Air Canada Rouge EGPWS warning at Huatulco

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CL-Skadoo!
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Air Canada Rouge EGPWS warning at Huatulco

#1 Post by CL-Skadoo! » Fri Feb 09, 2018 8:47 am

Good event to keep everyone on their toes. Listen to the magic box.
Incident: Canada Rouge B763 near Huatulco on Jan 29th 2018, EGPWS terrain warning prevents CFIT

By Simon Hradecky, created Wednesday, Feb 7th 2018 21:15Z, last updated Wednesday, Feb 7th 2018 21:38Z
An Air Canada Rouge Boeing 767-300, registration C-GHLU performing flight RV-1893 from Calgary,AB (Canada) to Huatulco (Mexico) with 250 passengers and 9 crew, was in level flight at 16,000 feet about 33nm north of Huatulco in non-radar environment, when air traffic control cleared the flight to descend to 6000 feet MSL at pilot's discretion. About 30nm north of the aerodrome the crew initiated the descent, about a minute later at 11,800 feet MSL the crew received an EGPWS "Caution Terrain" aural warning. The crew climbed the aircraft back to 13,500 feet MSL and continued to Huatulco before commencing the descent and landing safely.

The Canadian TSB reported Mexico's DGAC rated the occurrence a serious incident and opened an investigation.

According to approach plates for Huatulco the minimum safe altitude north of the aerodrome is 13,400 feet. Terrain is rising up to 3600 meters/11808 feet about 24nm north of the aerodrome.

https://flightaware.com/live/flight/ROU ... /CYYC/MMBT

Metars:
MMBT 300145Z 00000KT 7SM BKN210 26/// A2981 RMK 8/001=
MMBT 300045Z 00000KT 7SM BKN210 27/// A2980 RMK 8/001=
MMBT 292345Z 00000KT 7SM FEW040 SCT170 BKN210 29/// A2977 RMK 8/431=
MMBT 292245Z 20010KT 7SM FEW040 SCT170 BKN210 30/// A2975 RMK 8/431=
MMBT 292045Z 22010T 7SM SCT040 BKN210 31/// A2978 RMK 8/401=
Image
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Re: Air Canada Rouge EGPWS warning at Huatulco

#2 Post by Gilles Hudicourt » Fri Feb 09, 2018 10:32 am

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Re: Air Canada Rouge EGPWS warning at Huatulco

#3 Post by pelmet » Fri Feb 09, 2018 2:51 pm

Interesting. I wonder if they were on an airway or some sort of route with a minimum altitude.

The weather does look good at the airport and it appears to be daytime. It is possible that they could see hills and knew they would be clear but got a caution for being a bit too close. Or there could have been clouds over the mountains. The news report does say the TSB considers it a serious occurrence though.

I wonder if AC 767 have a terrain function mode which would seem obvious to have displayed in an airport like this on descent. If so, do they have any SOP on displaying the terrain on one of the displays. I'm sure Altiplano can let us know beyond another "good job done" statement.

There is a thread on Pprune about a EGPWS save down in the US recently where the controller cleared the aircraft to a lower altitude which was accidentally below the safe published altitude.

Looks like we may have had two major airline disasters by North American carriers prevented this year strictly because of EGPWS.

It can be a useful reminder in high terrain areas where radar vectors are not expected to emphasize that any altitude clearance on descent should be corroborated with charts to confirm that proper terrain clearance will be maintained. Obviously that applies to countries in the third world and elsewhere as well.

Things are pretty easy in the big airports with radar vectors and also in airports with no ATC where it is obvious that the pilots have to figure out the terrain for themselves. One can lower their guard when under ATC control but vectors are not being given.

https://www.pprune.org/rumours-news/604 ... regon.html
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Re: Air Canada Rouge EGPWS warning at Huatulco

#4 Post by 1000tolevel » Fri Feb 09, 2018 9:19 pm

I've flown into HUX over a dozen times, both on a heavy And a narrow-body, and I can attest that this arrival has its challenges. Especially for pilots who are used to fly mostly ILS in radar environment.

