is the ground? Five oh one, right?

No, that’s not right. Five oh one, or 501 feet is the minimum height above the ground that they needed to be for that approach. While he (incorrectly) answered his own question, the aircraft descended through FL10 (10,000 feet) travelling at about 298 knots. The aircraft should have been going no more than 250 knots once travelling under 10,000 feet.

They continued to discuss how low the overcast clouds were.

First Officer: “Yeah, I understand. But we can shoot it. We can shoot it because the overcast [unintelligible] reporting [unintelligible] eight hundred.”
First Officer: “The cloud base is from the ground. From the ground do we get minimums for us?”

They played the automated weather at Akron, which reported an overcast ceiling of 600 feet above the ground, with visiblity of 1½ miles (2.4 km) in mist. But the flight crew were distracted.

The Cleveland ARTCC controller instructed the flight to change to Akron approach.

The first officer contacted Akron approach and reported that they were level at 9,000 feet above mean sea level over the HUUVR intersection. The controller told the aircraft to fly a heading of 65° and to expect localizer 25 approach.

The controller then asked whether they had the weather at Akron.

First Officer: “We are in the process of copying the weather.”

Where I come from, that means “No.” But to be fair, the captain had been listening to the recording, which he repeated. Then the flight crew discussed the visibility. The required visibility minimum for the aircraft’s approach category was 1¼ miles.

Captain: One and half mile visibility, overcast at six hundred. Alright, we are visibility, we got it.

The next exchange is not clear on the CVR but went something like this:

Captain: Did you do my approach (brief)? [unintelligible] (We gotta go somewhere else, right?) [unintelligible]
First Officer: [unintelligible]
Captain : If you say that… I might be wrong. I’m not sure.

It’s not clear exactly what was said but the Captain’s tone is odd. Execuflight’s policy was that generally, the captain should act as Pilot Flying on all flights carrying revenue passengers. Not only had the captain passed this responsibility to his first officer, he also failed to insist that they should consider a possible divert to an airfield with better weather, despite his misgivings.

First Officer: [unintelligible]. The minima is five hundred and ten. [unintelligible] minima…
Captain: Localizer?
Captain: Four eighty, four eighty.
First Officer: Four seventy three.

I couldn’t make sense of this one at all. I scanned over my notes for 473 to see that it is the “height above the TDZE of the MDA for the localizer 25 approach” or what I would call the minimum descent height over the touchdown zone. But frankly, by this point in the narrative, I’m at a loss as to which heights are what and I strongly suspect the first officer felt the same. Frankly, I don’t think 510 ever comes up on the approach at all, it’s just a random number.

Meanwhile, the approach controller instructed the flight crew to reduce speed to 200 knots and descent to 4,000 feet msl. Then he contacted them again to say that they were behind a slower aircraft on approach (an instrument training flight in a single engine aircraft) and to reduce speed to 170 knots with a descent to 3,000 feet msl. Finally, the controller instructed them to join the localizer course for runway 25.

The aircraft reached 3,000 feet msl and levelled off.

First Officer: I will….try to drag every (thing).

This means nothing to me but the report says that it meant he planned to begin configuring the aircraft for landing by extending the flaps and landing gear.

Captain: Oh we got…we got… we got nine degrees pitch up.

He’s saying that the first officer was flying with a high pitch attitude but gosh, it makes me realise how much easier this is when we have the data from the FDR to tell us what the aircraft is doing!

As it is, we’re reliant on sound: the CVR recorded ‘increased noise consistent with a power increase and then the sound of a thump followed by noise similar to landing extension’. Unfortunately, from this point onwards the noise from the extended gear obscured the already not-very-good recording from the CVR and so it becomes more and more difficult to recreate what was happening in the cockpit.

Captain: Did you hear what he said? There is an airplane on the approach. (He is) slower than us. He hasn’t cancelled. We don’t know if he’s on the ground.

Then he complains again about the pitch attitude.

