Description

On 11 February 2022 an Airbus A320 (F-HEPB) operated by Air France on a scheduled passenger flight from Martinique to Guadeloupe as AFR605 was on a hand-flown visual night approach at destination. The crew lost visual reference, but continued the approach until a repeated ATC call prompted recognition that the aircraft was off the required vertical profile.  

Investigation

An investigation was carried out by the French Civil Aviation Accident Investigation Agency, the BEA using relevant quick-access recorder (QAR) data. However, the cockpit voice recorder (CVR) was not isolated after landing, and its data were lost. Relevant recorded ATC and meteorological data were available.

The 57-year-old captain had a total of 7,451 hours flying experience on A320 series aircraft and had held the rank of captain for almost 10 years. He had been based at Pointe-à-Pitre for almost eight months and was acting as pilot flying (PF). He had never previously made the right-hand visual approach to runway 12 at night. The 47-year old first officer had a total of 5,730 hours flying experience on A320 series aircraft and had made a night visual approach to the same runway the previous week.

What Happened

When the approach briefing was conducted, the crew decided to make a visual approach to runway 12 if conditions permitted, or if not, then an ILS approach to the same runway. 

When the aircraft was about 15 minutes from landing, the flight called the air traffic controller on duty, who was covering tower (TWR) and approach (APP) duties and advised her that “they wanted to land as soon as possible” and radar vectoring for an ILS approach to runway 12 was suggested. This was accepted, but the crew added that if conditions permitted, they would request a right-hand visual approach. The controller then gave the weather as “visibility 4,000 m, quite good runway visual range (RVR) of 5 km and cloud recorded as FEW at 1,300 feet, BKN [broken] at 2,100 feet and BKN at 3,700 feet" and the crew confirmed their plan. No visual approach charts were provided for the airport.

Descent continued with the autopilot (AP) and autothrust (A/THR) engaged. As the flight neared the airport, the crew reported that the weather conditions were “excellent” and requested a visual approach to runway 12 which was approved (right-hand).

Three minutes later, the aircraft levelled off at 1,900 feet, and the speed was gradually reduced to allow the extension of flaps 1, and then flaps 2.The AP was then disengaged and the thrust was set to idle, which automatically disconnected the A/THR. The captain then asked the first officer to replace the flight director (FD) with the flight path vector (FPV) and commenced a right turn to join base leg and called for landing gear down. Descent was commenced from 1,900 feet and the landing gear was extended. However, following an earlier oversight, the approach phase then had to be activated manually from the Multi-Function Control and Display Unit (MCDU) to allow the flight management system (FMS) to automatically manage the selection of target speeds. Flaps 3 was then selected and the turn onto final approach was made at altitude of 1,430 ft.

Selected QAR data from the eventually abandoned first Approach. [Reproduced from the Official Report]

The ground track of the aircraft during both approaches showing its premature turn onto an approach track south of the extended centreline on the first (visual) one. [Reproduced from the Official Report]

The controller clear the aircraft to land, with a spot wind of 110°/5 knots. This was immediately followed by the controller advising that a minimum safe altitude warning (MSAW) had occurred, and the controller instructed the crew to check their altitude. There was no response from the crew. At this point, the aircraft was at 1,100 feet on a heading of 160° and descending at an increasing rate - 1,570 fpm had become 2,060 fpm four seconds later. The first officer read back the landing clearance and full flaps were then selected. After a 13-second interval during which the excessive descent rate continued, the controller repeated the advisory to check altitude. The first officer responded to say they were checking and almost immediately, the recorded rate of descent reduced rapidly from 2,060 fpm to 750 fpm.

After a further 15 seconds, the crew “noticed that the aircraft was not aligned with the (extended) centreline of runway 12” and abandoned the approach. The aircraft was 2.5nm from the runway and on tracking parallel to its extended centreline but 1nm to the south of it. The minimum height recorded was 460 feet and the minimum speed recorded during the go-around was recorded as 128 KCAS (the VAPP had been 138 KCAS). After the absence of any further crew communication for 30 seconds after they had reported checking their altitude, the controller asked the crew where they were. The controller received the reply that “they were not far away and that they were going around”.

Half a minute later the crew requested radar vectoring for an ILS approach to runway 12. The remainder of the flight and a landing on the 3,129 metre-long runway took place without event. It was noted that the runway was not equipped with runway approach lights or centreline lighting although there was a precision approach path indicator (PAPI) set to 3.2°.

Why It Happened

QAR data showed the approach had been flown with idle thrust set and at a speed in excess of the target approach speed until six seconds before TOGA thrust was set to begin the go-around. It was concluded that the inappropriate continuation of the visual approach had been a consequence of poor performance by the captain. The investigation cited evidence the captain had continued a visual approach after losing sight of the runway and had thereby created a potentially hazardous situation. The visual approach was terminated only as a result of the controller’s repeat of her MSAW notification.

This appeared to be because the pilot monitoring (PM) first officer became overloaded at a critical point at least partly when the captain asked him to “manage speed,” and this action did not produce the expected result because the approach had not been activated in the FMS. This transient overload meant that the first officer had been unable to look outside as the captain sought to establish the aircraft on the extended centreline.

The captain stated that after turning onto what he believed was the correct final approach, “he had not seen the runway in front of him” as it had been “hidden by a curtain of rain” and he had only had sight of the ground. He stated that “he thought he recognised characteristic ground references and that he did not look at his ND [navigation display]."

