Clasificación de las medidas de mitigación

As co-pilot, I was flying the descent and approach at night to Madrid from the North to land on Runway 33. It is worth noting that at this time R33 had a steep upslope at the threshold, edge lighting only and a hump that made the far end lights invisible in the flare.

As we flew downwind it became apparent that we had a headwind of about 50 knots. We discussed the fact that this suggested that there might be a strong tailwind on finals. The surface wind on the ATIS was 190/3 knots. A number of requests for the surface wind were made during the approach, each of which received the reply "190/3 knots". The approach was conducted with care, with the landing configuration established in good time to ensure that the strong tailwind that was present did not make it difficult to achieve the correct approach speed. Once the final approach IAS was achieved, we watched the tailwind on the FMS. This came within limits at about 800 feet and continued to decrease to a tailwind of about 8 knots, well within limits, although somewhat above that to be expected from the surface wind of 190/3 knots and which was still being passed by ATC.

The Captain took control for the landing at 1000 feet as per the SOP. The landing was very smooth and seemed quite normal until the Captain said: "Look at the attitude"; at which point I saw that the pitch was decreasing through about 8 degrees.

As we taxied in I called the cabin crew at the rear and asked if they had noticed anything unusual during the landing, but they said they hadn't. Once on stand I inspected the rear fuselage which had a long streak of bright metal, clearly the result of contact with the runway during the landing. A subsequent discussion with the cabin crew revealed that they had heard a scraping sound but did not think it was something we would be interested in.

We never discovered whether the differing wind reports were a product of the unusual terrain around the 33 threshold or some defect with the anemometer or some other factor. The subsequent investigation revealed that we had encountered a tailwind gust of about 18 knots just before the flare, which probably made the Captain sense a sink and, in combination with poor visual cues, caused the over-rotation.

With hindsight I believe that having identified and successfully overcome a potentially serious problem, after the wind came within limits at about 800 feet, I relaxed too much. It is impossible to say whether I could have intervened successfully but in the event I reacted as if my job was over before the flare was reached. Although I was co-pilot in this event, the lesson is relevant to Captains. As they say "The job isn't over until the paperwork is done."

QUESTIONS

1. Would a post incident crew discussion have been a good idea?

2. When ATC are asked for a surface wind, do they give the most recent ATIS wind or the actual surface wind? 3. Do you think that there was a mind set to land?

4. What would you do in the event of a sudden and abnormal pitch change on short finals?

WHAT CAN ONE LEARN FROM THIS?

1. When a problem is encountered and successfully overcome, there may be a reaction which lowers what the experts call 'arousal' below normal and desirable levels. The more significant the problem, the greater this tendency may be, but often the flight will not be complete at this point.

SITREP 13 – In the air & later on the ground NOXIOUS FUMES

I had a flight with a sub-chartered operator on behalf of a major European airline from Birmingham to Frankfurt.

Take off was normal but after about 30 minutes the cabin staff announced that we were returning to Birmingham - no explanation was given. The captain spoke on the PA system 10 minutes before landing just to say that we were going to land in 10 minutes.

After landing, we exited the runway at the first available exit then immediately stopped and shut down. We were met by a full emergency call out and were evacuated from the aircraft. We were then advised that the flight deck crew had been severely affected by noxious fumes - thought to be from a partial engine failure.

Some interesting facets:

Fumes from the air conditioning system engine-tapped hot air, is not an uncommon event on BAe146 aircraft.

Neither pilot donned any apparatus or had taken advantage of crew Oxygen, although it was obvious that both were affected. The pilots were attended by paramedics after landing.

On evacuation from the aircraft, we were boarded to a standard passenger transfer bus parked about 30 meters from the aircraft but then stayed there for about 20 minutes.

Strangely, I was on my way to a meeting at Lufthansa Flight Training. As there was no possibility of a seat to Frankfurt that day, I took a Dusseldorf flight and continued by train - making the meeting start at 09.00 the following morning. This gave me the perfect opportunity to talk about this incident and the way it was handled, from a passenger’s point of view.

Discussing the events of the previous day at Lufthansa Flight Training (LFT) the first thing that was apparent was that, although the operator is a subsidiary of a major EC airline, the training between the airlines differs considerably. Since the passenger buys a ticket issued by the major operator, I felt that it has some responsibility for ensuring equal standards!

As a result, I agreed to forward copies of the Flight Operations Group Specialist Document, Smoke and Fire in the Air (SAFITA) direct to the operator of the HS 146 (and the two flight-deck crew). Because of its importance, that Specialist Document is recommended reading.

QUESTIONS

1. What would have been your first reaction to fumes on the flight deck?

2. When and how would you have handled the brief to the senior cabin crew member? 3. What would have been your instructions to the senior cabin crew member? 4. What would have been your order of priority in this situation?

5. Would you have landed back at Birmingham, if not why not?

6. Would you have ensured that there was a briefing to the passengers for an evacuation? 7. Would you have delegated this briefing to the senior cabin crew member, if not why not? 8. How in your opinion were these passengers cared for?

9. What would you have ensured was done for them?

10. Would you have been in a fitter state to care for the passengers and why?

11. What would have been your number one priority in this situation at the onset of fumes? 12. What would have been your number two priority?

WHAT CAN ONE LEARN FROM THIS?

1. It would appear that this first-hand account of an in-flight smoke/fire/fume event adds further proof of the need for training and improvements. The failure of the crew to use the protective equipment (oxygen masks and goggles) is a training failure. The failure of the crew to inform the passengers of the event is also a training failure, whereas the complexity of the checklist they were using is an organizational failure.

2. That the flight returned to Birmingham after 30 minutes in the air, which would have brought it into the Southern UK airspace, if not mid-Channel, instead of landing at a closer airport such as Stansted, or Manston or Ostend, exposed the aircraft to unnecessary dangers.

SITREP 14 – In the air