After the flight, we discussed our performance and it was quite clear that we had violated SOPs and agreed that it was a very poor approach and decision making. On my part as F/O, I wished I had been more assertive in asking the Captain to conduct a missed approach when things were not going as planned. I will now use strong, specific words to convey urgency in taking actions in undesirable situations. Examples like, "Captain, we are too fast/high, we need to prepare for a missed approach." , "Captain, we are not safe, GO-AROUND now".

I experienced distraction and automation lessons during the management of a Standard Instrument Departure (SID). I was acting as part of a three pilot augmented crew in the observer’s seat in full view of both instrument panels of a wide body airliner. An inappropriate automation mode selection coupled with conflicting traffic lead to a loss of situational awareness (SA) by both the pilot flying (PM) and the pilot monitoring (PF). The loss of SA developed to a point where the aircraft was rapidly decelerating towards a stall. The Captain was pilot flying (PM) and the FO was pilot monitoring (PF).

The auto-pilot/thrust was being utilised to comply with a SID that incorporated three altitude constraints, one at the VOR and the two at subsequent waypoints. Following takeoff we were given ATC vectors and instructed to stop our climb and level off due to conflicting VFR traffic, we were separated by 5nm and 500 feet. We were then given an instruction “own nav back to the VOR and comply with SID altitude constraints”.

The turn back to the VOR was approx. 70 degrees. The PF initiated the turn back to the VOR by rotating the HDG bug selector approx. 40 degrees and then selected the Vertical Speed (VS) mode, the VS was set at 1500’ per minute. The VS mode selection was non-standard practise but not prohibited by SOPs.

The VS selection was clearly done with the intention of complying with the VOR altitude constraint. The full HDG bug rotation of 70 degrees had not been made as the practise of initiating the turn with the HDG bug followed by selection in the FMC of the waypoint, PM verification, PF execution and then PF selection of the lateral navigation (LNAV) mode is regarded as the most expeditious practise.

After the initial 40 degree HDG bug rotation and selection of VS mode, a TCAS warning of “Traffic traffic” prompted both PF and PM to scan visually for the traffic. As soon as the TCAS warning sounded, I recognised that the imperative of the PF and PM to search for the traffic distracted from the management the auto-pilot/thrust system. The VS mode provides no speed protection, that is, as the auto-thrust reaches maximum and the aircraft climbs higher, the auto-pilot continues to pitch the aircraft up to maintain the set VS target. The eventual consequence if left unmodified is a rapidly decelerating energy critical situation where the aircraft will stall.

In amongst the distraction both the PM and PF scanning for the traffic and communicating the warning to ATC, the PM was endeavouring to turn the aircraft the full 70 degrees but had not recognised the increased threat level once the thrust had reached its maximum. The airspeed started to decelerate below the target speed, about five knots below the target speed I called out “airspeed” as I projected that speed would rapidly decay from that point. At about ten knots below the target speed I called out “increase airspeed” upon which the PM acknowledged the call, followed shortly after by the PF acknowledging. By that point the airspeed had decelerated below the minimum manoeuvring speed.

The PF attempted to resolve the dynamic situation by reducing the VS setting, however, the rate at which the auto-pilot was reducing the pitch was ineffective to counter the rapidly decelerating aircraft. The airspeed continued decelerating towards the stall speed indication on the speed tape of the PFD.
The PF realised the ineffectiveness of reducing VS and disconnected the AP. The PF manually reduced the pitch thus halting then slowly reversing the deceleration. As the aircraft accelerated, the PF selected a more appropriate AP mode and then re-selected AP on. We climbed away safely and met the altitude constraints at the VOR.

Analysis

The de-selection of the AP was the correct most expeditious method of resolving the energy critical situation. If the PF had awareness that thrust was in fact at maximum, I suspect that the PF would have recognised that reducing VS was an inappropriate response to resolving the situation.

This critical energy situation developed rapidly from a distraction and interrupted the normal practise of “own nav” to the VOR. The TCAS event consumed cognitive processing capability to realise the threat that the VS mode posed to the safe operation of the aircraft as the VS does not have speed protection.

Lessons

In high work load situations it is best to revert to automation levels that offer the best level of protection. If automation is not responding in a timely manner or not doing as anticipated, de-select automation and revert to manual flight.

He was granted access to sit in the jump seat of the aircraft by the captain and thoroughly enjoyed the experience, not only due to the novelty of being on the jump seat from start up to shut down but also because of a good lesson in human factors. The flight progressed normally and the weather conditions were suitable for a visual approach with light traffic. The first officer (who was the pilot not flying) obtained the ATIS (Automated Terminal Information System) which gives the weather conditions in the local area of the airport and the duty runway was prescribed as 05R in accordance with noise abatement with the nil significant surface wind. The approach to this runway takes you over the Manukau Harbour and landing heading towards the populated South Auckland area.

Normal decent was conducted under the guidance of the Auckland Approach Radar Controller and he also indicated that previous pilots were able to make a visual approach (not using instruments and visually manoeuvring the aircraft onto final approach). At around 10 nautical miles south of the airport (and visual with the airport / runway lights for some time already), the First Officer under the direction of the Captain requested the visual approach from the Auckland Approach Controller. This was approved and had the instruction attached to track for a 5 mile final in order to sequence behind a light aircraft ahead. This was read back and both the crew and the jumpseater sighted the other aircraft.

At this point the captain who was still managing the autopilot bugged a new heading in the heading hold autopilot command, and which started the aircraft in a gentle right hand turn which would set the aircraft up wide for a 5 mile approach to the runway. One minor problem though… He selected a heading to the right, which would take us over Manukau City and in the direction of runway 23L which is the reciprocal runway to the one which was in use. At this point the jumpseater was stuck between a rock and a hard place… did he hear the incorrect thing on the weather report? Does he say something and sound stupid? Does he let this mistake get detected by the crew or ATC????

As a relatively inexperienced pilot, having only just gained his instrument rating and commercial pilot’s licence he felt that it was not his place to say anything relating to the operation of the aircraft as he had neither been trained on the aircraft or company procedures. However there was a gut instinct telling him that he was qualified enough and had enough situational awareness to say something. Now the next problem was how to word it without sounding like a know-it-all or annoying the crew, who had been decent enough to let him in the jump seat in the first place!

The jumpseater settled on a subtle question which would jog the memory of the crew. "Which runway was in use again at Auckland?". This gave him an out should he be wrong! The captain immediately responded, "23L"…followed by a pause and then, "I think…hang on". He then re-read his handwriting of the ATIS report and exclaimed, "Oh S#*&, its 05R". The aircraft at this time was established at around a 20 degree angle of bank to the right. He immediately disengaged the autopilot and stopped the turn and rolled into a left hand turn.

