Perimeter Sanny accident report

[pelmet]

A department of highly trained and experienced professional accident investigators spent a very long time meticulously dissecting every aspect of the circumstances leading up to this accident. These investigators are specialists in every applicable field including operations and human factors who no doubt spent hours and hours exhaustively interviewing the crew. This team of experts spent months more compiling their findings in an extremely detailed and thorough report.

But you, pelmet, disagree with their findings.

Makes one wonder why we even have a TSB....

There is no shortage of reports over which there have been disagreements. It is not unusual for a safety board from a foreign country to place their conflicting view in the addendum to a report and on occasion, safety boards from differing countries have put out separate reports on the same accident with completely conflicting views. We even had in Canada a previous safety board split and put out two reports on the same accident(Arrow Air DC-8).

It should not come as a surprise to you Rockie that disagreements with findings happen even between the so-called experts.

There has been a lot of, shall we say, interesting ideas put forth on this accident. I disagree with some of them and have given the reasoning behind my opinions. I leave it to others to look at both sides of the arguments and come to their own conclusion instead of blind agreement with the conclusions of a safety board or poster on this forum.

As a final note on something that I feel is important. I mentioned that one poster had suggested holding until minimum fuel in hope that the weather would improve in this situation with no viable alternate. This was done by the crew of the 757 in the Antarctic(link to incident report on first page) that found themselves without an alternate and had just missed the approach when it was 300 overcast and good vis underneath. They held for a full two hours burning fuel. After all, they wanted to ensure everything was done legally. When they finally decided that they better start really trying to get in. It was a quarter mile in fog when they landed after barely making it in with enough fuel for one more approach. I can see potentially waiting if it is already super low weather and you have some fuel for waiting, but when it is half decent, get in while you can in such a scenario.

Thanks for the opinions.

[Rockie]

There is no shortage of reports over which there have been disagreements. It is not unusual for a safety board from a foreign country to place their conflicting view in the addendum to a report and on occasion, safety boards from differing countries have put out separate reports on the same accident with completely conflicting views.

Yes, there are on occasion differing political views on what happened between countries, religious objections, interference from people uninvolved in the actual investigation and of course straight up conspiracy theories. Most of these are given room to exist because of a lack of direct verifiable facts, and in some cases despite those facts.

In the case of Arrow Air in Gander, it was a dissenting "minority report" and not the official report. The official report states the airframe most likely iced up on the approach and on the ground in freezing precip and took off again without de-icing. Eye witness reports are consistent with that. Dissenting opinion on the board claims it may have been a bomb of some kind given the nature of the flight and the fact a Jihadist group claimed responsibility. But again, the FDR was rudimentary at best only recording 4 parameters, the CVR was non-functional and none of the crew survived. In other words a distinct lack of verifiable information.

The Perimeter accident we're talking about suffered no such ambiguity. It took place in Canada with no dissenting opinion (other than yours), and both pilots were happily alive to give their testimony which was backed up by recorders.

I'm confused why you think your theories are more valid than the TSB's official findings?

Note: I was unaware of the RNZAF B757 incident, but on reading about it, it's obvious this crew was extremely prepared and knowledgeable about every aspect of the landing they were conducting. I would not presume to second guess their decision making.

[pelmet]

Note: I was unaware of the RNZAF B757 incident, but on reading about it, it's obvious this crew was extremely prepared and knowledgeable about every aspect of the landing they were conducting. I would not presume to second guess their decision making.

Actually, I question the decisions a couple of fronts, one of which I mentioned earlier and another was the decision to leave in the first place on a flight with no planned alternate and the weather forecast they had at departure time and up to the point of no return. If you are happy with their decision-making, well all I can say is....interesting.

A department of highly trained and experienced professional accident investigators spent a very long time meticulously dissecting every aspect of the circumstances leading up to this accident. These investigators are specialists in every applicable field including operations and human factors who no doubt spent hours and hours exhaustively interviewing the crew. This team of experts spent months more compiling their findings in an extremely detailed and thorough report.

But you, pelmet, disagree with their findings.

I'm confused why you think your theories are more valid than the TSB's official findings?.

I have already given my reasoning in previous posts. Obviously you agree 100% with the report and have given your reasoning in previous post which I have quoted(which I take to mean that you automatically always agree 100% with every report). That is fine and I have no doubt that you are as convinced about your opinion just as you are about the statements you made in earlier posts.

Thanks for taking the time to respond.

[Rockie]

I'm wondering if you've read the RNZAF report. There are aspects to it you either don't know about or simply reject as if you knew better than they did. Believe me...you don't.

And you're right, I always accept the results of credible reports such as the TSB one on Perimeter. I do so knowing they have thoroughly investigated it and I haven't, and they have done so with all kinds of expertise I don't possess. A circumstance you should consider.

