CAT File No. O-2043-60
MoT File No. 149084
CIVIL AVIATION TRIBUNAL
Robert David Lawrence, Applicant
- and -
Minister of Transport, Respondent
Aeronautics Act, R.S.C. 1985, c. A-2, s. 7.1(1)(b)
Philip D. Jardim
Decision: October 6, 2000
I refer this pilot proficiency check back to the Minister for reconsideration to be reassessed as incomplete.
A Review Hearing on the above matter was held Tuesday, September 19, 2000 at 10:00 hours at the Federal Court of Canada in Toronto, Ontario.
On April 16, 2000, Captain Lawrence was given a pilot proficiency check (PPC) in an Airbus A330 simulator. During this check, Captain Lawrence was asked to perform a non-precision approach, which was the Localiser (LOC)/Distance Measuring Equipment (DME) Approach to runway 26L at London Gatwick Airport. In the course of this approach, the delegated check pilot, Captain David Lindal, assessed that Captain Lawrence had flown the aircraft 110 feet below the published altitude at the "GE" beacon, on the Air Canada Approach Chart: i.e., he crossed the beacon at 1,410 feet instead of 1,520 feet. Captain Lindal assessed this as a fail since the limits in the Approved Check Pilot Manual are +/-100 feet.
Captain Lawrence disputes this and claims that he was at 1,540 feet when the automatic direction finding (ADF) needles swung, indicating the aircraft's passage over the GE beacon, which is a non-directional beacon (NDB). He requested a review by the Civil Aviation Tribunal, hence our hearing today.
Pre-hearing agreement: Mr. Pratt disclosed that he had agreed with Captain Lawrence to restrict his evidence to what actually took place during the PPC check ride, and not to indulge in what took place subsequently. Accordingly, I shall ignore paragraphs 12 and subsequent of Captain Lindal's account of the PPC check ride, on pages 4 and 5 (Exhibit M-1).
Further it was agreed that Captain Lindal would present his evidence by conference call, since he could not be present today. This was done by speaker-phone in the court room, and everyone present could hear Captain Lindal, and he could hear us clearly. This proved to be an entirely satisfactory medium for the presentation of evidence by the witness, second only to his actual presence at the hearing.
Paragraph 7.1(1)(b) of the Aeronautics Act states:
7.1 (1) Where the Minister decides
(b) to suspend or cancel a Canadian aviation document on the grounds that the holder of the document is incompetent or the holder or any aircraft, airport or other facility in respect of which the document was issued ceases to have the qualifications necessary for the issuance of the document or to meet or comply with the conditions subject to which the document was issued, or
the Minister shall ... notify the holder, owner or operator of the Minister's decision.
Both parties delivered opening statements:
Mr. Pratt: The Minister will bring evidence to prove that on April 16, 2000, Captain Lawrence's PPC in an A330 simulator was unsatisfactory.
Captain Lawrence: I will bring evidence to prove that the PPC I did on April 16, 2000 should be declared as "Incomplete."
Captain Lawrence's only witness, Mr. Michael Bell, had not appeared at 10:00 hours. I offered to await his arrival for a reasonable period of time; however, after five minutes Captain Lawrence decided that he would like the hearing to proceed without his witness. I advised him that he was under no pressure to do so, as the hearing could wait for a reasonable period of at least 30 minutes. Captain Lawrence decided that he would like the hearing to begin, and we therefore commenced in the absence of his witness, at his request. Mr. Bell did arrive subsequently approximately 35–40 minutes late and remained for the duration of the hearing.
Mr. Pratt called his only witness, the check pilot, Captain David Lindal, who was on the speaker telephone from Maui, Hawaii. Captain Lindal was duly affirmed. Mr. Pratt presented four exhibits, which included a written statement by Captain Lindal, his handwritten notes, taken during the PPC on April 16, 2000, and the Transport Canada assessment form 0249. There was also a copy of the Air Canada Localiser/DME Approach Chart for Runway 26L at London Gatwick. This is the part of the PPC which Captain Lindal has assessed as a "fail."
In summary, Captain Lindal's evidence was as follows:
On the final approach of the PPC, a LOC/DME approach to Runway 26L at London, Gatwick, Captain Lawrence was asked to do a "managed approach." If the autopilot had been programmed properly, he said, the aircraft would have crossed the GE beacon at 1,520 feet.
Captain Lindal said that there was confusion between Captain Lawrence and the first officer regarding the speed for the descent and the location of the final approach fix (FAF) which is at 5.5 DME from the runway. The first officer was uncomfortable with the procedure, and at ½ mile back from the GE radio beacon, Captain Lawrence set a flight path angle of 3.3 degrees into the computer, instead of 3 degrees: this caused the aircraft to cross the GE beacon at 1,410 feet instead of 1,520 feet. This was 110 feet below the required altitude and outside of the 100-foot allowance in the Approved Check Pilot Manual. (See attached Appendix "A").
