AF471 - Nov 16th 2011 - Final Report
Guys, we're still arguing in circles around the crux of the matter. Why did Land 2 necessitate a G/A? The G/A procedure was messed up, but why was it performed in the first place? Perhaps someone inside AF can enlighten us as to their SOP's.
A GA is mandatory for any warning or caution light.
An automatic landing was still possible as Land 2 indicates the autoland system does not have redundancy for a triple channel autoland.
The lack of GA – mis selection, contributed to the incident, and appears to be associated with a weak design / switch location. Just because everyone else manages to select GA does not mean that the design is adequate for all situations, especially those with surprise
Boeing spends a lot of money on ergonomics and design to make sure it feels and works right based on scientific research and not personal opinion.
Porterhouse – similarly there was no reference to the nature of a system ‘failure’ in the report which triggered event (thanks wiggy), thus the absence of evidence of a weak system design is not necessarily evidence of good design … etc, it depends on the situation, crew awareness, and choice of action.
Bloggs
Incident reports are not unchallengeable, the authors are subject to a range of human views like us (hopefully less so due to experience), but none of this should prevent us considering what if – to speculate, to learn.
During the next quiet moment in the sim, set the thrust levers in normal approach range. (Do all pilots know what that is by look / feel?) Then with the seat in ‘normal’ approach position, reach out and check the GA and AT Disc switches – differentiate between them; repeat the check when looking out of the window.
Fix those experiences in memory; they just might help in a future situation.
Bloggs
Incident reports are not unchallengeable, the authors are subject to a range of human views like us (hopefully less so due to experience), but none of this should prevent us considering what if – to speculate, to learn.
During the next quiet moment in the sim, set the thrust levers in normal approach range. (Do all pilots know what that is by look / feel?) Then with the seat in ‘normal’ approach position, reach out and check the GA and AT Disc switches – differentiate between them; repeat the check when looking out of the window.
Fix those experiences in memory; they just might help in a future situation.
Join Date: Dec 2013
Location: Paso Robles
Posts: 261
Likes: 0
Received 0 Likes
on
0 Posts
thus the absence of evidence of a weak system design is not necessarily evidence of good design
Guilty until proven innocent.
similarly there was no reference
Last edited by porterhouse; 11th Feb 2014 at 20:05.
Join Date: Jan 2014
Location: All over Africa
Posts: 39
Likes: 0
Received 0 Likes
on
0 Posts
Quoting Rat 5:
The report states the following:
How convenient! Since when do crew remove or handle the CVR or FDR from the scene of a crash??? I thought that was the job of whichever authority was investigating the case/incident/crash.
The information in the report from the pilots testimony leads me to understand that the captain could see the runway, and he wanted to continue the approach visually. The first officer had decided to follow the above SOP to the letter and go around.
What isn’t in their testimony is:
1: The captain never said he had control.
2. He never called that he had the runway in sight.
3. He never called “Continue” at minimum.
In my evaluation based on the official report, a contributing factor would be lack of communication in the cockpit. No CRM.
Guys, we're still arguing in circles around the crux of the matter. Why did Land 2 necessitate a G/A? The G/A procedure was messed up, but why was it performed in the first place? Perhaps someone inside AF can enlighten us as to their SOP's. If the G/A was not necessary then that decision is the root cause of the subsequent problems. Why, how it was messed up; autopilot disconnect forces, the position of switches, etc.etc. are all consequent of the initial action and worthy of discussion under another topic.
In direct discussion of this incident I'm curious if the G/A decision was appropriate yes/no.
In direct discussion of this incident I'm curious if the G/A decision was appropriate yes/no.
2.3 Operator instructions for CAT 3 final approach
According to the currently applicable operational documentation (GENOPS,
TU777, QRH), “Regardless of the meteorological conditions, an automatic approach
and landing are always possible. However, in both cases the following conditions
must be met:
ˆˆ The aircraft equipment must have LAND2 or LAND3 status;
ˆˆ The QFU used must have an ILS CAT2/CAT3;
ˆˆ The automatic landing limitations must be respected;
ˆˆ The task-sharing must be that of CAT2/3 approaches.”
…
“The following events result in a single “WARNING” callout making a go-around
mandatory:
ˆˆ Any audio warning;
ˆˆ Any Master Warning or Master Caution (display lights on);
ˆˆ Any degradation in capabilities;
ˆˆ Any non-compliant flight mode annunciator (FMA) display or excessive deviation
below 500 feet.”
….
“The go-around is performed by the captain, the co-pilot monitors the flight path, performs the standard callouts and the announcement to ATC.”
According to the currently applicable operational documentation (GENOPS,
TU777, QRH), “Regardless of the meteorological conditions, an automatic approach
and landing are always possible. However, in both cases the following conditions
must be met:
ˆˆ The aircraft equipment must have LAND2 or LAND3 status;
ˆˆ The QFU used must have an ILS CAT2/CAT3;
ˆˆ The automatic landing limitations must be respected;
ˆˆ The task-sharing must be that of CAT2/3 approaches.”
…
“The following events result in a single “WARNING” callout making a go-around
mandatory:
ˆˆ Any audio warning;
ˆˆ Any Master Warning or Master Caution (display lights on);
ˆˆ Any degradation in capabilities;
ˆˆ Any non-compliant flight mode annunciator (FMA) display or excessive deviation
below 500 feet.”
….
“The go-around is performed by the captain, the co-pilot monitors the flight path, performs the standard callouts and the announcement to ATC.”
The following elements are based on recorded data (QAR, FDR) and accounts from the flight crew. The CVR, which was safeguarded by the crew, was erased by mistake before it could be read out by the BEA.
The information in the report from the pilots testimony leads me to understand that the captain could see the runway, and he wanted to continue the approach visually. The first officer had decided to follow the above SOP to the letter and go around.
