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:

And that's my point... they should never have been in the situation where they felt like they had to put the autopilot on. It should have already been in from when they started their approach.

I don't want to divert this into another discussion about the mindset of using and not using automatics.

My point is that when the weather isn't top notch, as in this situation, use whatever means you have at your disposal to keep your workload to a minimum.

I have lost count of the number of times (particularly at airports shall we say "less than major") where I have been given actual wx as being close to , but not at, limits, be it CloudBase or vis, only to have the hotshot next to me question why I have mandated an autopilot approach to an autoland assuming not prohibited on the particular approach plate.
I have also lost count of the instances where, at minima, we have on same occasions, seen enough to ascertain our position, but not enough to comfortably disengage the autopilot and wrestle the beast onto the ground, whilst trying to correlate the limited visual cues with some semblance of spatial orientation sufficient to prevent an awesome "arrival".
I have been in this situation often enough that my justification now is simply "it is much better,believe me" and cannot fathom why an experienced guy would wish to increases his workload in such weather, at such a major airport, what was he trying to prove, and to whom?
One thing he certainly proved beyond doubt was his total inability to make best use of the resources at his disposal. "Top Gun" isn't what is required, and wasn't what he achieved.

What is it again ? "a superior pilot is the one who uses his superior judgement to avoid circumstances where he may be called upon to demonstrate his superior skills" QED.

IMO the question is did the authorities 'cull the herd'?

captplaystation I would agree with your reasoning provided LVPs were in force.

If LVPs are not in force, then I would not "mitigate" the poor weather by doing an autoland - since I need to "monitor" the autopilot in poor vis. I'd rather do as trained, and monitor myself / colleague doing a manual landing. I'll leave autolands for, as trained, LVPs or "practice" ones in good weather.

I've seen enough "practice" autolands frighten me, largely I suspect due protected areas infringed, in good weather to not wish to play the same game in marginal CAT 1.

So I agree is an issue - fly a coupled App to Manual Landing from DH and if the references are not comfortably visible at DH, GA and tell ATC to implement LVPs - I'd suggest don't take part in their game and do Autolands without the appropriate protection ;)

NoD

SC.

Absolutely. I wonder when some folks are going to accept the fact that Commercial Air Transport flying is no longer what it used to be and also thank God for the greatly reduced accident rate that has resulted from the brilliant work done by the engineers. (They are the real heros; we pilots just get paid to have fun (arguably!)

Face the facts, guys. Todays aircraft are NOT designed for manual flying as we used to know it. There is far too much MCP/MCDU/AP/AT work involved for it to be comfortable in anything but the most benign of ATC/WX environments. The PM is usually overloaded, dealing with MCP/ATC/config changes etc etc, and is mostly out of the loop as far as monitoring what the PF is doing. (Several accidents are proof of this). Worse still is the fact that the PF is usually so busy concentrating on his (rusty) flying that he has little capacity to monitor what the PM is doing (did he set the correct requested FD heading/altitude/mode change? Did he execute LNAV? Did he select the correct waypoint to execute ( must be confirmed by both). Who is calling the FMA? (Critical, and yet often missed, with dire consequences, as we know). In the old days, basic scanning was straightforward, but it's a different ballgame now.

All this should be, and usually is, no problem on nice sunny days in the local environment, but as professional pilots, this is not where we spend a lot of our time. We are usually taking off or landing around the Midnight Hour when fatigue is an issue and performance is probably not at it's best.

So why not load the dice in your favour by using the equipment as it was designed to be used? No macho at stake here, no egos .Just do a safe job. But above all, we have to "Fight like crazy against Complacency", especially the automation kind, i.e by trying to understand as best as we can (not easy!) the ins and outs of these wonderful gizmos that we have been gifted with.

Eroding flying skills? Well, I always say--head down to the local flying club (Redhill?), climb into a Pitts special and prove to yourself (if so inclined), that you still have the Right Stuff.

But please don't try it when you have 400 or whatever customers riding down the back, (including maybe your wife and kids). You'll probably find you're not as hot as you should/used to be.