In answer to Mr. Pratt, Captain Lindal said that while the rest of the ride was generally satisfactory to that point, there had been other deficiencies. These included nonstandard procedures in programming the flight control unit (FCU), not selecting the yellow hydraulic pump "off" after an engine failure, and, not correcting the first officer's statement: that these hydraulic pumps were not a consideration as the Engine Fire push-button had been selected.
Captain Lindal said that he rated the London Gatwick LOC/DME approach as unsatisfactory for multiple errors, in addition to the altitude infraction:
- Failure to follow standard operating procedures (SOP's).
- Selecting the wrong flight path approach (FPA) angle—3.3 degrees, instead of 3 degrees.
- Flying the approach in selected rather than managed speed.
It should be noted here that no reference is made to the above errors and other alleged errors on the flight test report pilot proficiency check form 0249 (Exhibit M-4).
Captain Lindal said that Captain Lawrence should have programmed the approach, which is a "tricky one," into the autopilot, building the FAF into the flight plan, because the flight management system (FMS) database approach is somewhat different from the Air Canada plate. The crew did not do this; hence the navigation display did not show the FAF.
The first officer suggested that they request an "orbit" to resolve their confusion surrounding the FAF, but Captain Lawrence elected to continue the approach. He set an FPA of 3.3 degrees and "pulled the knob" setting the aircraft into a steeper than required flight path angle of 3 degrees. The aircraft, he said, described the flight path shown in Captain Lindal's diagram shown in the attached Appendix "A".
Captain Lawrence demonstrated an unsatisfactory knowledge of procedures, in that he did not fly the LOC/DME – 26L approach according to established procedure, which resulted in a violation of an ATC minimum altitude. Accordingly, PPC item 4C—Terminal Instrument Approaches—LOC was assigned an unsatisfactory rating.
Captain Lindal ended his testimony. It should be noted that there are some seven pages in his statement in M-1, and I have summarized them here, giving the salient points and his reasons for failing Captain Lawrence.
In his cross-examination of Captain Lindal, Captain Lawrence took issue with the following points:
- That Captain Lindal had not made reference to multiple errors in form 0249, nor in the debriefing.
- The clarity of the Air Canada chart used on the ride was poor. (I have to agree with this). Captain Lawrence said that if he were given such a chart on an actual flight, he would reject it and demand clearly printed material.
- The database in the aircraft did not match the Air Canada chart. Mr. Pratt agreed with this.
- During a previous instrument landing system (ILS) CAT II approach, the aircraft computer downgraded the approach to CAT I. Captain Lindal does not recall this, but Captain Lawrence said that it certainly did happen. At this stage, Captain Lindal had said that he was to continue the approach as though it was a CAT II. Captain Lindal said that he could not disagree with this, but that he does not recall it happening.
- There were problems with the aircraft computer, and Captain Lindal did not call maintenance.
- With regard to the yellow hydraulic system pump switches, Captain Lindal conceded to Captain Lawrence that this was not a "memory item."
- Although he did not call for an after take-off check, Captain Lawrence asked, and Captain Lindal confirmed, that all the items on the check had been performed.
- Captain Lindal was not sure from which instruments and/or displays he took the aircraft's altitude at the passage of the GE beacon. In further questioning he said that he took them from the Captain's side, but seemed unsure as to which instruments he used to determine passage of the GE beacon.
- Captain Lawrence questioned Captain Lindal about Captain Lawrence's remark, that the altitude
restriction had been met. Captain Lindal said in his statement that the remark had been made after the passage over the GE beacon, as the aircraft was descending through 1,200 feet. This would have been 10 to 15 seconds after the GE beacon passage.
- Captain Lawrence asked Captain Lindal whether the landing following the approach was acceptable. Captain Lindal said that he was "not paying attention"—he had decided that the ride was going to be a fail." He did believe that Captain Lawrence had landed the aircraft on the runway.
- He asked Captain Lindal whether he had reported the simulator as "Broken" after the ride because of inconsistencies with the FMS. Captain Lindal said that, "he did not write anything up."
In redirect, Mr. Pratt asked Captain Lindal whether it is normal that hold patterns are held in the FMS database. Captain Lindal replied "sometimes yes, sometimes no."
Mr. Pratt sought to further confirm that Captain Lindal's reason for failing Captain Lawrence was "multiple errors, rather than just the altitude." Lindal replied that there was a lack of satisfactory knowledge of the aircraft and procedures, but that the glaring error was the altitude.
