reducing "Crew-caused"
approach and landing

Pilot-in-charge Monitored Approach

2013 B738 undershoot Bali Indonesia

Brief account : 

The Boeing 737-800 flew a day non precision approach and continued when the required visual reference was lost below MDA. Despite continued absence of visual reference, the approach was continued until the EGPWS annunciation 'TWENTY', when the aircraft commander called a go around. Almost immediately, the aircraft hit the sea surface to the right of the undershoot area and broke up. All 108 occupants were rescued with only four sustaining serious injury. The Investigation attributed the accident entirely to the actions and inactions of the two pilots.

Crew-related factors : 

In this event the F/O had been designated as PF and was intended to make the landing.   The Captain was 48 years old with 15,000 hours. Recent training had noted a "habit to continue approach and land even violate from stabilised approach element" and rated him "at minimum standard for CRM Threat and Error Management of workload management."

The F/O was 24 with 1200 hours total: he was a foreign national and had been in the company for 2 years. The VOR/DME approach was flown initially with the autopilot engaged in LNAV and VNAV. ATIS information before and after the accident was for light winds, 10k,nil weather, broken cloud at 1700ft.  The MDA was 465 ft. 

However in fact a significant thunderstorm was present in the area and moved over the approach path. At 1000 ft an auto-callout was made, the F/O stated that the aircraft was stabilised and reviewed the go-around. At about 900 ft the Captain told the F/O he had an "approach light" in sight, and to continue but he was also aware of the thunderstorm to the right. The F/O said the runway was not in sight.  

The aircraft started deviating slightly above the optimum path below about 700 ft. An EGPWS "minimums" call was made followed by a "500 ft" callout at which point the F/O disconnected the autopilot. At the 400ft radio callout the Captain called to continue the descent. At 300 ft the decsent rate had built up and the aircraft was continuing on the offset VOR track which was now taking it away from the centreline.  

The aircraft entered heavy rain at about 250 feet, and at the 200ft RA callout the Captain called to continue, and then took control fropm the the F/O, who said he could not see the runway. The aircraft continued below the proper profile and away from the centreline until 20ft RA at which point the Captain called for a go-around just as the aircraft impacted the sea (runway elevation is 11ft).

The Captain had expected to be able to continue through the rain: "his decision to continue the approach while it was raining, was based on his observation of the dark area on the right side of the final approach track was relatively narrow and he expected to be able to see the runway shortly after passing through the rain. When at 300 feet the PIC stated that he entered the cloud and then at 200 feet the outside environment was "totally dark" and| he added that this was his first experience flying into such condition." 

The crew did not comply with many aspects of their SOPs, and it is clear that the Captain was fixated on landing come what may, to the extent of taking control to continue. The degree to which a change of procedure to PicMA might have helped is debatable given the Captain's wilfull ​disregard of the conditions. However, if PicMA had been the SOP and

1) the F/O was intended to make the landing (as it was in this case) then as the aircraft neared the MDA the F/O would have been looking for the cues, and if inadequate he would have been trained to positively call for a go-around, although given his mind-set, the Captain would possibly have continued down anyway. However the Captain would have had to make a specific mental reversal of the plan he had been trained for under these circumstances, which would have been to go around. 

2) On the other hand if it had been the Captain's landing, therefore the Captain would have been monitoring (as was actually the case here. The F/O would have called "Decide" at MDA, and the F/O would have been primed to make a go-around. Again the Captain might possibly have called for a continuation of the descent while leaving the F/O at the controls, but more likely he would have simply called for a landing.

Although the sequence might then have been the same, the F/O's attention would have been more directed to continued instrument monitoring, instead of the vain search for visual cues. This might have detected the increasing rate of descent, and possibly triggered a rejected landing earlier in the proceedings.    

All that can be said with certainty is that use of PicMA would have thrown some additional obstacles into the mental processes of the Captain, possibly diverting him from the decisions which led to the accident and prevented the F/O from intervening. 

Bali Indonesia
Expected weather: 
Pilot in charge: 
F/O under direction
Early transition: 
Go-around : 
Below DH/A
PicMA potential: 
Vert Guidance: 
Both Head Up: 
Fully prepared: 
Actual Weather: 
Autopilot :