[Peetwo]

Only my own opinion; a notion or ramble may be a more fitting description -  but the deep, systematic flaws in the ‘training’ programs seem to be appearing on a regular basis.  We have quite a long list from the last couple of years; Mildura, Mooranbah, Melbourne, Sydney, etc.  Newcastle being the exemplar where the crew were rescued from landing on the coal loading dock by an alert ATCO.  

My mind keeps picking at what I can only call – ‘disconnection’.  The modern aircraft, particularly the Airbus are so ‘automated’ that it is quite possible for the crew to feel ‘remote’ from the operational reality.  When you have a control column’ in one hand and the power levers in the other, the aircraft is ‘with you’, firmly between your feet on the rudder pedals.  The flight path, profile and speed – controlled by you.  Reality.   It is quite a surreal experience to be playing with automatic systems, remotely asking a computer to sort out the task at hand.  Is it possible that crew are becoming more focussed on the ‘keyboard’ and connected to the computer; rather than cognisant of the external factors?  It’s academic; but clearly something is going wrong, regularly, and if the ATSB can’t or won’t provide a solution, we need to examine the basic tenets.  

Then there is the simulator syndrome; in the ‘sim’ the event being discussed here could have been stopped; a discussion held while the ‘aircraft’ patiently waited at 1000 feet until the point of the exercise was understood; then, reversed back to where the initial problem occurred and- it’s off to the races, problem solved.  Is this ‘attitude’ endemic? the reality of a 50 ton aircraft at 135 KIAS on final approach is that it will not patiently park at 1000’ while the mysteries are unravelled, it’s real. It’s dynamic and it is no place for a crew to be disconnected  from the task at hand.  

Please note; not knocking or denigrating anyone or anything; just trying (struggling)  to understand the radical causes.  Thinking out loud if you like.

To begin excellent thought provoking post by the Ferryman..

 'Disconnection' is indeed the key word here and it is not solely in the cockpit where this 'disconnection' is occurring. The investigator - & to a certain extent the regulator - seems to be failing to join the dots, although maybe there is a light at the end of the tunnel..

Moving on from the Sydney Jetstar approach dust-up incident and back to more familiar ground with Melbourne approach incidents...  

Noticed that the ATSB today have just released their latest Bulletin of aviation short investigations - Issue 43.

Hidden in the SIB - within the Jet aircraft section - there was this incident - Flight below minimum altitude involving a Boeing 777, A6-ECO, near Melbourne Airport, Vic on 18 July 2014 

Okay this is where we see the disconnection start to creep in with all those other Melbourne approach incidents. Quote from the summary page:

..As the aircraft approached BUNKY, air traffic control (ATC) cleared the crew to descend to 4,000 ft, and cleared the crew for the RNAV-U (RNP) runway 16 approach. ATC radar data shows that the aircraft overflew BUNKY at 5,000 ft, then continued descent, passing through 4,000 ft about 5 NM prior to BOL. Descent then continued, leading to an ATC Minimum Safe Altitude Warning alert as the aircraft descended through about 3,400 ft, about 4 NM prior to BOL. ATC questioned the crew about their altitude, and advised them that the relevant radar lowest safe altitude was 3,200 ft. Moments later the aircraft passed over BOL at about 3,000 ft and maintained that altitude until intercepting the vertical profile of the RNAV-U (RNP) runway 16 approach. The approach continued for an uneventful landing...

However this is where the disconnection becomes suddenly recoverable, because the international operator is strangely  forthcoming with the findings of their own internal investigation.
Summary continuing:

..The operator’s investigation found that descent below the 4,000 ft altitude restriction at BOL occurred because the crew programmed the Flight Management Computer (FMC) to overfly BOL at a ‘hard altitude’ of 3,000 ft. The operator’s investigation found that the potential for deviation below the 4,000 ft minimum altitude restriction at BOL was increased by factors related to aeronautical charts and the FMC navigation database...

To which the ATSB (without Exec PC interference) were able to make the following solid conclusions - Hoorah!

..For operators, this incident highlights the need for careful attention to FMC navigation data management, particularly any procedures that relate to crew modification of navigation data. Operators should remain mindful that any manipulation of FMC navigation data by flight crew has the potential to introduce errors. Additionally, operators are encouraged to work closely with aeronautical information service providers to ensure that aeronautical charts (and any other operational information) are presented in a manner that minimises ambiguity and reduces the potential for misinterpretation. For flight crew, this incident highlights the need for careful attention to approach procedure documentation and FMC navigation data management..

This was followed on in the full report by these active inputs from DIPs, that systematically identifies the holes in the cheese (again without any Exec PC editing)(warning - P2 actually recommends that the CASA Officers get a choc frog for their input to the following.. ):

Review of the factors identified in the investigation


The operator’s investigation found that descent below the 4,000 ft altitude restriction at BOL occurred because the crew selected the ‘hard altitude’ of 3,000 ft for BOL. The potential for deviation below the 4,000 ft minimum altitude restriction at BOL was increased by factors related to aeronautical charts and the FMC navigation database. Some of these factors are discussed in the following paragraphs.

The ATSB obtained comments and responses from involved parties including:

• the United Arab Emirates General Civil Aviation Authority on behalf of Emirates Airlines
  
• Airservices Australia
  
• the Civil Aviation Safety Authority (CASA).
  

