A319 CDG go-around nearly goes down Sept 2009
 

Report: Air France A319 at Paris on Sep 23rd 2009, go-around nearly goes down

An Air France Airbus A319-100, registration F-GRHU performing flight AF-2545 from Moscow Sheremetyevo (Russia) to Paris Charles de Gaulle (France) with 85 passengers and 6 crew, was performing an ILS Category I approach to Charles de Gaulle's runway 27R in fog, visibility of 3000 meters below scattered cloud ceiling 200 and broken cloud ceiling 300 feet, autothrottle was engaged and the autopilot had captured both localizer and glideslope at 3000 feet. Subsequently both autopilot and autothrottle were disengaged, the flight director remained engaged in approach mode and the approach was flown manually by the captain (pilot flying). Descending through 2170 the gear was selected down and full flaps deployed. When the airplane descended through 400 feet AGL the flight director modes changed to LAND, airspeed was 132 KIAS (Vapp 128 KIAS) and pitch angle 0.7 degrees nose up. At 200 feet AGL, the decision height, the captain did not see the runway ahead and decided to go-around. When the airplane descended through 150 feet AGL at 132 KIAS the thrust levers were placed into the FLX/MCT detent, the engines spooled up from 45 to 85% in about 5 seconds, the airplane pitched up to 5.6 degrees nose up, the flaps were selected to 3. 4 seconds later the pitch angle had reduced to 4.6 degrees nose up, the autopilot 1 was engaged - autopilot mode was still LAND - and the gear was selected up. At that point the airplane had reached 170 feet AGL at 145 KIAS. 5 seconds later the thrust levers were placed into the CLB detent, the airplane is still at 170 feet AGL and the airspeed was 161 KIAS, the nose pitched down 0.6 degrees nose down. 2 seconds later the height reduced to 127 feet at 169 KIAS, the attitude had reached 3.9 degrees nose down. The autopilot gets disconnected, a ground proximity warning "Sink Rate" is issued. At the same time the crew communicated their decision to go-around to the tower, the controller cleared the airplane to 3000 feet and to continue on runway heading. The crew did not read back, the tower repeated the instructions two times before he received the read back. The airplane descended further to a height of 76 feet at a speed of 182 KIAS, the aircraft pitched up to 8.1 degrees nose up producing a vertical acceleration of 1.65G, the airplane begins to climb and the ground proximity warning ceases. 1 second later the pitch increases through 9 degrees nose up with an airspeed of 184 KIAS and the master caution activates probably because of maximum flaps speed being exceeded (185 KIAS). The thrust levers are retarded to a position close to IDLE while the airplane climbed through 650 feet AGL at the maximum recorded speed of 192 KIAS. 15 seconds the autopilot gets engaged, the nose pitches down to 2.5 degrees nose up, the thrust levers are placed into the CLB detent, then the autopilot gets disengaged again and the pilot flying pulled the stick. 13 seconds later the thrust levers are placed to IDLE, the pilot monitoring selected an altitude of 4000 feet into the master control panel. When the airplane climbed through 1600 feet, the pilot flying called for the autopilot and placed the thrust levers into the CLB detent. The autopilot again pitched the aircraft down and is disengaged after 2 seconds. Flaps were now selected to 1 and the flight stabilized. The crew subsequently performed an ILS Category III approach and completed a safe landing.

The French Bureau d'Enquetes et d'Analyses (BEA) released their final report in French concluding the probable cause of the serious incident was:

Loss of altitude due to
- the use of the autopilot in an inappropriate way
- the non-activation of go-around mode due to the thrust levers being placed into wrong detents
- lack of monitoring of pitch angle by the crew

Contributing factors were:

- inaccuracies in the wording of the documentation of the procedure
- deviations from the procedure regarding operating limits

The captain (53) had 14230 hours flying experience thereof 3800 on type and 3627 in command on type. He was certified for CATIII approaches.

The first officer (42) had 4176 hours flying experience thereof 684 on type. He was certified for CATIII approaches.

The BEA analysed, that the autoflight system remained in LAND mode all time because the thrust levers were never placed into the TOGA detent. Only TOGA cancels all previous modes and activates the go-around mode.

The autopilot mode therefore continued to descend the aircraft while the changed thrust setting increased the speed. The desire by the captain to engage the autopilot suggests that he wanted to reduce his high workload. The recommendations by the operators also suggested the use of the autopilot. During normal operation the TOGA detent is very rarely used. After placing the thrust levers from nearly IDLE into the FLX/MCT detent (which is a long way the BEA annotates) the engines reacted as wanted, following the autopilot activation the crew was surprised however about the reaction of the aircraft. It is likely that the crew focussed on the speed and the pending flap overspeed and did not notice the flight mode announciations. The crew attempted three times to engage the autopilot while still in the wrong flight mode.

According to the Flight Crew Operating Manual by Airbus a go-around from manual flight control should be done by advancing the thrust levers into the TOGA detent and according flight control inputs. Once a positive climb is established, the crew should read the flight mode announciators and verify the modes.

The operators manual did not mention that the flight mode announciators should be read and verified, however, general guideline required every change in the flight mode announciation should be called out.

