A Frightening Near Accident (A320)

( http://www.caa.co.uk/docs/33/FOD200316web.pdf  ) -14 May 2003 (file inserted immediately below)

“The aircraft cleared terrain by 56 ft.”    (SSA = Sector Safe Altitude)

SAFETY REGULATION GROUP

FLIGHT OPERATIONS

DEPARTMENT COMMUNICATION

Flight Operations Department, Aviation House, Gatwick Airport South, Gatwick West Sussex, RH6 0YR

Website address: http://www.caa.co.uk/publications

16/2003

1 OPERATIONAL CONSIDERATIONS WHEN THE ACCURACY OR RELIABILITY OF NAVIGATION

EQUIPMENT IS IN DOUBT DURING THE APPROACH PHASE

1.1 Introduction

1.1.1 The Air Accidents Investigation Branch (AAIB) is participating in an investigation into a serious incident

where an Airbus A320 aircraft carried out two go-arounds, the first, after unreliable VOR navigation

information and the second, after experiencing an EGPWS "Too Low Terrain " alert. Whilst the

technical investigation continues, it is considered prudent to remind operators and their flight crews of

the following recommendations and advice.

1.2 Background

1.2.1 The same crew and aircraft flew from London (EGLL) to Addis Ababa (HAAB) via Alexandria (HEBA)

operating without incident to this en-route stop, disembarking passengers and refuelling. A long desert

leg was flown via Khartoum with few navigation aids available for updating aircraft position. The aircraft

was not fitted with GPS. On arrival at Addis Ababa VOR/DME (ADS), the crew were cleared to carry

out a standard VOR/DME approach to runway 25L. There was a thunderstorm around 5 nm southwest

of the airfield and therefore ADF information was not used. Navigation accuracy was low inbound and

changed to high in the area of the VOR. The VOR/DME identified correctly and indications appeared

normal up to the start of the procedure, but during the outbound leg an unexpected large correction left

was required to acquire the radial.

1.2.2 After flying the ADS DME 13 nm arc, both a left turn to intercept the correct 249 degree inbound QDM,

and descent to 11200 FT AMSL was commenced. The VOR radial started fluctuating during the

descent and the indications disappeared. With no adequate visual reference, a standard missed

approach was flown and the aircraft joined the hold. The crew confirmed with ATC that the VOR/DME

was serviceable and the crew carried out a navigation accuracy check that appeared normal and

elected to carry out a further approach.

1.2.3 Again the VOR fluctuated occasionally during the inbound leg and a "400 FT" radio altimeter callout

was heard approximately 5 nm from the airfield at which point the Captain initiated a go-around and the

crew heard the EGPWS Terrain Clearance Floor "Too Low Terrain" alert. It would appear that the

aircraft was around 2.6 nm north of intended position. The aircraft cleared terrain by 56 ft.

1.2.4 Evidence so far indicates that the VOR was transmitting an erroneous signal that the aircraft may have

used to update the Flight Management Guidance System (FMGS) position. The map showed the

aircraft to be in approximately the expected position, but because this aircraft is not fitted

FLIGHT OPERATIONS DEPARTMENT COMMUNICATION - 16/2003

with GPS, any error transmitted from the VOR could result in an error in the computed FMGS position

because position refinement is taken only from ground-based navigation aids in non-GPS aircraft.

Similarly, the EGPWS terrain mapping position information was in error due to the navigational

inaccuracy and therefore failed to work as expected.

1.3 Advice to Flight Crews

1.3.1 Flight crews are reminded of the necessity of carefully monitoring the portrayal of navigational

information, especially when flying in areas of limited navigational aids. In the event that the accuracy or

reliability of navigation information is in doubt, or if conflicting navigational information is evident, then

an immediate go around should be flown when below SSA. If an EGPWS alert is received then crews

are reminded to carry out the correct actions immediately with the required vigour.

1.4 Recommendations

1.4.1 Operators should ensure that the details of this incident, and the advice contained above, are

brought to the attention of their flight crews.

1.4.2 Operators should endeavour to use aircraft with GPS on routes that involve long sectors both

over water and terrain that terminate in remote areas served with few navigation aids. This will

ensure that both FMS position update computations and EGPWS are provided with a choice of

information sources from ground-based and satellite navigation systems

 

Some Pilot Commentary

I always assumed GPS was a necessary component of EGPWS. Tell me why I shouldn't be worried that it isn't.
a necessary component of EGPWS?

No

Tell me why I shouldn't be worried

Looks like you know!

I'm pretty sure there has been a serious suggestion that plates should carry typical radalt readings for a NPA?

400' on a VOR approach WOULD raise a question mark and a few figures on the plate would be VERY useful
On most units from the USA...