Captain Lawrence further asked Captain Lindal whether the computer having downgraded the ILS approach from a CAT II to a CAT I was indicative of an FCU fault, and that one of the consequences of this is that target speeds are not reliable. (See Exhibit D-14.) Further, the altimeter setting was 1008 millibars.
Following a brief adjournment, Captain Lawrence called his witness, Captain Michael Bell to the stand. Captain Bell was duly affirmed.
He has been flying for 30 years, is qualified on the A330 and A320 with substantial military experience on the Aurora, Sea King and the Tutor. Captain Bell is also an instructor with Flight Safety Inc.
Captain Lawrence questioned him about his experience with aircraft and simulator database and publication discrepancies. Captain Bell advised that digital computers have particular problems with these, and changes in venue, for example, when a simulator is switched from an approach in New York to one in London.
Mr. Pratt sought to have Captain Bell confirm that the simulator used for this PPC is a "level D" simulator, which is "state of the art" in simulators. He did so confirm.
Captain Lawrence's evidence: At this stage, Captain Lawrence was duly sworn. In summary, Captain Lawrence's evidence was as follows:
- He established the aircraft on the localiser approach at London Gatwick R/W 26L. He crossed the GE beacon at 1,540 feet, continued the approach to the minimum descent altitude, saw the runway, landed 1,000 feet into it and pulled up within 1,000 feet of the end of the runway, and applied the parking brake.
- He was dumbfounded when Captain Lindal stopped the ride due to an airspace violation. "I saw the altimeter at 1,540 feet as the ADF needles swung to indicate passing over the GE NDB," he said.
- Captain Lindal showed him the multipurpose control and display unit (MCDU) showing 1,430 feet, which is 90 feet below 1,520.
- On leaving the cockpit, the co-pilot pulled the recall button for three seconds, which recalls data from the electronic centralized aircraft monitor (ECAM). This showed an FCU autoflight fault, barometric reference standard, i.e., 1013 Mb.
- During the debriefing, Captain Lindal did not mention the 110-foot error until he wrote up the form 0249.
- Captain Lindal suspended both the captain's and the first officer's instrument ratings, but the first officer's was reinstated the next morning. (This was after Captain Lindal had spoken to Captain Mowser, the Director of Operations/Training.)
- Captain Lawrence continually made reference to the unsatisfactory clarity of the chart given to the crew for this PPC. Exhibit M-3. This he asserted combined with FMS computer faults combined to create an unreasonable situation for his PPC ride.
- The simulator was further deficient in that it had no pads on the rudder pedals and the pilots' feet kept slipping off.
- The FCU did not match the Air Canada charts.
- The FCU was set to 1013 Mb. And the pilot's altimeter was set to 1008. This 5-Mb difference accounts for an altitude error of 140 feet, (28 feet per millibar).
- He was late starting his descent and therefore set an FPA of 3.3 degrees to compensate for this. He changed the FPA setting back to 3 degrees at the GE beacon at 1,540 feet. Captain Lawrence presented a series of exhibits, D-5 through D-14. Included in this was D-9, which is a diagram of the profile for the said approach. (See attached Appendix "B").
- The FMS has an inherent error of at least .28 nautical mile (NM)—Exhibit D-10. This is equivalent in this case to 108 feet. If Captain Lindal was looking at the MCDU for the altitude at crossing the GE fix, instead of the DME on one of the VOR's or the ADF's, he would have read my altitude incorrectly as lower than it was, due to this inherent system error.
- As far as Captain Lawrence is concerned Captain Lindal did misread his altitude at the GE beacon.
- If the inherent navigation error is not the cause, then altimeter error could be the cause of his mistake. The difference between 1013 Mb and 1008 Mb is equivalent to 140 feet as discussed above.
- There are three ways of determining where the aircraft is: A. the NAV display, B. the ADF's, C. the DME's. The NAV display is tied to the FCU.
- Captain Lawrence asserted that he continued his approach to a successful single-engined landing. Had he followed the flight path suggested by Captain Lindal he could not have done so, as he would have grossly undershot the runway.
- Exhibit D-14 is an extract from the "Sextant Avionique" manual—the manufacturer of the AIRBUS FMS. This manual describes that when there are faults in the system, control knobs can become temporarily inoperative, and altimeter settings can revert to standard. (1013 Mb) There are also other errors, which can occur, and are described herein.
In his cross-examination of Captain Lawrence, Mr. Pratt asked Captain Lawrence in effect whether his version of the aircraft flight path was really the correct one, D-9, as opposed to Captain Lindal's—Annex A, M-1. Captain Lawrence replied that when Captain Lindal took his altitude reading, he had already passed the GE beacon inbound, and was therefore lower.
He further asked whether it was normal to say, "we met that altitude" on an approach. Captain Lawrence replied that he particularly did so because he knew that he was high on the approach. He had started down late, hence this is why he set 3.3 degrees instead of 3 degrees, which he selected on passing the GE beacon at 1,540 feet, on seeing the ADF needles swing.
In reply to further questioning, Captain Lawrence said that while the simulator was doing what he expected it to do for the most part, it had faults, which were evident throughout the flight. He further said that the difference between the Air Canada approach plate and the aircraft FMS, and the illegibility of the chart further added to the general confusion.
Captain Lawrence said that there was no confusion with the FPA of 3 degrees.
In an extended cross-examination by Mr. Pratt, Captain Lawrence asserted that Captain Lindal's notes were inconsistent with what he had written on form 0249, and that they may well have been written later, rather than at the time of the check. He further asserted that Captain Lindal was not telling the truth when he said that he did not see the FMS downgrade their ILS approach from CAT II to CAT I.
It is not possible to determine exactly what the aircraft was doing because of faults in the simulator. Captain Lawrence asked Mr. Pratt how he could have maintained a 3.3-degree FPA and not ended up very low, miles back from the runway. Instead of which he had continued his approach to a successful and uneventful landing on one engine.
The two parties have a totally different recollection of what happened that day.
In his closing summary, Mr. Pratt reiterated the evidence of Captain Lindal, particularly with respect to paragraph 9 of his statement (M-1). The only inconsistency in his handwritten notes from the assessment form 0249 is that he wrote 1,400 feet in the notes and used 1,410 feet on the form. He asserted that there was no evidence that Captain Lindal would say anything other than what he saw that day. The PPC should be assessed as a fail.
Captain Lawrence's summary was:
- That he had proved that due to malfunctions in the simulator, he had been unable to do a CAT II approach.
- There had been multiple simulator failures, which caused the FCU to default to 1013 Mb.
- The .28 NM error in the IRS would cause a 108-foot error.
- In addition, the charts did not match the aircraft database.
- Further, when the simulator is "slued" to another part of the world, digital errors can occur, and did in this case.
- Captain Lawrence asserts that this PPC ride should be declared incomplete.
In cases of conflicting evidence such as this, one's decision often comes down to credibility, on a balance of probabilities. However in this case, it is abundantly evident that there has been a lack of attention by Captain Lindal, and awareness of the intricate technicalities of a complex aeroplane/simulator, and, the effect of faults on simulator performance.
I have decided to refer this PPC assessment back to the Minister for reconsideration for the following reasons:
- There is evidence that Captain Lindal did not notice certain events which evidently took place:
- Reversion of the FMS from CAT II to CAT I on the ILS approach. Captain Lindal says he did not notice it, but does not dispute that it happened.
- That Captain Lawrence changed the FPA from 3.3 degrees initially to 3 degrees at the GE beacon. Evidence of this is that he continued the approach to a successful landing on one engine. Had he maintained a 3.3 FPA, he could not have done this.
- Captain Lindal admits to not paying attention to the landing—he seemed preoccupied with his observation that the aircraft was 110 feet low at the GE beacon. I find this surprising.
- Captain Lindal appears to be unaware that there were simulator errors, and the effect of those errors on its performance.
- Captain Lindal's vagueness as to where he was looking when he observed the aircraft transiting the GE beacon. It is evident that he may have been looking at the MCDU moving map display, instead of the ADF's or DME's. (i.e., raw data.) This could have resulted in his seeing the transit of the fix after the aircraft had passed it, due to the .28 to .34 NM error inherent in the IRS system. The resulting six to eight seconds would easily have produced the altitude discrepancy.
- The poor quality of the plate given to the crew for the LOC/DME approach to Runway 26L at London Gatwick. It is difficult to read.
- There is evidence that there were faults in the FMS which could have caused the barometric setting of the FMS altimeter to revert to 1013 Mb instead of the PFD altimeter setting of 1008 Mb. This could have caused an error of 140 feet.
- Captain Lawrence's testimony that as they were leaving the simulator, the first officer showed the faults on the ECAM control panel, (P.1 indicating/recording systems, ECAM controls. Part of Exhibit D-12). The first officer pulled the recall button for three seconds and up came "FCU AUTOFLIGHT FAULT BARO REFERENCE STANDARD."
This is clear evidence that there were faults in the system, which precluded normal operation of the simulator.
Further, these faults could well have contributed to Captain Lawrence's flying the approach in selected rather than managed speed.
Based on the above analysis, and in fairness to the applicant, the matter is referred back to the Minister for reconsideration to be reassessed as incomplete for the reasons given.
Philip D. Jardim
Civil Aviation Tribunal
- Date modified: