Investigation report has been released (linked on this news release page):

http://www.tsb.gc.ca/eng/medias-media/c ... 180604.asp

The investigation determined that the runway lights and the visual guidance system (PAPI) had been set at a low intensity during the rain shower that had obscured the view of the airport environment. Both the shower and the low lighting limited the visual references available to the crew to identify the runway properly until the aircraft had exited the rain shower and visibility sharply improved.

The sudden and unexpected poor visibility during the final approach increased the flight crew's visual workload and led to inadequate altitude monitoring. The crew did not notice that the aircraft had descended below the normal angle of descent to the runway threshold until the enhanced ground proximity warning system issued an alert.

"The crew initiated a missed approach 0.30 nautical miles from the runway threshold at an altitude of 40 feet above water."

yowzers

What is it with Canada and seriously messed up NPAs? Don't they do height checks?it happened on an Airbus it nearly ended in tears for a Boeing so it's not type specific. Disappointing.

litz wrote:

"The crew initiated a missed approach 0.30 nautical miles from the runway threshold at an altitude of 40 feet above water."

yowzers

How did the GPWS not go off?

litz wrote:

"The crew initiated a missed approach 0.30 nautical miles from the runway threshold at an altitude of 40 feet above water."

yowzers

That's truly frightening.

aemoreira1981 wrote:

How did the GPWS not go off?

The GPWS would not go off as it was in the landing configuration with all required parameters met.

However, the EGPWS (position included) may not have sensed the location as being not on a runway as it was so close. But still ... maybe it did, and that is the reason for the go-around.

aemoreira1981 wrote:

litz wrote:

"The crew initiated a missed approach 0.30 nautical miles from the runway threshold at an altitude of 40 feet above water."

yowzers

How did the GPWS not go off?

. The EGPWS went off twice at 63 feet and 49 feet.

Great YouTube of the incident both inside and out to refresh memories.
https://www.youtube.com/watch?v=uN3Fd0x0FoQ

So would runway lights typically be manually turned up during rain? Or automatically increase as it got darker?

smokeybandit wrote:

So would runway lights typically be manually turned up during rain? Or automatically increase as it got darker?

Runway/taxi lights, approach lights and PAPI are manually controlled by the tower. Strange that they were not full bright in heavy rain.

longhauler wrote:

Runway/taxi lights, approach lights and PAPI are manually controlled by the tower. Strange that they were not full bright in heavy rain.

The way I understand the report is this: the PAPIs were on during the approach at their daylight setting; when the rain shower obscured the view, the controller turned on the runway lights but to the night setting. This had the effect of dimming down the PAPIs, which one would expect at night so that they don't dazzle the crew.

The fail on the controller's part seems to be recognizing that it was a rain shower in the daytime, and not dusk, and thus not putting the runway lights to full bright when he turned them on; as a result the crew lost visual reference.

I wonder if it isn't an issue of the controller being poorly trained on the functionality of the runway lights/PAPIs. It certainly was one slice of Swiss cheese...

Beech

40'.
I hate to run afoul of you pro pilots here, but I cannot imagine how this isnt a massive loss of SA, as the passenger window video clearly illustrates. It's amazing how calm the pax were.

Oh, and shame on West Jet for their disingenuous initial denials. As someone else mentioned, a large boat could have ended everything.

FlyHappy wrote:

40'.
I hate to run afoul of you pro pilots here, but I cannot imagine how this isnt a massive loss of SA, as the passenger window video clearly illustrates. It's amazing how calm the pax were.

Oh, and shame on West Jet for their disingenuous initial denials. As someone else mentioned, a large boat could have ended everything.

That’s what island landings look like with runways right on the beach. Water water and were here. That’s how I felt landing in Kona.

PSA1978 wrote:

Great YouTube of the incident both inside and out to refresh memories.
https://www.youtube.com/watch?v=uN3Fd0x0FoQ

That passenger has clearly just never landed at SXM before. She said "it's like we're landing on the beach", and then "oh look, everyone's watching!" It seems like you're going to land on the beach even during a normal landing there - the beach is right off the end of the runway. And everyone's watching every plane that comes in; that's not something you'd say if you'd ever been there before.

The point being, she'd really have had no way of knowing this was an abnormal approach from inside. In fact, I doubt many people would, even if you'd been there many times. It's always just water water water until at the last second before touchdown you can see the hotels to the left and then to the right. But I think it would be tough to judge whether you were high or low based on the angle of those unless you really had a clear mental image of how they normally look on approach. I've been there I think four times now and to me it still always looks like we're going in the water because the plane is below the roofs of the hotels while still over the water.

So as a passenger, you just have to trust the pilots. And most people do.

Note that I'm not saying this *wasn't* an abnormal approach, just that her saying "oh my god, we're so low!" wasn't prescient. She'd almost definitely have said that in a normal landing too.

Good job WestJet, quality piloting here and even better PR response. Shameful all around, fortunately the plane was smarter than the pilots and warned them.

32andBelow wrote:

FlyHappy wrote:

40'.
I hate to run afoul of you pro pilots here, but I cannot imagine how this isnt a massive loss of SA, as the passenger window video clearly illustrates. It's amazing how calm the pax were.

Oh, and shame on West Jet for their disingenuous initial denials. As someone else mentioned, a large boat could have ended everything.

That’s what island landings look like with runways right on the beach. Water water and were here. That’s how I felt landing in Kona.

I've landed in KOA many times, as well as a several other water adjacent runways, including old Kai Tak in Hong Kong (landing approach there was mountain-side).
Sorry, but that's not what a landing should look like - that pax was correctly concerned - they were way too low.

longhauler wrote:

I remember being very aware of how long it takes high bypass ratio engines to spool up after reading the report of the Air France A320 crash at Habsheim in 1988. (If you recall, engine performance was one of the areas of interest).

http://reports.aviation-safety.net/1988 ... F-GFKC.pdf

It states that certification requirements dictate that go-around thrust be within 3% of commanded thrust no longer than 8 seconds after selecting TOGA thrust from flight idle. In this crash, thrust was at ~84% 5.5 seconds (the point of first impact) after commanding TOGA thrust. In this case, TOGA was estimated to be around 91%, so it appears that the engines were operating within standard.

As noted above, low energy go-arounds are a common simulator exercise. But in all honesty, I'd rather see it above a runway at 50' and not water. And remember, one of the parameters of "low energy" is that the thrust has been brought below flight idle, and thus TOGA would be achieved longer than 8 seconds.

It amazes me how few people understand turbo lag happens in turbomachinery. Maybe it is because turbo cars in my adolecent years had a two or three second spool up!

New engines are getting closer to the maximum certified spool up time, so flight idle thrust goes up with bypass ratio to keep within limits. Different versions of the same engine will have different programmed minimum flight idle fuel flow and thus spool times.

I'm glad everyone made it out ok.

Lightsaber

sevenair wrote:

What is it with Canada and seriously messed up NPAs? Don't they do height checks?it happened on an Airbus it nearly ended in tears for a Boeing so it's not type specific. Disappointing.

They can't help it, they're Canadian.

In all seriousness though, this is concerning. Can't believe I only heard about this incident just now.

BenTheGreat97 wrote:

So I came across this article multiple times with pictures today while browsing, and I didn't see any thread on the subject yet.

Westjet denies that the incident happened, people have said the picture is photoshopped, everyone has a different opinion.

All I've been able to find is the one article here http://christinenegroni.com/westjet-den ... t-maarten/ and a PPRuNe forum post, but it seems to be only speculation on the legitimacy of the photo.

Anyone have more info or thoughts?

Yeah, not an expert but when comparing the Westjet with KL aircraft, you can clearly see what appears to be exhaust trail in the water behind the Westjet plane. The KL does not have this.

PSA1978 wrote:

Great YouTube of the incident both inside and out to refresh memories.
https://www.youtube.com/watch?v=uN3Fd0x0FoQ

It sounds like the pilot tried to level off. You can hear the engines spool up, then stay consistent (from about 0:14-0:21), then they spool up again to TOGA (0:25) and they blast off. Might be my layman's ear, but it sounds like they tried to recover the approach by leveling off first without realizing how low they were, saw the runway lights, then went around.

osupoke07 wrote:

PSA1978 wrote:

Great YouTube of the incident both inside and out to refresh memories.
https://www.youtube.com/watch?v=uN3Fd0x0FoQ

It sounds like the pilot tried to level off. You can hear the engines spool up, then stay consistent (from about 0:14-0:21), then they spool up again to TOGA (0:25) and they blast off. Might be my layman's ear, but it sounds like they tried to recover the approach by leveling off first without realizing how low they were, saw the runway lights, then went around.

They did advance the throttles but more to do with them being off course laterally (from the investigation report):

Approximately 1 nm from the runway, the aircraft exited the shower; the visibility sharply improved, and the crew realized that they had been tracking toward an incorrect visual reference, which was a hotel situated to the left of the runway. At this point, the aircraft was 190 feet AGL, descending at 940 fpm, rather than 320 feet AGL on a standard 3° angle of descent. Now able to see the actual runway, the crew recognized that the aircraft had deviated laterally to the left of the inbound final approach course, but they were not immediately able to assess their height above water. The PF advanced the throttles from 52% to 75% N1 and began to correct the lateral deviation, but the aircraft continued to descend at about 860 fpm.

