[Peetwo]

Update: Courtesy the Times, via the Oz.

‘Get-home-itis’ and macho pride is a lethal mix for pilots


A photograph from the cockpit of this week’s doomed flight, which was carrying players from Brazilian football club Chapecoense. Picture: Twitter

• Charles Bremner
  
• The Times
  
• 7:01PM December 1, 2016
  

Flying on fumes, as pilots call it, may sound impossible in the modern age but running out of fuel still happens. The cause is usually psychological.

Pressure to reach a destination, known in the industry as “get-home-itis,” can lead to flight planning that cuts corners and introduces risk.

Every year dozens of small aircraft fall victim to wishful thinking by pilots who gamble on stretching range to the maximum.

Unexpected headwinds and air traffic delays quickly eat up reserves. The fate of turning into a glider only very rarely befalls airliners, which are governed by strict regulations on reserves and benefit from computerised monitoring of fuel burn.

In a case eerily similar to this week’s crash, an Avianca Boeing 707 came down near John F Kennedy airport in New York in 1990. The crew of the Colombian airliner was reluctant to declare an emergency when they were put into a holding pattern while low on fuel. After flying from Medellin to New York, they told controllers that they were concerned about fuel but failed to make the distress call that would have given them immediate priority to land. Seventy-three people were killed and 85 survived.

The crew’s failure was put down to language problems plus the reluctance of all pilots to declare an emergency that was likely to damage their pride and land them in trouble.

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Pilots explained the fate of the LaMia airliner this week as the likely result of risk-taking under pressure. Miguel Quiroga, the captain, was intent on landing the football team in Medellin, a difficult mountain-ringed airport, in time for them to sleep and prepare for a match.

He was not only pilot-in-command but also co-owner of the small Bolivian charter airline that is struggling to make its name.


Rescue teams at the scene of the Colombia plane crash.

The pilots told the controllers only that they had a “fuel problem” when it was almost too late and even then failed to utter the magic word “emergency” that could have saved them, according to other pilots on the frequency.

Gustavo Vargas, the airline’s managing director, was at a loss to explain why Captain Quiroga, a former military pilot, decided to forgo a fuel stop in Bogota and head straight to Medellin. According to the rules he was required to have enough fuel to fly back to Bogota if he met unexpected delays once he had arrived over Medellin. Unless there was a physical explanation such as a fuel leak or a feed problem, the crew was breaking the rules.

Pilots who operate in South America were astounded that a crew would cut margins so fine in a mountainous area prone to unpredictable weather. Pilots are trained intensively on the danger of bad decision-making under the pressure of “macho” pride and external factors.

Commercial pressures on airlines have in recent decades led to the cutting of fuel margins on busy routes. Aircraft sometimes land to refuel short of their destination, but the decision is closely regulated. That does not seem to have been the case at Medellin.
The Times

MTF...P2

 Ps I like to add to the mix (discussion.. ) the following archived post from P9 off the O&O thread:

A Sunday rant. (My turn).

This report –HERE - Absolutely overdue and most definitely obfuscated.  Don’t read the fluffy ‘abridged’ version, download the whole disgusting thing for the full nauseating effect.

Well Senator Sterle; I’ll see your 42 tons and raise you 49 tons.  The differences are worthy of comment.  Our 49 tons was doing about 280kph approaching the ‘bridge’, it cannot be reversed, nor can it be decoupled; it also had many of your fellow West Australians inboard. Had it 'jack-knifed', there is no friendly RTA to sort out the mess; only fire engines, police and ambulances initially, coroners and inquiry later.  

This nasty, grubby little report from the ATSB, for what they seem to find a cut and dried matter, has been three years in the making.  It is a grubby attempt to distract the reader away from several core issues which are not even paid the courtesy of being obfuscated; they are simply ignored.  

No calculator required for the simple mathematics.  Using the index finger of your right hand, count the fingers on your left hand – Norfolk (1) Mildura (2) Mildura (3) Perth (4).  Four known close calls all with several things in common, short of fuel and rapidly changing weather, three ending happily on runways, one ditched in open water.  

The common threads are easily discerned,but even this latest pathetic report tries to hint at pilot error.  It is a good thing that the ATSB do not apportion blame; but they do hint at it.  Why?, well, another common factor is the sacred cow of the BoM, who only need to be within +/-70% accuracy of actual in their forecast (from memory) to be off the hook.  This level of accuracy has little intrinsic or practical value to a pilot.  In court the responsibility will all fall to the pilot, everyone else has wriggle room and bolt holes, all except the poor mutt in the dock.  