Nobodys fault really, and especially for we old timers-.("The older I get, the better I was"). Today, the market demands that some of us fly ultra long haul, which means maybe one or two handling sectors a month. So I'm for max use of automation on the line, but at all times trying to "Mind the Store", i.e keeping the basics in mind. With Big Brother watching your every move these days, (unstabilised approaches, etc, etc, etc), who wants tea and biccys with the Chief Pilot? I rest my case.

(p.s no comments please from the short haul/lo co guys. I am sure you fellows are well in the groove. Flight Director? What's that!)

After the melbourne similar incident, Airbus changed the go around procedure to call out FMA after initiating a go around "MAN TOGA, SRS, GA TRACK" so that if you have not gone to TOGA it should be picked up straight away.

Amen brother! :ok:

''After the melbourne similar incident, Airbus changed the go around procedure to call out FMA after initiating a go around "MAN TOGA, SRS, GA TRACK" so that if you have not gone to TOGA it should be picked up straight away''

And we've got a step further in that the PM checks and calls "Thrust Set'' as a belt and braces system. It not something we do often, the safety net needs to be in place.

53 year old pilot flying a manual approach down to minimums with punters on board?

When he can't cope with the go around he engages the auto pilot?

Reminds me of my younger days flying with WW2 pilots who couldn't cope with a swept wing jet approaching way on the back side of the drag curve.

Manual throttle was banned except in the case of an engine out.

Landings were often controlled crashes.

There were a few who due to "ageing" and loss of visual accommodation couldn't read the warning panel and would ask what the warning was while they were trying to manual fly.

My third employer (also "flag carrier") wouldn't allow us to fly manually (we were allowed to fly CWS but when I first tried around 5 grand on approach after an atlantic crossing it was promptly re engaged by sir).

I realized in my late thirties that I my performance was degrading so tailored my use of equipment to my physical condition (night flight, fatigue, etc).

In my last company if I had tried to fly a manual approach to minimums on a check I would have failed.

We did practice raw data as well as FD approaches but only when neither pilots were tired and never with weather below 500ft.

The simulator is the place to play heros.

On the age thread I seem to remember reading that the skipper on AF Rio flight wasn't in the cockpit when it crashed - presumably in the bunk.
If he couldn't remain awake to fly through the most dangerous weather zone on this planet then perhaps he shouldn't have been flying the route.

My third employer flew very differently to my first two, we had to learn a table of configuration+attitude+power= performance.
I initially pooh - poohed the system but realize that they were ahead of their time.

BA only taught that system on Concorde at that time (see Mike Riley's book -stick and rudder).

Apparently prior to the Rio accident AF did not have a simulator exercise at cruise level to cope with loss of air data (Aerlingus did).


And what was a 46 yr old doing in the RHS and not doing?
Command failure or ex military? Seems rather old to be in that seat in AF.

The decision was foolish to fly a manual approach to minimums with punters on board - even if he could. He obviously, on this occasion, had a deficiency in his abilities in managing and understanding the automatics.

My point is; is it a culture and training problem in Air France?

misd-agin I see that cdg is listed as the 5th busiest airport in the world (10th Jun 2010 listings). With two from the states, LHR and one from Japan above it. So it would appear misd out on that one as well!:ugh:
If you ask nicely next time the capt may let you sit up the front for landing and you may get a better understanding of what the other fellas on this thread are discussing.

The Don

check your stats.
 

CDG no 5?

Uhm.. no? Check those stats again, or provide source please. CDG is typically around number 7 or 10 depending on what year (as well as 2010), with pretty much everyone above being American airfields.

Un peau de thread drift?

Ref calling FMA modes...yes it is important, but less important than making sure the aircraft is doing what you want rather than the modes saying what you want them to say!

If you are flying le bus manually and you select TOGA you will get all ther correct FMA's but you still have to pull the stick back to point the aircraft upwards, it will not do it itself!

donbdense - CDG is high on the list. Sorry, it doesn't feel as busy as some of the others on the list. Maybe it's having two landing runways/3 parallel runways vs. the single arrival runway ops, or intersecting runway configuration, that some of the 'busier' feeling airports are limited to.

