Cobalt wrote:
wasn’t anywhere near the ceiling (let a lone the MDA) when he reached the missed approach point.
In that case, armchair thinking makes it obvious that the safest decision would have been another approach to Narsarsuak where he knew for a fact that the weather was better than minimums rather than diverting low on fuel to a place where the weather could have changed one hour later when he gets there.(Having read the report last night I don’t recall seeing this mentioned as an option).
So what thought process makes you kind of ‘automatically’ divert to your alternate when you know flying the approach again 500ft lower, but still above the mda, would put you below the clouds? Perhaps he was not sure that he did not have enough fuel for the alternate but he was sure another approach would kill his options to go to the alternate?
Some AOC operators have rules about single approaches followed by an automaticdiversion, but this is sometimes not the safest approach. Is there a rule to that effect for Part 91 ops?
This thought process reminds me of the DC9 at San Juan in the Caribbean who run out of fuel having killed his options of diverting by flying multiple approaches to the destination, not the case here.
OTOH JasonC wrote:
The basic point is you don’t leave Iceland until you know you can definitely land in Narsarsuaq.
Well, in this case the TAF’s would have made him think he should be able to land at destination and alternate, and actual wx also later confirmed it…the only pre-flight planning question in the report was that even at planned FL and max range cruise, he had 5min fewer than the required 45 mins final fuel after the alternate which, while not 100% legal, would not have been a killer by itself.
My grandtotal experience with Atlantic crossings of one is around 19 events fewer than yours so.. what would you do if ATC limits you 8000ft lower than planned, resulting in you losing your minimum fuel targets? (As a minimum you would at least change your cruise settings from ‘recommended cruise’ to ’ max range cruise’, which this P180 pilot apparently did not, but that would have given him only 10-15 mins extra final fuel given the headwind)
@MOD perhaps you could move this part of the thread to a new one about ‘Decision making when flying in remote/oceanic areas’ to minimize thread diversion
[done]
BGBW ATC advised ceiling and asked if he wants to try again. For some reason (stress, confusion, fatigue, heck maybe he made a tiny mistake and misread an altitude on the approach chart) he was convinced he would not make it into BGBW. Maybe he was stressed out about BGBW in the first place and focused on this stress. Similar to TAM3054 (stressed out focus about the inop thrust reverse) and AF447 (stressed out focus about climbing higher). Once he diverted he put himself in a corner obviously.
Easier said then actually decided for when alone and stressed but entering a holding overhead BGBW and taking 10 minutes to analyze the situation and come up with the best decision might have helped.
Antonio wrote:
what would you do if ATC limits you 8000ft lower than planned, resulting in you losing your minimum fuel targets?
You asvise ATC of this and if no improvement you have to know when to turn around or divert for a fuel stop.
If I remember the Universal FMS correctly it has a PNR/PET calculator included.
Antonio wrote:
My grandtotal experience with Atlantic crossings of one is around 19 events fewer than yours so.. what would you do if ATC limits you 8000ft lower than planned, resulting in you losing your minimum fuel targets? (As a minimum you would at least change your cruise settings from ‘recommended cruise’ to ’ max range cruise’, which this P180 pilot apparently did not, but that would have given him only 10-15 mins extra final fuel given the headwind)
If landing in Greenland, not getting your preferred level as a turbine aircraft happens all the time. If it happens you recalculate your fuel, decide if you can accept the clearance and if not, turn back to Iceland/Canada. Remeber, in most cases out of Goose Bay and Iceland you obtain your oceanic clearance on the ground, and you are advised of your level being unavailable before even starting engines.
You can certainly go and try to negotiate with ATC to get higher but due to the lack of RADAR over Greenland procedural separation often means they will not allow you to climb further.
As Snoopy points out, landing should have been possible if he had flown the approach properly. Often, as in this case, up there you dont really have a good alternate particularly once you have descended and tried an approach. So you have to make sure you get in.
If you are not comfortable flying the approach into Narsarsuaq, a better plan is to fly direct to Sondrestrom BGSF which typically has much better weather and an easier approach. It adds distance to the trip but is a more conservative approach.
Snoopy wrote:
entering a holding overhead BGBW and taking 10 minutes to analyze
That is a good one! For some reason when under stress in the air, (I recall my own ‘low’ fuel situation) , your thinking tends to get more tunnel vision and you have to ensure you are factoring all available data correctly when making a decision. It helped me to write down the three options, weigh each one with known facts (so much easier with Golze!) and then decide, but it took me a while.
I am not familiar with his FMS, but it should have been capable of entering and maintaining the hold on autopilot, leave the flying aside for a few minutes, gather the data on a piece of paper/ipad and then decide. The pilot felt pressed to decide immediately for some reason, when he still had over an hour’s worth of fuel.
He could even have started climbing out on hdg towards BGSF and then run his numbers, then 10 mins later, once he had a more clear picture, decide to fly back to BGBW and fly another approach. This would not have damaged his options for BGSF, that he apparently was so keen on preserving.Whatever the case, in order to understand the situation, we have to try and figure a process that works when we only have a few able neurons…
Remember Apollo XIII when the astronauts asked Houston to rerun some basic calculations for them in case the astronauts had made an error, for IRS alignment before reentry: they were tired and stressed and very aware of their limited brain capacity.