There was a period of bemusement on the flight deck afterwards and lots of joking and laughter at the fact that it took a "second officer" to correct a mistake by a captain. They were both very appreciative of the fact that the jumpseater had spoken up and prevented a fair amount of paperwork for ATC and the crew. The jumpseater felt good having helped prevent a potentially very embarrassing situation.

After the flight the captain turned to the jumpseater and took a reflective stance on the occurrence. He said that the flight was their 5th sector of the day, the 3rd of which was operated into Auckland. On the previous 2 sectors into Auckland both of them had been into Auckland on runway 23L which created a mindset that it must be the same as when we were last here because the weather hasn’t changed much. Also it was 2330 on a Friday night and the end of a rostered-on period. It was a good lesson in mindsets and also cross-checking information. He also commented on the fact that an extra pair of eyes can make such a difference on late flights when fatigue starts to become a factor in operations. The lessons were taken out of the occurrence and I know that the jumpseater is very aware of making a similar mistake in the future.

It also goes to show that even an inexperienced person may be able to prevent an incident with a subtle question or statement. In fact this is recommended now in many passenger briefs that if they notice anything relating to the operation of the aircraft that they alert the crew. This was demonstrated when in the 1980’s a commercial aircraft had a mid-air collision with another and the entire thing was recorded on video by a passenger who thought that the pilot had seen the other aircraft. Unfortunately no one survived that accident.

This night time occurrence was a good lesson learnt by all involved on human factors.

The engine start and initial taxi for departure was from the Ice runway at McMurdo Pegasus, Antarctica. The control tower instructed the aircraft to atop and maintain present position, due to a report that a flight line fire extinguisher had been entangled in the aircraft nose wheel gear.
The aircraft was stopped immediately, engines secured and area inspected. Upon inspection, the situation was confirmed - the nose wheel had 'climbed' onto the foot assembly of a mobile fire extinguisher, pushing it some 20m before the aircraft had been warned and halted.
Both the aircraft captain and first engineer had visually cleared the area surrounding the aircraft just prior to the embarkation. However, it was assessed that the extinguisher had been masked by the nose landing gear and was not therefore readily visible.
Moreover, the extinguisher unit was able to be seen by any crew member from the flight deck due to its close proximity to the aircraft nose. The initial taxi was slow, with no impact being felt and the presence of the fire extinguisher being masked by the expected corrugations that are usually felt when operating on snow and ice.
The fire extinguisher was removed without further incident or significant damage/

Comments on the Incident

A complex event with a number of Human factors considerations combining with numerous environmental distractions, when operating in an environment like Antarctica all contributed to this event. Fortunately, the relatively soft surface of the operating environment - in this case - likely mitigated any risk of significant damage tot he aircraft. However, had the extinguisher damaged or become entangled in the nose wheel gear, the potential outcome could have been far more severe.
This incident highlights the need for clear coordination between air and ground crews. All personnel should remind themselves of the basic safety procedures around their aircraft and SOPs, including use of standard phrases.
Regardless of location or aircraft type, aircrew should make no assumptions and follow normal routines.
Ensure that ground crew are briefed on expectations and requirements where practicable.

The training aircraft was a Cessna 152.

We were getting close to the flight test date and the training had been proceeding quite normally and we were making good progress.

One November morning I arrived at the training organisation and as was normal practise the student pre-flighted the aircraft and advised me that there was 70 litres of fuel on board.

We took off normally and proceeded to the training area where the usual upper air exercises were completed followed by two forced landings without power into the local low flying area. We decided to do one further practise forced landing before heading home.

On climbing back to 2500’ and on a westerly heading, I observed another aircraft, a light twin, heading in our direction at the same altitude and about 2 nm to our north. It appeared that this aircraft would pass fairly close to us so I took control and performed a 180* steep turn to the right in an effort to avoid a possible conflict.

On levelling out it appeared as though the other aircraft was still heading towards us so I commenced a steep descending turn, again to the right and losing about 3 - 400‘ in the process, with the intention of getting beneath the other aircraft. This manoeuvre was successful and the other aircraft was observed to pass overhead on a southerly heading.

On climbing back to 2500’ and about to commence another practise forced landing the engine suddenly lost power and began to surge. I took control and trimmed for best glide. I chose a suitable field (the same one we had used previously) and began to carry out the emergency drills.

The engine continued to surge and I reasoned that the steeply banked manoeuvres had allowed air into the fuel system. In the hope that this would clear I continued to try for partial power throughout the descent although I remained fully committed to a landing without power. I asked my student to make a Pan call and select 7700 on the transponder. At the 1000’ area I decided to abandon any hope of restoring power and closed the throttle.

The subsequent landing was made by slipping over a row of small trees, into wind, and I managed to bring the aircraft to a halt within 2/3’s of the field length of 300 metres. The aircraft was undamaged.

I was unable to make radio contact with the local control tower but managed to inform a passing helicopter that we were safe. The pilot relayed this message to the tower. I then contacted the aircraft operator by cell phone.

On exiting the aircraft I dipped the fuel tanks. The left tank appeared almost empty although some fuel was visible. The right tank contained approx 18 litres. I would like to add that due to the aircraft dipstick being painted white it was very difficult to read accurately, and had been the subject of past comment.

On securing the aircraft, we made our way to a nearby house. The police and fire service arrived shortly afterwards.

Later that day the CFI of the organisation accompanied by myself and another instructor returned to the aircraft. On rechecking the fuel I noticed that the majority of the fuel had now flowed into the opposite tank. The CFI started the aircraft which ran normally. The aircraft was then taxied to either end of the field to check the surface for takeoff.

A LAME then arrived and after an inspection, the addition of more fuel, and an engine run up a successful take off was performed by the CFI.

A fuel load of 70 litres, minus 6 unusable should have given a total endurance of 2 hrs 45 mins assuming a consumption rate of 23 l/hr. The aircraft had been operated at power settings ranging from 2300 rpm in the cruise, full power during maximum rate turns, and idle during stall entry and two practise forced landings. I would estimate the time between start up and touchdown to be 1 hr 50 mins. The aircraft tachometer indicated 1.6 hrs.

Tacho start: 5605.6. Tacho stop: 5607.2

I believe that this incident illustrates several important points.

1. Although the instructor is normally the pilot in command on training flights, it is standard practise for the student to measure the fuel quantity and establish a safe endurance, especially in advanced training. This was a timely reminder for both student and instructor to be absolutely certain of the amount of fuel on board.

2. It was later established that although I was advised of the fuel on board, it was highly likely that due to the dipstick being painted white and therefore difficult to read, the true fuel quantity was likely to have been in error. The dipstick was soon replaced with one much more easily read and all members of the organisation were reminded of the importance of being certain of the true amount of fuel on board any aircraft they fly.

3. Fuel consumption figures are based on correct leaning procedures. Although the training power settings did not require the mixture to be leaned, I think it likely that the actual consumption rate was higher than the standard planning figure used. Other users of this aircraft were advised to take this into account.

4. Currency in emergency procedures certainly made this incident easier to cope with than may have been the case otherwise. The student and I acted as a crew during the descent, sharing the workload which enabled me to concentrate fully on a successful outcome.

5. Always be aware of the time, especially when operating aircraft with relatively low fuel capacity when loaded, such as the C152.

6. Always be aware of any limitations on certain manoeuvres while operating with low fuel states. The POH will list these.

7. Never trust light aircraft fuel gauges, especially those of older vintage. The more modern types however are normally very accurate.

I experienced valuable CRM & SOP lessons during the management of a minor abnormality that developed rapidly into a critical situation. The incident occurred during the approach phase of a 10-hour long haul sector into a major European airport. A minor abnormality combined with preoccupation, automation downgrade, and loss of awareness to a point where the wide body airliner was 10 seconds from stalling at low altitude over a metropolis. The Captain was pilot flying (PF) while the FO was pilot monitoring (PM). I was acting as part of a 3 pilot augmented crew in the observer’s seat. The observer’s seat is located immediately behind the central pedestal in full view of both instrument panels.

The auto-pilot/thrust was being utilised to comply with a standard ATC radar vectors profile onto an ILS approach. The aircraft was situated 15 NM from the airport on base leg with the first stage of flap extended, descending through 4000 feet to 3000 feet, speed 210 knots. ATC instructions were complied with in a timely manner using appropriate automation modes. It all felt like a normal unremarkable line flight.

ATC directed to reduce speed 180 and 80 degree intercept heading to the LLZ. The second stage of flap was required to be set to reduce speed to 180 knots as the minimum manouvering speed for the first stage of flap was 190 knots. About 5 NM from the LLZ and 5 seconds after the second stage flap position was selected, an EICAS warning annunciated which indicated a relatively minor flap abnormality.

Unilaterally without direction, the PM advised ATC of the flap abnormality and that vectors may be required. No urgency or distress situation was declared or deemed necessary due to the abnormality. I was instructed by the PF to run the appropriate QRH checklist. The reading of the checklist was delayed due to the location of the QRH not being in reach of the observer’s seat. Normally the QRH would be physically handed to the 3rd pilot in such an augmented crew by the PF or PM. The flap abnormality procedure did not have any specific actions but required that crew note that the rate of flap extension would be slower than normal and extra time would be required. As a function of the flap abnormality, the minimum manoeuvring speed indication on the primary flight display (PFD) speed tape remained high, unchanged at 190 knots instead of automatically reducing to 170 KIAS as with a normal extension of the second stage of flap.

ATC acknowledged the abnormality and instructed a 30 degree intercept heading onto the LLZ. As the auto-pilot manoeuvred the aircraft onto the new intercept heading, the airspeed was passing 200 KIAS and the rate of decent was starting to reduce to maintain 3000 feet. Thrust was at IDLE as commanded by the auto-thrust system, however it was expected to increase as the airspeed target and altitude constraint were reached.

As the aircraft rolled out, the pilot flying (PF) and pilot monitoring (PM) began a discussion on how to handle the abnormality, the auto-thrust unexpectedly disengaged. The EICAS auto-thrust disengagement warning was called then cancelled by the PM and acknowledged by the PF. Without being directed by the PF, the PM unsuccessfully attempted to re-engage the auto-thrust. To complicate matters further, the auto-pilot also unexpectedly disengaged which was also called then cancelled by the PM and acknowledged by the PF. The PF began to manually manipulate the flight controls. Again, without being directed, the PM unsuccessfully attempted to re-engage the auto-thrust. The PM clearly had become preoccupied and missed the SOP call “LOC active”, I called “LOC active” but this was not acknowledged by either PF or PM.

The PM queried the PF if we were to continue on the ILS or if we were to break off the approach and request ATC vectors to recircuit to resolve the flap abnormality. The query of the PF had to be made a second time as the PF did not respond to the initial query. The delay in the PFs response was clearly due to cognitive capacity being abruptly diverted to manually manipulating the flight controls. In addition, as the aircraft had started to level off at 3000 feet, the airspeed had reduced 10 knots below the target speed to 170 KIAS. The energy state of the aircraft was becoming critical. The PM made the call of “airspeed” as SOPs require the call if airspeed reduces five knots below or ten knots above the target speed. I did not observe or hear a clear acknowledgement or response from the PF to the “airspeed” call.

By this time the aircraft had been allowed to pass through the LLZ as the PF was slow in following the flight director pitch & bank commands. ATC advised of the mistake at the same time we identified the lapse ourselves, and instructed a vector back onto the LLZ as there was a parallel runway conflicting with our flight path. The aircraft continued to decelerate as it turned back towards the LLZ. The PF was manipulating the flight controls to follow the flight director to maintain altitude of 3000 feet and the new intercept heading, however not particularly accurately.

As the airspeed reduced through 165 KIAS the PM for the second time called “airspeed” but more assertively. Again, I did not observe or hear a clear acknowledgement or response from the PF to the call. I observed no response from the PF in terms of increasing thrust to maintain airspeed or positively reducing pitch. The PM then communicated with ATC as the aircraft turned back to intercept the LLZ. The airspeed continued to reduce to a point where the speed trend vector (which indicates the airspeed in 10 seconds) touched the stall indication on the speed tape of the PFD. At this point I decided my safety buffer had been compromised; as I could not take control from the observers seat, I aggressively made the “airspeed” call and reached forward from the observer’s seat in a non-standard procedure to move the thrust levers from the IDLE position to approximately half way up the power quadrant. This action appeared to re-activated the awareness of the PF to include thrust control in the competent handling of the aircraft.

Simultaneously as thrust awareness was regained, the flap abnormality cleared and the glideslope was intercepted. Flaps extended at the normal rate and the auto-pilot/thrust were able to be re-engaged. The rest of the approach from glideslope intercept at 9 NM was completed as per SOPs. All activities described from EICAS warning to glideslope intercept occurred within approximately 2 min covering 6 NM. As may be appreciated, the time frame for this occurrence was highly compressed.

Analysis

This critical energy situation developed rapidly from a relatively minor abnormality where active errors combined with a latent error to manifest themselves to a point where we were 10 seconds from the stall warning activating over a major European metropolis. A mitigating factor to the stall not actually occurring was that the aircraft was unintentionally allowed to descend slightly from 3000 feet and therefore wing loading was not as significant factor.

The flap abnormality was later attributed to a membrane of material in the leading edge area restricting slat /flap movement. This appeared to confirm the abnormality resolving itself as the leading edge slats had snagged the material during extension which eventually overcame the tension of the membrane.

