A319 CDG go-around nearly goes down Sept 2009

[sharpclassic]

Cosmo,

I do agree with you with the mindset of the issuse but what I was trying to convey was that had the AP been engaged during the approach, the PF most probably would not have become so overloaded that he forgot to put the thrust Levers into TOGA...

[cosmo kramer]

sharpclassic,
I understand the point, but it's not really addressing the underlying issue - why he could become so overloaded from performing a standard maneuver.

One thing is not "getting in". Of course the approach can be conducted at a greater ease with auto pilot engaged, better overview and capacity to look out, then disconnect and land. But from the start of the go-around all this is history, and the point is now only to get the aircraft away from the ground. It's a new maneuver, a new task and the fact that he didn't land but initiated the go around should have been a reset point. And then a maneuver that is quite simple - pitch, throttle, breathe and take it easy. Only those two things are really important. As long as both engines are operating it will get away from the ground even with landing flaps and the gear down.

Then how could the go-around get so messed up. That is the issue to uncover, rather than to blame it on underuse of automation.

Was it training? fatigue? or... what was the reason? Or perhaps it was none of those and simply the one time in the career where the curtain goes down on an otherwise skilled pilot - Then how come the co-pilot didn't react? Training? fatigue? the same questions over again.. plus some new ones, like culture? hierarchy? etc.

If the reason is found it can, perhaps, be corrected.

[solitaire]

Solitaire...the b737-800and 400 will have autopilot disconnect when the TOGA switch is pressed. So, yes...modern aircraft do require manual go-arounds. The 737-800 is a modern aircraft but will not do an auto go-around like the 747.

I stand corrected. Not flown the 737 but even the 747-100 did auto go-arounds so assumed that more modern aircraft would too.

Back in my box now.

[odericko2000]

The 737 only does auto go-arounds on condition that you are performing a dual channel approach, on hitting TO/GA one auto pilot is knocked off and the remaining autopilot takes over the go around, on single channel approaches when you hit TO/GA the autopilot flying the approach at the time is knocked off and the PF has to take over the go around....manually that is

[cosmo kramer]

The 737 only does auto go-arounds on condition that you are performing a dual channel approach, on hitting TO/GA one auto pilot is knocked off and the remaining autopilot takes over the go around

Actually both AP remains engaged in pitch mode until missed approach altitude is captured or another roll mode is selected. Both provided that sufficient time has passed for the stabilizer has returned to normal trim, otherwise - oh god - the pilot has to fly the aircraft manually! A dangerous beast such a 737, not suitable for modern day Commercial Air Transport, since "Todays aircraft are NOT designed for manual flying as we used to know it."

[odericko2000]

Thanks for pointing out my mistake cosmo, it's true both AP stay engaged in pitch. But selecting another roll mode jus gives you singleAP roll mode operation the pitch still remains in TO/GA dual AP control, everything else you pointed out is dead accurate

[CONF iture]

BEA Report

I don't know if it has been posted before but here is the BEA report.
Some interesting comments but I could not find an English version.

[Graybeard]

So, if you are expected to use automatics all the time they are available, the only time you hand fly is when something is broken..

9,000 hours watching George fly a fully functioning airplane, and a total of five hours hand flying a cripple in that period.. What could go wroing?

GB

[rigpiggy]

I hand fly every approach in the wigglepig, @ 300-1 we do a pma, not because I need to but our SOP's require it. 300-2 is easy peasy, PMA's are done down to 200-R1200. Don't forget you are pilots people, not monkeys as HR/Accounting/Flt Ops want you to be. Fly the GD Airplane


Sharpclassic - almost 2 miles vis and 300' ceiling, and you want to mandate autopilot approaches?

Obviously I'm not a fan of the 'new' way of thinking that mandates every increasing use of the automation.

[Airbrake]

Rigpiggy, we all agree manual flying skills are being eroded by automation, and regular practice is important. However, doing a manual approach in marginal CAT1 conditions is probably not the best time to do it.

At the very least a go around costs you 15mins of fuel and time, which in a typical short haul schedule is going to compress the rest of your day and probably delay several hundred passengers.

Explaining to them that you fancied a bit of manual flying as the reason for their delay would be met with a certain amount of irritation. Our Airfrance colleague made a poor decision and showed that he had given even less thought to his go around than he had to his decision to fly a manual approach.

[Huck]

The moral: you can hand-fly a Cat I, but you better not screw it up......

[Nubboy]

Just had a quick scan at the beginning of the report in french.
14,000 hrs, TRI on type, 3,800 on type. Elected to hand fly with manual thrust . Fully configured and stable at 2,000' agl. Immediately following an A330 which got in. However a previous AF had just missed. A new METAR showed 1000 m vis, scattered 1500', broken 230'. Decided at 200', put power on to FLX/MCT and pitch to 5deg at 150' agl. Reduced flap to config3, engaged AP1 and called for gear up. Watched aircraft level off and start descending. Disconnected AP and pull hard ish. Missed Go around instructions from ATC. Master warnings audible ove the R/T link. Min height of 76' agl.

Seems like a lot of dubious decisions and poor airmanship here. I wonder who was head down and looking in, and head up and looking out. 50 foot height difference between decision and commencing the go around. Not pushing the thrust levers all the way to TOGA. Not reading the FMA and seeing LAND gren still illumintated. Not pitching to at least 10deg nose up one engine inop, or preferably 15 with both engines working. Going for the autopilot before climbing safely away from the ground.

Sometime ago we had a series of events in the poor vis sections of our sim training. The instructor would fail the GO AROUND mode after inducing a low level go around due to another failure or winding the vis/cloudbase right down. Even if you selected TOGA, the FMS was stuck in LAND mode. You had to disconnect the autopilot, ensure TOGA thrust and hand fly away from the runway. Any crew that didn't would find the box on legs heading downhill, with the thrust rolling back. Not pretty.

Lessons for us all here I think.

[hetfield]

Sometime ago we had a series of events in the poor vis sections of our sim training. The instructor would fail the GO AROUND mode after inducing a low level go around due to another failure or winding the vis/cloudbase right down. Even if you selected TOGA, the FMS was stuck in LAND mode. You had to disconnect the autopilot, ensure TOGA thrust and hand fly away from the runway. Any crew that didn't would find the box on legs heading downhill, with the thrust rolling back. Not pretty.

Sounds familiar... Sometimes longer de-briefing.....

[wiggy]

solitaire

I stand corrected. Not flown the 737 but even the 747-100 did auto go-arounds so assumed that more modern aircraft would too.

Back in my box now.

Just to be clear there's no need to get back in your box, you're not far wrong.

If you opt to fly a coupled approach in a genuinely modern Boeing product such as the rip roaring up to date 747-400 or the 777 you will, by default, be flying a multi channel approach. If you hit the TOGA switches with the Autopilot engaged you will do an automatic go-around.If TOGA is pressed the power should run up to Go around power, the aircraft will pitch to fly a 2000' ROC and the aircraft will hold the current ground track..the autopilot certainly shouldn't disengage.

[Huck]

The instructor would fail the GO AROUND mode after inducing a low level go around due to another failure or winding the vis/cloudbase right down.

My kind of instructor.

[CONF iture]

translated notes from the report

The leading idea for the captain was to proceed with a 'smooth' go around by slowly applying thrust. By doing so he inadvertently stopped to the second detent he met which is MCT but does not trigger the all go around logic.

Following an earlier event of dubious go around maneuver, Air France had decided :

• To practice a go around exercise on all engines with low level capture.
• To modify how teaching go around maneuvers to ensure that the reading of FMA in the initial phase of the procedure does not occur at the expense of the control of pitch and thrust, the monitoring of the primary parameters remains a priority in all circumstances.

Following the incident of September 2009, the company has reminded all pilots :

• The thrust levers must be forwarded to the TOGA mechanical stop.
• Any alteration of the procedure in order to obtain a smoother go around must be prohibited.
• Pitch control is paramount.
• AP should be engaged only after the trajectory has been stabilized and the FMA is coherent.
• A return to basic principles of flight and appropriate training are necessary.

[waddawurld]

It seems to me that while its already been discussed that when flying an approach to weather minimums crews should have briefed both the approach AND potential missed, and that the PF should at least have mentally gone over the missed approach (go around) procedures--memory items et al, but the idea that you disengage the AP at minimums (or near) or that you engage it at the start of the missed IMHO is, at best, poor practice, and I would hope, contrary to SOP's. It was for us. You want to fly the approach manually-- disengage at the IAP not the DH(A), and if you miss, you stay in the mode of flight you were in during the approach until you have a stabilized go-around established. I'm just sayin...

[p51guy]

Going into Atlanta one day in turbulent IFR conditions at 300 ft my MD80 autopilot shut down. We were still in the clouds so had to do what we could to salvage the approach. We did a recovery and landed but it was not what we planned. Sometimes you don't get what you expect.

[A4]

So the Capts a TRI on type......... ok That's even more worrying. He wanted a "smooth" go-around - ok, once it's going up just come back to the CLB detent if you don't want/need TOGA - the important thing is to make sure it's going UP! This aircraft got within half wingspan of touching down....

I'm an advocate of maintaining handling skills - but there's a time and a place and marginal LVP's is not the time. There are serious questions about decision making and situational awareness here.

I know we can all make mistakes but how can a TRI make such a fundamental error?

A4

[misd-agin]

Following an earlier event of dubious go around maneuver, Air France had decided :

• To practice a go around exercise on all engines with low level capture.
• To modify how teaching go around maneuvers to ensure that the reading of FMA in the initial phase of the procedure does not occur at the expense of the control of pitch and thrust, the monitoring of the primary parameters remains a priority in all circumstances.

Oh, that's really exciting news. A focus back to flying the airplane FIRST. Geez, where'd we lose focus on THAT?