Report: Hermes A320 at Lyon on Apr 11th 2012, unstabilized approach, dual input, descended below safe height
By Simon Hradecky, created Tuesday, Mar 17th 2015 16:16Z, last updated Tuesday, Mar 17th 2015 16:46Z
A Hermes Airlines Airbus A320-200 on behalf of Air Mediterranee, registration SX-BHV performing flight BIE-9861 from Ajaccio to Lyon (France) with 178 passengers and 7 crew, was on approach to Lyon in darkness and instrument meteorological conditions, a captain under supervision in the left hand seat was pilot flying, an instructor in the right hand seat was commander of the flight and pilot monitoring. ATIS indicated an ILS approach to runway 18L, the approach controller reported low winds and suggested an ILS approach to runway 36L which was accepted by the crew. The controller realized the aircraft was high on approach and advised the crew had 40 track miles to go querying whether this was okay with them, the crew responded they needed to make a "thirty six", which the controller interpreted they were okay for runway 36 and provided a vector of 315 to intercept the localizer runway 36L and cleared the flight for the ILS approach. The aircraft went through the localizer without intercept, the FMGS still had the ILS of Ajaccio selected and thus had not tuned the ILS frequency for Lyon. The controller detected the aircraft had gone through the localizer and provided a new heading to now intercept the ILS from the other side and cleared the aircraft to descend to 3000 feet and for the ILS approach, the crew managed to complete reprogramming the FMGS and the FMGS auto-tuned the ILS for runway 36L, yet, the aircraft went through the localizer a second time as the autopilot had not activated LOC capture. The altitude capture activated, the aircraft still at 240 KIAS, the crew selected 400 feet instead of 3000 feet into the altitude window, which caused the autopilot to revert to vertical speed mode at 1200 fpm rate of descent. The crew turned left to capture the localizer, activated the approach mode and engaged autopilot 2. The localizer capture activated, the aircraft turned onto the localizer but descended below minimum safe altitude.
Descending through 2460 feet MSL (950 feet AGL) at 230 KIAS in clean configuration the Ground Proximity Warning System GPWS activated "TERRAIN! TERRAIN! PULL UP! PULL UP!", the instructor took control of the aircraft without corresponding call out, disengaged the autopilots, placed the thrust levers in the CLIMB detent and pulled the nose up to 9.5 degrees nose up, however, the automation, due to clean configuration, did not detect the terrain avoidance manoeuver and continued flight director modes vertical speed and heading select.
In the meantime the minimum safe altitude warning activated at the controllers console, the controller called the aircraft advising they were below minimum safe altitude and instructed the aircraft to climb to 2500 feet MSL, then to report when they were established on the glide.
While attemtpting to level off at 2500 feet the instructor applied nose down inputs for 20 seconds, the airspeed began to rapidly increase and the aircraft began to descend again descending through 2150 feet MSL at 320 KIAS. The thrust levers were placed into the IDLE detent, the MSAW activated a second time at the controllers desk prompting the controller to transmit: "... check your altitude immediately, you are too low!".
The captain under supervision applied nose up inputs while the instructor applied nose down inputs, for a minute aural and visual warnings of dual input activated. The instructor, continuing to talk to ATC, requested vectors for a missed approach, the controller cleared the aircraft to climb to 5000 feet.
The instructor now applied nose up inputs to climb the aircraft to 5000 feet, the captain under supervision applied nose down inputs, overall the aircraft began to climb and the thrust levers were placed into the CLIMB detent.
The instructor finally officially took over control, autopilot 2 was engaged and the aircraft climbed to and levelled off at 5000 feet. The aircraft positioned for another approach to runway 36L and landed safely.
France's BEA released their final report concluding the probable causes of the serious incident were:
The serious incident was due to:
- initially, continuing the descent during the ILS approach to runway 36L while the airplane was not configured or stabilised on the localiser axis, resulting in dangerous ground proximity;
- after the first GPWS warning, the inadequate application of the GPWS emergency procedure, in particular in terms of setting the attitude.