The auto-thrust disengagement was a known malfunction of the type of the vertical descent mode selected when associated with certain abnormalities. Re-engagement is a simple matter but must be completed in the correct sequence but is not a normal occurrence which pilots practise. The auto-pilot disengagement was an irregularity which was later suggested by the Captain to have been a result of unintended actions by the PF.

The ATC speed instruction should have been immediately recognised as a threat to safety when the flap abnormality appeared. The PF should have bugged up to 190 KIAS to maintain the safety margins of the minimum manoeuvring speed limitation. However, in the context of multiple abnormalities occurring and the distractions (PM operating unilaterally) it is understandable that the cognitive processing normally devoted to airspeed control lapsed.

From my experience of company line flights and competency assessments, the restriction not to decelerate below this minimum manoeuvring limitation is clearly understood by all pilots. I have received training on other fleet types in the same airline, which clearly imprinted the need to “bug up” or increase the target airspeed to the minimum manoeuvring speed to protect safety margins in such situations. The training deficiency on this fleet to cover this aspect of threat management has not successfully captured by the safety management sysytem. If fact the training pilots or operatives on this fleet have developed their own distinct sub-culture that emphasises certain aspects but not others. Despite the outputs of the safety management system indicating there is a fleet specific training issue, the resistant sub-culture of the training operatives conflicts with safety improvements. A latent error is clearly apparent.

The training systems of airlines are required by aviation authorities to understandably focus on competency skills related to major malfunctions. I believe competency training and assessments should be dynamic and evolve with the maturity of experience on an individual basis to incorporate management skills (knowledge) of minor abnormalities to raise the level of expertise.

Additional casual factors: Steep authority/command gradient, Captain was 3 months from retirement, FO had just returned from long-term sick (depression) leave, long haul flight, 12 hours difference from base time zone, fuel on board nearing minimum reserves, no training or SOPs for situations requiring 3rd pilot assistance.

Lessons

From a CRM perspective, the actions of the PM to work outside the team decision-making process to communicate with ATC and attempt to re-engage the auto-thrust distracted from the duties of monitoring. In this situation as the PF was manually flying, PM attention should have been primarily devoted to monitoring the flight path and airspeed. Failure to carefully monitor the PF intercepting the LLZ was a critical feature of subsequent airspeed management errors. The failure to capture the LLZ error confounded the awareness of the PF to a point where energy management became critical.

After reviewing the company standard calls I realised that the second and subsequent “airspeed” calls should have been prefixed with the condition and suffixed with a corrective action, for example “low airspeed, increase speed”. The prefix and suffix are designed to further enhance the activation of awareness in exactly these situations. As these situations do not occur on a regular basis, it served as an important reminder to regularly review standard calls.

A company incident report was filed. The airlines safety management system manager discussed the incident with the flight operations human factors manager and fleet manager. The human factors training manager was to incorporate the lessons learnt from this incident into next years human factors training modules.

The freezing level was reported at 3000 feet AMSL and we had neither deicing nor anti icing gear. You are now getting the picture as to where this is going no doubt!
We decided not to fly out to Kiakoura East (KIE) which had a lower MSA - company pressures on operating expenses meant that we were to save money for the company. This was a near fatal mistake for us in that we were flying through the tops of some cumulus cloud at minus 12 degrees. Both of us were alert to the possibilities of in-flight icing so we monitored the air speeds and leading edges carefully.

Clearly we were flying a clean configuration and were indicating approximately 130KIAS. The flight was relatively uneventful until we were abeam the Kaikoura mountain range. First I noticed some moderate to severe turbulence associated to the cumulus cloud and the lee wave from the strong westerly over the ranges (so I thought - it actually disguised the buffet before a stall). Speed was good and there was only a little ice forming… certainly not enough to be too concerned about at that stage.

Shortly after, we flew into some cloud for approximately a minute or so which gave rise to the second event. Quickly the control column became sluggish and unresponsive and turbulence was more severe. I had the copilot look outside and he reported a dangerous amount of ice forming on the leading edge. I continuously checked the speed which remained at 130KIAS. Now in my mind (extremely junior and inexperienced at the time) this was not symptomatic of a pending stall situation as the speed was well above Vs (some 36 knots in that configuration). What I had not taken into account was that the increasing ice on the leading edge dramatically lowered the stall speed to match cruise speed.

It did not take long to realise the danger we were in as suddenly the aircraft entered a wing drop spiral dive to port (towards the ranges). I did what I had been trained to do - I pushed the control column forward (neutral aileron), went to full power and kicked in opposite rudder. This had no recognisable effect and the aircraft gained considerable speed as it plummeted towards the sea. The aircraft rolled violently around the longitudinal axis - we were totally out of control.
Given that the aircraft was descending rapidly the OAT increased as did the airspeed over the surfaces, the ice began to break away from the leading edges and crashed against the tailplane.
The speed not only exceeded Vmo, but also exceeded Vne. Despite this we pulled back on the controls and reduced our sink rate until we gained control of the aircraft at about 3000 feet. We then requested and were granted radar vectoring back to Palmerston North.

Engineers later discovered a twisted main spar.

The reason I bring this incident to this forum is to raise the importance of HF awareness at a managerial level. This company apepared to choose to put money before safety. I will admit my fault in flying that night under those conditions as pilot in command of the aircraft. I looked at the Metar and TAF but still chose to fly. I was solely responsible for the active failure in this case. The question is why did I still fly?

The answer comes back to a series of latent failures (as it does in most cases) in the company. This company, had a very poor safety culture…. pure and simple. They allowed inexperienced pilots to conduct these flights knowing that they needed to gain hours before applying for third-level airlines. They did not pay the pilots because they knew that there were many others who would fly for free. This meant that pilots would have to maintain daytime employment elsewhere to pay the bills. This was a direct causation of fatigue.
So here you now have inexperienced pilots flying for free, in a fatigued state, in adverse meterological conditions without the legally mandated equipment for IFR ATO's and often over MCTOW.

Unfortunately due to the anti-safety culture of the company, this occurred again where this time a pilot was killed.

It should never have come to this… Human Factor management must be an integral part of any aviation company if we are to prevent deaths in the future… we must continue to learn from our mistakes.

Safety is an ABSOLUTE MUST…..

1) The pilot monitoring should have been assertive and voiced his concern about the 250kt below 10,000ft restriction (this restriction is commonplace internationally).
2) The pilot flying's use of flap instead of speedbrakes

The pilot monitoring has been made aware of a threat (threat detection) through his expertise (knowledge of procedure (speed restriction) and aircraft systems (speedbrake vice flaps)) but has failed to practice the throughput of communicating (communication/assertivness/teamwork).

The pilot monitoring was also busy speaking with air traffic control (ATC) which is in itself a stressful situation during the approach phase of the flight as there can be many frequency changes (various TMA sectors) and instructions to comply with.

Because of the poor communication between the flight crew; the flaps were extended above maximim manuvering speed.

It also highlights some of the issues faced by maintenance personnel ever night around the world, Yes it is important that good communication is very important and in this example apparently failed. The fact that most aircraft maintenance, on in service commercial aircraft is preformed at night all these issue are compounded by fatigue, the maintenance staff are working when there bodies and the environment tell them they should be asleep.

Here is a brief introduction to how TCAS operates.

There are some obvious errors that can be observed in this incident. One of this being the PM retracts the landing gear right after the “Rotate” call, before checking the altimeter VSI for “Positive Climb” and hearing “Gear Up” command from Pilot Flying (PIC). The flight crew also recycled the landing gear without firstly, referring to the QRH. There was another critical procedure the flight crew had done wrong. The PM did not complete calling the ‘Red Light Illuminated With Landing Gear Handle Up’ procedure, but had continued with the unrelated ‘Unable To Raise Landing Gear Handle After Takeoff’ checklist.

These errors can lead to many underlying threats. These include the PM not complying with Standard Operating Procedures (SOPs), the damage of the gear door upon impact with the runway, the tire burst condition after takeoff, the wrong QRH initiated, as well as landing with the landing gear assembly damage and in a tire burst situation. These threats have the potential, when linked together, allow incidents to develop into disastrous accidents!

The two air- to- ground sensors of MD-90 to prevent gear retraction on the ground are mounted only in the nose gear. There will be no protection of early retract landing gear under the case like this. Mistake as to what the crew made in this case will cause serious impact to the flight safety, especially that gear door were open and brake was automatically applied for de-spin.

There are several lessons that can be learnt from this incident. Firstly, pilots should ensure that they have a full knowledge of the SOPs and QRH for their aircraft. In this case, according to the Flight Operations Manual (FOM), turns after takeoff should not normally be made below 400’ AGL, and it is recommended to turn at or above 400’ AGL. It is to be noted that even though the airlines hold regular proficiency training and checks for their pilots, it is still each pilots’ responsibility to ensure that they are, at all times, familiar with the QRH checklists.

Secondly, each crew should ensure that they have a full understanding of Flight Crew Training Manual (FCTM) Abnormal Operation. In this case, landing with ‘Abnormal Landing Gear Configuration’. Different aircraft may have slightly different concerns in handling situations like this. Therefore careful judgment must be exercised by the crew, with the consultation of the operations manual as to what the appropriate actions should be. Thirdly, Crew Resource Management (CRM) sessions for the flight crew should emphasise on areas such as crew coordination and workload management. Pilots can all learn from this incident. After all, as it is said “Try to learn from the mistakes of others. You won't live long enough to make all of them yourself”.

There are quite a lot that can be learnt from this incident. Firstly, the maintenance department should not have dispatched any aircraft when they cannot guarantee the safe operation of that particular aircraft, even under time pressure. Secondly, the crew should always consult the manual before accepting the aircraft for the flight. In this case, the crew did not take the required measures to break the chain of errors at the beginning and then failed to insist that proper corrective action be taken by maintenance. Instead, they were rushed and accepted the response from maintenance and remained silent. Thirdly, more training on the pressurisation system would be beneficial. If the crew had full knowledge of the system and could understand what the ‘could not be operated’ statement really meant on the operations manual, then the required action after the detection of the fault could have been done correctly. Fourthly, always complete the QRH checklist first before making any decisions. Here when the warning sounded, QRH was not followed before the crews’ decision to dump fuel.

As is often the case, there was a lengthy error chain in this incident as can be identified by using the Reason’s Model. These include the upper strategic management department to not properly manage available resources, and the line management who had not implemented procedures for the safe dispatch of an aircraft. Together these create an unsafe precondition for when the aircraft was dispatched. The unsafe act of the crew when signing the maintenance log led to the productive failure of not breaking the error chains before the flight, hence this incident. Luckily, the last barrier in the crew coming to realisation of the problem prevented this incident from developing into a disastrous accident.

From the Crew Resource Management (CRM) point of view, there are also many lessons that can be learnt. How to manage threat under time pressure should be more emphasised. This includes both the crew and maintenance. The crew to comply with the policy of confirming the desirable configuration for signing the maintenance log for the dispatch of an aircraft, and the maintenance department for its correct compliance. The threat management should also include effective workload management and teamwork management. Threat management requires that the threat be identified, then assigned a level of risk, and lastly to allow decisions to be made to minimise or eliminate the threat. Acceptance of an undesired state and ‘hoping that things will work out’ is choosing to ignore the threat.

Communication is also crucial in aviation. CRM should help to build an environment where message is not only communicated, but communicated effectively and clearly. In this case, between the crew and the maintenance department. Also, communication within the crew should encourage everyone to have a say, not just allow the PIC to make his decision. In abnormal situations it is critical that every crew member thinks and speaks if deferring to the PIC. A team can only function at its optimal strength when every crew member shares their opinions and knowledge.

This incident allows us to learn a lot from both the operational perspective, as well as from the Human Factor perspective.

Also, another useful skill for pilots is the ‘VVM Skill’. Pilots are encouraged to Verbalise, Verify, and Monitor. Using the above incident as an example, the flight crew should Verbalise what they intend to do, Verify that the speed and altitude is appropriate and Monitor that the flaps actually travel to the desired position.

During the flight, Pilot In Command (PIC) is Pilot Monitoring (PM) and the Senior First Officer (SFO) is Pilot Flying (PF). The weather report at their destination was low ceiling with low air temperature. Air Traffic in the area is light. During the arrival phase of the flight, the flight was cleared to their destination via a particular arrival and to cross this reporting point at 250 knots and descend and maintain 11,000 feet. Meanwhile the Air Traffic Control (ATC) advised that a new ATIS is available. So, the other flight crew not flying was monitoring the new ATIS. During descent, the flight is on the correct profile and the indicated speed was around 285-289 knots and decelerating. However, the deceleration rate was not as quick as expected. At about 14,000, the PF commanded “Flaps 1”and at the same time, a change of ATC frequency was instructed. Due to fatigue and distraction, the PM interpreted the speed incorrectly and selected flaps to 1. As soon as the flap speed warning was triggered, the PM realised the mistake and immediately advised the PF to reduce speed. Unfortunately, the flaps did partially extend above flap limit speed. After arrival all required reports were submitted. Then, the engineer was briefed by the PIC about the flaps extension above the limit speed.

ATC gave a speed reduction instruction. PF thought the speed was below Flap Up
Manoeuvring Speed, and he commanded flaps one without checking flap extension limit speed. At the same time, PM was busy with ATC communication and failed to check the speed prior to selecting the flaps; the pilot at the back not flying was focusing on updating the ATIS and also failed to detect the flaps extension were exceeding the speed limit. The flaps limit speed exceedence was correctly filed into the maintenance log after landing.

