A319, Luton UK, 2012
From SKYbrary Wiki
|On 14 February 2011, an Easyjet Airbus A319 being flown by a trainee Captain under supervision initiated a go around from below 50 feet agl after a previously stabilised approach at Luton and a very hard three point landing followed before the go around climb could be established. The investigation found that the Training Captain involved, although experienced, had only limited aircraft type experience and that, had he taken control before making a corrective sidestick input opposite to that of the trainee, it would have had the full instead of a summed effect and may have prevented hard runway contact.|
|Actual or Potential
|Human Factors, Loss of Control|
|Flight Conditions||On Ground - Normal Visibility|
|Type of Flight||Public Transport (Passenger)|
|Actual Destination||London Luton Airport|
|Take off Commenced||Yes|
|Flight Phase||Missed Approach|
|Location - Airport|
|Airport||London Luton Airport|
|Tag(s)||Flight Crew Training,|
Non Precision Approach
|Tag(s)||Inappropriate crew response (automatics),|
Procedural non compliance
|Tag(s)||Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,|
Temporary Control Loss,
Unintended transitory terrain contact
|Damage or injury||Yes|
|Causal Factor Group(s)|
On 14 February 2011 an Airbus 319-100 being operated by Easyjet on a scheduled passenger flight from Faro Portugal to Luton, which was being used as a line training sector for a Captain-under-training, commenced a go around just before a previously anticipated daylight landing in normal visibility and struck the runway at a high rate of descent and in a three point attitude as the go around was being initiated. The rest of the go around and second approach to landing were uneventful and none of the 148 occupants were injured but all three landing gear assemblies were found to have exceeded their certified loads and were replaced.
A Field Investigation was carried out by the AAIB. The Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were removed from the aircraft and downloaded but the CVR record of the event was found to have been overwritten because the associated CB had not been tripped after landing.
After the eventual landing, a ‘LOAD<15> report was found to have been generated as a result of the go around runway contact which required an aircraft inspection for possible structural damage before further flight. The dual triggers for this were found to have been a normal acceleration of 2.9g and a rate of descent of 750 fpm, both of which substantially exceeded the respective alert thresholds. Although a full structural inspection was required by the aircraft manufacturer, the only action required was the replacement of a series of components on all three landing gear legs which was achieved by the replacement of the complete assembly in each case.
The PF was found to have been a trainee Captain occupying the left seat and on his tenth line training sector with a total of 672 aircraft type hours experience. The Training Captain was experienced in that role but had only 500 aircraft type hours experience.
It was established that the approach to runway 26 at Luton had been by radar positioning to the Instrument Landing System (ILS), flown initially with the AP engaged and had involve capture of the ILS GS from above. However, prior to this, after the PF made an inadvertent selection of an unwanted mode on FMS prior to becoming established, he had disconnected the A/T and AP and elected to complete the approach manually. The aircraft had subsequently been fully established by 5.5nm DME and a stabilised approach had been flown thereafter.
The prevailing weather was CAVOK with the surface W/V at the time of the go around as recorded at runway 26 TDZ sensor being a mean of 315º/13 knots with variation between 297º and 342º and between 9 knots and 17 knots.
As the aircraft approached the flare, a high rate of descent developed and the aircraft descended below the nominal glideslope. After a momentary reduction of thrust, a go around was initiated with dual sidestick input by both pilots and TO/GA thrust selection. However, the FDR data showed that this had been immediately followed by a 15º forward sidestick input by the trainee Captain which was partially countered by a simultaneous aft input by the Training Captain. As both sidesticks were moved to the fully aft position, the Training Captain reported announcing ‘I have Control’ and the aircraft made very hard runway contact before lifting off and climbing away.
The dual sidestick input by the Training Captain prior to taking control was noted and it was observed in particular that had his corrective aft sidestick input made in response to the trainee’s forward sidestick input been preceded by selection of the priority ‘take over’ button on his sidestick, the severe runway impact “may have been prevented” whereas in the event, the two opposing inputs were summed and the corrective effect diminished.
It was found that neither pilot had previously experienced the ‘TOGA 10’ procedure for a low level go around that was required in the investigated event but both had practised it in the simulator - although it was not established whether this training had necessarily included an element of surprise.
In respect of the trainee Captain’s actions when attempting to initiate the TOGA 10 manoeuvre, it was considered by the Investigation that since he appeared to have made a sidestick input opposite to that expected as well as briefly retarding the thrust levers before selecting TOGA, “one possible explanation is that there was momentary confusion between the actions of his left and right hands”.
It was noted that the pilots involved had been provided with additional simulator training prior to their return to line flying, which for the Captain U/T had been as a co-pilot.
The formally stated Conclusion of the Investigation was that:
“Both pilots responded to an increased rate of descent approaching touchdown and each initiated a TOGA 10 go-around. Their initial sidestick inputs were in opposition and, without the use of the takeover sidestick pushbutton, the net effect was a pitch-down control input. If the commander had operated the sidestick takeover pushbutton, his nose-up pitch input would not have been counteracted by the nose-down input of the Capt U/T. In the event, his control input reduced the effect of the nose-down input made by the Capt U/T.”
The Final Report AAIB Bulletin: 1/2013 EW/C2012/02/03 was published on 10 January 2013. No Safety Recommendations were made.