[pelmet]

I'm wondering if you've read the RNZAF report. There are aspects to it you either don't know about or simply reject as if you knew better than they did. Believe me...you don't.

And you're right, I always accept the results of credible reports such as the TSB one on Perimeter. I do so knowing they have thoroughly investigated it and I haven't, and they have done so with all kinds of expertise I don't possess. A circumstance you should consider.

Thanks Rockie,

Admittedly, I was the one who brought up the NZ thing as there is a relationship with both reports stating that they were both caught with no alternates and how it was dealt with. However, as this is a Perimeter YSK accident thread, I prefer to refrain from changing the whole subject to focus on a different incident. Feel free to start a new thread if you like.

And please feel free on that thread to actually detail what you feel that I don't know about or reject.

As requested, I will consider your other comments and opinions in your last post.

[pelmet]

They could have reached YGL by using some of their reserve fuel, which is what it's there for; their legal alternate crapped out after they took off, and they were under no obligation to land with 45 minutes of usable fuel remaining. I've run into a surprising number of pilots who think that reserve is untouchable, but this is precisely the situation for which it's intended.

I was finally able to get YGL approach plates today.

While I agree that reserve fuel is there to be used in an emergency, you better be careful. In this case, just diverting to YGL and going into your reserve fuel you better know how much are you going to have left when you reach YGL? Let's say you use 20 minutes of reserve fuel to get to YGL. That leaves you with 25 minutes of fuel left. How accurate are those fuel gauges on the old Metro?

Meanwhile, at 1.5miles YGL vis is at published minimums for the RNAV approach(unless they had LPV VNAV installed which I doubt). The forecast for their alternate of YGW crapped out and went to one-half mile. What is to say that YGL which is affected by the same weather system won't do the same when you get there. And then your 25 minutes of fuel left until dry tanks(if the gauges are working properly) will get even lower as you have to set yourself up for an approach.

So now you have barely any fuel left, perhaps enough fuel for a second approach, and no better approach lighting than YSK where you could have been working on getting in on stabilized approach attempts for the last hour. The only thing that YGL has that is better is a longer runway.

When your destination weather has allowed you to see the runway, be very careful about diverting to an alternate that only has non-precision approaches combined with poor weather when you will arrive with nearly empty tanks . And remember, you may encounter unanticipated winds enroute.

[Old fella]

Arrow Air 1985 - I remember that one. wasn't there issues on mis-calculated weights, reduction in thrust on an outboard engine(wasn't a failure but reduced thrust due maintenance on the older engine), incorrect posted reference speeds because of the wrong calculations on onboard weights(troops for the most part are big boys and their gear). Put that up against the possibility of the very thin layer(s) of frost/ice and or cold soaked wing- conditions were there for it, certainly was possible for an unrecoverable stall..............

As for the convenience of a bomb going off that a very precise time, well leave that to those who attend movies and watch television and are into conspiracy theory novels.........

[rigpiggy]

TC is looking at an npa requiring infants to be in child seats. One thing that bothered me was not approving kelty packs or equivalent to restrain the child

[ninjacrumb]

One thing I noticed in this report was that there was a lot of discussion of Human Factors and the role in the crash. One Human Factor not discussed was the length of the flight itself.

As a 15000 hour pilot I can tell you length of flight plays a big part in a pilot's decision making, and the pilot may not be aware of it. Sitting in an airplane for 3 hours, especially a buzzing Metro is uncomfortable for everyone. Your butt is sore, you're tired and probably have to take a long pee, and as the pilot you're aware that the passengers feel the same way.

Why did this crew attempt a second approach, one with a tail wind which I bet dime to dollar if it wasn't a long flight they wouldn't have done.

A 30 minute to one hour flight doesn't have the same "feel". If you miss you go to your alternate, stretch your legs and take a nice pee. Missing on a 3 hour flight however means you have to fly even longer, take the people to an airport they don't want to be at. Wait for the weather to improve, then go back. Or stay in a completely foreign to the pilot town and baby sit your passengers. This is a very real Human Factor.

I thought about this Human Factor a few years ago when Air France went off the runway in YYZ while landing in a thunder storm. Why would the crew continue into a thunder storm? They wanted the flight to be done. 10 minutes of stress in a 6 hour flight was tolerable.

For the Baffin Islanders, answer honestly. Is flying to YIO and missing the same as missing in Pang? Especially if YFB is your alternate and you're in a plane with no lav. I don't think they're the same. If I missed in YIO and had to fly back to YFB my cockpit would probably have 21.5 expletives per hour also.

To the TSB Investigators if you're reading this, nice report thorough job however I personally feel this should have been looked at also as I feel this is a very real Human Factor.

[pelmet]

I suppose out of the tens of thousands of pilots flying everyday, there could be some pilots where this could be a factor. This is where professionalism comes into play.

But remember, if you are paid by the hour, perhaps in some minds, a further alternate is a good thing. Various scenarios can come into play for various situations.