This particular flight was on UJ70/UJ39 via NUDOS and was cleared for the VOR DME 25 (most likely) and to descend PD (pilot's discretion) to 6000' which is the HUX VOR minimum crossing altitude for the approach. As Oscar mentioned below, Oaxaca AAP clearly states that they are non-radar before the descent clearance and the handoff to HUX Tower. And also that the descend must be done with reference to terrain. In this case, Airways MOCA (if on the airway) or Grid MORA (in both cases 14,200') must be respected until 25NM for the MSA (13,400'). Just like when cleared to descend via a STAR, the altitude restrictions must be respected regardless of the altitude cleared to.

Right after NUDOS (33 DME from HUX) the MOCA is 14,200' as indicated on the Enroute charts (not the approach plate). Then 25 DME from HUX, the approach plate shows a MSA of 13,400' for that sector (east of R-338°). So without any help from radar, the aircraft can not technically descend below 13,400 until the VOR, even thought the VOR MCA is 6,000'. One must do a shuttle-descent over the VOR from 13,400 down to an altitude from which to start the approach (8,000 is reasonable since there is 20 track miles to go to land). This is what makes it a very unusual arrival.

Now sometimes, ATC asks for DME to HUX (with double-confirmation) and clears down to a lower altitude (ex. @ 20 DME, CLRD to 9,000', etc...). Or if it is daytime and the mountains are visible, you can descend visually and cross the VOR at 6,000', or at night with a bright moon.

This serious incident is a perfect example of the "Swiss cheese" effect. And in this case the EGPWS was the last slice where the hole wasn't lined up. It did indeed save the day.

I guess Air Canada's powerful PR machine would've had a hard time to call this one a "Hard Landing" (see Halifax 2015).

As much as I hate to admit it, the pilots will have to shoulder the blame for this incident. In their defence, AC pilots are not used to non-precision approaches at night in mountainous terrain, let alone without radar. Not too long ago they refused to operate into places like PVR at night. And I'm pretty sure that the skipper for this flight was a Mainline Pilot who transferred to Rouge. I also think that there should be an airport specific company briefing package for the pilots to review before operating there for the first time.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#5 Post by FICU » Fri Feb 09, 2018 9:55 pm

Situational awareness is paramount flying south of the US!

Departing Panama city I had a controller try to vector us into rising terrain while IMC. We immediately questioned him and he apologized profusely.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#6 Post by pelmet » Fri Feb 09, 2018 9:58 pm

1000tolevel wrote:
Fri Feb 09, 2018 9:19 pm
I also think that there should be an airport specific company briefing package for the pilots to review before operating there for the first time.
Are you suggesting that AC does not have a briefing package/page for crews going into various airports. I am under the assumption that as an airline, they would have something like this. My company certainly does.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#7 Post by monkey » Fri Feb 09, 2018 10:18 pm

HUX can be "challenging" if your used to vectors onto the approach or star arrivals all day every day. Really it comes back to basic IFR flying, following sector altitudes along airways, minimum sector altitudes on approach charts until you arrive over the VOR to begin the approach. You might even have to shuttle down prior to beginning the approach. Still its pretty basic IFR stuff. Although not in the normal flying for North American Ops. This particular airline has had a bad string of incidents over the past few years. They seem to be very much trending towards a fatal event. Not sure whats changed so much at AC, maybe lack of experience or training?
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Re: Air Canada Rouge EGPWS warning at Huatulco

#8 Post by 1000tolevel » Fri Feb 09, 2018 10:26 pm

[quote]I wonder if AC 767 have a terrain function mode which would seem obvious to have displayed in an airport like this on descent. If so, do they have any SOP on displaying the terrain on one of the displays. I'm sure Altiplano can let us know beyond another "good job done" statement.
[/quote]

Doesn't matter if TERRAIN not displayed, it's a Pop-Up alert. It will appear along with any EGPWS alert. Having it displayed might prevent you from getting there though...
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Re: Air Canada Rouge EGPWS warning at Huatulco

#9 Post by pelmet » Sat Feb 10, 2018 2:59 am

1000tolevel wrote:
Fri Feb 09, 2018 10:26 pm
I wonder if AC 767 have a terrain function mode which would seem obvious to have displayed in an airport like this on descent. If so, do they have any SOP on displaying the terrain on one of the displays. I'm sure Altiplano can let us know beyond another "good job done" statement.
Doesn't matter if TERRAIN not displayed, it's a Pop-Up alert. It will appear along with any EGPWS alert. Having it displayed might prevent you from getting there though...
Your second sentence is exactly why I suggest that the terrain display be used if it is on board. It makes it obvious where the terrain is and likely will prevent a crew from just mindlessly starting the descent once cleared by ATC. It is also quite handy enroute in certain areas as well where the mountains are higher than expected and someone might just want to descend to 10,000' in the event of a depressurization event. Some people used to wonder why I would put the terrain display on at mountainous airports(one guy even pointed out a note that said "not to be used for navigation" statement as a reason why not to use it). Subsequently, we had a near CFIT, the company decided to suggest people use it for arrival/departure at mountainous airports and amazingly, lots of people display it now.

monkey wrote:
Fri Feb 09, 2018 10:18 pm
HUX can be "challenging" if your used to vectors onto the approach or star arrivals all day every day. Really it comes back to basic IFR flying, following sector altitudes along airways, minimum sector altitudes on approach charts until you arrive over the VOR to begin the approach. You might even have to shuttle down prior to beginning the approach. Still its pretty basic IFR stuff. Although not in the normal flying for North American Ops. This particular airline has had a bad string of incidents over the past few years. They seem to be very much trending towards a fatal event. Not sure whats changed so much at AC, maybe lack of experience or training?
Maybe, their hiring policies need review. It is very nice to require a degree in any subject even though it has nothing to do with aviation but that won't teach you how to prevent a CFIT. Nice questions about getting along with cabin crew feel good and can have a place but perhaps some interview questions such as....Tell me about what you do to ensure terrain clearance at busy and not so busy airports, what would you do if a generator light illuminated 15 knots below V1, how do you go about preventing yourself from landing at the wrong airport or wrong runway on a visual approach. Are you familiar with this particular well-known incident(example given) and what is the lesson you have learned from it.

Seeing as they don't even do a sim eval, at least getting an idea of whether someone takes extra time to go beyond reading the minimum required info can be useful.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#10 Post by Panama Jack » Sat Feb 10, 2018 5:05 am

pelmet wrote:
Sat Feb 10, 2018 2:59 am
Maybe, their hiring policies need review. It is very nice to require a degree in any subject even though it has nothing to do with aviation but that won't teach you how to prevent a CFIT. Nice questions about getting along with cabin crew feel good and can have a place but perhaps some interview questions such as....Tell me about what you do to ensure terrain clearance at busy and not so busy airports, what would you do if a generator light illuminated 15 knots below V1, how do you go about preventing yourself from landing at the wrong airport or wrong runway on a visual approach. Are you familiar with this particular well-known incident(example given) and what is the lesson you have learned from it.

Seeing as they don't even do a sim eval, at least getting an idea of whether someone takes extra time to go beyond reading the minimum required info can be useful.

Pelmet,

I am not an Air Canada guy so I don't have anyone I need to defend but what you are saying is B.S. and makes it sound like you have a chip on your shoulder. Having an instrument rating and instrument experience SHOULD teach you something about situational awareness vis-a-vis minimum IFR altitudes but how many guys have plowed into the side of mountains or trees who didn't have a degree? The issue here is training, a suitable aerodrome briefing from the operator of the particularities and hazards of an aerodrome, as well as an SMS program and safety culture that encourages hazard reporting and information sharing. Any pilot can screw something up really badly. I have known of very well qualified pilots who have landed at the wrong airport, and look at the Eastern guys who flew a perfectly serviceable airplane into the Everglades. One of KLM's Sky Gods plowed his 747 into another 747, and let's not even talk about the carnage in the Canadian bush.

These days most recurrent training sessions are so fixated on SOP's, aircraft system malfunctions, TCAS, EGPWS and windshear recoveries that basic IFR and airmanship atrophy. I don't blame the pilots for this loss, although yes, anybody who does hold an Instrument Rating should know better.