To those remarking about the noticeable thrust effects on the water surface ...

40-something feet above the water, and transitioning into a climb, at 75% or more N1 ... heck yeah, that's gonna show up in the water.

Darned lucky nobody was under there in a boat, it would have probably done them in like a waterspout (e.g. a tornado over water)

cumulushumilis wrote:

The EGPWS went off twice at 63 feet and 49 feet.

Thanks, I just saw that in the TSB report.

When the EGPWS first went off, they convinced themselves it was false. (It was not). When it went off a second time, again they throught it was false.

It was a full 9 seconds from the first EGPWS alert until they decided to go around. At the lowest point in the go-around, they were actually below the surface level of the runway. Had they been approaching anywhere but onto an island, they likely would have hit terrain.

longhauler wrote:

cumulushumilis wrote:

The EGPWS went off twice at 63 feet and 49 feet.

Thanks, I just saw that in the TSB report.

When the EGPWS first went off, they convinced themselves it was false. (It was not). When it went off a second time, again they throught it was false.

It was a full 9 seconds from the first EGPWS alert until they decided to go around. At the lowest point in the go-around, they were actually below the surface level of the runway. Had they been approaching anywhere but onto an island, they likely would have hit terrain.

I'll have to read that when I find time. Certainly several contributory factors in this event, but the human factors here by the flight crew are certainly a major concern.

Another prime example of where more automation in the cockpit is a good thing.

longhauler wrote:

cumulushumilis wrote:

The EGPWS went off twice at 63 feet and 49 feet.

Thanks, I just saw that in the TSB report.

When the EGPWS first went off, they convinced themselves it was false. (It was not). When it went off a second time, again they throught it was false.

It was a full 9 seconds from the first EGPWS alert until they decided to go around. At the lowest point in the go-around, they were actually below the surface level of the runway. Had they been approaching anywhere but onto an island, they likely would have hit terrain.

Are false EGPWS warnings relatively common?

Where’s jumbo in this discussion? Everything was all ok & safe according to him.

"The investigation determined that the runway lights and the visual guidance system (PAPI) had been set at a low intensity during the rain shower that had obscured the view of the airport environment." Shouldn't this kind of obscured view be an immediate cause to abort the approach? The controller didn't adjust the lights and didn't make it rain, I get that, but doesn't the flight crew bear the greatest responsibility here if they cant see the runway?

Could this have been avoided if the pilots paid closer attention to instruments, or was the idea that the runway was closer than they thought make that irrelevant? Like if you're that low based on instruments and you don't see Maho Beach under you, there's a problem.

spacecadet wrote:

PSA1978 wrote:

Great YouTube of the incident both inside and out to refresh memories.
https://www.youtube.com/watch?v=uN3Fd0x0FoQ

That passenger has clearly just never landed at SXM before. She said "it's like we're landing on the beach", and then "oh look, everyone's watching!" It seems like you're going to land on the beach even during a normal landing there - the beach is right off the end of the runway. And everyone's watching every plane that comes in; that's not something you'd say if you'd ever been there before.

The point being, she'd really have had no way of knowing this was an abnormal approach from inside. In fact, I doubt many people would, even if you'd been there many times. It's always just water water water until at the last second before touchdown you can see the hotels to the left and then to the right. But I think it would be tough to judge whether you were high or low based on the angle of those unless you really had a clear mental image of how they normally look on approach. I've been there I think four times now and to me it still always looks like we're going in the water because the plane is below the roofs of the hotels while still over the water.

So as a passenger, you just have to trust the pilots. And most people do.

Note that I'm not saying this *wasn't* an abnormal approach, just that her saying "oh my god, we're so low!" wasn't prescient. She'd almost definitely have said that in a normal landing too.

This a highly presumptive, dismissive response...and I think it is clear looking out the window the water and the horizon are abnormally low. Frankly, I seem to recall so many "experts" on this site saying this was perfectly normal and go-arounds happen so there was 'nothing to see here.' What a bunch of BS. This week's report sort of vindicates those who clearly saw something very dangerous happen off one of the world's most famous beaches.
Most of us do trust our pilots - to not put us in a position like this that could have easily ended up with the authorities fishing bodies off Maho Beach.

There's no question that this was a serious incident, and equally no question that the video from outside the plane showed that the situation was abnormal. I think the only point that was being made was that it's very difficult as a passenger looking out a side window to tell if a plane is too low as it approaches the runway over water. I hear people saying "We're so close to the water" every time I'm a passenger landing on 22 at LGA. The passengers had no way of knowing that they were too low on that WS flight because looking right or left, they couldn't tell whether they were close to the runway or good distance away, as they were.

dakota123 wrote:

Are false EGPWS warnings relatively common?

No, ever since the conversion from GPWS to EGPWS, false warnings are rare. I should mention though that the warnings of the original GPWS were not "false" they were just triggered by unusual terrain (fast rising) and often expected.

From reading the report, I see Westjet's SOPs are the same as most airlines, in that if one can definitely determine the EGPWS warning to be false, it can be ignored. Twice they incorrectly thought the warning false.

Where I fly, there are a few additional caveats ... if you are in "mountainous" terrain, reduced visibility or at night, a go-around is performed immediately regardless of whether you think it false.

stburke wrote:

Another prime example of where more automation in the cockpit is a good thing.

One by one by one, advanced sytems are reducing and eliminating things that brought down aircraft decades ago.

Things like EGPWS, TCAS, GPS navigation/situational awareness, RNAV non precision approaches (when properly used) etc, are making flying much much safer. The last "problem" is Human Factors. Throw a human into the equation and we find a way to screw things up!

And the greatest cause of Human Factor accidents ... fatigue!

We can solve it, but with the only solution being more pilots, it's an expensive solution.

dakota123 wrote:

longhauler wrote:

cumulushumilis wrote:

The EGPWS went off twice at 63 feet and 49 feet.

Thanks, I just saw that in the TSB report.

When the EGPWS first went off, they convinced themselves it was false. (It was not). When it went off a second time, again they throught it was false.

It was a full 9 seconds from the first EGPWS alert until they decided to go around. At the lowest point in the go-around, they were actually below the surface level of the runway. Had they been approaching anywhere but onto an island, they likely would have hit terrain.

Are false EGPWS warnings relatively common?

Not at all. The algorithms are robust. I wouldn’t think twice about believing an EGPWS Warning.

Wow. That is l.o.w.

PSA1978 wrote:

Great YouTube of the incident both inside and out to refresh memories.
https://www.youtube.com/watch?v=uN3Fd0x0FoQ

Wow. That is low.

We don't need to discuss how well the passengers understood that they were low (I think this was clearly too low even from untrained passenger viewpoint). But the *pilots* would also have seen the sea. They were not looking out of their windows at all? Busy ignoring GPWS and not looking at the water approaching them?

FlyHappy wrote:

As someone else mentioned, a large boat could have ended everything.

Even a small sailboat would have a mast hitting them. Perhaps a mast would not bring them down though.

Is there no Minimum Descent Altitude stipulated for approaches to TNCM?

stratocruiser wrote:

Is there no Minimum Descent Altitude stipulated for approaches to TNCM?

Like any approach, there would be a DH (ILS) AH (Cat3 ILS) or MDA (Non-precision) stipulated. In the case of the approach they were doing, an MDA would be noted.

To go below that altitude would be the transition from instruments to visual. In theory, the runway must have been visual to go below MDA ... and ... it must remain visual right until landing. If sight of the runway is lost, then a go-around must be performed.

So either they didn't know what they were doing (which I doubt) or they saw what they thought was the runway and continued descending. It was noted in the TSB report that they saw what they later determined to be a hotel. If they are not familiar with the airport, then this is not a surprise.

One thing to remember though, is that although you are visual from MDA to landing, the LNAV/VNAV information is still correct. It can guide you to the runway, or more importantly, can show you that you are way off course, or not where you think you are ... and go-around.

Almost every runway we land on these days has an ILS, a GPS/RNAV app with glidepath or an RNAV visual with glidepath.

That is not to say that pilots dont accept visual approaches. But one of the above approaches with glidepath should be on the PFD as a point of reference for just this reason.

For those of you discussing an obscured horizon: this isnt a Cessna from your local flying school. This is a 737 with a well trained crew, flying Class II navigation over water on a medium stage flight in daylight hours.

This is nothing short of a complete loss of Situational Awareness. That, IMO, is a total disgrace.

Don't mean to take thread off topic, but haven't seen any updates in other threads lately. What is the status of Saint Martin and SXM now 8 months after the storm? Hopefully the island is recovering and planes are again flying over Maho beach!

slcguy wrote:

Don't mean to take thread off topic, but haven't seen any updates in other threads lately. What is the status of Saint Martin and SXM now 8 months after the storm? Hopefully the island is recovering and planes are again flying over Maho beach!

https://flightaware.com/live/airport/TNCM

Yes, flights are resumed.

longhauler wrote:

dakota123 wrote:

Are false EGPWS warnings relatively common?