Captain: You need to (look). You need to… I mean, we were were flying like (one thirty
nine). Nine degrees pitch up.

Based on the radar returns, investigators believe that, during this time, the aircraft pitch increased from about 5° to 12° nose up. Over the same period, the airspeed slowed from 150 knots to about 125.

The aircraft was about four nautical miles from the Final Approach Fix for the localiser 25 approach. The controller contacted the flight crew to say that the slower aircraft ahead had cancelled its IFR flight plan and he cleared them for the localiser approach. The captain acknowledged the clearance and confirmed that they were established on the localiser.

The slower aircraft ahead was a training flight. Afterwards, that flight crew reported that they broke out of the clouds about forty feet above the MDA of 1,540 feet amsl. They levelled out at the MDA at three nautical miles out, where they had visual contact with the ground but they couldn’t see the runway ahead. They activated the PAPI and runway lights to high intensity. The runway PAPI lights came into view when they were about 2.3 nautical miles out.

The FAF was about 4.8 nautical miles and the missed approach point was at 1.1 nautical miles. Normally, the PAPI lights are visible from about 5 miles during the day and up to 20 miles at night.

Back to the Execuflight cockpit, the captain and the first officer were still arguing. They were cleared to descend to the FAF crossing altitude of 2,300 feet amsl but they remained at 3,000 feet for about two minutes.

Captain: Look, you’re going one twenty. You can’t keep decreasing your speed [unintelligible].
First Officer: No. One tw– how do you get one twenty?
Captain: That’s what I’m saying. If you keep decreasing your speed–
First Officer: But why?
Captain: Because we’re going to stall. I don’t want to sta–

The controller interrupted them to change to the local advisory frequency. The captain did so and made a position report.

The pilot of the instrument training flight then spoke. “Hey guys. Ah, we just landed on the loc and broke out right at minimums, (right at a) mile.”

Captain: Appreciate it.
First Officer: Full flaps.

Full flaps is 45°. The standard approach profile was 25° flaps until the minimum descent alttitude, only applying full flaps once the runway was in sight. The reason for this is so that the aircraft is able to climb away safely if they have to go around. Having heard that the previous aircraft only just broke out of the clouds at the last minute, there’s a high chance that they will need to go around so it’s a particularly odd time to decide to set full flaps.

Captain (reciting the landing checklist): Gear down. Before landing. Three lights. One and…

He does not appear to be bothered by the full flaps.

The aircraft’s airspeed, which had stablised at about 130 knots, began to decrease again. The first officer reduced the power and the aircraft began to descend. They were just crossing the Final Approach Fix.

First Officer: Alright, we got to minimums.

In other words, they can continue to the MDA. At this point, the aircraft was passing through 2,700 feet above mean sea level (400 feet above the Final Approach Fix minimum crossing altitude) and was travelling at around 109 knots. They are too high.

The rate of descent began to increase rapidly. As the aircraft reached 2,300 feet, the descent rate was about 2,000 feet per minute with an airspeed of around 118 knots. The captain calls out the too-fast descent.

Captain: On localizer. You’re diving. You’re diving. Don’t dive! Two thousand feet per minute, buddy.
First Officer: Yeah.
Captain: Two thousand feet per minu–Don’t go two thousand feet per minute.

Yeah, don’t do that. The ‘normal’ descent in that aircraft on that approach would be one thousand feet per minute; however that rate of descent was not going to get them to the MDA in the distance they had left. It seems likely that the first officer was intentionally expediting their descent to ensure that they would be able to break through ‘just in time’ like the previous flight had.

Captain: Don’t go two thousand feet per minute.

This seems to be an odd thing to repeat. I’m going out on a limb here: it seems very laid-back or careful phrasing for the captain of the flight. Personally, if I’m ever in that position, I’d like the other person in the cockpit to be crystal clear about my error. REDUCE DESCENT NOW! Or maybe even I HAVE CONTROL!

But then, politeness and social tact have never been my forte.

Captain: When you are fifteen hundred feet above the ground. Or minimums.

