A319, Montego Bay Jamaica, 2014
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|On 10 May 2014 the crew of an Airbus A319 failed to manage their daylight non-precision approach at destination effectively and it culminated in a very hard touchdown which exceeded landing gear design criteria. The Investigation concluded that the comprehensively poor performance of both pilots during the preparation for and execution of the approach could be attributed to both their repeated failure to follow SOPs and retain adequate situational awareness and to a failure of the aircraft operator to fully deliver effective training even though both this training and its SMS met relevant regulatory requirements and guidance.|
|Actual or Potential
|Human Factors, Loss of Control|
|Operator||Air Canada Rouge|
|Type of Flight||Public Transport (Passenger)|
|Origin||Toronto/Lester B. Pearson International Airport|
|Intended Destination||Montego Bay/Sangster International Airport|
|Take off Commenced||Yes|
|Location - Airport|
|Airport||Montego Bay/Sangster International Airport|
|Tag(s)||Approach not stabilised,|
Non Precision Approach,
Approach Unstabilsed at Gate-no GA,
Deficient Crew Knowledge-automation,
Deficient Crew Knowledge-handling,
Copilot less than 500 hours on Type
Inappropriate crew response - skills deficiency,
Inappropriate crew response (automatics),
Procedural non compliance,
Ineffective Monitoring - PIC as PF
|Tag(s)||Flight Management Error,|
Incorrect Aircraft Configuration
|Damage or injury||No|
|Causal Factor Group(s)|
On 10 May 2014, an Airbus A319 (C-FZUG) being operated by Air Canada Rouge as flight AC1804 on a scheduled international passenger flight from Toronto to Montego Bay made a hard landing which exceeded landing gear design criteria at destination after an unstabilised non-precision approach in day VMC and was thus unfit for further flight. There was no structural damage to the aircraft or injury to its occupants.
It was noted that the Captain, who was PF for the investigated flight, had approximately 10,000 flying hours which included 4,200 hours on type of which 500 were as commander, all obtained since he had been employed by Air Canada Rouge as a Captain seven months earlier. Prior to that he had been employed by Air Canada mainline since 2006, gaining his A319/A320 type rating in 2008. The First Officer had approximately 12,000 total flying hours which included 475 hours on type. He had joined Air Canada Rouge at the same time as the Captain after just five months at Air Canada mainline.
It was established that, having previously been "unaware" that the runway 07 ILS approach at Montego Bay was not available despite inclusion of the relevant NOTAM in their "flight release documentation", the crew had already briefed for the ILS approach. When offered either an RNAV or VOR/DME approach to the same runway at a relatively late stage in the flight and accepted the latter, the necessary re-brief was carried out only 12 minutes before landing and specified a managed (automation-performed) approach. The Jeppesen plate used for the approach is shown below.
The flight crew had then held "a non-operational conversation" lasting nearly 3 minutes which ended approximately 8 minutes prior to touchdown as the aircraft descended though 10,000 feet. Two minutes later, ATC queried whether the aircraft would be able to proceed direct to LENAR and this was answered in the affirmative. With the airspeed at 250 KIAS and the aircraft level at 3,000 feet and tracking towards LENAR, the PF selected a target speed of 190 KIAS on the FCU and the A/T effected a corresponding thrust reduction.
With the aircraft about to turn directly onto the FAT just inside LENAR, the PF requested flaps 1. The aircraft established in the FAT at approximately 9.6 nm from the threshold with the airspeed of approximately 200 KIAS and began its final descent. During the next minute, the FMA modes changed as expected to 'NAV' and 'FINAL DES', and the selected speed was successively set to 180, 190, 200, and finally to the calculated Vapp of 134 knots. The rate of descent reached 2,000 fpm but began to reduce once the selected speed had been reset to Vapp.
The FAF was crossed at the correct height of 2000 feet at Vapp + 54 knots. Flaps 1 were still selected contrary to the applicable SOP of Flaps 3. The PF selected the correct 3.2° FPA and in response, the FMA modes changed to TRK and FPA. The crew did not make the SOP calls for the FAF position or complete SOP actions for the position. The latter included setting the missed-approach altitude in the FCU.
