INDONESIA KNKT finds pilot deficiencies in Runway Excursion
Recommends that its DGAC adopt ICAO recommendations
Time for global mandate on Pilot Standards?
Here is a quote from a recent Indonesian investigation of a Lion Air A330- 300 runway excursion:
At 0714 UTC (1414 LT) the aircraft departed Soekarno-Hatta International Airport, Jakarta and cruised at flight level (FL) 400 (altitude 40,000 feet). The Second in Command (SIC) (46, ATPL, 17,130 hours total, 235 hours on type) was a qualified Pilot in Command (PIC) under line training for standardization training program and occupied the cockpit left seat. The PIC (48, ATPL, 16,916 hours total, 2,216 hours on type) was a qualified instructor occupied the cockpit right seat. The SIC acted as Pilot Flying (PF) while the PIC acted as Pilot Monitoring (PM). …
The SIC handed over the aircraft control to the PIC, considering the weather condition and lesser flying experience on the aircraft type. The PIC refused it and asked the SIC to keep controlling the aircraft.
The pilots noticed that an aircraft ahead made go around due to windshear and a pilot of another aircraft behind LNI 208 requested to change runway to 23 for landing. … The ATCO provided radar vector for LNI208 to point HORAS to performed Instrument Landing System (ILS) approach runway 23.
During approach approximately 1,000 feet, the SIC handed over the aircraft control to the PIC and the PIC became the PF. At 0940 UTC, when the altitude approximately 500 feet, the autopilot disengaged. The SIC advised to the PIC that the wind velocity was 16 knots from 275 degree.
After Flight Management Computer (FMC) call out “RETARD”, the SIC noticed that the aircraft position was getting closer to the left runway edge and advised to the PIC to fly right.
At 0941 UTC, the aircraft touched down and the PIC realigned the aircraft to the runway centerline by applying right rudder pedal.
The left main landing gear travelled out from the runway near the taxiway D and returned to runway centerline near taxiway E. ..
In the findings the KNKT stated: “During the Covid-19 pandemic the operation department had difficulties to maintained pilot proficiency and recent experience since the aircraft operation reduced and travel limitation issue.” and further reported the SIC had not flown in the last 90 days at all, the instructor had flown 2:56 hours in the last 90 days.
Komite Nasional Keselamatan Transportasi ( KNKT) issued an immediate recommendation to the Indonesian Directorate-General of Civil Aviation (DGCA) that the regulator should require its airlines to “adopt existing guidance issued by ICAO”.
For a number of years the issue of pilot competencies has been a global aviation safety focus, ICAO met on the issue in 2019 to “to review pilot licensing requirements, as part of a discussion that has gained urgency following two fatal crashes of Boeing 737 Max aircraft in the past year.” Contemporaneously therewith (March 29,2019) the leaders of the Committee on Transportation and Infrastructure and the Subcommittee on Aviation requested a federal investigation of international pilot training standards and training for commercial pilots operating outside of the United States, including training for the Boeing 737 MAX.
A working paper prepared for the 40th Assembly meeting (August 2019), the following was concluded (or is it merely recommended?):
The Assembly is invited to consider and support a multi-pronged approach to enhancing pilot training and competency that includes the following strategies:
a) an improved screening process and training for basic non-technical competencies …
b) a renewed focus on the competency and quality of training …
c) …competency-based training and assessment (including evidence-based training) methods;
d) ..responsive to changes in pilot licensing requirements, or introduction of new technology;
e) … maximize the use of simulation and are designed to prepare pilots for air carrier operations;
f) …understanding of the appropriate use of automation and appropriate manual flying skills;
g)…, effective crew resource management;
h) data-driven training programs…;
i) ab initio programs with operator sponsorship and support;
j) a partnership with the International Civil Aviation Organization and industry to define rules, recommendations, guidelines and the expected quality and performance required of flight academies;
k) internationally recognized proficiency and qualification standards that cannot be compromised; and
l) …high value on the knowledge, competence and experience of instructors.
Since 2019, ICAO has issued CBTA Instructional System Design and Competency development in practice, both excellent instructional guides. It also adopted Amendment 5 to the Procedures for Air Navigation Services — Training (PANS-TRG, Doc 9868) another advisory recommendation to its Members like Indonesian Directorate-General of Civil Aviation.
NTSC’s response to the runway excursion indicates that
the DGCA has not adopted theses ICAO recommendations!!!
The UN aviation safety organization is composed of 193 independent states and thus cannot effectively mandate the adoption of very specific standards such as pilot competency. It leads through its Montreal bully pulpit, the most visible (compelling?) is its SAFETY PAGE, where it lists its Members’ Priorities:
Members looking at this significant safety sign see a numbers of focus areas. There is FATIGUE MANAGEMENT, BUT NO PILOT COMPETENCE.
The FAA took a well-deserved hit for the Boeing 737 Max 8 disaster. That same tragedy precipitated the 2019 meeting focused on the need to learn from the cockpit performances of the Ethiopian and Lion Air crews. It might be institutionally uncomfortable for ICAO to issue a mandate directed at some of its Members, but this NTSC repetition of lessons of these two crashes and of its country’s urgent need to increase it standards is a dramatic reminder. Such an admission UNDERLINES the need for ICAO to mandate a Pilot Competency for all its Members.
By Alfred Chua24 November 2020
Indonesia’s National Transportation Safety Committee (NTSC) has advised the country’s civil aviation body to develop guidelines surrounding proficiency and training exemptions in light of the coronavirus outbreak, following a runway excursion involving a Lion Air Airbus A330-300.
Releasing its preliminary investigation report for the September incident, the NTSC says that the Indonesian Directorate-General of Civil Aviation (DGCA) should also require its airlines to “adopt existing guidance issued by ICAO”.
This was after it found that Lion Air “did not have any guidance” to manage proficiency and training exemptions at the operational level.
The NTSC also found that prior to the incident, that the co-pilot had not flown in the last 90 days, while the pilot-in-command, an A330 instructor, had only flown close to three hours in the last 90 days.
“The absence of guidance may place the two pilots, who were not recently [assigned as flight crew], as a hazard for flight safety,” NTSC investigators note.
The pilot flying then attempted to hand control of the aircraft to his colleague, who was the A330 instructor, but the latter refused it. The pilot flying did so, considering the weather conditions and his lesser flying experience on the aircraft.
“The pilots noticed that an aircraft ahead made go around due to windshear and a pilot of another aircraft behind [them] requested to change runway to 23 for landing”, and repeated their request to change the runway, the NTSC states.
This time, they got the go ahead, and proceeded to approach Runway 23. At approximately 1,000ft, the pilot flying handed command of the aircraft to his colleague.
As the aircraft approached the runway, the pilots noticed that the aircraft was fast nearer the left runway edge, and the pilot-in-command attempted to steer the aircraft to the right by applying the right rudder pedal.
The NTSC notes that the “left main landing gear travelled out from the runway…and returned to the runway centerline”.
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