There are various contribution factors to this incident. Misconception on the utilisation of the Flaps is one of the contributing factors. Flaps are designed to be used as lift devices and are normally deployed close to minimum manoeuvring speed when the airplane has to be slowed down for the approach. Speed brakes should be used to dissipate airspeed and lose altitude rather than flaps. In addition, poor quality of monitoring of the flight crew can be seen in this incident. The PF made the initial error, but the PM has not provided sufficient support to keep the PF out of trouble. The role of PM is equally important to the role of PF, and that includes monitoring by the pilot not flying (flight crew member 3- sitting at the back seat) as well.

Workload in the cockpit is usually high during the approach and landing phases of each flight. In this incident, everyone in the cockpit was busy with descent profile execution, talking with ATC, listening to the ATIS and other required tasks. However, under these types of situations, the flight crew is required to exercise multi-tasking skill to centralise their attentions on the primary task, ‘Aircraft Flight Path and Configuration Control’, even while their divided attentions are on other secondary tasks, such as talking to ATC and copying ATIS. It is essential to maintain vigilance, prioritises tasks one at a time and keeps everyone in the loop during the critical phase of the flight. Good Crew Resource Management (CRM) skills would have prevented this unnecessary event from happening. Fatigue is also measured to be a possible contributor factor of the event other than crew’s negligence and careless.

Climb and descent are the flight phases that are the most challenging for the PM. Although there are designated pilot flying and pilot monitoring, all the crew on the flight deck have to participate in monitoring. Around 70% of monitoring errors occur when the flight is not at cruise altitude. To trap errors, pilots develop techniques to reduce the chance of an error occurring. These are vital to maintaining a safe operation. The ability to effectively monitor can be influenced by factors such as fatigue. The crew should be aware that fatigue will affect their performance and take steps to reduce the effect by paying extra attention to error trapping. In conclusion, utilising the speed brake as they were designed to be used, better workload management and proper monitoring skill application could have prevented this event. Let as all learn from mistakes!

During ground preparation, Tower asked flight crew what’s their maximum altitude when they requested for Air Traffic Control (ATC) clearance. They replied the maximum altitude they can take is FL320. Before takeoff, flight crew informed tower again the maximum altitude they can take was FL320; however, tower did not say anything and cleared the aircraft for takeoff.

After passing 5000 feet, the controller made a check with the aircraft if the maximum altitude for them was FL320. The flight crew answered that they could reach flight level 320 around a particular reporting point. While passing FL150, the controller relayed information from another Control (which the aircraft must contact next) saying that they must cross this particular FIR boundary at FL330. Flight crew of the aircraft immediately replied that they could not reach the requirement due to performance. Also, they started to negotiate with the controller if there were any options they can take to carry on the journey and to question controller what was the reason behind the ATC requirement. The ATC controller did not give the reason behind the ATC requirement or allowed the aircraft to continue their journey. All the lower altitude requests from the aircraft were denied by ATC. For these uncertain factors, flight crew of the aircraft decided to return to their departure airport.

The First Officer (FO) was the Pilot Flying (PF) in this sector. He continued to act as PF while the Pilot In Command (PIC) was busy setting up the approach, comforting the passengers and thinking about what to do on the ground. They did mention to each other the issue of an over-weight landing problem; however, they forgot to verify again the landing weight before the approach and ended up landed at 4 tones over maximum landing weight. The flight crew failed to log the correct entry into aircraft logbook nor seek maintenance for an inspection of the aircraft structure.

The underlying threat that initially led to the occurrence of this incident was the blockage of the airspace for an unknown reason. From then the flight crew was under high workload in preparation of the aircraft for landing. The flight crew forgot to plan to consume more fuel to reduce landing weight. Landing above the maximum landing weight can be a serious threat to aircraft. It has the potential to cause structural damage and more severely, structure failure, as well as the possibility to overrun the runway. The flight crew missed to verify again the landing weight before final approach which would have allowed the flight crew to trap the error, and avoid an overweight landing.

Due to the fact that there is no fuel-jettison system in MD90, descent planning and the way to consume more fuel during air return at a heavy weight are always issues for flight crews. An overweight landing may only be performed under the following circumstances. Firstly, during any condition, or combinations of conditions, mechanical or otherwise, where an immediate landing would reduce the potential for additional problems that may compromise safety. Secondly, during situations when the serious illness of crew or passenger require immediate medical attention. In the event of an overweight landing, landing performance and performance requirements for a possible missed approach shall always be considered by the flight crew before the approach.

To think and to plan ahead in such of air return event is important to flight crew. Assess the situation, if condition is not that urgent for overweight landing, flight crew should have the knowledge of how to increase the fuel burn by ways such as configuring the aircraft to increase fuel burn and to fly extra holding pattern if required. In the case of unavoidable overweight landing condition, flight crew should be aware of the gear load limit, landing performance and missed approach climb gradient.

There are also various Crew Resource Management (CRM) considerations associated with this event. This event involves CRM issues of communication and workload management. Communication is the process of sending a message and having it received as one intended. Many factors can affect how well (or not) this works. More at fault is ATC’s failure to explain the reason behind the request for a maximum altitude. Had ATC been better communicators the problem of the altitude could have been resolved before a takeoff was made.

Workload management is the skill of balancing the required tasks with the time available. If there is little time available during ab- normal situations, then some tasks can be left undone with only critical actions taken to ensure a safe result. If more time is required, the flight crew should by all means take the appropriate actions to increase it, such as entering a hold. Another point to note, and have been discussed widely, is the ‘get home –itis’. This is where a crew accepts a bad situation of weather or aircraft mechanical status because they simply want to get home. Although today airlines require their operations to be cost effective and efficient, pilots should not forget their primary task when operating the aircraft- safety should always come first!

The weather on the day was very fine with light winds and high clouds. As this aircraft approach its destination, the flight crew requested a visual approach as soon as they switched to Approach Control in order to save time and fuel. With the airport and the preceding traffic insight at all times, the aircraft was cleared to descend to 2000 ft. Suddenly, their descent was stopped at 4000 ft because of another traffic coming from the north for a straight in approach. Anticipating that Air Traffic Control (ATC) might give them a sudden clearance to turn base, the flight crew configured the aircraft for landing at that moment.

At 4000 ft the aircraft had gears down and landing flaps, as the flight crew had anticipated, Approach Control asked them if they still had the preceding traffic insight and that there was another aircraft in sequence to follow them. The flight crew responded, "affirmative". Then this aircraft was cleared for the visual approach and initiated a descent maintaining VFE (-10kts) in order to lose altitude with speedbrakes extended and landing configuration set. The speedbrakes were stowed at around 1500 ft with a speed of approximately 170 kts. The aircraft’s profile was high at about 1,500ft at 3.1 nm to touchdown. At 1000 ft, descent rate was still high but decreasing, and the speed was slowing coming back to the normal approach speed. The flight crew decided to continue the approach and landed.