The following factors contributed to the serious incident:
- inadequate application of normal procedures, task-sharing and emergency procedures, resulting in highly degraded crew situational awareness (position in space, configuration);
- the limited experience on type of both crew members;
- the operator’s desire to quickly train a pilot with low experience on type as a Captain;
- variable criteria to serve as a Captain;
- the use of inappropriate MSAW phraseology by the controller.
The BEA reported that both crew members help ATP Licenses and had extensive experience on Boeings, however little experience on A320s. The instructor had a total of 17,000 hours, thereof 620 hours on type. The captain under supervision had 10,500 hours total experience, 33 hours thereof in command on ATR-42s and 25 hours on type, after the demise of Olympic Airways the captain under supervision had not flown for two years before being recruited as an A320 captain by Hermes Airlines.
As of the day of the occurrence the captain under supervisions had flown 13 legs, 9 sectors as pilot flying and 3 as pilot monitoring while being under supervision for line orientation.
The BEA stated that nominally and legally the requirements for becoming a captain had been fulfilled, the legal requirements were:
- a minimum level of experience specified in the operations manual of the operator
- and acceptable to the national civil aviation authorities;
- participation in a "Captain" course;
- completion of at least 10 sectors if qualified on type.
The operator required:
- a minimum of 3,500 flying hours in air transport;
- successful completion of the "Captain" course as defined in Part D of the manual;
- line-oriented flight training with a minimum of 10 legs;
- to be appointed "Captain".
The BEA wrote: "Airline officials indicated that, during this period, the airline had received 4 Airbus in addition to the Boeing 737 already in service. Given the urgent need for flight crew and regulatory documentation, the operations manual was drafted hastily and contained inconsistencies in the criteria for appointments to various positions.
The instructor had not flown with the captain under supervision prior the occurrence leg. The instructor provided testimony that on departure from Ajaccio he manually selected the ILS of Ajjacio into the FMGS just in case of a return to Ajaccio.
The BEA analysed: "The failure to carry out checks of the RADIO NAV page on the FMGS, which are normally carried out when passing FL100 in a climb and during approach preparation, did not allow the crew to detect that the FMGS had not automatically selected the ILS for runway 36L at Lyons Saint-Exupéry and that the Ajaccio AC ILS was still active on arrival. Changing from runway 18L to runway 36L shortened the approach distance, resulting in the aeroplane being high on the arrival path. The crew, who had not repeated their request to make a turn– which the controller did not understand - had therefore less time to prepare for the arrival on runway 36L. When trying to capture the localiser axis, the crew used a great deal of their resources managing the display of the ILS frequency to the detriment of their monitoring of the aeroplane’s vertical flight path and its configuration. The selection on the FCU of a target altitude of 400 ft, while the altitude of Lyons airport is 880 ft, indicates a loss of situational awareness and introduced a risk of dangerous ground proximity. During the GPWS PULL UP emergency procedure, the failure to maintain the control column to the rear stop meant that the aeroplane could not reach the best climb angle in a night-time environment with poor weather conditions in which the crew had few or no external visual references. The 9.5° attitude displayed did not correspond to the missed approach attitude (15°) or to that of the GPWS procedure (control column to the rear stop)."
The BEA analysed:
The dual input phase occurred after the crew’s decision to abort the approach, after the second MSAW warning. A period of confusion was observed during a flight phase that was inherently dynamic and required precise flight control, especially at high speed.
The occurrence of dual inputs, which is a reflex action, may have been encouraged by a combination of several factors:
- the instructor did not formalize his taking over the controls (no “I have control” callout); even though the dual input phase did not immediately follow the control take-over the lack of callout did disrupt the role sharing;
- the crew had extensive experience of aeroplanes with dual flight controls and although the instructor was dual-qualified to fly Boeing 737 and Airbus A320, whose interface with the flight controls is very different.