...GPS is included for the very purpose of providing useful accurate position data, so the avionics function as intended.

To those that fit equipment that do not include GPS...the question must be asked, why not?

Could it be the old 'distrust' of the USA controlling the GPS signal(s)?

The country in question controls the VOR, do they not?

It is not permitted to rely on GPS as a primary means of navigation. Nothing, I suspect, to do with suspicion of GPS accuracy in this case - my guess (and it is only a guess) is that this A320 was fitted with INS.

Similarly, INS is not to be used as a primary means of navigation.

The question, however, has to be asked - in this situation, which would have been more accurate - GPS or VOR/DME?
"the question must be asked, why not?" - cost, pure and simple. NOT anti US, however hard you try

Capt Stable - "my guess (and it is only a guess) is that this A320 was fitted with INS." - the report says GPS NOT FITTED, so the approach was, I understand, being flown 'raw data', but on a dodgy VOR
My suspicion is that the INS hadn't had a chance to update itself after the long transit, hence the reason for flying it raw data.
Generally it is not permitted to fly approaches using INS (twin IRS, anyway), so it is possible this would HAVE to be flown in RD regardless of the INS state?
Interesting comments from some, who really should know better.

INS/GPS not approved as a primary means of navigation?

Hmm, have not noticed all that many VOR/DME's at 30West...or 140West for that matter. Last I noticed, pressure pattern navigation was not authorized on the OTS...but hey, maybe I missed an amendment.

Some EGPWS are equipped with their own dedicated GPS (and terrain data base), thus are able to give warnings as needed.
Best piece of kit to come down the pike in many a moon, IMHO.
Should (IF used correctly) eliminate CFIT, and that is no small achievement, wouldn't you say?

Several US air-carriers use GPS for approaches (primary means of navigation)...Alaska Airlines the most, so far as I know.
 

Driven Risks

Peter B. Ladkin

Article RVS-J-97-10

Human beings are flexible, inventive and adaptable. Even in error. Certain kinds of human error are resilient enough to overcome technology specifically designed to avoid them.

Consider the downing of Korean Air Lines Flight 007 over Sakhalin island in August 1983. The 1993 International Civil Aviation Organisation report says that the identification was bungled: `` ...the pilot of one of the USSR interceptor aircraft...had been directed, by his ground command and control units, to shoot down an aircraft which they assumed to be a United States RC-135''. While there remains considerable uncertainty about many aspects of the accident, this is one of the most well-substantiated, in part by recent interviews with the pilot. Why was such a grievous mistake made?

Cognitive psychologist James Reason uses the term confirmation bias for the partly unconscious ability to value evidence that confirms a hypothesis, no matter how wrong-headed, while ignoring evidence that contradicts it. This was a very low-tech incident. Identification was made visually. Interceptor pilot and controllers were expecting a military aircraft; identification was incomplete and the decision process was rushed; the pilot perceived what he thought were evasive manoeuvres; sensitivity could have been heightened by nearby secret military tests; no commercial flight should have been within hundreds of miles. Clearly, extra electronics would have helped to improve identification - or so one might think.

Or would they? In July 1988, the USS Vincennes, an Aegis-class warship, bristling with electronics to manage a complex wide-area air battle in open ocean, shot down Iran Air Flight 655 on a scheduled flight to Abu Dhabi. The Vincennes was fighting small Iranian boats, and made a high-speed manoeuvre that caused chaos in the fighting systems control room. IR655 was off-schedule, and flying towards the fight. It was first identified as an F-14 attack aircraft, on the basis of a momentary F-14-compatible transponder return. The crew then experienced a form of confirmation bias: the transponder return was consistently thereafter misreported, and the aircraft was misperceived as descending towards the Vincennes, whereas it was in fact climbing. The report shows that the decision to fire was made notwithstanding persistent contrary evidence from the electronics, concluding that `` stress, task-fixation and unconscious distortion of data may have played a major role...'' We can see similar cognitive features in this case - expectations, urgency, a sensitive military situation, (mis?)perceived manoeuvering of the suspect aircraft, confirmation bias, ultimately misidentification. So much for sophisticated electronics solving the identification problem.

Now to a current theme. More than half of the 2,200 airliner fatalities during 1988-1995 were due to controlled flight into terrain (CFIT), in which the pilots are unaware of imminent collision. Most CFIT cases happen on approach to an airport, and usually involve human error. Airline accidents on non-precision instrument approaches (NPAs) occur with a frequency five times greater than on precision approaches. CFIT is a big killer. So what to do?

