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TSB report finds WestJet pilots misidentified runway during approach into St. Maarten

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The Transportation Safety Board of Canada (TSB) has released its report regarding WestJet’s much talked-about Sint Maarten missed approach back in March 2017. The report found that “unexpected weather conditions on final approach, reduced runway conspicuity, and inadequate flight path monitoring led to a risk of collision with terrain.” (www.theluxescape.com) Altro...

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Highflyer1950
Highflyer1950 22
Company communication probably suggested that its not a good thing thing if you are both looking outside and nobody is flying the aircraft. Also, one of those little instruments is there to tell you the alitude but it only works if you look at it! When the EGPWS activates maybe its time to utilize that expensive training, however if the airspeed is that low, with the throttles at 55% and you may very close to the shaker in that nose hign attitude, maybe your way behind the power curve and your plane! Too harsh?
rapidwolve
rapidwolve 5
Not harsh enough, Highflyer.
bentwing60
bentwing60 4
Don't think so.
blackstock
Michael Blackstock 4
Not at all.
MICHAELKOHUT
MICHAEL KOHUT 1
Highly UNskilled piloting...
bbabis
Bill Babis 7
Frightening to read. Less than 6 seconds from impact and they were oblivious.
bentwing60
bentwing60 3
Good thing they flew out of the rain shower, as if that's anything unusual down there.
williambaker08
william baker 2
Correct me if I’m wrong. Doesn’t St marteen only have one runway???
bentwing60
bentwing60 1
williambaker08
william baker 7
That’s what I thought. My thought is thou there is if there’s only one runway how the hell did you misidentify it. Lol we’re we not paying attention to the Nav equipment?? Did we lose directional awareness. The rule of thumb in aviation is never put yourself or your plane someplace your mind hasn’t been 5 minutes before.
Kairho
Kairho Carroll 6
Looking at the photo in the article it is very easy to see how that hotel looks brighter and still runway shaped from the aircraft's position and the atmo conditions. Looks easy to misidentify, especially if one hasn't been there all that much. [but doesn't negate the poor piloting skills though]
ba151
Bruce Atkinson 2
Did you look at the picture? The hotel in the rain looks like a strip of concrete to me. Are you even a pilot? On an actual airplane in IMC? Bad piloting absolutely. A great lesson in how a number of errors can lead up to a huge disaster.
bbabis
Bill Babis 1
The lateral issue with the runway identification is secondary.. No matter where they were, this crew damn near belly flopped it with no clue of their verical situation while on an approach!
bentwing60
bentwing60 0
Spot on!!!
williambaker08
william baker 0
carllipe
Carl Lipe 0
Highflyer1950
Highflyer1950 6
Just as an added comment. the approach is offset 3 degrees if I remember. Personally I see nothing wrong with pickng up the hotel or the Sunset bar as a vsual clue to the runway environment 4 - 6 nm out and then making minor adjustments to final but again, somebody has to monitor the inside.
blackstock
Michael Blackstock 3
I see no problem in doing an offset approach either, but in this case it appears that they were approaching the hotel as if IT was the runway. re: 'According to the report, “the features of a hotel located to the left of the runway, such as its colour, shape, and location, made it more conspicuous than the runway environment and led the crew to misidentify it as the runway.”'


Spatial disorientation almost became a controlled flight into terrain accident.