However, I have seen this topic come up a number of times about flying in Latin America and, in particular, Mexico, and it can catch out aviators who are more familiar with flying in radar environments. Like FICU I was once given an off airway "Direct To" clearance by a controller in Costa Rica whilst out of radar contact. A quick check of my chart indicated that there was a mountain ridge separating where we were and where we wanted to go at our altitude and I told the Captain that we needed a climb clearance for this to work out. Anybody remember the American Airlines 757 going into Cali? Around Mexico City, ATC has given traffic "descend and cleared direct to" clearances right into the side of volcanos (in the good old pre-GPWS days) and one now defunct airline would include such scenarios into their training programs (and on the simulator building wall, most pilots could read their names of amongst those who had "died" in the simulator). Fortunately, they had EGPWS and acted appropriately - EXACTLY AS TRAINED. Happy ending. Everyone survived. There will be an investigation. We will learn from this. And hopefully the lessons will help the aviation system improve.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#11 Post by Jim la Jungle » Sat Feb 10, 2018 6:59 am

So true:
These days most recurrent training sessions are so fixated on SOP's, aircraft system malfunctions, TCAS, EGPWS and windshear recoveries that basic IFR and airmanship atrophy. I don't blame the pilots for this loss, although yes, anybody who does hold an Instrument Rating should know better.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#12 Post by Axial Flow » Sat Feb 10, 2018 8:43 am

An iPad with Foreflight synthetic vision which I am sure the crew could afford would have saved the day before the EGPWS had to go into action. Unfortunate that airliners have less situational awareness than a Cirrus.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#13 Post by pelmet » Sat Feb 10, 2018 3:16 pm

Panama Jack wrote:
Sat Feb 10, 2018 5:05 am
The issue here is training, a suitable aerodrome briefing from the operator of the particularities and hazards of an aerodrome, as well as an SMS program and safety culture that encourages hazard reporting and information sharing.
If your excuse for flying into a mountain in a non-radar environment is that you were not properly trained by the airline, you shouldn't be flying at the airline in the first place. The airline cannot train for all the hazards that are out there of which there are so many. I suspect that AC does have an aerodrome briefing, does have an SMS program and does have a safety culture that encourages hazard reporting and information sharing. In fact, I guarantee you that they have the last two items and one can easily brief themselves on the first item by simply looking at the chart.

It seems with every incident that AC has, that the training department gets the blame instead of the guy flying the aircraft(part of the I'm not responsible for my own mistakes culture). The bottom line is....pilots need to do a lot of self-training(reading up on incidents and safety info, discussing incidents with other pilots, forums like this etc) instead of blaming everything on the training department.

There are plenty of good publications out there including a large number of accident reports and magazines with safety related material. Your next sim instructor isn't likely to cover it all in his limited available time just to meet the regulatory requirements.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#14 Post by altiplano » Sat Feb 10, 2018 3:25 pm

what you are saying is B.S. and makes it sound like you have a chip on your shoulder.
Time and again...
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Re: Air Canada Rouge EGPWS warning at Huatulco

#15 Post by pelmet » Sat Feb 10, 2018 4:14 pm

altiplano wrote:
Sat Feb 10, 2018 3:25 pm
Time and again...
I was actually expecting another Job Well Done statement from you. But seriously.......does the company have an airport briefing package/information page/etc. for each airport as many other companies do. I assume so but confirmation would be nice. What about using the terrain display in mountainous airports like this? I would assume so as well as I do not doubt their overall commitment to safety on an issue like this.

I hope these questions are not indicative of a chip on my shoulders. They are simply recommendations by myself and probably worthy of at least consideration of a reply. but perhaps you truly do think that it is B.S.(which would be quite concerning).
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Re: Air Canada Rouge EGPWS warning at Huatulco

#16 Post by Boney » Sat Feb 10, 2018 5:29 pm

I would say, “job well done in acting immediately upon the EGPWS terrain call out”.

Now, we wait for the report so that all may learn from this incident.

Cheers.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#17 Post by pelmet » Sat Feb 10, 2018 5:40 pm

Boney wrote:
Sat Feb 10, 2018 5:29 pm
I would say, “job well done in acting immediately upon the EGPWS terrain call out”.
Yeah....glad it wasn't MEL'd.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#18 Post by monkey » Sat Feb 10, 2018 6:27 pm

This isn't a "job well done" you reacted to a GPWS call out and saved 250 lives scenario. Should be a demotion and a ton of extra training scenario, at the very least. The standard needs to be much higher. There have been way to many serious incident going on lately with this airline. Something else is going on here. Whether it be training as some suggested, or lack of experience, company culture ... There is a clear trend line here and its not positive.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#19 Post by Eric Janson » Sat Feb 10, 2018 10:40 pm

If the timeline is correct - decent rate from 16000 was quite high (4200 feet in 'about 1 minute').