No, ever since the conversion from GPWS to EGPWS, false warnings are rare. I should mention though that the warnings of the original GPWS were not "false" they were just triggered by unusual terrain (fast rising) and often expected...

Thank you longhauler - for your interesting insights out of the life of a pro!

I remember back when this incident happened I was having a discussion over social media with some guys about it and one guy was trying to convince us that they were showboating and that it’s perfecly ok to do. He had at that point a year or two of experience at one of the regional carries in the US and we were a bit alarmed that someone flying passengers around and taking responsibility for their lives would think like that. He got lectured and then pretty mug disappeared which is a shame because I wanted to show him this report and prove that it was not showboating, but actually a mistake because contrary to his believe, human factors is a very real thing.

There is another element that may have had something to do with this and I have not seen it discussed above.

Windshield wipers.

I don't know how they are in the 737; I have been in the jumpseat but not in inclement weather.

But in one airliner that I have flown that has a windshield which was designed the same time as the 737, the wipers actually detracted from the safety of the flight.

They were ridiculously loud to the point of making communicating difficult, for one. And with no hot mic, which I'm guessing is the same setup as WestJet 737s, you are not only shouting over the rain hitting the glass at 150kts but also the wipers themselves.

Secondly of course is the obvious one, the view out the window. The wipers actually made it worse to see. A technique I saw that somewhat work was, the pilot monitoring reaches up for the pilot flying's wiper knob around 300 feet AGL, and manually turns them from OFF to SLOW and back to OFF, every few seconds. That would actually momentarily clear the water off, for about one second of slightly improved visibility.

Again -- I don't how just how the 737 is in this regard, but in general, if it's raining real good, it's not always easy to see anything out the window of these jets.

goboeing wrote:

There is another element that may have had something to do with this and I have not seen it discussed above.

Windshield wipers.

I don't know how they are in the 737; I have been in the jumpseat but not in inclement weather.

But in one airliner that I have flown that has a windshield which was designed the same time as the 737, the wipers actually detracted from the safety of the flight.

They were ridiculously loud to the point of making communicating difficult, for one. And with no hot mic, which I'm guessing is the same setup as WestJet 737s, you are not only shouting over the rain hitting the glass at 150kts but also the wipers themselves.

Secondly of course is the obvious one, the view out the window. The wipers actually made it worse to see. A technique I saw that somewhat work was, the pilot monitoring reaches up for the pilot flying's wiper knob around 300 feet AGL, and manually turns them from OFF to SLOW and back to OFF, every few seconds. That would actually momentarily clear the water off, for about one second of slightly improved visibility.

Again -- I don't how just how the 737 is in this regard, but in general, if it's raining real good, it's not always easy to see anything out the window of these jets.

Excellent point, something most people don’t even consider. I can’t say for sure what the status of their windshield wipers were, but on the MD-80s I fly, they are incredible loud and distracting. Often times it’s easier to squint through the rain, then to have. Windshield wipers on.

jfklganyc wrote:

This is nothing short of a complete loss of Situational Awareness. That, IMO, is a total disgrace.

While I agree 100% with your sentiment, I am reminded of when my training as an Air Accident Investigator started 30 years ago. (It was a union position at which I jumped, and have taken many years of courses since).

One of the instructors said "start from the point that the pilots are not idiots". The idea being that if they were idiots, the investigation could stop right there.

So when I see an incident like this, my thought is always leaning to what series of events and what series of occurrences led them to that point. If they are still alive, one could just ask the pilots. If they are not, then you have to put yourself in their seat and imagine the series of events. The problem with asking the pilots is that one has to remember they are trying to keep their jobs, not to mention in some countries risking legal discipline. So ... go back to imagining you are sitting in their seat, and go from there.

And, like your sentiment, I can't figure it out. No pilot would go below MDA without visual confirmation. So they must have seen something. Then, in reduced visibility they got two EGPWS warnings ... why not go around? Why did they wait 9 seconds. (Standard is that action must be completed within 5 seconds of a warning). Why did they disconnect the autopilot so far back? Why didn't they refer to the displayed VNAV/LNAV info they readily had? And lastly, how could anyone see less than 100' on the radio altimeter without concrete under them???

Remember, it is very easy to sit at one's desk a year later with all the facts and point fingers, but this one I don't get. And you are right, Situational Awareness was lost. In today's age of IRS/GPS navigation backed up with EGPWS, that's hard to do.

longhauler wrote:

stburke wrote:

We can solve it, but with the only solution being more pilots, it's an expensive solution.

Maybe one day it won't be as expensive as the status quo if the human factor is triggered too often by that single reason.