The aircraft's trajectory and profile (Graphics: BEA):
The aircraft's trajectory and profile (Graphics: BEA)
By Simon Hradecky, created Tuesday, Mar 17th 2015 16:16Z, last updated Tuesday, Mar 17th 2015 16:46Z
A Hermes Airlines Airbus A320-200 on behalf of Air Mediterranee, registration SX-BHV performing flight BIE-9861 from Ajaccio to Lyon (France) with 178 passengers and 7 crew, was on approach to Lyon in darkness and instrument meteorological conditions, a captain under supervision in the left hand seat was pilot flying, an instructor in the right hand seat was commander of the flight and pilot monitoring. ATIS indicated an ILS approach to runway 18L, the approach controller reported low winds and suggested an ILS approach to runway 36L which was accepted by the crew. The controller realized the aircraft was high on approach and advised the crew had 40 track miles to go querying whether this was okay with them, the crew responded they needed to make a "thirty six", which the controller interpreted they were okay for runway 36 and provided a vector of 315 to intercept the localizer runway 36L and cleared the flight for the ILS approach. The aircraft went through the localizer without intercept, the FMGS still had the ILS of Ajaccio selected and thus had not tuned the ILS frequency for Lyon. The controller detected the aircraft had gone through the localizer and provided a new heading to now intercept the ILS from the other side and cleared the aircraft to descend to 3000 feet and for the ILS approach, the crew managed to complete reprogramming the FMGS and the FMGS auto-tuned the ILS for runway 36L, yet, the aircraft went through the localizer a second time as the autopilot had not activated LOC capture. The altitude capture activated, the aircraft still at 240 KIAS, the crew selected 400 feet instead of 3000 feet into the altitude window, which caused the autopilot to revert to vertical speed mode at 1200 fpm rate of descent. The crew turned left to capture the localizer, activated the approach mode and engaged autopilot 2. The localizer capture activated, the aircraft turned onto the localizer but descended below minimum safe altitude.
Descending through 2460 feet MSL (950 feet AGL) at 230 KIAS in clean configuration the Ground Proximity Warning System GPWS activated "TERRAIN! TERRAIN! PULL UP! PULL UP!", the instructor took control of the aircraft without corresponding call out, disengaged the autopilots, placed the thrust levers in the CLIMB detent and pulled the nose up to 9.5 degrees nose up, however, the automation, due to clean configuration, did not detect the terrain avoidance manoeuver and continued flight director modes vertical speed and heading select.
In the meantime the minimum safe altitude warning activated at the controllers console, the controller called the aircraft advising they were below minimum safe altitude and instructed the aircraft to climb to 2500 feet MSL, then to report when they were established on the glide.
While attemtpting to level off at 2500 feet the instructor applied nose down inputs for 20 seconds, the airspeed began to rapidly increase and the aircraft began to descend again descending through 2150 feet MSL at 320 KIAS. The thrust levers were placed into the IDLE detent, the MSAW activated a second time at the controllers desk prompting the controller to transmit: "... check your altitude immediately, you are too low!".
The captain under supervision applied nose up inputs while the instructor applied nose down inputs, for a minute aural and visual warnings of dual input activated. The instructor, continuing to talk to ATC, requested vectors for a missed approach, the controller cleared the aircraft to climb to 5000 feet.
The instructor now applied nose up inputs to climb the aircraft to 5000 feet, the captain under supervision applied nose down inputs, overall the aircraft began to climb and the thrust levers were placed into the CLIMB detent.
The instructor finally officially took over control, autopilot 2 was engaged and the aircraft climbed to and levelled off at 5000 feet. The aircraft positioned for another approach to runway 36L and landed safely.
France's BEA released their final report concluding the probable causes of the serious incident were:
The serious incident was due to:
- initially, continuing the descent during the ILS approach to runway 36L while the airplane was not configured or stabilised on the localiser axis, resulting in dangerous ground proximity;
- after the first GPWS warning, the inadequate application of the GPWS emergency procedure, in particular in terms of setting the attitude.
The following factors contributed to the serious incident:
- inadequate application of normal procedures, task-sharing and emergency procedures, resulting in highly degraded crew situational awareness (position in space, configuration);
- the limited experience on type of both crew members;
- the operator’s desire to quickly train a pilot with low experience on type as a Captain;
- variable criteria to serve as a Captain;
- the use of inappropriate MSAW phraseology by the controller.
The BEA reported that both crew members help ATP Licenses and had extensive experience on Boeings, however little experience on A320s. The instructor had a total of 17,000 hours, thereof 620 hours on type. The captain under supervision had 10,500 hours total experience, 33 hours thereof in command on ATR-42s and 25 hours on type, after the demise of Olympic Airways the captain under supervision had not flown for two years before being recruited as an A320 captain by Hermes Airlines.
As of the day of the occurrence the captain under supervisions had flown 13 legs, 9 sectors as pilot flying and 3 as pilot monitoring while being under supervision for line orientation.
The BEA stated that nominally and legally the requirements for becoming a captain had been fulfilled, the legal requirements were:
- a minimum level of experience specified in the operations manual of the operator
- and acceptable to the national civil aviation authorities;
- participation in a "Captain" course;
- completion of at least 10 sectors if qualified on type.
The operator required:
- a minimum of 3,500 flying hours in air transport;
- successful completion of the "Captain" course as defined in Part D of the manual;
- line-oriented flight training with a minimum of 10 legs;
- to be appointed "Captain".
The BEA wrote: "Airline officials indicated that, during this period, the airline had received 4 Airbus in addition to the Boeing 737 already in service. Given the urgent need for flight crew and regulatory documentation, the operations manual was drafted hastily and contained inconsistencies in the criteria for appointments to various positions.
The instructor had not flown with the captain under supervision prior the occurrence leg. The instructor provided testimony that on departure from Ajaccio he manually selected the ILS of Ajjacio into the FMGS just in case of a return to Ajaccio.
The BEA analysed: "The failure to carry out checks of the RADIO NAV page on the FMGS, which are normally carried out when passing FL100 in a climb and during approach preparation, did not allow the crew to detect that the FMGS had not automatically selected the ILS for runway 36L at Lyons Saint-Exupéry and that the Ajaccio AC ILS was still active on arrival. Changing from runway 18L to runway 36L shortened the approach distance, resulting in the aeroplane being high on the arrival path. The crew, who had not repeated their request to make a turn– which the controller did not understand - had therefore less time to prepare for the arrival on runway 36L. When trying to capture the localiser axis, the crew used a great deal of their resources managing the display of the ILS frequency to the detriment of their monitoring of the aeroplane’s vertical flight path and its configuration. The selection on the FCU of a target altitude of 400 ft, while the altitude of Lyons airport is 880 ft, indicates a loss of situational awareness and introduced a risk of dangerous ground proximity. During the GPWS PULL UP emergency procedure, the failure to maintain the control column to the rear stop meant that the aeroplane could not reach the best climb angle in a night-time environment with poor weather conditions in which the crew had few or no external visual references. The 9.5° attitude displayed did not correspond to the missed approach attitude (15°) or to that of the GPWS procedure (control column to the rear stop)."
The BEA analysed:
The dual input phase occurred after the crew’s decision to abort the approach, after the second MSAW warning. A period of confusion was observed during a flight phase that was inherently dynamic and required precise flight control, especially at high speed.
The occurrence of dual inputs, which is a reflex action, may have been encouraged by a combination of several factors:
- the instructor did not formalize his taking over the controls (no “I have control” callout); even though the dual input phase did not immediately follow the control take-over the lack of callout did disrupt the role sharing;
- the crew had extensive experience of aeroplanes with dual flight controls and although the instructor was dual-qualified to fly Boeing 737 and Airbus A320, whose interface with the flight controls is very different.
The aircraft's trajectory and profile (Graphics: BEA):
The aircraft's trajectory and profile (Graphics: BEA)