To me, that life-saving process is
On this last part about communicating, for some reasoning, however flawed or not, but that is another matter, we are reluctant to declare emergencies.
But even then, we can simply exercise PIC authority and say ‘unable’ to a clearance and inform of our decision (the P180 pilot did so when he decided to continue climb enroute to BGSF).
I have done it a couple of times when waiting what seemed too long for a clearance to avoid wx and it was not forthcoming…simply said ‘now turning left 15 deg to avoid’ before running out of options. Perhaps not 100% legal when in controlled airspace, but at least ATC knows what you are doing and you are doing it before it is too late. My impression is that 95% of the time it results in a safer situation than declaring an emergency or continuing heading into the wx. ATC never refused and simply came back and asked to ‘advise when able/expecting to resume navigation to…’
On the ‘decision’ and facts gathering part, you can also try to enlist help , but if single-crew, then that is ‘limited’ to ATC. If you do not have onboard wx, then obviously you have to ask ATC.
JasonC wrote:
Often, as in this case, up there you dont really have a good alternate particularly once you have descended and tried an approach. So you have to make sure you get in.
Tim (where is he?) once said something similar about arctic flight planning, especially on routes where the luxury of an alternate simply does not exist. You have a PNR but once past it, you are committed. Perhaps you have fuel to perform some holds and approaches, but not for a diversion. In that case, your best option may well be flying an approach below minimums. Of course before you put yourself in that corner, (ie before PNR) you need to have all available data indicating a very high likelihood of a successful approach at destination, but after that… you are committed.
Perhaps the P180 pilot, once having put himself into a bad corner where it was clear he could not divert to BGSF, he should simply have flown the approach below his believed minimums. He obviously thought he could not be successful on this approach, perhaps he made an error in reading mda or had an ADF failure (could he not use an FMS overlay approach??) or, like in the ‘overload when flying in IMC’ thread he misunderstood the ceiling figures…even then, and even if ceiling had been 200ft lower than mda, it would be safer to continue descent towards the runway before the map than to divert with not enough fuel. Ideally, further analysis should be done as to what (missed approach, obstacles left or right of course, obstacles on course below mda or…?) is driving the MDA and the MAP, but that may be above available computing power.
It is clear that when under stress, once you have to start breaking rules you have been trained for, lack of brain power makes it very difficult unless you have pre-trained such thought process. Rules normally keep you safe, but once some mistakes or event have put you in a bad position, no matter whose fault it is, you have to exercise your authority.
I hesitate a bit to write this, since we all make mistakes and a bit of humility is on order when looking at somebody elses, but sometimes there are accident chains that make you wonder if any amount of thinking by that pilot would have helped.
He couldn”t calculate the fuel required, nor could he fly the aircraft to maximise range, and that with hours of planning available before the flight. And he couldn’t figure out why he went missed (way above MDA at the MAPt).
Why is it taboo to simply say that this pilot was so much out of his depth that the real mistake was to even contemplate this flight?
Cobalt wrote:
Why is it taboo to simply say that this pilot was so much out of his depth that the real mistake was to even contemplate this flight?
+1
It’s become widely accepted in aviation that nearly every accident can be traced not to one single cause, but rather a chain of threats and errors that all contribute to the final outcome
I have always thought of this as quasi-theoretical mumbo jumbo. Swiss cheese and all that. It’s like saying all accidents are freak events, a result of all the stars aligning suddenly and unexplainably. Nothing is really wrong technically, no decisions where really in error etc etc. If you let the stars align freely, they will, and there is nothing you can do about it once you set action in motion. That is what happened here. The pilot bit off way more than he cared to chew, and the outcome was the most probable one, except he was crazy lucky to survive.
Swiss cheese and all that.
Isn’t the point of TEM that you plan beforehand. If you took off with perhaps insufficient planning hoping that destination was above minima that would be first hole in the cheese. If kept below planned cruise level, or winds were not as forecast, or temperature was higher, or not using planned power setting, etc the detailed fuel plan would have been amended and a tDODAR action started, second hole. Shooting the approach without checking fuel plan, was the approach part of the plan?, third hole. Not declaring an emergency on diversion to get a better level. Fourth hole. Shutting down an engine to reduce efficiency in some strange theory of efficiency, etc.
We are not talking any determinism here, divine or by the forces of historical materialism (passim Popper), just analysing the actions taken through a free agent which led to the accident.
I am not sure how much oceanic flights the guy had before but of it is his first one he may have kept the same planing habits and risk aversion: these have saved his life for the past 500 flights but are completely inadequate to a completely different flight.
On that flight his critical fuel is function of six or seven variables with few binary ones, I don’t think he blow all of them to see what would happen in few scenarios…I think he did is like what most of us do live inside the cockpit: just multiply average burn rate with estimated hours and add a “random” reserve number, this look stupid after facts.
On that flight, I think one may have to be more defensive/aggressive on some bits than text books or usual practices to get it done (e.g. ship twice fuel, descend bellow minima…)