I’m not sure of my interpretation of this. He might mean, ‘Don’t descend so quickly when you are this close to terrain,’ which would be a reasonable thing to say, although again, a bit oblique for my tastes. Or he may have been continuing to speak when he realised they had reached the MDA and so he interrupted himself to say they were at the MDA.

Either way, they reached the MDA. They were travelling at 113 knots with a reasonable descent rate of about 830 feet per minute. Unfortunately, the aircraft continued its descent.

Captain: Ground.

A confirmation that the ground was in sight, I guess?

Captain: Keep going.
Captain: Okay, level off, guy.

As he spoke, there was a loud rattling sound: the stick shaker had activated to warn of an impending stall. It sounds like he did level off, but without adding power.

Then the Ground Proximity Warning System kicked in. PULL UP.

Aerial photograph showing the location of the accident site relative to the runway 25 threshold. Source: Ohio State Highway Patrol

And that is the end of the recording. The aircraft crashed through trees and into an apartment building, where it burst into flames. It was just twenty-four seconds after the captain had repeated “Don’t go two thousand feet per minute.” The first officer had slowed his descent, but even 830 feet per minute is too fast if you don’t know where the ground is.

An aircraft security camera filmed the aircraft as it appeared over the trees in a left-wing-down attitude about 1.8 nautical miles from the approach end of runway 25. The aircraft passed out of the camera’s view but the explosion and postcrash fire were still visible.

Pieces of the left aileron and an outboard portion of the left wing were located in an area of ground scarring in the front yard. The airplane traveled through the building and came to rest on an embankment located behind the building.

The left main landing gear was in the remains of the apartment building. The right main landing gear were behind the building, before the embankment. The burned remains of the fuselage and empennage were on the embankment, along with most of the right wing, the nose landing gear, both engines and the APU. The investigators were able to confirm that at the time of impact, the landing gear was down and locked and the flaps were extended to 45°. Both engines were operating and ingested building insulation and soil during the crash.

Photograph of the fuselage and engines at the accident site. Source: Honeywell International

The Summit County Medical Examiner’s Office performed autopsies on the captain, the first officer and the seven passengers. The medical examiner determined that the cause of death for both pilots was “inhalation of products of combustion and thermal injury.” According to the autopsy reports, no significant natural disease was identified in either pilot. Review of FAA medical certification records showed that neither pilot had reported any significant medical conditions or the use of any medications.

The medical examiner determined that the cause of death for five passengers was “blunt force trauma,” and the cause of death for two passengers was “blunt force trauma…with inhalation of products of combustion.”

The ExecuFlight CEO expressed his shock and confusion at what had happened.

Planes just generally don’t fall out of the sky. I can tell you that there were very well seasoned pilots, both of them. They like to fly together. We monitor the flights leg by leg since it started and it’s typical for them to give us a doors open, doors closed message, we’ve got them all.

Some pieces of this are already obvious and some of the conversation will remain a mystery. But I’ve gone on too long already. Next week I’ll take a look at the background; there’s still quite a bit of ground to cover to make sense of this. In the meantime, I’ll be interested to hear your opinion so far in the comments.