In this event, the aircraft was still above 5,000 feet while it was abeam landing runway. The flight crew chose to accept the visual approach in improper condition. Then disturbance arises from ATC, the aircraft was cleared to 2000 ft originally but it was revised to 4000 ft then, the descent profile was disturbed, when the aircraft was turning base leg, the flight crew was prompted by ATC to accept the visual approach. The flight crew accepted it and set up the landing configuration immediately. The aircraft did not get sufficient descent rate on base leg while they were setting the landing configuration. The aircraft passed about 1,500 ft on final where it was only 3.1 nm to touchdown.

Although this may seem like a simple incident with no harm done to the aircraft or its passengers, there are many threats and errors that can be identified. Fine weather with light winds and high clouds can often cause the flight crew to become over relaxed or confident. This is an underlying threat and can often affect flight crew’s judgment. The flight crew misjudged the situation and made the error of requesting a visual approach in improper condition. Also, another threat arises when the flight crew was prompted by ATC to accept the visual approach. The flight crew had disordered the priorities between safety and economy, and chose economy over safety. High rate of descent and high approach speeds, as well as failing to execute a go- around when the profile of the aircraft was obviously high on finals were also errors committed by the flight crew.

The Pilot In Command (PIC) as Pilot Flying (PF) misjudged the situation, and the Senior First officer as Pilot Monitoring (PM) did not advise PF positively when he doubted that the stable approach could be done. It cannot be emphasised enough just how important crew coordination is. When an ab- normal situation is encountered, do not hesitate to raise questions about it. Do not allow misjudgement or overconfidence lead the aircraft into an undesired state. If things are not right, say “NO” to ATC. Pilots should learn to trap the errors as early as possible. Apply a sound judgment and follow the stable approach requirement are essential practice to maintain safe operations.

A visual approach is an occasional manoeuvre during daily aircraft operations, every time when elected to perform a visual approach, the threat level arises and the thoroughly approach briefing, including what situation the approach must be abandoned is required before the visual approach initiated. Using an available approach aid during a visual approach is also encouraged. It can’t be overemphasised if at any time during an approach there is doubt that any element of the stable approach can be achieved or maintained, the approach should be discontinued. Any struggling manoeuvre below one thousand feet is unnecessary and it will jeopardise the flight safety.

Here are also some Crew Resource Management (CRM) considerations associated with this incident. How to operate the flight in economic way is a hot issue in high oil price today. Performing the visual approach is one of the options to save fuel, but the increase in threat level and work load needs to be carefully considered by the flight crew before such procedure is carried out. It is important that flight crew carry out the good skills of Threat/ Error Management and crew coordination to cope with the undesired situation. The autopilot will be disconnected somewhere during the visual approach, after that the PM should assist in enhancing crew cooperation and situation awareness by sharing the information early enough to avoid further undesired aircraft status. The PIC as PF, in this case, should maintain clear mind and be ready to make a sound decision at any time during the approach as required, such as initiating a go around. It can often be tough to make the correct decision in good weather conditions as it would seem like that there is no reason to abandon the visual approach. However, to ensure that every flight is a safe operation, make sound judgments and, if there is any doubt, don’t be hesitated to abandon the approach as safety should always come first!

The flight commenced pushback on time. After both engines were started, the Pilot In Command (PIC) instructed ground crew to disconnect the tow bar and to give hand signals at aircraft’s right side. Subsequently, ground crew did not acknowledge flight crew’s instructions instead the flight crew heard a bang and felt the aircraft shake. The PIC suspected ground crew was having difficulty removing the tow bar. After several attempts, the ground crew was still unable to do so. As a result, ground crew informed PIC that they were going to pull the aircraft forward and requested to have parking brake released. The flight crew realised that the ground crew would like to adjust the angle between the aircraft and the tow bar. However, it is very risky for the ground crew to pull the aircraft forward with engines running. The PIC confirmed the parking brake was released and he then briefed his flight crew the threats due to the decision made by the ground crew of pulling the aircraft forward with engines running.

Not long after, the flight crew heard screams and cries through the interphone while the aircraft was still being pulled forward. Immediately the ground crew person on the headset advised PIC to set the parking brake, and during a short period of time thereafter, the ground staff repeatedly asked the PIC to release and set the parking brake several times. The ground crew became momentarily unavailable and it was not clear to the flight crew as to what exactly was happening.

The flight crew was not informed of the seriousness of the accident a while later. Eventually, the ground crew explained that the ground engineer had been injured. Once the PIC became aware of the incident, he immediately tried to calm the ground crew while trying to assist by following their instructions closely, including the shutting down of the engines. The flight crew was informed by ground staff that the injured ground engineer was trapped under the nosewheel! As the flight crew dealt with the situation, an airport emergency squad arrived and assisted and gave medical attention to the injured ground engineer. Finally, he was removed from the scene, and the aircraft was towed back to the gate.

After parking at the gate and making the appropriate passenger announcement (PA) to the passengers, the flight crew contacted their operation base. All of the staff at base gave the flight crew valuable assistance to help them coordinate the entire situation on the ground. Also, as requested by the flight crew, local maintenance personnel had saved the Cockpit Voice Recorder (CVR) data. The head ground staff also gave the flight crew professional advice and his perspectives on how best to handle this very regrettable occurrence. One of the recommendations from base was that as a precaution the flight crew should take an alcohol test. The flight crew proceeded to complete all required reports. A local Airport Police Officer came to the aircraft to take a statement from the PIC. The PIC requested if the flight crew could take an alcohol test, but the flight crew was told that it was not necessary and that there was no restriction for the flight crew to continue their flight back to base. After the PIC had a discussion with their flight crew regarding their physical, emotional and mental state, all members agreed that they were fit and well to continue the flight. The flight proceeded normally back to home base.

There are various threats that can be identified in this incident. Firstly, the flight was scheduled to depart at night. Ramp operations at night can often be difficult. Secondly, at the airport where this incident occurred, ground handling device/ equipment is not up to date. Thirdly, pulling the aircraft forward with its engines running is the most crucial threat which led to this accident.