Given the terrain I'm not sure why you'd want to descend - just keep 13500 until the VOR and shuttle down in the hold. Even in VMC. Grid MORA is showing as 16100 on Jeppesen FD Pro. Doesn't make sense to descend to 11800.

So what if you are cleared to 6000'?

This is all part of an approach briefing.

(At my company we have an ALAR checklist that lists various factors with the associated risk ranked 1-4. A quick scan of the checklist is a useful reminder of the level of risk on any given approach)

The fact that this is not a radar vectored ILS but a non precision approach with significant terrain should be a trigger to be extra alert.

Lots of questions - hopefully the report will give some clarity about this incident.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#20 Post by pelmet » Mon Feb 19, 2018 8:27 pm

Occurrence Summary:
C-GHLU, a Boeing 767-333ER aircraft operated by Air Canada rouge was conducting flight ROU1892 from Calgary Intl, AB (CYYC) to Bahias de Huatulco Intl, Oaxaca, Mexico (MMBT) with 9 crews members and 250 passengers on board. While in a non radar environment in level flight at 16 000 feet ASL in the vicinity of enroute waypoint NUDOS, ATC authorized the flight to descend to 6000 feet ASL at pilot’s discretion. At 30 nm North of MMBT, the flight crew initiated the descent and, approximately 1 minute later at 11 800 feet ASL, an EGPWS "Caution Terrain" aural warning was received. The flight crew climbed back immediately to 13 500 feet ASL and continued to MMBT before commencing the descent and the approach. The aircraft landed at MMBT without further incident.

The Mexican Secretaria de Comunicaciones y Transportes of the Directorate General of Civil Aviation (DGAC) has opened an investigation on this serious incident in accordance with ICAO Annex 13.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#21 Post by confusedalot » Mon Feb 19, 2018 8:43 pm

Something is missing in this picture. Others are saying it was daytime with good weather, yet an egpws warning was produced? Controller authorized an altitude below safe ifr while on an ifr flight plan?

I will be interested to hear the outcome......sounds like either the controller made an incomprehensible criminally incompetent mistake or two people were sleeping in the cockpit, based on the sketchy information on this thread.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#22 Post by ahramin » Mon Feb 19, 2018 9:03 pm

Confusedalot unless you are on radar vectors, terrain clearance is YOUR responsibility, not ATC. 6000' is a normal clearance into Huatulco and gets issued every day. Until this incident I'd never heard of an airline pilot who thought they could bust through the MOCA for their airway, MSA, and MORA altitudes because of a descent clearance.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#23 Post by confusedalot » Mon Feb 19, 2018 9:21 pm

Explain to me like I was five years old, after 59 years on this earth, and after 39 years of flying, why I have never heard a controller clearing me below minimum altitude UNLESS I was cleared for a full approach?

I know huatulco, i know the terrain. Smartass.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#24 Post by confusedalot » Mon Feb 19, 2018 9:32 pm

Oh and one more thing, every single airplane driver in this world knows that there is such a thing a minimum radar vectoring altitudes that the controller knows at any given place but you may perhaps not, since they are not published on jepps. So clearing an airplane to 6000 feet east of Hualtuco does not make sense, knowing the cumulogranites that just so happen to permanently be there.

So...are you going to question the controller on his minimum radar vectoring altitude in comfy yyz? You better have a good answer for that if you do.

Which brings me to my first point; something is missing in this picture, nothing more.
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Re: Air Canada Rouge EGPWS warning at Huatulco

#25 Post by justwork » Mon Feb 19, 2018 10:13 pm

confusedalot wrote:
Mon Feb 19, 2018 9:32 pm
Oh and one more thing, every single airplane driver in this world knows that there is such a thing a minimum radar vectoring altitudes that the controller knows at any given place but you may perhaps not, since they are not published on jepps. So clearing an airplane to 6000 feet east of Hualtuco does not make sense, knowing the cumulogranites that just so happen to permanently be there.

So...are you going to question the controller on his minimum radar vectoring altitude in comfy yyz? You better have a good answer for that if you do.

Which brings me to my first point; something is missing in this picture, nothing more.
From reading the initial post, this incident appears to have occurred in non-radar environment. It would seem to me, that if in this situation and issued a descent at pilots discretion, it would be obvious to follow the appropriate published altitudes.
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