The second post is up! Operational Failures: Execuflight 1526 Part Two

Category: Accident Reports,

23 Comments

  • Just skimming through this quickly, a few things strike me:
    Sylvia seems a bit confused about “MDA” and “MDH”. And it can be very confusing. Not for nothing it is always stated in the Jeppesen manuals.that they are “intended to be used by experienced, instrument-rated pilots”.
    Virtually EVERY operator, private, commercial, airline, makes a considered choice about what altimeter setting the company will ALWAYS use when departing, approaching, landing. In other words: During those segments of the flight when operating in close proximity to the ground.
    Many UK companies use QFE. Simply put: if the aircraft is on the ground, the altimeter will show zero.
    Others prefer QNH. With the aircraft on the ground, the altimeter will register field elevation. Which, when landing at Schiphol, Amsterdam, may be MINUS 11 as the airport is at the bottom of a former lake. But at Geneva, if I remember correctly, when set on QNH it will show about 1410 ft.
    In the approach charts, “heights” are referenced to the ground, BUT only in relation to the landing runway. (airport). It is impossible to shift references to undulating terrain when making an initial approach into an airport in the mountains.
    The word “altitude” relates to sea level, so if the crew see a mountain peak on the chart with a height, a crosscheck with their altimeter will instantly tell them if they will (or will not) clear it with the altimeter set on QNH. And that is precisely why many pilots prefer to stick to QNH. But: if the company prescribes QFE the crew are NOT at liberty to change it..
    The company will have their crews trained to be familiar with and use of the procedures they have adopted as SOPs.
    So the crew will, or should, know which setting to use and what the implications are.
    Simply: Airport elevation 1500 ft, MDA 2000 feet means that the actual minimum will be 500 feet (on QNH). With QFE the MDH would simply be shown as 500 feet. Getting too complicated?

    OK again:
    Airport X is 1500 ft above sea level.
    According to the Jeppesen, the minimum an aircraft may descend to in the approach – without ground reference – is 500 feet above the ground.

    With the altimeter set at QFE, it should show just that: 500 ft.
    And, on landing, should be zero.

    But: with the altimeter set at QNH, the aircraft may descend to 2000 feet. Which will represent 500 ft above the runway.
    After landing, it still should indicate 1500 ft.

    Why do many operators use QNH?
    It heightens situational and terrain awareness especially when operating in a mountainous area. The crew are not at liberty to change the procedure: they use company SOP: at all times either QNH or QFE.

    About the accident flight:
    Insofar as the rest of the approach is concerned: There seems to have been an alarming lack of crew coordination, it all sounds very sloppy.
    On what constituted relatively short finals in a jet, a rate of descent in the order of 2000 fpm is nearly an automatic, unavoidable crash.
    Flap setting? I just wonder if the crew had forgotten to extend them at all during the initial phase of the approach (9 degrees pitch up!) and decided to extend full flaps later – but nowl too early – to compensate?
    It seems that the aircraft was not properly configured, not on a stable approach and yes, there had been every reason to go around. A bizjet, with both engines at full power, should have been able to go around even with the drag from 45 degrees flaps.
    The captain did not really seem to manage the situation at all. Sad !

    • I’m not a pilot, but since you said “the captain did not really seem to manage the situation at all” I have to say that is my impression as well. Captains have a huge amount of responsibility and have to be able to step in no matter how that is perceived by the other crew members. If they are unable or unwilling to do that they need more training, or they should not be captains.

    • Rudy, I wondered if the first officer got confused between the two, actually.

      With QNH and QFE, I feel it is clearer because one would never refer to the QNH as height nor to the QFE as altitude. The terminology is very clear. Above, you never use altitude when referring to the MDH.

      Note the quote from the accident report: The localizer approach to runway 25 had a final approach fix (FAF) minimum crossing altitude of 2,300 ft msl, a minimum descent altitude (MDA) of 1,540 ft msl, and the height of the MDA above the runway 25 touchdown zone elevation (TDZE) was 473 ft.

      Are you happy with the reference to “the height of the MDA”? Because that is the terminology that I am not coping with.

    • > Why do many operators use QNH?

      Because in most countries, the QFE isn’t understood. Most altimeters wouldn’t be able to set the QFE at Jeffco. It’s at 5,700 feet.