As the aircraft began to descend at an excessive rate, it appeared neither pilot had heard the controller’s first MSAW call. It was only after the repeat call that the first officer “saw on his ND that the aircraft was not on the approach path." He then noticed that the captain’s ND had been left on a 20-mile range instead of the appropriate 10-mile range and reset it. He then located the airport at approximately an 11 o’clock position and informed the captain, upon which a go-around was recognised as the appropriate action.

There was no enhanced ground proximity warning system EGPWS activation and a simulation carried out by the original equipment manufacturer OEM showed this would only have occurred if the aircraft had continued its descent on a ground track parallel to the runway centreline to within 1nm of the runway. At that point, a Mode 2 ‘TOO LOW TERRAIN’ warning would have been triggered at approximately 245 feet agl.

It was noted that the Air France Caribbean Network Flight Crew Information Booklet specified that “visual approaches are a standard practice inside the network (and) are performed at all aerodromes." It then listed a series of specified conditions under which visual approaches could be made if all were met:

• the pilot can see the aerodrome; 
• the pilot is able to keep sight of the ground; 
• the pilot considers that the visibility and ceiling are suitable for a visual approach and
  that landing can be completed; 
• at night, the ceiling is not lower than the minimum altitude of the sector, or of the path to be taken to join the circuit where applicable [this was 6,500 feet due to high terrain east of the airport];
• in controlled airspace, the pilot has received a visual approach clearance. 

These conditions had not all been met. Neither had a list of relevant Standard Operating Procedures (SOPs) contained in the Operations Manual (OM) Part ‘A’ as well as a series of generally recommended practices for all visual approaches such as use of the A/THR.

It was also found that between 2020 and 2022, five night-time MSAW warnings involving Air France aircraft had been recorded at Pointe-à-Pitre, all of which had occurred during visual approaches.

The following Contributory Factors were identified by the Investigation:
In respect of the crew’s decision to follow a night visual approach path in weather conditions that were ultimately adverse:

• a wish to optimise the path and flight times;
• their desire to maintain flying skills without using automation;
• their familiarity with the use of such approaches on this flight sector.

In respect of the abandoned visual approach:

• the threat, not identified during the approach briefing, due to the PF’s position (left seat) for a right-hand circuit;
• the underestimated risk of encountering low-height clouds;
• the decision to use the automation level corresponding to daylight conditions (A/THR switched off), which resulted in a heavy workload for the crew and degraded the performance level of both pilots.  

Safety Action taken was noted to have included, in summary, the following:

• Air France published visual approach instructions to all pilots requiring them to: 
  • give a full briefing, specifying the key points of the flight path (references overflown, speed, configuration), to facilitate [effective] monitoring;
  • make use of all relevant means of navigation - FMS, radio-electrical aids, etc.;
  • cease an approach in the event of loss of visual contact with the aerodrome; 
  • use the A/THR in ‘speed’ mode to avoid flying below the manoeuvring or approach speed and to free up time for the PM, who is liable to be very busy on this type of approach; 
  • use the “terrain” function at night on at least one of the NDs;
  • in the event of an MSAW warning, stop descent immediately, check the altitude and altimeter subscale setting and climb back to the safe altitude if necessary;
  • commence an immediate go-around in the event of any doubt regarding position or any loss of contact with the aerodrome, even if this is temporary.
• Air France issued a ‘Company NOTAM’ which specified that in order to make a night visual approach, at least one of the pilots involved must have previously performed such an approach before and recommended that the pilot with this previous experience should act as PF. It also stated that “in the event of loss of visual contact with the aerodrome, even temporarily, a go-around must be carried out immediately and that in the event they are advised of an a MSAW activation, the relevant instructions in OM Part ‘A’ - stop descent, check QNH value, climb back to safe altitude if necessary - must be followed".
• LIDO (the Air France contracted Navigation Chart Provider), published a detailed visual approach chart for runway 12 at Pointe-à-Pitre on 29 September 2022 which included gates and their associated altitudes. A RNAV visual approach aid including these navigation gates was also integrated into the A320 FMS database.

Safety Lessons which were highlighted by the Investigation included, in summary, the following:

• A visual approach is often seen as one which enables pilots to maintain their flying skills. The use of the A/THR for such approaches, as recommended by the Air France OM and Airbus, reduces the crew’s workload. Pilots can also effectively train to fly without the A/THR on a straight in path associated with a 3D approach operation.
• Performing a semi-direct, night visual approach when, as in this case, there are cloud banks or rain without using the A/THR, introduces complications which can lead to a reduction in safety margins.
• It is up to each aircraft operator to define its operational policy concerning visual approaches and the operational conditions for carrying them out. When visual approaches are permitted, it may be important for operators develop decision aids which enable their crews to objectively and simply determine whether it is appropriate to make a visual approach (appropriate weather conditions, environment, recent experience, etc.). Such decisions aids should also enable crews to properly prepare for such an approach (use of automation, FMS documentation, tailored charts, etc.), according to an operator risk assessment which should be regularly reviewed against relevant safety events and OFDM outputs so that decision aids can be adapted as necessary.

The Final Report was initially published in the definitive French language on 11 August 2023 and this was followed on 3 April 2024 by an English Language translation.

Related Articles

• Controlled Flight Into Terrain (CFIT)
• Night Visual Approaches
• Flying a Visual Approach
• Visual References
• Minimum Safe Altitude Warning (MSAW)
• Missed Approach
• Pilot Workload
• Decision Making
• Standard Operating Procedures (SOPs)