The RNP approach had been designed by GE Naverus (Naverus), based on information in the Airservices Australia Aeronautical Information Package (AIP). The charts and FMC data used by Emirates were supplied by LIDO. LIDO developed the charts and database based on information in the Airservices AIP.
Procedure design – level depiction on the ARBEY STAR
No minimum altitude was specified at BOL on the ARBEY FOUR STAR.

Operator comments
Within the STAR, BOL had a coded speed restriction of a maximum 185 kt for approaches to runway 16, but did not specify a minimum crossing altitude. This allowed arrivals from other directions to cross BOL at a minimum altitude of 3,000 ft, instead of 4,000 ft as required via ARBEY. This conditional altitude restriction was specified in the approach charts only and not on the STAR chart. This procedure design did not protect the MEA of 3,400 ft on the arrival segment from position BUNKY to position BOL by a 'hard procedural altitude'. BOL is located at a distance of 11.6 NM from runway 16 and a crossing altitude of 4,000 ft would permit a constant approach angle crossing BOL on a 3.0° vertical descent path. Based on this, a lower crossing altitude (3,000 ft) for other arrival directions does not seem necessary.

The operator suggested that Airservices Australia consider procedural amendments to specify a minimum crossing altitude over BOL (of 4,000 ft or above) for all approaches and within the STAR design. This would protect against descents below MEA (and outside controlled airspace) within the arrival segment from BUNKY to BOL. It would also satisfy the requirement of Airservices Australia to be able to specify higher crossing altitudes (above 4,000 ft) for traffic separation. If Airservices Australia, as the State AIP, changed the procedure design, the various chart providers would then amend their corresponding FMC/FMS databases as well as the STAR and instrument approach charts.

CASA comments
CASA suggested a possible solution would be to include the altitude restriction in the STAR chart. This would then make the altitude obvious on the text and plan view, and the altitude restriction would be coded in the FMS. They also found that the overall complexity of the STAR chart did not aid pilots’ awareness.

Airservices response
In controlled airspace, the approach procedures are designed to keep aircraft 500 ft above the control area steps. The 4,000 ft minimum altitude was designed to keep aircraft in controlled airspace prior to BOL, rather than for terrain clearance.

Airservices further commented that a minimum altitude of 4,000 ft was not depicted on the STAR chart at BOL, as BOL was also applicable to the runway 27 arrival. This allows ATC to assign a higher altitude at that point for a runway 27 arrival due to potential runway 34 departures. No altitudes are depicted because two (or more) levels would be required to cater for the different runways. Only one level is permitted to be depicted against a waypoint (for a STAR) to avoid potential confusion as per Section 1-1-22 of Airservices 'Departure, Arrival and Air Route Management Design Rules' manual (ATS-MAN-0010).

Altitude requirements are not always specified on a STAR chart, and ATC is generally responsible for deciding whether altitudes are to be included or not. This occurs in the procedure design phase. When they are not included on the chart, ATC assigns individual altitudes to aircraft in order to facilitate vertical separation between them and assure terrain clearance.

   
This led to the following safety action & safety message statement:

Safety action


Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Aircraft operator

Crew awareness of restrictions on STAR
Soon after the occurrence, the aircraft operator published a company Notice to Airmen (NOTAM) for crew awareness. The NOTAM pointed out that approaches into Melbourne may include altitude restrictions that depend on the particular STAR being flown. The NOTAM also pointed out that some altitude restrictions may be depicted on the approach chart plan view only, and not necessarily on the relevant STAR chart, or the approach chart profile view. The NOTAM advised crews to exercise caution when reviewing STAR and approach procedures to ensure that all applicable altitude restrictions were observed.

Flight crew operations manual
The operator intends to reconsider Flight Crew Operations Manual guidance dealing with the benefits of changing initial approach fix ‘at or above’ altitude restrictions to hard altitudes, and discuss the depiction of altitude restrictions on the relevant charts with the chart provider.

Flight management computer coding
The operator has identified the FMC coding issue as a threat in their Hazard Identification and Risk Assessment statements. All new destinations and also, within the review cycle, existing destinations, will be checked against this threat and corrective action will be taken if applicable.

Airservices and CASA
CASA and Airservices intend to discuss the coding of the FMC at the next international instrument procedures panel, where an ‘integration’ subgroup includes FMC coding specialists. The aim of the discussion is to ensure the charts are used in the cockpit the way they are intended.

Safety message

For operators, this incident highlights the need for careful attention to FMC navigation data management, particularly any procedures that relate to crew modification of navigation data. Operators should remain mindful that any manipulation of FMC navigation data by flight crew has the potential to introduce errors. Additionally, operators are encouraged to work closely with aeronautical information service providers to ensure that aeronautical charts (and any other operational information) are presented in a manner that minimises ambiguity and reduces the potential for misinterpretation.
For flight crew, this incident highlights the need for careful attention to approach procedure documentation and FMC navigation data management.

For producers and providers of aeronautical information products, a guiding principle specified in Procedures for Air Navigation Services, Aircraft Operations is to keep all charts as simple as possible. This may assist in reducing flight crew workload and the risk of error, and coding issues when entering data into flight management systems.

What a difference in outcome when compared to final reports for the Virgin & Qantas Melbourne approach incidents (back a couple of pages from about here). More is the pity that the positive lessons learnt will not be disseminated across a greater worldwide industry/stakeholder audience because the report is basically buried in a ATSB short investigation bulletin..FCOL

MTF..P2