  • Rudy: what happens when a plane using QFE goes from one airport to another? Are they supposed to calculate corrections on the fly, or adjust the altimeter to cope with (e.g.) the 219-foot difference (per WIkipedia) between Dayton and Akron-Canton airports? ISTM that adds one more task to busy pilots, especially on short hops like this. (When I was skydiving I was told to zero the altimeter on the ground, and not to adjust it even if it disagreed with someone else’s in the air — but skydivers usually return to where they left, or close by, so they wouldn’t have this problem. Using QFE in a point-to-point seems to ask for trouble.) It has been over 40 years since I flew IFR, so I don’t remember whether the plates I was using had height as well as altitude listed, but this plate seems too open to confusion.
    That being said — this sounds horribly like TWA 514 at Dulles; some fault has been assigned to different terms used by pilots and controllers, but at the time the CVR transcription read like neither of the pilots understood how to read a non-precision approach plate (specifically, whether they could descend to an altitude before or after crossing a fix). That flight had the excuse of having to divert due to high crosswinds at National; here, the crew should have read the plate and sorted out its meanings before closing the doors, given the short flight.
    As for the captain’s management — AUGH! The company rules leave one wondering whether Execuflight assumed its copilots would never level up to pilot, but ISTM that on a segment so short they don’t get to a typical altitude the captain should not have handed over control. It’s easy to say from here that he should also have told the passenger to sit down immediately — but AFAICT being a charter captain requires people skills (i.e., keeping customers happy) that aren’t needed when piloting a scheduled flight with a cabin crew.

      • Adjust the altimeter to what? In the US in the 1970’s, we got local sea-level-corrected barometric pressure (the same pressure that’s shown on detailed weather maps) from the ATIS and set the Kollsman window in the altimeter to show that value; for such a short flight (less than 200 miles) the difference would be trivial. Do UK airports give uncorrected pressure, and if so where does that leave pilots who use altitude rather than height? (Rudy’s comment suggests there’s no uniform practice.)

        • First of all you generally don’t fly from airfield to airfield on QFE. You take off on QFE (at zero feet) and switch to the QNH once you’re in the air. You would have noted both the QNH and QFE before flying. Normally, in a small plane, you’d then stay on QNH until you get close to the circuit for your destination.

          At that point you’d request the QFE at the destination, either from the ATIS or from ATC. You put that into the altimeter (in BARs, not inches). You can then join the circuit at circuit height (usually 1,000 feet) and land, when your altimeter will show zero again.

          The one exception to this is when requesting MATZ penetration, which is a very common thing to do. A MATZ is a Military Aerodrome Traffic Zone and you can often get a very useful radar advisory service from the military controllers. The Military controller will usually give a crossing level in QFE so you twiddle your altimeter and cross at the correct height. Occasionally he will ask you to stay above his MATZ and again you need the QFE as a MATZ extends upwards to 3,000 feet QFE.

          My usual mistake is to forget to set the altimeter back to QNH for the rest of the flight. Not a good idea when you’re close to the terrain.

          The other point to note is that, in the UK, the transition level is usually Flight Level 30 so, even as a little Cessna 150, you may well be travelling cross-country on flight levels.

  • I can’t understand why captain just didn’t call out for a go around instead of twice questioning the decent rate of 2,000 fpm that close to the ground. Also wondering about the passenger who entered the cockpit if he / she had any influence on what happened as it seemed they were quite ill prepared from the start and maybe got distracted by the guest. But since both pilots were so experienced and had flew together for years what was so different with this approach from any other they already had done.