World's busiest airports by traffic movements - Wikipedia, the free encyclopedia

Been to 25 out of the top 30. Just short of 19,500 binocular hours with another 1000+ monocular hours. Probably enough to have an opinion.

"Busy" can be pretty subjective. I've flown into 16 of the top 20, but LGA at 26 generally "feels" busier than all of them. It all comes down to runway configuration and departure/arrival procedures. How's that for some thread drift.

If you fly Boeing it doesn't matter, since the auto pilot disconnects as soon as you press toga. A go-around is always flown manually unless you are doing a dual channel approach (autoland). With a single channel approach, the auto pilot is not able to perform the go-around. Doing a dual channel approach with a manual landing is a very bad idea, since the autopilot will then trim the stabilizer quite a lot nose up by 370 feet. This pitch up, you do not what to deal with when you disconnect at 200 feet in poor vis. Doing an autoland when LVP not in force and no protected TDZ, may also not be the best idea, for the reasons given by NigelOnDraft. All in all no auto pilot go-around available, in the above situation.

This leads to this question; when every Boeing pilot has to do a manual go-around, how come that Airbus pilots absolutely should leave the autopilot on? Like already said, it's not that difficult to shove in a handful and pull the nose up.

..or are the manual flying skills deteriorating that much when flying Airbus?

:D

"it's not that difficult to shove in a handful and pull the nose up."

I don't think it's just Airbus that have a problems with G/A

Thomsonfly 737 stalled on approach says UK accident report

Not sure what model of Boeing you're talking about (377??) , but this certainly doesn't apply to any modern one!! They are all perfectly capable of flying automatic go-arounds.

Cosmo,

We do it that way because that's the way that Airbus designed the aircraft to be flown. As Phantom Driver said, love it or hate it, modern aircraft aren't designed to be flown the old fashioned 'Atlantic Baron' way.

If a G/A is done by hand in a Boeing, then you do it by hand as that's the way that Boeing designed it to be done. As a result, the way that you were trained to fly your Boeing (I assume) would teach you the method and mindset of doing a G/A manually.

As the Airbus is capable of doing the G/A automatically (once we have put the thrust levers in the TOGA gate) we are trained to do it this way, especially when the weather is marginal.

It's not an Airbus vs Boeing thing, it's just the way the two different types have been designed.



Going back to my original point, we talk about the 'Swiss Cheese' Model in CRM..... this incident could have been stopped as far back as ToD when during the brief the PF had said something along the lines of... "As the weather isn't great, I'm going to leave the autopilot in till we get visual. If we don't get visual, I'll hit TOGA, get the Gear and flap up and the aircraft will fly the missed approach which is in the FMGC"

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.

But that is the case in point. Thrust levers were not put in the Toga detent. So how would the autopilot have helped in this situation?

Instead of the usual "use the maximum level of automation" brigade going to work, I think it would be rather more appropriate to look at the cause for not being able to execute a simple maneuver without struggling to connect the auto pilot, instead of monitoring aircraft flightpath.

You are right, it's not Airbus versus Boeing, since there are numerous examples of this being a problem across all fleets. For Boeing the most outspoken with the Turkish crash in Amsterdam.

Nevertheless, I feel it's troublesome if Airbus pilots only have the mindset to do an automatic go-around and that the emphasis of their training is to do so, as you say. It should be in their mindset to get the aircraft to a safe altitude, before completely unnecessarily messing around trying to engage the auto pilot (Boeing made sure about nobody doing so by making a minimum use height of 400 feet for the 'Atlantic Baron' NG). To me it says that this is a more pronounced problem for Airbus crew.

Your reasoning is completely false in my opinion:
Engage the autopilot (leave it on in the first place) to ensure safe flightpath.

Rather that:
Ensure a safe flight by using you skill obtained from your training and regular practice, then engage the magic to reduce your workload.

My point is, this is not an incident primarily caused by underuse of automatics, rather than perhaps poor skills and training. This should be addressed rather than allowing the management to say "Ok boys, we know that you are no longer able to safely fly the aircrafts, so please use the autopilot at all times".