In the simulator picture in the link above, visually at that one moment, I can understand this. My concern is all the other clues that were overlooked or disregarded down this path. We can set here and second guess it, but if an approach does not 'feel' right, it most likely is not right. If things start piling up, crews should feel empowered to go around. See something, say something and all that. Tenerife was over 40 years ago now, and we are still learning those lessons.
twinsemi
Tom Winsemius 2
Are you sure you don't mean that we are still NOT learning those lessons?
chalet
chalet 6
Extremely poor airmanship. Hadn't the visibility improved the way it did, no question that a horrible crash would have occurred.
patpylot
patrick baker 5
there is only one runway, equipped with at least a localizer, which reads out on the panel, just in front of both pilots, available for consultatation during reduced visibility.. wow.....
cmg344
Carlos Mainzer 3
Yes, 113.0 PJM VOR which could have been consulted in order to 'locate' runway 10.
jimbradfield
James Bradfield 4
This is one of those common goof-ups if both the pilot and co-pilon are complacent in regard to their duties.
Don’t get me wrong, I have made my share of mistakes in the cockpit, but now I always have my electronic 2nd opinion
with me to double check entry path, alignment, and situational awareness.
Also, I have my electronic navigator set so I always know how high I am about terrain because I don’t want to suffer from cranial-rectal disorder which I think was displayed in this situation.
I know about this disorder because I have suffered from it a few times myself.
sgbelverta
sharon bias 6
I'm not a pilot. But when I read this, "The alert response procedure recommended by the aircraft manufacturer and the operator led to a delayed response to the first EGPWS alert and resulted in the aircraft’s descent from 63 to 40 feet above ground level before corrective action was taken.” I have a problem. I don't know why there was a delayed response, but that needs to be fixed. That's why we have all of these fancy computers and monitors. It's to keep aircraft from flying into land or someplace they don't belong. St. Maarten ranks in the top 10 worst airports to fly info. If that information alone didn't guide the pilots attention span, they need to get out of commercial aviation.
Highflyer1950
Highflyer1950 5
A little to your point if I may, The EGPWS alert requires an immediate response for sure. However, if you allow your speed and altitude to decay to the point where applying thrust from 52% to 75% while in a high nose attitude might only result in getting your rate of descent to start shallowing. Any further back pressure on the flight controls may place you closer to aerodynamic stall territory until your rate of descent is arrested and a positive climb rate is attained. I believe the simplest explanation is inattention to the operation of the aircraft and as bentwing60 suggested, a trip to the chief Pilots office. My comment regarding airspeed is just that, a comment. Their speed may have been perfect, adherance to MDA, not so much.
bentwing60
bentwing60 4
TNCM is pretty low on my totem pole of difficult approach airports. No way a top ten worst among pros.. The weather is usually not that much of a challenge and all instrument approaches are to the east for runway 10 over water which is pretty much FLAT. 28 is VFR only, and NA at night and easy to see why after your first trip in and out on 10 which is prevailing because of the prevailing winds. You did read that they were an airline crew so I don't think they will be leaving their day job, But, a trip to the chief pilots office would certainly be in order for being so lax as to not monitor an instrument approach procedure. Cheers.
danpend
Dan Pendleton 2
Well. Heck! Just tear down the mountain range east of 10/28 so you can make 28 and instrument approach runway. Solve a few issues.
Greg77FA
Greg77FA 2
Bad piloting.
hwh888
Harry Hallstrom 1
As in most Caribbean approaches in summer months, a lot of haze makes things hard to see add a tropical shower to the mix, a maxed out work load into a low or no visibility final and it's a recipe for a possible disaster. The flight was seconds from a major accident. Don't know the experience level in the cockpit but this situation got way way out of hand.
Flightdog
Roger Curtiss 1
A HUD would have ben handy to have.
JimHeslop
Jim Heslop 1
Looks to me like, as so often happens, both crew may have been looking out the window instead if one monitoring the instruments.
KatzyBaby
KatzyBaby 1
Scary situation. IMHO there is no way a hotel looks like an actual runway, with or without instruments. I think ranking the causes would put inattention/situational awareness as #1.
twinsemi
Tom Winsemius 1
This is very different from what Westjet said in the immediate aftermath of the incident, when they framed the reaction as "articles with unfortunate and frankly, irresponsible headlines". They praised their pilots and procedures by concluding with the following in their blog:
"Relying on their skill, training and experience, our pilots who landed our Boeing 737-800 at SXM last week made the right call, and the process worked the way in which it’s intended." Really????????????
patpylot
patrick baker 1
if the pilots are going to try the excuse of an intense rain shower caused us to goof this approach, i can't buy their argument. This is the tropics- rain showers come and go quickly, so declare missed approach, go around, and come back in 10 minutes to a more predictable landing.
JayBell
Jason Bell 0
Negligent ATC. TNCM Tower failed to inform WJA2652 of just released atis Novemeber with updated approach visibility of 2000m, 1600m short of 2652's minimum permissible visibility to shoot the approach. In this weather the 737 was forbidden to land.