As the aircraft descended through 1,780 feet approximately 5.2 nm from the runway threshold at 186 KIAS, the AP was disconnected and the remainder of the approach was flown manually by the PF. Flaps 3 was then requested - but the PM only selected Flaps 2 (without a corresponding callout) due to the airspeed being marginally above the limit for Flaps 3. Landing clearance was given and a few seconds later, the ALT/SEL (with 2,000 feet selected) was pulled. Since the aircraft was below that altitude, the A/T increased engine thrust from 34% to 87% but since the aircraft was now in manual flight, no climb followed, only an increase in airspeed. As the aircraft momentarily levelled off at 185KIAS approximately 4.5 nm from the runway, the PM selected Flaps 3 but as the speed increased due to high thrust, a Flap Overspeed Warning was annunciated for 3½ seconds. No call for this selection was made. Further FCU inputs were made and the A/T was disconnected. The aircraft became aligned with the PAPI just inside 2nm from the runway. This put the aircraft inside the applicable mandatory Stabilised Approach gate which was at 690 feet (MDA + 100 feet) which was not called. By 500 feet, airspeed was Vapp + 21 and the aircraft was back on the vertical profile.
With the aircraft approximately 1 nm from the runway and passing 370 feet at Vapp+ 12, the PF made the 500 foot stable approach call, which included "a hundred above, stable, minimums, runway in sight". The engines remained at idle. As the aircraft descended through 200 feet approximately 0.5 nm from the threshold, airspeed was decreasing below Vapp, the pitch attitude was 5.6° nose-up and the rate of descent was 570 fpm. As the aircraft descended through 80 feet, the PF "applied nose-up side-stick input, consistent with the landing flare" with the airspeed now 11 knots below Vapp and the rate of descent approximately 650 fpm. The true AoA at this time was calculated to have been almost 10°. At 40 feet agl, the airspeed was approximately 19 knots below Vapp, pitch attitude had stabilised at 9.8° nose-up and the rate of descent was approximately 860 fpm. The true AoA at this point was calculated as approximately 13.8°. As the "30" auto callout was given, "the thrust levers were momentarily advanced to maximum take-off thrust […] but increased by only 4% before the aircraft touched down".
Touch down occurred with a 3.12g vertical load factor and a pitch angle recorded as 7.7° nose-up. The touch down speed was 108 KIAS and the position was calculated as having been less than 40 metres past the displaced runway threshold. With the ground spoilers extended and the autobrake activating normally, reverse thrust was selected and the aircraft subsequently taxied off the runway to its parking gate without further incident. Once there, the crew reported the hard landing and the FDR data was reviewed and appropriate maintenance inspections performed. It was found that both main landing gear assemblies had been subjected to a high load exceedance. With the approval of both Airbus and Transport Canada, authority was obtained to position the aircraft out of service to Miami with the landing gear locked down where the main gear shock absorbers were replaced in accordance with Airbus recommendations.
It was noted that the normal landing technique is to reach 30 feet agl at Vapp in a stabilised condition and begin a progressive flare while simultaneously closing the thrust levers to achieve idle before touchdown. In the investigated case, full nose-up side-stick input was applied in the prematurely commenced flare and the calculated true AoA eventually exceeded 15° with the elevator position oscillating between 1° and 5° nose-up. It was noted that this sequence is consistent with activation of the aircraft's high-AoA protection system. This is designed to enable the PF to "pull the side-stick fully aft and achieve the best possible lift, minimising the risk of aerodynamic stall or control loss".
It was found that according to the Air Canada Rouge stabilised approach criteria, the aircraft was "stable at the FAF arrival gate" even though its airspeed was 54 knots above Vapp and was not configured with the proper flap setting as per configuration SOPs. The aircraft had not been stable at the subsequent mandatory arrival gate "because of its excessive airspeed, vertical speed deviations, incomplete landing checklist, and unstabilised thrust".
A range of other SOPs had been breached during the approach including the following:
- the PM must check the airspeed before all flap selections to ensure that the setting called is within the correct speed range and if it is, respond with ‘SPEED CHECKED’ before making the requested selection.
- All active FMA modifications must be announced by the PF and all such calls must be cross-checked by the PM on the PFD.
- The PM shall alert the PF by calling ‘Glideslope,’ ‘Localiser,’ or ‘Airspeed’ when a significant deviation is observed during an approach or when a flag or warning is observed. In particular, airspeed deviations of more than 10 knots above the target airspeed or more than 5 knots below it, a vertical speed greater than 1,000 fpm, bank angles greater than 7° and pitch attitudes lower than -2.5 or greater than 10° must be called.
Various flap and gear selection calls and landing checks during the final approach segment are compared with the actual occurrence sequence in the illustration below.
The Investigation noted that Air Canada Rouge had a pilot training programme explicitly approved by Transport Canada and an SMS which met all their guidelines. Nevertheless, the long history of unstabilised approaches leading to accidents and serious incidents at Canadian operators was continuing. A number of aspects of the investigated event which had contributed to the continuation of an unstabilised approach to a landing were identified as relevant to the poor pilot performance in this investigated event and interpreted as the consequence of "ineffective defences":
- Poor flight planning and briefing.
- Distraction from primary tasks by "non operational conversations".
- Failure as a team to manage an initially automated approach effectively.
- Failure to transition effectively to a manual approach once the AP had been disconnected.
- A lack of awareness of energy management throughout the approach.
- A complete failure to pay any attention to the prescribed stabilised approach criteria.
- A lack of appreciation of the consequences of continuing the approach with the A/T disconnected.
- The failure to adhere to a range of SOPs compromised the effectiveness of CRM.
- The absence of any simulator training scenarios which would assist pilots in "recognising an unstable approach leading to a missed approach".
More generally, the Investigation also identified the absence of an adequate specification of the frequency and delivery of relevant pilot training in automation proficiency.
The formal statement of Causes and Contributory Factors was as follows:
- The flight crew’s selection of a higher target speed before the final approach fix resulted in an increased thrust and high airspeed condition. This condition contributed to the crew’s confusion and misunderstanding of what the aircraft was doing, and resulted in their mismanagement of the configuration sequence.
- The inadvertent flight control unit selection resulted in a second high-airspeed and increased-thrust condition. The aircraft deviated above the approach profile between the final approach fix and the 500 foot arrival gate, and a flaps 3 overspeed alarm sounded. In response, the pilot flying disengaged the autothrust.
- The timing of the operational discussion as the aircraft descended past the 500-foot arrival gate may have diverted the attention of the pilot monitoring from his duties, causing an essential task (a “Stable” call) to be missed. As a result, the flight crew missed an opportunity to recognise an unstable approach.
- The pilot flying made the “Stable” call when the aircraft was not stabilised, as its airspeed was high, the landing checks were incomplete, and the thrust was at idle. As a result, the flight crew continued an unstable approach.
- Management of the aircraft’s energy condition diverted the flight crew’s attention from monitoring and controlling airspeed during the descent. As a result, the aircraft passed the final approach fix arrival gate at a high airspeed and with a flaps configuration that was not in accordance with the standard operating procedures.
- While on short final approach, the airspeed decayed well below final approach speed (Vapp), placing the aircraft in an undesired aircraft state at a very low altitude.
- When the flight crew recognised the undesired aircraft state, the late addition of engine power was insufficient to arrest the descent rate, resulting in a hard landing.
- The flight crew did not adhere to the standard operating procedures, which required the monitoring of all available parameters during approach and landing. With both flight crew members focused on the airspeed conditions and aircraft configuration delays, the instability of the approach was not identified and a go-around was not conducted.
- Air Canada Rouge did not provide flight crews with simulator training in recognising an unstable approach leading to a missed approach. As a result, the occurrence flight crew did not recognise the multiple deviations in airspeed and thrust or the deficiencies in coordination and communication, and they continued the approach well beyond the stabilisation gates.
- Air Canada Rouge did not include autothrust-off approach scenarios in each recurrent simulator training module and flight crews routinely fly with the automation on. As a result, the occurrence flight crew was not fully proficient in autothrust-off approaches, including management of the automation.
Findings as to Risk were also identified as follows:
- If flight crews do not conduct thorough briefings, including missed-approach briefings, they may not have a common action plan or set priorities, resulting in reduced crew coordination, which might compromise the safety of flight operations.
- If flight crews are distracted by other operational and non-operational activities and do not follow standard operating procedures, critical tasks associated with flying the aircraft may be delayed or missed.
- If flight crews do not adhere to standard procedures and best practices that facilitate the monitoring of stabilised approach criteria and excessive parameter deviations, there is a risk that threats, errors, and undesired aircraft states will be mismanaged.
- If an air operator’s standard operating procedures (SOP) are not consistent with its stable approach policy, there is a risk that flight crews will continue an approach while deviating from the SOPs, resulting in an unstable approach.
- If standards for flight crew training in relation to automation proficiency (Standard 725.124 in Part VII of the Canadian Aviation Regulations) are not explicit with regard to frequency, there is a risk that air operators will exclude critical elements from recurrent training modules and that flight crews might not be proficient in all levels of automation.
Safety Action taken by Air Canada Rouge as a result of the event was noted to have primarily included significant enhancements to recurrent pilot training. This now includes simulator training in unstable approaches leading to a go-around and more manual flying, including CFIT recovery, steep turns, approach to stall, upset recovery, autothrust disconnection and reconnection and operations with autothrust off. New and/or improved recurrent training modules on distraction, leadership and professional standards including "open communication" and dealing with SOP non-compliance by the other pilot have also been introduced and the Company has also "refined" the SOPs which cover its stable approach policy.
The Final Report of the Investigation was authorised for release on 13 October 2016 and officially released on 9 January 2017. No Safety Recommendations were made.