E195, vicinity Warsaw Chopin Poland, 2019

E195, vicinity Warsaw Chopin Poland, 2019

Summary

On 11 October 2019, an Embraer ERJ195LR abandoned an initial landing attempt at Warsaw after a hard bounce but the correct go-around procedure was not followed. The rate of climb rapidly increased to over 4000 feet per minute. Concurrently, the required engine thrust was not set and airspeed rapidly diminished to a point where the stick shaker was activated. Stall and Upset Recovery procedures were not correctly followed and the aircraft commander was slow to take control of the situation. Full control was regained at 1,200 feet above ground level and a subsequent approach and landing were without further event.

Event Details
When
11/10/2019
Event Type
HF, LOC
Day/Night
Day
Flight Conditions
VMC
Flight Details
Type of Flight
Public Transport (Passenger)
Flight Origin
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Missed Approach
Location - Airport
Airport
General
Tag(s)
Unplanned PF Change less than 1000ft agl, CVR overwritten
HF
Tag(s)
Inappropriate crew response - skills deficiency, Manual Handling, Procedural non compliance
LOC
Tag(s)
Aircraft Flight Path Control Error, Environmental Factors, Extreme Pitch, Hard landing, Aerodynamic Stall
Outcome
Damage or injury
No
Non-aircraft damage
No
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Aircraft Operation
Safety Recommendation(s)
Group(s)
Aircraft Operation
Investigation Type
Type
Independent

Description

On 11 October 2019, the crew of an Embraer ERJ195LR (SP-LNO) being operated by LOT Polish Airlines on an international passenger flight from Brussels to Warsaw mishandled the initial landing attempt at destination and commenced a day VMC go-around which was then grossly mishandled with the high rate of climb and insufficient thrust combining to rapidly diminish airspeed to the stall threshhold from which recovery was only achieved below 1000 feet agl. The subsequent positioning and second approach were without further event. 

Investigation

An Investigation was carried out by the Polish State Commission on Aircraft Accidents Investigation (SCAAI). Digital Flight Data Recorder (DVDR) data was recovered but relevant CVR data was overwritten when the recorder was not secured after the landing.

It was found that the 41 year-old Captain had a total of 4,450 hours flying experience which included 2,840 hours on type and 2,090 hours in command. The 38 year-old First Officer, who was acting as PF for the sector into Warsaw, had a total of 726 hours flying experience of which all but 207 hours were on type. Both pilots were based at the occurrence airport. Four members of cabin crew were on board, one of whom was occupying the flight deck supernumerary crew seat during the approach and landing sequence at destination although this was not rostered or necessary.

What Happened and How

After a stabilised flap 5 approach to runway 33 at destination, the First Officer disconnected the AP on receiving a landing clearance. The mean surface wind was from 240° at 11 knots with some gusts during which the wind would naturally veer and prevent any dramatic increase in crosswind component. Just before touchdown, “the aircraft slightly lost its direction” and touchdown occurred with a 1.96g vertical acceleration and bounced and the PF immediately decided to initiate a go-around procedure for which the stop altitude was 3000 feet. 

The A/T was automatically disengaged in accordance with the system operating logic and the thrust levers were moved forward to 72° TLA but without pushing the TO/GA button. The latter omission significantly prevented the Flight Guidance Control System (FGCS) from generating the standard FD indications which would have displayed the correct climb profile. In the absence of this guidance and of the required callouts, an abnormally high pitch angle was adopted relative to the recommended 8° and the rate of climb reached 4,384 fpm which led ATC to ask the crew to “confirm it”. The Captain reacted to this query and the consequently rapidly reducing airspeed by increasing the engine thrust levers to 75° TLA which, although this was the correct position for a go-around, such action at the already steep pitch angle simply increased that angle and the angle of attack. The pitch angle soon reached its recorded 32.2° maximum as the rapid reduction in airspeed continued.

Whilst this extreme climb was being flown by the First Officer, the PM Captain was “retracting the flaps and landing gear and responding to the ATC query about the non-standard rapid climb” and it was concluded that in concentrating on his tasks as PM, he “did not notice” the flight path control errors of the PF which had resulted in a very substantial loss of airspeed.

By the time the aircraft reached a recorded 1,218 feet agl, the airspeed had reduced to 95 KIAS (which was 42 knots below the landing VREF), and the "Low Speed Awareness" and "Stick shaker" were activated. Within a short time, the crew then found themselves in a more difficult situation, “which directly endangered the flight safety”. It was found that only then had the Captain “become directly involved in aircraft control and in the ‘Upset Recovery’ procedure", the latter manoeuvre being completed at a recorded altitude of 1,044 feet agl. However, “this procedure was not performed in accordance with procedure specified in the carrier’s OM.

At an unidentified point in this episode, it was stated that the PM “took over as PF” without relinquishing his function as PM. It was also speculated that the pilots’ aircraft control performance could have been in some way affected by the presence of a stewardess on the flight deck for both the takeoff and landing on the sector concerned. This presence was claimed by the aircraft operator to have been an operational necessity but this claim was shown by the Investigation to be entirely untrue with no basis for it for on either passenger cabin seat availability or aircraft trim reasons.

Overall, it was concluded that:

  • The First Officer did not inform the Captain about any aircraft control issues that exceeded his capabilities.
  • The Captain did not identify the problems faced by First Officer in a timely manner or promptly identify the potential hazard and the First Officer’s problems during touchdown, did not recognise the subsequent procedural irregularities and failed to take over control soon enough. 

The Causes of the Serious Incident were formally recorded as:

  1. The incorrect execution of the ‘Bounced Landing Recovery’ and ‘Go-Around’ procedures.
  2. The delayed reaction of the aircraft commander as Pilot Monitoring to the errors made by the First Officer as Pilot Flying during both the attempted landing and the go-around.

Seven Contributory Factors were also identified:

  1. The weather conditions (a gusty crosswind).
  2. An aircraft control error during landing.
  3. The low experience of the First Officer.
  4. The failure to follow standard procedures during the ‘Bounced Landing Recovery’ and during the ‘Go-Around’.
  5. The lack of proper cooperation between the two pilots.
  6. The incorrect application of the ‘Stall Recovery’ procedure.
  7. The incorrect execution of the ‘Upset Recovery Manoeuvre’.

Four Safety Recommendations were made as a result of the findings of the Investigation as follows:

  • that LOT Polish Airlines revise their simulator training program regarding the ‘Bounced Landing Recovery’ procedure.
  • that LOT Polish Airlines revise their simulator training program regarding stall recovery at low altitudes.
  • that LOT Polish Airlines introduce an obligation that First Officer flying experience in a particular aircraft type must be communicated to a Captain and if the flight time on type is less than 500 hours, a First Officer should be treated as inexperienced.
  • that LOT Polish Airlines introduce a limit for inexperienced First Officers (defined as in the previous recommendation) who may only land an aircraft when the crosswind component is not more than half of the maximum permitted for a given aircraft type.  

The Final Report of the Investigation was completed on 23 May 2023 and subsequently published online in English translation the following month.

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