An interesting day in Rome which highlights the complexity of modern airport and airspace operations.

Not that landing an Airbus A320 with a landing gear issue is a simple job, however: just ask the crew of Wizz Air 3141 who arrived on final approach to Rome Ciampino airport this morning (June 8th 2013) to find their normal  procedures rudely interrupted by a warning that the left undercarriage was unsafe. Further preliminary information can be found at http://aviation-safety.net/database/record.php?id=20130608-0.

I was operating to the other, larger, Rome airport – Fiumicino – just prior to 8am. By this point, the crew had already followed the published procedure for a missed approach from Ciampino in order to troubleshoot their landing gear problem, flying around in circles, generating options. But what else was happening as a result of this?

Firstly, the Wizz Air had decided to divert from single-runway Ciampino to one of the runways at Fiumicino as it was longer. This meant that all inbound traffic was now re-routed to the other, parallel, runway. Delays began to form as more aircraft entered the system than there was capacity for with only one runway in use. (Normally, Fiumicino has a third runway dedicated to take-off, however this is currently under reconstruction.)

On the ground, the fire services were diverted to the Wizz Air runway; standard practice in an emergency situation but it meant that they were unavailable elsewhere on the airport. Therefore, aircraft fuelling had to stop. Delays on the ramp now also begin to form: planes unable to fuel, can’t push back for their next flight, occupying parking stands due to be used by incoming aircraft… which continue to land.

Ultimately, however, there is only a limited amount of fuel which can be burnt trying to resolve a problem like this in flight, and the length of the delay on the ground was limited by the needs of the Wizz Air to get on the ground in as controlled manner as possible. Once the situation was stable the fire services could, at least partly, be released back to their normal duties, after which normal operations continue, albeit with only one runway.

Regarding the issue of fuel management, this type of situation is particularly interesting, as it happens at the end of the flight when fuel is already nearing a minimum level. As pilots, we normally think of fuel as time – time to diagnose, generate options, decide on some course(s) of action and carry them out, considering as many possible sources of information as are available to assist us. In this case the crew were able to not only diagnose using their aircraft systems, but through information from ground observers during a low pass over runway 34R they knew their information was correct in the absence of being able to physically see the undercarriage. Then, rectification using checklists for additional attempts at lowering the gear, both normally and through a manual handcrank which allows gravity to pull the gear down, along with airborne maneuvering to try and swing the gear in to position through rocking the wings, climbing and descending sharply.

But ultimately, preparation had to be made for an uncertain landing, and this will have been talked through between the pilots, with the cabin crew, the passengers, ATC and, if possible, the airline themselves, with the very real possibility of an emergency evacuation on the runway. This could result in additional injuries, as passengers rapidly leave a large aircraft which is sitting at an angle in the middle of a tarmac runway.

Needless to say, these thoughts are stressful for all parties involved. But what if the crew had arrived with the bare minimum of fuel, and this process of troubleshooting and decision-making needed to take place under severe time pressure?

In that situation, the complexity of the environment, combined with the increase in stress, can lead to unnoticed mistakes and omissions. The safety margin for error absorption is reduced. So it makes sense to simplify wherever possible. This can be done by making decisions earlier in flight, when everything is going as planned and ATC is quieter, or even prior to leaving the ground in the first place. How much fuel – time – does our arrival fuel give us to troubleshoot any last-minute issues, such as landing gear or wing flaps which fail to work as planned? Where will we be needing to go to sort out any problems? Are we familiar enough with the area to know what options offer the highest appropriate margin of safety? How assertive will we have to be in order to use those options – what will we say when we have minimum fuel and need to divert to an alternate airport and ATC tell us to “stand by”?

Keep it simple. Keep it safe.

Wizz Air Evacuation on Runway 34R at Rome Fiumicino, 8th June 2013

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On March 13th 2012, an incident took place with an Air France Airbus A340-300 on approach to Paris Charles de Gaulle (France).

A summary of the report is given here: http://avherald.com/h?article=45f1317a

The French BEA have offered recommendations in French: Final report available at http://www.bea.aero/docspa/2012/f-zu120313/pdf/f-zu120313.pdf

F-GLZU

As is often said, there are many aspects to an incident and no single cause can be solely attributed to an unintended end result. However, this case reminds me of a message drilled home by one of my instructors during training on the Airbus A320. We all know that Aviate is our number one priority: to fly the aeroplane in a safe manner.

This means we have to make the aeroplane do what we want. In this incident the crew wanted the Airbus on the proper approach slope and the correct speed and configuration, but was unable to achieve that result.

But how did they know that they were so far outside the normal approach parameters that a go-around was inevitable? Reading the report, it certainly seems that they did not in fact know that this was the case. How do any pilots find themselves saying “This isn’t going to work.”.

We do it by asking the question “Is this going to work?”. During a normal approach we have distances or heights mandated (either legally or by airline Standard Operating Procedure, SOP) at which we are required to be stable within the normal parameters in order to be allowed to continue the approach. We ask the question at these points, and if the answer is “no” we perform a go-around or discontinued approach. In this case, having crossed the final approach point higher than they should have been, they either

  1. Specifically chose to continue
  2. Were simply unaware of their speed/height/distance – they didn’t ask the question “Is this going to work?”.

In the first case, choosing to continue regardless, what motivating factors would have made them continue? Not wanting to have to accomplish a go-around and second approach, followed by paperwork and explanation? Not having a sufficiently strong SOP culture, either due to there being no requirement to abandon the approach, or working in an environment where the crew felt they could get away with ignoring the SOP?