Flight crew’s actions were not a contributing factor in this very unfortunate accident. They followed Standard Operating Procedures (SOPs) closely and were very supportive in trying to help the situation on the ground. One threat that is always present but not always identified is the schedule time pressure threat. If us pilots always keep this in mind and take deliberate actions to avoid falling into the “comply with the schedule” trap we may be able to prevent errors caused by short cuts or bypassing of procedures. A long term threat that might affect, not only the flight crew of this flight, but all personal associated is the latent emotional and psychological threat. All individuals involved will be deeply impacted by the severe consequences suffered by the ground engineer. It is recommended that flight crews and associated individuals have some form of therapy following accidents. Thus, learning from accidents and work toward helping to prevent similar accidents from happening again

The case itself was prudently managed by the PIC and his flight crew. They used their best knowledge of Crew Resource Management (CRM) to coordinate and cooperate as a team to manage the challenges and consequences that followed the event. The flight crew was aware of the latent risk of aircraft movement, but assumed that the ground crew should have been aware of the risk too. The flight crew will normally assume that staff involved with aircraft operations have been properly trained and checked as being competent. However, a reminder to the ground crew might have avoided this unfortunate accident. Efficient communication between the flight crew and all ground crew working around them is crucial for the safe operation of the aircraft.

This sad event shows why airport ramp areas are one of the most dangerous industrial workplace environments. While there are CRM issues with this case, they do not lie with the flight crew. An interesting point to note was the flight crew’s decision to continue as the operating flight crew. It raises the question: How bad does an event have to be before the involving flight crew decides that they will not be able to operate safely? Recognising and admit when one have exceeded their emotional limit is crucial for the safe operation of aircraft. Taking advice from the station staff or the daily counter should be treated carefully as they have other influences that could bias flight crews’ decision making. The duty pilot back at base is also a useful resource to consult with for any abnormal situations.

Murphy’s law is always the golden rule in aviation safety: “If anything can go wrong, it will.” It is also cited as, “if there is more than one possible outcome of a job or task, and one of those outcomes will result in disaster or an undesirable consequence, then somebody will do it that way.” Flight crew should be on alert during all phases of aircraft operation, and should always be prepared for the worst!

This Boeing 777 flight was on its way to its international destination. Senior First Officer was the Pilot Flying (PF) at the left seat relieving Pilot in Command (PIC), and First Officer (FO) was acting as Pilot Monitoring (PM). Cruise altitude was FL350.

Along the track there was a huge weather build-up. About 40 nautical miles prior to the weather, the crew initiated a slight turn to the left for avoidance purposes. At the same time a Controller Pilot Data Link Communications (CPDLC) message was sent to Air Traffic Control (ATC) requesting 30 nautical mile deviation to the left. ATC replied, “UNABLE DUE TO TRAFFIC, RIGHT SIDE AVAILABLE, SAY INTENTIONS”.

However, the flight crew had initiated their turn to the left prior to receiving ATC clearance! The aircraft was coming closer to its conflicting traffic! The flight crew immediately requested climb to FL355 with left 30 nautical mile deviation. ATC replied “IF YOU NEED LEFT SIDE, NEED ALTITUDE CHANGE FL340, REQUEST INTENTIONS”. The flight crew ‘accepted’ the message and started descent to FL340. However, this message was not an ATC clearance, it was only an ATC suggestion! The flight crew had mistaken it to be an ATC clearance!! Upon reaching FL 340, the flight crew sent a CPDLC position report to ATC indicating their flight level. ATC replied “CONFIRM FLIGHT LEVEL”, as ATC was not aware of the flight crew’s descent. The flight crew re- sent another text message confirming FL340. Luckily the aircraft had not come into close contact with any other traffic! The flight crew did not realise their violation with ATC, and subsequently, did not notify the PIC when he returned for duty.

There are various threats associated with this incident. Firstly, poor weather conditions and weather build- ups may be dangerous for flight operations. Actions must be taken by the flight crew to avoid poor/ dangerous weather at all times. Secondly, the conflicting traffic is also a very serious threat which may lead to near miss or accidents. The Regulations state that the pilots should always adhere to the flight plan route unless otherwise requested and a clearance has been obtained to deviate from flight plan track. Thirdly, communication with ATC had not been well established. The request for deviation should have been made by the flight crew prior to track deviation.

There are also various errors committed by the flight crew. The flight crew should have obtained the deviation clearance earlier, prior to the turn. The flight crew initiated their turn to deviate from cleared flight route without ATC clearance. In addition, the flight crew had also misinterpreted ATC suggestion as ATC clearance. There are also oceanic contingency procedures for weather deviations when a clearance cannot be obtained. The flight crew was obviously unaware of its existence. Also, the PIC was not aware of this incident until when the aircraft arrived at its destination. The PIC was unaware of the state of the aircraft is not desirable during flight operations.

Highly experienced Senior First Officer paired with a First Officer (FO) with a little over a year of line experience. PIC was not present in the flight deck. Misunderstanding of
CPDLC messages sent by ATC, and non compliance with established procedures led to the ATC deviations. The flight crew acknowledges the threat of the approaching severe weather and the need to take appropriate measures to avoid it. However, the flight crew did not follow the established weather deviation procedures stated in the manual, which would have given clear instructions on how to handle a weather deviation without prior ATC clearance. It is crucial for flight crew to remain familiar with the instructions there stated and follow them closely as required. Prior to entering any specific region, good airmanship calls for a review of applicable contingency and weather deviation procedures which might be needed to assure flight safety.

The flight crew took an ATC message offering an alternative for approving the deviation, as a clearance, even though the message was only advisory in nature and ended with the “say intentions” interrogative/request. The threat of the impending weather and high workload at the time may have distracted the crew from reading and interpreting the ATC message correctly. The latent operational threat posed by the use of CPDLC for ATC communications cannot be overstated. Flight crew can minimise errors by recognising that although CPDLC is an efficient, expeditious and generally a safe system, human interaction is still required for its operation and thus prone to errors. Hence, verification and confirmation of the exact meaning of all CPDLC messages by the crew is of the utmost importance. If in doubt, request confirmation by any means available prior to deviating from the current clearance.

Furthermore, operating in an ATC environment where only long range communication systems are available, (i.e. HF, SATCOM, DATA LINK, etc.) poses the additional threat of a possible time delay when sending and receiving messages versus normal VHF voice communications. Multi-scan radars have weather detection capabilities up to a distance of 320 nautical miles. With adequate monitoring, the decision making process can, and therefore, must begin early to allow sufficient time to receive the necessary ATC clearance.

Another point to consider is, the PIC was not present in the flight deck when this event took place and was unaware that an ATC violation had occurred, (so was the operating flight crew at the time). This is an important lesson for commercial pilots that, at handover a thorough briefing of not only of the current conditions should be made, but also a review and analysis of previous clearances/messages might help to detect and possibly correct an existing error, or might help give light to one that may have occurred earlier during the flight. This would give the PIC crucial information that may be used to file a report if he deems necessary. With a thorough briefing using good communication skills, then the PIC may have noticed that an ATC violation had occurred. One way to improve in this area is by de-briefings. At the end of all flights the crew, led by the PIC, should review the flight. This can allow all pilots involved to learn from their mistakes! In addition, this will also allow those pilots not involved, but have heard about the incident to learn from other people’s mistakes.