The BEA analysed that in the phase of a go-around the pilot flying is focussed on the trajectory of flight and work memory checklist items therefore has reduced capacity for verifying the flight mode announciators. The changes would be more easily seen by the pilot monitoring, the standard operating procedures did not distribute the tasks appropriately taking the work load and capacities of crew members into account.

The BEA listed another similiar incident during which the crew placed the thrust levers into the FLX/MCT detent instead of the TOGA detent, see Report: Jetstar A320 at Melbourne on Jul 21st 2007, descends towards runway despite go-around initiated. In September 2006 the crew of an Airbus A320 commenced a go-around at 50 feet AGL following a precision approach but failed to spot the autopilot had disengaged. In March 2007 the crew of an A330 initiated a go-around at Abidjan but failed to control the altitude and pitch angle resulting in a sharp nose down rotation and a ground proximity warning.

inaccuracies in the wording of the documentation of the procedure

what they need is the manuals translated into Frog:ok:

All AF Airbus maunuals are already in frog !

Almost as good as the one on 22/10/93 where they forgot to raise the gear subsequent to cleaning up the flaps after T/O, and due to the excessive aerodynamic noise and buffeting Monsieur le CDB shut down both engines ? ? ! ! @ 4500ft. :eek: Difficult to confuse start levers (or whatever Airboos calls them) with gear handle, but well, got to get rid of the damn noise Eh? bet the noise from the RHS was even louder & more insistent after that stunt :=
Well, the engines were restarted by 1600ft and they WERE going to Lourdes, so i guess that is alright then.

Would these Air inter (& ex Air Inter? ) pilots be the same ones whose union was clamouring to have everything translated into French.

"Live another day,

check your FMA...."

How many times in the last few years would that have saved the day? Kenyan ? Ethiopian ? Turkish? Flash Airlines? TAM ? etc etc

Why do we continue to read about Airbus go-arounds that are so mismanaged? How difficult is it to push the thrust levers all the way forward till they won't go any further and pitch to follow the FD's? :rolleyes:

The Capt had close to 5000 hrs on type and 14000 total time - you'd think that he would have a reasonable idea that when < 200' agl it is rather important to ensure you're going up in the event of GA. The actions on the thrust levers are also rather alarming.

I'm sure all the Airbus bashers are going to come out the woodwork - but a GA in a Bus is NOT difficult.

A4

& may I add in this case increasing pitch attitude.

This is a scenario I often demo in the sim to impress upon the crews the feeling of climbing due to acceleration. It seems from my own observations that we are so busy during the go-around that we concentrate on everything apart from our primary flight instrument!

Here's the future operating in the present day -

"G/A"

at 170'

"A/P on" :eek::ugh::{:uhoh::yuk::(:bored::\:ooh:

Then "gear up"


Aviate, navigate, communicate. ABC, 123, baby you and me (with apologies to Jackson Five fans)

A remarkably similar scenario to an Australian A320 that executed a go-around in Melbourne.

Thinking that myself Mr CW.

Perhaps due to the same cause, a management change to SOPs to save money but contrary to the recommended procedure as laid down by the manufacturer. :=:uhoh::mad:

See discussions starting at page 68, also page 101:

USAir Flight 1016.

Thanks Huck.

Now, is it just me, or is this really NOT the time to do a no autopilot and no autothrust approach?!

Automation is there to reduce workload in situations like this, not to increase it as seemed to happen in this case.

Leave the automatics in and if at DH you're not visual, slam the thrust levers all the way forward, get the gear and flap up and the aircraft will pretty much do the go-around for you.... leaving you as the pilot the capacity to monitor what is going on.

Complete loss of situational awareness caused by a totally unnecessary increase in work load.

CFIT
 

//disclaimer: not A3xx rated//
wouldn't the gear retraction trigger a "don't sink" call from the EGPWS?
with all manner of visual cues (classic vestibular-acceleration is something we all experience and learn to overcome...?) ii have to agree with the 'basic airmanship' comments thus far..
neilki

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.

Misd-agin,

When the cloud base is 100' above your minima, flying into an airport as busy as CDG, I would absolutely use the automatics every single time. The whole point of automatics is to take the workload off us and enable us to step back and monitor the whole situation better.

At the time of the G/A, the PF was obviously so overloaded with the flying that he forgot to put the thrust levers into the TOGA gate.

Don't get me wrong, I love a bit of manual flying whenever I can and I practice it as often as I can, but only when the weather is decent. We're paid to make decisions. Making the decision that this was a good time to practice some manual flying wasn't a great one.

"as busy as CDG". That was good for a laugh. I've been there. 'Busy' is obviously a subjective term, especially to U.S. flyers.

Obviously not the sharpest knives in the drawer. Flying performance, and attempting to engage a/p at very low altitude, IMO support my POV.

How does their attempts to engage the A/P at low altitude support your PoV exactly?

In the midst of a G/A, at 170' AGL, I'm of the opinion that flying the a/c is more important than trying to engage automation.

I've yet to see a G/A procedure that inserted 'auto pilot - on' before the 'gear up' command. :sad: