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A320 Go-Around with inappropriate mode

selection
A320 & A319 events
Presented by
Marc Baillion / Director of Flight Safety

17th Flight Safety Conference

Content

Reminder: Thrust Levers are also mode selectors


Approach
Go Around
Operational considerations

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17th Flight Safety Conference

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FBW Thrust Levers are also mode selectors

FBW Thrust Levers


besides their thrust control function

are also mode selectors


They have MULTIPLE additional functions e.g.

Engaging the common modes when TOGA is set


Sequencing the FMS flight plan into the missed approach
procedure when TOGA is set

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17th Flight Safety Conference

Content

Reminder: Thrust Levers are also mode selectors


Approach
Go Around
Operational considerations

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21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

First Event
Synopsis
During a scheduled passenger service, an A320 performed a
missed approach in foggy conditions during which it reached a
minimum 38ft radio altitude

Official investigation

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Approach conditions
ILS approach CAT 1
Day condition 0900E 2500 FG BKN003
A320
64 tons
S/F FULL
L/G DN
VAPP 138kt
Airport elevation 433ft
Missed approach altitude : 4000ft selected

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17th Flight Safety Conference

Approach
Captain Pilot Flying (PF)
AP1+2 engaged in G/S LOC
LAND mode engaged automatically below 400ft

A/THR engaged and active in SPEED mode


VAPP 138kt selected

No visual reference at minima (DH = 200ft)


Crew decided to Go Around

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21-24 March 2011

17th Flight Safety Conference

DFDR Animation

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

21-24 March 2011

17th Flight Safety Conference

Content

Reminder: Thrust Levers are also mode selectors


Approach
Go Around
Operational considerations

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21-24 March 2011

17th Flight Safety Conference

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Go Around
At 220ft: Thrust levers moved to just above FLX/MCT, and then
retarded to FLX/MCT

A/THR de-activation
AP 1+2 were still engaged in LAND mode

At 115ft: CONF 3
At 70ft: EGPWS DONT SINK alert
PF pulled the stick (2/3 of full back stick)
AP disconnection
Master warning and AUTOLAND warning triggered

Lowest radio altitude of 38ft


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Go Around
At 200ft: L/G UP and thrust levers to CLB
AFS still in LAND mode
A/THR active

At 300ft: AP1 transiently engaged


At 600ft: AP1 transiently engaged and thrust levers pushed to
TOGA

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17th Flight Safety Conference

DFDR Animation

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

21-24 March 2011

17th Flight Safety Conference

Content

Reminder: Thrust Levers are also mode selectors


Approach
Go Around
Operational considerations

Page 13
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

Second Event
Synopsis:
During a scheduled passenger service, an A319 performed a
missed approach in misty conditions during which it reached a
minimum 75ft radio altitude, L/G UP, CONF 3

Official investigation

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Approach conditions
ILS Approach CAT 1
Day condition 3000 BR SCT002 BKN003
A319
53,9 tons (MLW 61 tons)
S/F FULL
L/G DN
Vapp 124 kt (VLS + 9)
Airport elevation 390ft
Missed approach altitude: 2000ft selected
Go Around briefing: Soft Go Around
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17th Flight Safety Conference

Approach
Captain Pilot Flying
Manual flight with FDs ON
LAND mode engaged automatically below 400ft

ATHR disconnected
No contact at minimum (DH = 200ft)
Go Around initiated at 200ft

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21-24 March 2011

17th Flight Safety Conference

DFDR Animation

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

21-24 March 2011

17th Flight Safety Conference

Content

Reminder: Thrust Levers are also mode selectors


Approach
Go Around
Operational considerations

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17th Flight Safety Conference

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Go Around
At 200ft: PF advanced thrust levers progressively to FLX/MCT
detent in 5s

PF simultaneously increased pitch to 6 Nose Up


A/C remained in LAND MODE
A/C (still manually flown) stopped descent at 150ft RA
CONF 3 selected at 150ft

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Go Around
At 170ft: AP1 engaged & L/G selected UP
Thrust Levers were still in FLX/MCT detent
AFS still in LAND mode commanded pitch down to regain the
glide,

At 180ft: PF moved thrust levers to CLB detent


At 120ft: EGPWS warning SINK RATE triggered
Descent rate approx. 1400ft/min

PF disconnected AP and pulled almost full back stick


A/C minimum height 75ft RA, L/G UP in Conf 3, CAS 180kt
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Go Around
At 110ft: VFE exceedance, Master warning triggered
At 500ft: Thrust levers retarded to IDLE
At 900ft: AP1 transiently re-engaged while AFS still in LAND
mode

AFS commanded pitch down to regain the glide


Thrust levers moved to CL detent
PF disconnected the AP and pulled the stick

At 1600ft: AP1 briefly re-engaged twice


Both FDs were disengaged and re-engaged in V/S HDG 1s later

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

DFDR Animation

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

21-24 March 2011

17th Flight Safety Conference

Content

Reminder: Thrust Levers are also mode selectors


Approach
Go Around
Operational considerations

Page 23
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

TOGA Selection
PF did not correctly move the thrust levers to the TO/GA
position when carrying out the missed approach procedure (both
events)

The relatively low missed approach altitude resulted in the


decision to adapt the procedure (A319 event)

Apply TOGA in the proper way by pushing


the thrust levers quickly to the mechanical stop

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Monitor Basic Flying Parameters


Monitor the basic flying parameters:
Pitch ~15!
Thrust
Positive vertical speed

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AP Engagement
Check FMA before connecting AP
Connect AP only when FDs showing the intended flight path

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17th Flight Safety Conference

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Check Lists
A320 event: the aircraft operator had changed the SOP for the
go-around

FMA check was moved from 3rd to 9th line in the check list

A319 event: FMA check was removed from the check list
completely but referenced as general rule in another document
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17th Flight Safety Conference

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Check Lists
According to the investigation board official reports of both
events, changes to the check lists may have resulted in the flight
crew being unaware of the flight mode status

Operators need to take great care when


changing or omitting items from check lists

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