Ask The Pilot

[Quickstatus]

It’s humans, mistakes happen

Agree, however, blind /automatc tick boxes and form filling only take you so far.

 

[mjt57]

Maybe have someone on a captain's salary holding up a stop/go sign at the entrance to the runway along with a "roadworks ahead" sign....

 

[jb747]

Even more noteworthy, but neither crew selected TO/GA when they realised things looked wrong. In the case of MAS, the captain didn’t because “he didn’t want to startle the FO”. I suspect he would have been even more startled if they’d run into something.

 

[RSD]

Even more noteworthy, but neither crew selected TO/GA when they realised things looked wrong. In the case of MAS, the captain didn’t because “he didn’t want to startle the FO”. I suspect he would have been even more startled if they’d run into something.

That comment from the MAS captain certainly stood out too as a bit of a clanger decision - and I'm sure that it wouldn't have been just the FO that was startled if they ripped the nose gear off on a parked Hilux... makes you wonder just how much thinking was really going on in the coughpit! First time I've ever heard a captain being sensitive to an FO's feelings!

 

[Quickstatus]

Maybe have someone on a captain's salary holding up a stop/go sign

Hey those road lollipop people earn a pretty penny - maybe not captain level but I would not be surprised around FO pay grade

While some airlines need to get their governance up to scratch, I wonder if lights at runway entry can modified in some way to indicate shortened runway?.

Then there is the general issue of NOTAMS in the airline industry.

 

[RSD]

Hey those road lollipop people earn a pretty penny - maybe not captain level but I would not be surprised around FO pay grade

Maybe when the captain finds out at the runway threshold from the lollipop person that the FO didn't read the NOTAMS or ATIS properly he can smack the FO around the head with the lollipop sign!

 

[jb747]

Maybe when the captain finds out at the runway threshold from the lollipop person that the FO didn't read the NOTAMS or ATIS properly he can smack the FO around the head with the lollipop sign!

That’s the entire point…the captain should have read both items himself. All of the pilots should individually gather all of the data necessary for the take off calculations, then they should be done completely separately, and only coming together when you have a final answer. That’s intended to avoid missing things on the ATIS, making assumptions, and data entry errors. Actually, exactly the sort of thing that has happened here.

 

[Dale Eastham]

I agree that NOTAM information can be missed....but, there's no excuse for not having a good read of the paperwork for your departure airport, even if you leave everything else until later. My take on this is that reading of NOTAMS wasn't something they did at all.

ATIS isn't that long, and it was normal to write the entire thing down. Also for all pilots to get it separately, as any error would transfer to the take off data. To me this is obviously a case of only one person getting it. Most of the time, in modern aircraft you get it off the ACARs, so the entire thing is on a print out for you to read.

Lights aren't necessarily all that obvious, given that the end of the runway is the better part of 2 miles away. Also runways aren't level, and things can be hidden by the bumps. This is accentuated by aircraft with low coughpits. You would expect the obstructions to eventually be noticed, and for TOGA to be selected.

It's an inadequate system, but they should also have done much better.

And yet, in the same period of time, lots of other aircraft used the runway without issue. I suspect that the systemic failure lies within both airlines.

Thanks JB for the answer. I hadn't considered the level of the runway may well hide such things - low coughpits too.
With the instructor (in the GA world) I always wrote down everything & then checked what I had against what he had - started as a check to ensure I'd understood everything from ATIS & the tower in the learning phase, but just seems like good sense ever since to continue that way.

The fact that the captain saw the shorter threshold and did [nothing] is somewhat horrifying.

 

[torks]

The other thing I thought was a bit unusual was the Bamboo airlines flight had a pilot flying and pilot monitoring sitting in the two seats, with the pilot in command sitting in the jump seat. It doesnt say anything about being a training flight, so it seems wierd having the most senior pilot sitting in the jump seat for a critical portion of the flight.

 

[jb747]

The other thing I thought was a bit unusual was the Bamboo airlines flight had a pilot flying and pilot monitoring sitting in the two seats, with the pilot in command sitting in the jump seat. It doesnt say anything about being a training flight, so it seems wierd having the most senior pilot sitting in the jump seat for a critical portion of the flight.

I expect that the pilot sitting in the left seat was also a captain. They're carrying two, and one is nominated as being in overall charge.

 

[RSD]

That’s the entire point…the captain should have read both items himself. All of the pilots should individually gather all of the data necessary for the take off calculations, then they should be done completely separately, and only coming together when you have a final answer. That’s intended to avoid missing things on the ATIS, making assumptions, and data entry errors. Actually, exactly the sort of thing that has happened here.

Totally agree - relying on one person to gather, absorb and interpret the data isn't a good way to operate at all - it sounds like some of these airlines need a big reset as they seem to be lacking the required safety and operating culture leaving too many gaps for things to fall through - luck only gets you an indeterminate distance...

 

[Rabs97]

The entire NOTAM system is rubbish. The volume unmanageable, the format unreadable and indecipherable. This isn’t just a pilot complaint, some safety investigation bodies have said the same:

https://www.reuters.com/business/aerospace-defense/bunch-garbage-campaign-ease-pilot-overload-antiquated-safety-warnings-2021-04-28/

Missing the message | Flight Safety Australia

How do you find the vital pre-flight information you need when it’s buried deep in a stream of NOTAMs? This frustration, felt by pilots around the world, is finally being addressed—but don’t expect change anytime soon ‘They’re just a bunch of garbage that nobody pays any attention to.’ Robert Sum

www.flightsafetyaustralia.com

I don’t know why, in this age of digital technology, we don’t make the NOTAMs very easy to understand and read:

“Melbourne airport Runway 34 will have a reduced runway length of 2000m take off distance available due to works closing the northern end of the runway between 1200-1800 UTC tonight for your departure. Ensure the OPT setting for Runway 34 reduced length is used”.

Or even program the performance calculation app to only use the reduced length for departures in that time period unless knowingly overridden by the crew if the works are cancelled. Just removing another potential error for crews who may be fatigued or unable to decipher the NOTAM.

 

[Rabs97]

Or for a more humorous take on the situation:

 

[jb747]

The entire NOTAM system is rubbish. The volume unmanageable, the format unreadable and indecipherable. This isn’t just a pilot complaint, some safety investigation bodies have said the same:

There's no doubt that it's an overall rubbish system. But, having said that, it was never that hard to read through the ones relevant to your departure, unless they're Australian, in which case they've been known to refer to other notices that you aren't actually given. In particular, this applies to works programs. But, it was on the ATIS, and there's no excuse there.

I don’t know why, in this age of digital technology, we don’t make the NOTAMs very easy to understand and read:

“Melbourne airport Runway 34 will have a reduced runway length of 2000m take off distance available due to works closing the northern end of the runway between 1200-1800 UTC tonight for your departure. Ensure the OPT setting for Runway 34 reduced length is used”.

Actually that's not easier, especially if you aren't a native english speaker. Far too many words.

Or even program the performance calculation app to only use the reduced length for departures in that time period unless knowingly overridden by the crew if the works are cancelled. Just removing another potential error for crews who may be fatigued or unable to decipher the NOTAM.

Online access to any aircraft system will never be granted. That's a massive issue in itself.

Also, reading through the ATSB report, the crews mention being time pressured. That's interesting in itself. Where is this pressure coming from. I know I never particularly cared. If we're a few minutes late 'cos it took me a while to get ready, then so be it. It might wind up a few people on AFF, but it was never something a crew should care about at all.