At the 2000m viz sitation, the Tower should've stacked the 737 in a hold. The PF expected to see the runway at the MAPON, but got hit with showers and mistook the hotel to the left of the runway while in the rain for rwy10. When they broke out in decent visibility 1nm from rwy10 realized they were flying at the hotel. Go around.

The 40' above MSL is the WestJet crew's error, as is the trend to ignore the first "Pull Up!" EGPWS, while heeding the second They caught it and saved the plane from disaster. The PM should've watching the altitude. It's 3 degree glide slope from LESOR at 1700' at 96 magnetic to the PJM. Straight in.

The TNCM Tower failed to warn 2652 about the drastic reduction in visibility and to wave off the approach and send them in the holding pattern.
williambaker08
william baker -1
And you know this how?? Were you flying the plane??
JayBell
Jason Bell 2
It's in the report. http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2017/a17f0052/a17f0052.pdf

The crew got info MIKE (unlimited visibility) before crossed SLUGO. The tower then published NOVEMBER with viz now 2000m and didn't inform WJA2652. The 738 crew didn't know they were headed for 2000m visibility at LESOR, forbidding lawful approach.

Crucial weather info was withheld from 2652. The crew, not knowing they couldn't conduct the approach, expected to acquire visual of the runway before the MAP. Just after the MAP the 737 got showered on. In this shower the PF mistook the hotel left of the field for the runway.

Competent ATC would alert the arrival that visibility was 1600m below permissible, aborting the approach and placing in a hold.

Rwy10 is a visual approach that requires 3600m visibility from LESOR to the runway. The crew set the autopilot to 3 degree glide slope, 96 magnetic, appropriate approach speed, but at some will be hand flown by visual reference. The PF got the wrong reference, and the PM, by not catching the steep descent and only discovering from the EGPWS blasting off, had to have messed up. But the plane, after NOVEMBER, never should've been allowed to conduct an approach. The 738 shouldn't have been there to confuse a hotel for a runway.
bbabis
Bill Babis 1
Bogus argument Jason. This is why we have procedures and minimums. To make unexpected or unknown changes a non event. If you want to say its not their fault because they shouldn't have been allowed to start the approach, then I say it could have also been avoided if they were never allowed to have licenses in the first place.
JayBell
Jason Bell 2
Please, read the report in full before forming an opinion. There is without doubt deserving blame to be allotted to the pilots. They dropped it to 39'-40' 0.5nm offshore from PF and PM error.

This incident has more than one blameworthy party. In the interest of aviation safety, real ATP should never form an opinion from mainstream media news stories.

The second blameworthy party, omitted from the luxescape.com headline, is rwy10 was inaccessible to wja2652 under the published visibility minimums in accordance with the aircraft type regulations. As if closed for repairs. And closed before wja2652 crossed AVAKI (IAF) and during Twr's instruction to fly direct the IAF and descend to 2600. At about 25nm out, the 738 was prohibited under the regulations from attempting any landing on rwy10 until visibility improved to at or above the minimums.

November was published at 1526, a SPECI. Right here, any competent twr would've informed wja2652 of the 2000m viz but the TNCM didn't. The wja crew had no knowledge or expectation that the weather information they were provided and were acting on was false.

IFR is a legally binding contract. The deal is ATC owns the IFR aircraft's ass in return for safe separation from other aircraft and relevant flight info. Relevant info is being told that the unlimited visibility an arriving flight crew is expecting is now so limited that the arrival is going in the hold until further advised. Withholding this info while instructing the arrival to fly toward an IAF it legally can't cross is ATC error.
ba151
Bruce Atkinson 2
He probably read the report.
TWA55
TWA55 0
Maybe Canadian acrft should be restricted until they figure 1. left from right, and 2. runway versus hotel. Just seems there have been too many piloting errors eg. SFO. I live next door to Canada and can only comment that I hope their driving skills are no reflection to their piloting skills.
rapidwolve
rapidwolve 1
All I can say is..WOW..yes those knuckleheads should get their butts kicked, but do not make it seem like Canadian pilots are the only 1's who screw up!

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