Put in more electronic helpers. For example, Boeing 757 pilots are trained to use the flight-management system (FMS) to determine position and course. But this can also go wrong. The report on the CFIT crash at Cali in late 1995 included as causal factors an FMS database ambiguity and an FMS function that caused pertinent course information to be erased which would likely have highlighted a misapprehension by the pilots. No wonder the FMS didn't help. Connoisseurs also see evidence of confirmation bias in the crew's behavior and communication with air traffic control.

But some electronic helpers seem to be almost foolproof. A solution has been proposed to CFIT in the form of electronic equipment called an Enhanced Ground Proximity Warning System (EGPWS) to warn pilots of dangerous terrain ahead of the aircraft. Its predecessor, GPWS, looked down but not ahead, has been in use in the U.S. for 20 years, and seems to have helped. It didn't help at Cali, and a recent model didn't help in Guam. But the enhanced version must surely be much better. How could it fail?

One can take a cue from the downing incidents. What could go wrong is what won't change. An airline-pilot colleague who has written FMS handbooks summarizes the views of many professional pilots: `` Shooting an approach is generally easier in a steam-gauge airplane than in a hi-tech airplane. Less training, less monitoring, less information to sort.'' More high-tech devices will not alleviate this particular situation, no matter how wonderful they seem.

There appears to be near-unanimity in the aerospace industry on the value of EGPWS. But note that it's treating the symptoms, not the cause. How can we judge how well EGPWS will work, unless we thoroughly understand CFIT? And that's a question of knowing about human error, not of fancy technology.

 

http://www.rvs.uni-bielefeld.de/publications/Reports/inside-risks.html
   
 

Re:  http://www.caa.co.uk/docs/33/FOD200316web.pdf 

Further to this A320 near accident (see the Bluecoat exchange below)

 It's interesting to note that the RNP Required Nav Performance index) on many DME's is inadequate for accurate updating for an approach. I wonder how (BA, Egyptair or Kuwait) Airways explains that anomaly with respect to that Addis Ababa DME/VOR approach anomaly (whichever of those three airlines were involved).

Note that Air France doesn't appear to operate A320 into Addis Ababa and Lufthansa operates A319 into there.

 
   

-----Original Message-----
From: bluecoat [] On Behalf Of Chris Habig
Sent:
Friday, May 23, 2003 12:12 AM
To: 'Bluecoat'
Subject: Re: [bluecoat] US RNAV approaches

 

From: Chris Habig <chabig@mac.com>

Date: Thu May 22, 2003  10:10:25  AM America/Denver

To: SparkyBrodbec@yahoo.com

Subject: Re: [bluecoat] US RNAV approaches

 

Yes. The DME updating is just not accurate enough for the approach.

This is because the DME navaid infrastructure around certain airports

is not sufficient to provide the required accuracy.

 

Here are some references:

 

AIM 1-1-25, d:

 

"Aircraft with AFM-RNP certification without GPS may be limited to

certain RNP levels, or phases of flight. For example, RNP base on

DME/DME without other augmentation may not be appropriate for phases of

flight outside the certified DME service volume."

 

AIM 5-4-5, j, 3, (e):

 

"Some aircraft have RNP approval in their AFM without a GPS sensor. The

lowest level of sensors that the FAA will support for RNP service is

DME/DME. However, necessary DME NAVAID ground infrastructure may or may

not be available at the airport of intended operations. For those

locations having an RNAV chart published with LNAV/VNAV minimums, a

procedure note may be provided such as "DME/DME RNP-0.3 NA"; this means

that RNP aircraft dependent on DME/DME to achieve RNP-0.3 are not

authorized to conduct this approach. Where FAA flight inspection

successfully determines the availability and geometry of DME facilities

will support RNP-0.3 and that the DME signal meets inspection

tolerances, a note such as "DME/DME RNP-0.3 Authorized" will appear on

the chart. And where DME facility availability is a factor, the note

may read "DME/DME RNP-0.3 Authorized; ABC and XYZ Required"; meaning

that ABC and XYZ facilities have been determined by flight inspection

to be required in the navigation solution to assure RNP-0.3."

 

Chris

 

> Is the DME update just not that accurate/reliable for approach accuracy?

 

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-----Original Message-----

From: bluecoat - On Behalf Of Marc Brodbeck

Sent: Thursday, May 22, 2003 10:25 PM

To: bluecoat

Subject: [bluecoat] US RNAV approaches

 

Wondering why in the US we have for RNAV approaches,

eg RNAV (GPS) rwy 22L KEWR, the following note/restriction:

 

1. GPS or RNP 0.3 required

2. DME/DME RNP 0.3 not authorized

Is the DME update just not that accurate/reliable for approach accuracy?

 

2 nearby ILS DME's?

 

Thanks,

Marc