  • Firstly, a crew NEVER is so experienced that they can ignore proper procedures, least of all in a relatively fast moving complicated jet.
    I have not even bothered to study the report in detail, the sequence of events makes it very clear: this was not really a difficult approach, not even marginal. There simply was no structured procedural work flow where not even a proper crew briefing was conducted, the co-pilot did not seem to know what was going on and check lists did not appear to have been properly completed. No discussion about when a go-around should be (have been) initiated and a casual attitude towards a dangerously high rate of descent, a remark about a high pitch angle that in my experience may have been due to forgetting to extend flaps at all until late in the approach, and total confusion about the implications of using the wrong altimeter setting. Yes, the question arises: Who appointed the captain to be the commander in the first place?
    I have worked for years in a company where we worked often in close harmony, two captains paired together. We knew exactly what to expect from the other guy but we ALWAYS kept a close eye to the procedures. The main base was in the US, we were based in Europe with one of the company jets, a Ce550.
    Once I did an FAA simulator check in MCI with an American colleague with whom I rarely worked together. The instructor made an error, the FAA inspector got him flustered and he added to the error by giving me a total electrical failure PLUS an engine failure just at V1.
    We instantly reverted to procedure and got a compliment from the FAA because we had managed from what, “in his book had been a non-survivable situation” and he added “I could see that you work very often together”. He was impressed when we told him that we rarely if ever worked together, we were just teamed for the training and had reverted to company procedure.
    In a small company, self-discipline (sticking to proven procedures) equals survival. If it is a private jet, the manufacturers have written basic operating procedures formulated by their test pilots and engineers. There is no excuse EVER for not having any. When the simulator training starts, the operator often provides the books and the instructor. If not, the operator will be asked by the training establishment to provide the procedures and if they do not have them the pilots will be trained according to the manufacturers’ standards.
    The alternative has been described in far too many accident reports.
    Some sloppy operators give new crews a “quickie” rating by allowing their first pilots to train up the rest or, worse, to be trained by a previous owner, a method that the authorities are trying to avoid but some, obviously, slip through the net.

    Obviously vertical separation between aircraft is not a very simple matter.
    I do not know when pilots started to realize that a barometer could be used to indicate the distance between an aircraft in flight and the ground, but I reckon that it was in the early days of aviation.
    At the front in WW 1, pilots could use it to formulate data that could be transferred by artillery operators to more efficiently train their guns on the enemy. And in combat it was handy to know quickly how much room you had to spare in a dogfight before hitting the treetops when trying to evade the Red Baron.
    And it would not have taken long before the pilots discovered that an altimeter had to be set and re-set when the barometer dropped, or the other way around. With falling pressure, the aircraft might have been shown to be at 200 feet when in reality it was on the ground, with a “rising glass” it may have shown to be buried or sunk into the sand, when in fact still firmly sitting on the dispersal in front of the hanger.
    The procedure thus became to “zero” the altimeter before take-off. With the introduction of a barometric scale on the instrument, the actual pressure could be read straight inside the cockpit.
    Of course, with the increasing ability of aircraft to cover distances, the aircraft could also move between areas of different barometric pressure and stay in the air long enough to require updates if there was a change in pressure during the time.

    In the USA – and I avoided this a bit so not to make it even more complicated – all flights use a local setting below 18:000 ft, which requires pilots to obtain regular altimeter setting updates on cross-country flights.

    But this is becoming far too long, and complex even for this forum.
    I will try and explain it all in (even greater) detail, maybe submit it directly to Sylvia.
    And who knows, perhaps it will help to avoid people losing their lives one day,
    So long !

    So long

  • At Sylvia’s request I will do a write-up about altimeter settings, in fact the continuation what I had already started.
    Cliff already gave us a piece of the puzzle but there is more.
    Actually, for a properly trained crew making proper use of the data available to them, including in the on-board library and approach plates, as well as sticking to PROCEDURE, it should be straightforward enough, not really that difficult at all.
    And the captain handing over to the co-pilot?
    In many operations the co-pilot is trained to the exact same standard as the captain. In one particular situation where we had to shut down an engine in-flight the co-pilot happened to be the handling pilot.
    I did not see any need to take over, he did a sterling job and it allowed me the room to do what I had been appointed captain for: to MANAGE the situation. We made an unscheduled stop. The company sent an engineer, the aircraft was fixed and we flew out again the next day.

    • Yay!
      Also, to clarify: I don’t think that the first officer should not be allowed to handle a difficult situation. In this particular case, it seems clear that the captain was not happy with how the first officer was handling it. In addition, the first officer stopped responding to any input whatsoever; he was fixated. So I’m at a loss as to why, given the circumstances of speed too low, descent too fast and FO not responding, that the captain did not take control.