ATSB, ASA, BoM and CASA need to resolve this situation; we now have escaped four times from disaster where bad weather and low fuel reserves have been intricately bound with poor, late weather forecast.  It’s a trend and ATSB should be screaming from the roof tops, demanding something be done to reverse that trend.  Do they? No sir, they do not.  We get presented with a snide, trite, puerile little report which tries to shift the spotlight off the piss poor service to the travelling public delivered by our expensive ‘safety watchdogs’.    

When planning for the return flight at Paraburdoo, the Perth aerodrome forecast (TAF) and the trend forecast (TTF) did not contain any forecast operational requirements for this aircraft to carry sufficient fuel to fly to an alternate aerodrome. At 2300, 5 minutes after take-off, the Perth TTF changed with the forecast onset of fog 65 minutes after the estimated time of arrival (ETA).

Snipe 1: perhaps on the basis of the new forecast the aircraft should have landed and uploaded more fuel, then tried again?  Bollocks.

At 0010, which was about the time when the aircraft commenced its descent and shortly before the aircraft no longer had sufficient fuel to divert safely to a suitable landing aerodrome, the Perth TAF was amended to indicate a requirement for the carriage of sufficient fuel to divert to an alternate airport on the basis of more than four OKTAS8 of cloud with a base below the alternate minimum of 700 ft above the aerodrome reference point. The forecast also predicted that 35 minutes after the aircraft’s ETA, there was a 30 per cent probability of fog reducing the visibility to 300 m, which was below both the alternate and landing minimums for runway 03.

Snipe 2: Neatly blurred; the implication is that somehow it’s the pilots fault that there is insufficient fuel.  There is little point (other than spite) to be mentioning any of the above; they were dead set legal and righteous to continue and had adequate fuel to complete the task as scripted on the weather forecast as applicable to the time; not the clucking future but right there and then.

Soon after, at 0014, a TTF SPECI9 was issued for Perth Airport indicating that the visibility had reduced to 7,000 m and the airport was partially covered in fog. The observed visibility, as reported on the TTF SPECI issued at 0030, which was soon after the aircraft’s landing time, was 900 m in fog.

Snipe 3:16 minutes from touch down, visibility 7000 meters partial fog – so what, still all good. Continue on; the nasty bit is the statement “soon after” etc.  This implies the landing was in ‘marginal’ (borderline illegal) conditions.  

When you break down the time line, you realise that this flight was always legal, the only ‘indiscretion’ was a conflict with company procedure.  The decision to land off the go around was righteous, given the circumstances.  ATSB would prefer you believed otherwise, they just hint at it though.    Pure spite and malice. 

During the flight, the flight crew did not seek or obtain an amended or updated forecast for Perth.

2255 – Take off.  Time en-route 90 minutes - ETA Perth 0130.

2300 – amended forecast for Fog at 1 hr 05 minutes after ETA.  Fog @ 0235.

0010 – Top of Descent (TOD).  Forecast amended to reflect a 30% chance of low visibility 35 minutes after landing; fog forecast from 0205.  

0014 -  Special weather visibility 7000 meters.

0030 visibility 900 meters.  AFTER LANDING...... FFS.  What's your point?

The captain reported that he normally obtained the latest TTF for Perth when overflying the automatic en route information service (AERIS) at Meekatharra, about 360 NM (667 km) north-north-east of Perth.

However, the timing of the flight and the delay normally encountered in updating the available weather information on the AERIS meant that he did not expect to obtain the latest TTF at that time.

When the aircraft was about 240 NM (440 km) from Perth, the crew obtained the latest automatic terminal information service (ATIS) weather observation for Perth, which provided no indication of deteriorating weather.

Routine, bog standard, sensible operating practice.  The rules and the BoM failed the public yet again, with everyone off the hook except those burned alive.  It is high time the ATSB started bringing this trend into focus instead of drafting a carefully prepared, prejudicial statement for prosecution use.

The Beyond all Reason methodology and those that espouse it are not only becoming an international embarrassment, but part of the causal chain.

There you go Glen; my little Sunday rant; and yes, I feel better now.

Toot toot.