PPRuNe Forums - View Single Post - B737 Go-Around tragedy. Pilot error all over again
Old 31st Dec 2019, 08:36
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Goldenrivett
 
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Originally Posted by Stuka Child
maybe you can share it for everyone to read.
https://www.skybrary.aero/index.php/..._2002_(HF_LOC)
Click on the red link.

"When initiating the auto “Go-around”, the auto throttle became engaged, and increased automatically the engine trust to the EPR limit. The application of the under wing engine power also gave a pitch up movement. The flight director pitch bar commanded a pitch attitude of 15o. (The AFDS commanded a level off at 2 500 ft (the last assigned altitude by ATC). The AFDS calculates the high closure rate to 2 500 ft and captures that altitude almost immediately; causing the A/T to change from Go-around mode to retard power to MCP selected speed (150 kt)). The aircraft therefore climbed very rapidly through the MCP selected altitude of 2 500 ft and with the aircraft pitch increasing to 21o. AAIB/N considers that the Commander at this time had lost situational awareness (being “behind the aircraft”).

2.2.3 As the Commander noticed the speed to be rapidly decreasing, he pushed the control column forward. This was in order to follow the command of level off at 2 500 ft. Pushing the control column forward is also an elementary flying procedure to increase the speed and to prevent the aircraft from entering a stall.

2.2.4 The First Officer at this time called for “Bug up”. The Commander reached for and reset the MCP speed. This was contrary to company Standard Operation Procedure. Simultaneously the Commander continued to push the control column even more forward. The aircraft reached a maximum altitude of 2 895 ft and the load factor reached a negative g-value of –0.6.

2.2.5 The aircraft then entered a rapid dive, and the speed increased. Different warnings were given of ground proximity and the command of pull up by the aircraft systems, but not registered by the crew. The A/T reduced the trust from 98% N1 (full power) to 45% N1 (idle power). The negative pitch reached a maximum value nose down of 49o. Up to this time the First Officer had been somewhat passive and confused. Now he acted as an active and co-operative crew member and asked: “What are you doing” and next, he called out: “Pull up!” - “Pull up!”. Both pilots pulled back on their control columns, and the aircraft, after reaching a maximum speed of 251 kt, recovered from the dive with a clearance of 321 ft (radio height) over the north end of the runway 01L. During the pull-up the load factor increased to positive G-value of 3.59."

What common effect causes some disoriented crews to push to 49o nose dow?
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