What isn’t in their testimony is:
1: The captain never said he had control.
2. He never called that he had the runway in sight.
3. He never called “Continue” at minimum.
In my evaluation based on the official report, a contributing factor would be lack of communication in the cockpit. No CRM.
Yet another AF problem with manual flight.
Incident: Air France A321 at Paris on Jul 20th 2012, speed drops to alpha prot on approach
How many incidents have AF had now with basic airmanship and flying the aircraft?? They really need to look at this before they kill anybody else.
Incident: Air France A321 at Paris on Jul 20th 2012, speed drops to alpha prot on approach
How many incidents have AF had now with basic airmanship and flying the aircraft?? They really need to look at this before they kill anybody else.
Join Date: Jun 2000
Location: last time I looked I was still here.
Posts: 4,507
Likes: 0
Received 0 Likes
on
0 Posts
2.3 Operator instructions for CAT 3 final approach
According to the currently applicable operational documentation (GENOPS,
TU777, QRH), “Regardless of the meteorological conditions, an automatic approach
and landing are always possible. However, in both cases the following conditions
must be met:
ˆˆ The aircraft equipment must have LAND2 or LAND3 status;
ˆˆ The QFU used must have an ILS CAT2/CAT3;
ˆˆ The automatic landing limitations must be respected;
ˆˆ The task-sharing must be that of CAT2/3 approaches.”
I ask again: therefore why was a G/A required? I read the 2nd paragraph of the post and it talks about warnings etc = G/A. But a simple down-grade from Land 3 to Land 2 does not require a G/A. On B767 there is no Master Caution for such a change; is there on B777?
According to the currently applicable operational documentation (GENOPS,
TU777, QRH), “Regardless of the meteorological conditions, an automatic approach
and landing are always possible. However, in both cases the following conditions
must be met:
ˆˆ The aircraft equipment must have LAND2 or LAND3 status;
ˆˆ The QFU used must have an ILS CAT2/CAT3;
ˆˆ The automatic landing limitations must be respected;
ˆˆ The task-sharing must be that of CAT2/3 approaches.”
I ask again: therefore why was a G/A required? I read the 2nd paragraph of the post and it talks about warnings etc = G/A. But a simple down-grade from Land 3 to Land 2 does not require a G/A. On B767 there is no Master Caution for such a change; is there on B777?
Join Date: Jun 2008
Location: Rocky Mts High
Age: 61
Posts: 32
Likes: 0
Received 0 Likes
on
0 Posts
A lot of posts and " pontifications " in this thread reveal the emperor without clothes. Sigh, stfu if you have never had Cat 2/3 training or expertise!
Unless the skipper had called visual or continue, they are duty- bound to go around once the automation degraded to LAND 2. Their lowest minimums then changed to Cat 3A minimums and
A) they are below a gate ( usually 1000' AGL ) to change their " minimums "
settings.
B) the actual reported weather was below Cat 3A.
C) if they had not briefed on downgrading to Cat 3A.
Any of the above three provisos would have predicated the PM to call for Go Around.
I agree with totempole that the 777 is designed, certified for 2 man operations and the CAT 2/3 training is based on that. Introducing a 3rd person making a call out from a location the PF not expected to hear from in a " tunnel vision " scenario on a deeply focussed Cat 2/3 approach can have a " stun " effect leading to brain farts. I am sure a lot of pilots feel this way BUT WITH THE MODERN CRM CRAP, it is not politically correct to say so. You will deemed to be " not a team player, a maverick " going against new conventional " wisdom ".
Unless the skipper had called visual or continue, they are duty- bound to go around once the automation degraded to LAND 2. Their lowest minimums then changed to Cat 3A minimums and
A) they are below a gate ( usually 1000' AGL ) to change their " minimums "
settings.
B) the actual reported weather was below Cat 3A.
C) if they had not briefed on downgrading to Cat 3A.
Any of the above three provisos would have predicated the PM to call for Go Around.
I agree with totempole that the 777 is designed, certified for 2 man operations and the CAT 2/3 training is based on that. Introducing a 3rd person making a call out from a location the PF not expected to hear from in a " tunnel vision " scenario on a deeply focussed Cat 2/3 approach can have a " stun " effect leading to brain farts. I am sure a lot of pilots feel this way BUT WITH THE MODERN CRM CRAP, it is not politically correct to say so. You will deemed to be " not a team player, a maverick " going against new conventional " wisdom ".
Join Date: Mar 2010
Location: L.A.
Age: 56
Posts: 579
Likes: 0
Received 0 Likes
on
0 Posts
Normal GA practice.
What were the crew rosters like till the material incident date?
Were there any phisiogical causal factors that might have undermined the Captain who was PF?
Were there any stressful events enroute.
Were there any phisiogical causal factors that might have undermined the Captain who was PF?
Were there any stressful events enroute.
In training...
The single engine GA occurs at decision; is sedate due to low power availability; and is practiced endlessly. The all-engine GA is always unexpected; the aircraft can climb like a f...t in a bath; the MA altitude may be very low; and the manoeuvre is never practiced in the sim. The result being surprise combined with not entirely organised chaos.
Disregard the fact that this should have been either a (manual?) landing or a simple TOGA-push GA - it became more complex the second the wrong button was pushed. The reaction was then to go into a manual GA. Thats not a bad decision, as the PIC may not have realised why the a/c did not GA automatically when the (wrong) button was pushed.
The problem therefore comes down to an inability to do a manual GA under pressure. The primary reason for that may well be that the last time this pilot did an all-engine GA was ten years ago. The secondary reason appears to be a complete inability of Air France pilots to hand fly their aircraft. Unless all Air France pilots are given a 2-week gliding course, I for one will not be flying with them.