In the second case, simply being unaware, could fatigue or tiredness have contributed to slower processing of a rapidly changing environment? Did they brief themselves that they may be kept high and, if so, what modes would be selected on the autopilot control unit in order to still make a safe and stable approach? If not… did the element of surprise cause such tunnel-vision that they simply forgot to ask the question… “Is this going to work?”

In any case: not having been there, it is sensible to assume that we are all capable of making the same mistakes. So, we put aside blame on CRM, SOP adherence, ATC or fatigue and look at how to handle the situation. That situation is that we are now so far above the normal approach profile that the aircraft starts to pick up spurious signals from the runway transmitters, causing it to start climbing instead of descending. No bad thing to be climbing away from terrain, except that in this case the spurious signals commanded such a sharp climb by the autopilot that the speed of the aircraft washed off, bringing the aircraft close to a stall. For another example of why this is bad, see the Dutch Safety Board final report in to Turkish Airlines 1951 at Amsterdam Schiphol, here: http://www.onderzoeksraad.nl/en/index.php/onderzoeken/Neergestort-tijdens-nadering/#rapporten

Turkish 1951 Amsterdam

Thankfully, the crew of Air France 3093 noticed the sharp climb, reacted by disconnecting the autopilot and shoved the nose of the aircraft forwards in order to accelerate. The autothrust disconnected, adding further distraction to the task of ensuring the Airbus A340 remains airborne. Having stabilised, the crew FINALLY made the decision to go-around.

But that is not where the story ends. Having been put in to a near-stall by incorrect autopilot commands 30 seconds previously, the crew decided to make an automatic go-around. In order to do this, they re-engage the autopilot. When the autopilot re-engages, it picks up a false runway approach slope again and now enters a nose-dive back towards runway 08R. Again disconnecting the autopilot, a manual go-around is finally flown.

It is easy to say that the go-around on 08R is a simple straight-ahead climb to 4000ft and that the autopilot was not to be trusted. So why was it re-engaged again for the first go-around attempt? Reversion to an automatic motor-response in a time of stress? Reluctance to make a manual go-around when tired and surprised by what has just happened? What about focus on manual flying skills brought about by the investigation in to Air France 447 which crashed in the South Atlantic ocean following a …stall situation?

(Incidentally, the A340 involved in this incident was also previously involved in an incident over the South Atlantic bearing eerily similar hallmarks to that of the fateful A330 of AF447 – for further information see http://avherald.com/h?article=44280b2a)

We can be grateful for two things: the aircraft and occupants are now safe; and the incident has reminded us of the need to always fly the aircraft in a safe manner regardless of the external factors.

Once a month (normally), commercial pilots pick up their new roster to see what they will be doing, or at least expect to do for the next month.

Seeing a CRM – Crew Resource Management – training session on the roster often results in a small inward sigh, not least because they are often combined with ‘business awareness’ training, ‘customer expectation’ training and other things which, for many pilots, are clear from previous careers in corporate business and customer service.

Sometimes, however, sad accidents remind us in commercial aviation of the need for a flight deck operation which is coordinated and well-planned. The case of Afriqiyah 771 (Airbus A330-200, registration 5A-ONG) brings to mind the harsh reality that, in a scrappily-managed and poorly-briefed approach, the often-present fatigue can combine with some handling mistakes to result in the total loss of an aircraft and almost all occupants.

How can we always be expected to properly brief our intentions when the other pilot is clearly tired, bored, irritable or just looking at something interesting out of their window?

Good CRM is about more than just keeping their interest for long enough to share a mental model. It serves as a backup and safety net for situations where SOPs are ignored (such as flying below the minimum altitude to get visual with the runway before performing a go-around), when holes in training or currency lead to poorly-flown go-arounds, or perhaps where fatigue leads us to succumb to tricks of the mind, such as somatogravic illusions (accelerating at a normal nose-up angle leads to mistakenly believing a climb is steeper than it really is, maybe leading to an unintentional push forwards on the controls).

Briefing these risks in advance may for many pilots be a secondary, less-interesting aspect to flying than, well, the actual flying. The truth is that we manage risk for a living: this assessment is our primary job. Our CRM (non-technical) tools are there to catch us when the other holes in the cheese line up. Indeed, they will probably keep us away from the go-around in the first place.

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Airlines continue to compete in Europe for a share of the low-cost market. Recently, BA released seats for sale from London Gatwick airport at a reduced price for passengers not checking-in hold baggage. But is this a discount for passengers or a charge?

As with all things, the relative perspective is what counts. For passengers already flying with low-cost airlines such as easyJet, Ryanair and others, enjoying offerings of no-frills for reduced fares, this becomes an equal product for comparison whether BA like to admit it or not.

The legacy airline offer ‘free’ drinks and snacks on board, along with a two-bag cabin allowance rather than one bag and no refreshments on the other carriers. Of course, the truth is that they are not ‘free’ but, as so often misrepresented by mobile phone companies who offer ‘free’ handsets for a monthly priced contract, the cost of these items is amortised and more by the overall price paid.

I recently travelled by train from London Paddington to a destination in the South West of England. The price of the ticket was far more than I would pay to drive the same distance at a time of my choosing. However, in the carriage was a seat-back touch-screen TV. I was clearly paying for that with part of my ticket fare.

Looking then at the BA offering, will passengers see their fares as low-cost with added Frills For Free, or will they see it as an unsustainable last gasp for a share of the low cost market which is eclipsing the profits of BA’s  sister, Iberia? Will regular BA passengers be pleased with the discount or will it bother them that BA are actually eating in to their own profit by offering the same frills for a much-reduced price, simply because of a saving of fuel amounting to, traditionally 3-4% of the weight per hour – in this case for a 20kg suitcase, about a pint of fuel – around $1.

Perhaps this is a Loss Leader for BA, but maybe it will work out. Time will tell.

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