  • Sylvia,
    Yes I see your point but in this particular case I would not have been happy with the guy who was the CAPTAIN either. I am at a loss to find anything redeeming in the performance of BOTH – this of course assuming that the report is the full and complete story.
    Not having anything else to go on, like training- and performance records, it makes me wonder how these two got through their training in the first place, who trained them and who signed them off?
    In other words: Whose performance was worse? Neither pilot seemed to be operating this flight even close to acceptable standards. And even worse, both seemed to shrug off a need to do something, to react in order to avert disaster
    And that brings me full circle back to the question: Who trained them and who signed them off? The “easy cop-out” is to blame the pilots, but there HAS to be another story behind it.
    Even when I was in my first job, flying a Cessna 310 (forget about the previous thousands of hours clowning around in C 172s, Super Cubs and many other SE types), we got annual checks and additional briefings from RLD (Dutch CAA) appointed check pilots who did this additionally to their “day job” as captains with Transavia and KLM.
    Even though we were not officially regulated, we prided ourselves that we were pros, operating to standards that were set and supervised by airline check captains.
    Ultimately, the credit probably goes to one of our company directors who held a PPL with IFR and who acknowledged the need to maintain certain standards to keep their private operation safe and professional.
    When I became “THE” pilot of the late Dr. Tony Ryan, we were given a set of SOPs that were written by Aer Lingus captains seconded to Air Tara. I only once nearly failed a line check: Coming from France via the Cork VOR into Shannon for runway 24, we were allowed to keep “any speed you want”, so we kept 340 kts IAS. It was CAVOK, no wind.
    I overcooked it, far too fast. Dr. Ryan did not like the rumble and vibrations of the speed brakes. Just at that moment our check pilot, Brian Wade, was answering a question from Dr. Ryan through the open cockpit door. Quickly I asked ATC for a circling for 06. Granted! With power at the idle stop all the way we flew a perfect teardrop over the threshold of 24, the right speed at the correct moments for flaps, perfect timing for the checklists, gear down at the correct height, speed and position on final. Only then did we set ref power and did not need to adjust them again until touch-down. All text book – except: the original runway assigned had been 24, but Brian never knew and gave us “AS” for approach planning and approach execution. (AS = above standard). Not really deserved but perhaps we earned it for “improvisation and adapting”!

    • Haha, that’s pretty brilliant. I only just got a chance to sit and read it properly.

      I think there’s a lot to be said for strong SOPs and making sure that all the staff adhere to them.

  • My perspective as a USA pilot: I never learned a difference in terms between “height” vs “altitude” (i.e. that one is AGL and one is MSL). I grew up using the government charts that don’t really call out that distinction. That said, it has never mattered because we always work in MSL (corrected for local pressure, unless above 18k’ then it is always standard pressure).

    The only use I have in my flying for the AGL value of the MDA/DA (the one in parens) is to quickly check if that is below the lowest clouds reported from the wx frequency, as those are read in AGL values. Otherwise it is not really saved in my head when shooting the approach, I am always concerned with the larger-font MSL numbers.

    To me it sounds like the pilot-flying was having general trouble with proper power settings, exacerbated by trying to salvage an approach they were “behind the airplane” on. It also sounded like their approach “briefing” caused way more harm than good – maybe all signs of being tired or otherwise not fully engaged?

    • I only recently noticed that the height/altitude split doesn’t seem as clear in the US because as you say, it doesn’t usually matter. But the weather is a good example of why you need to have the AGL as well.

      More tomorrow but yes, fatigue comes up.

  • Hmm. With both pilots completely “out of it”, I’m flashing on that incident you posted where pilot and co-pilot both went into hypoxia (but the controller talked the conscious one down).

    But from the report, they had gotten down to 3,000 (above sea level?) and been there for two minutes. Would the experienced folks here consider that sufficient to expect a recovery from hypoxia?

    • In cases of hypoxia, the drill is to get under 10,000 feet and cabins are (I think still? I should check this) kept at about 8,000 feet. So yeah, at the height they were at, they would have recovered.

      But you are right in that there’s an issue with taking new information in and making sense of what is going on.

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