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|
Attributes | |
ACN | 659403 |
Time | |
Date | 200505 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : mia.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Thunderstorm |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : lga.tower |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 190 flight time total : 8000 flight time type : 475 |
ASRS Report | 659403 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 200 flight time total : 6000 flight time type : 2100 |
ASRS Report | 659409 |
Events | |
Anomaly | non adherence : far non adherence : published procedure non adherence : company policies other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
After a stabilized; not rushed approach; and a smooth landing; maximum automatic brakes engaged after spoiler deployment. As the PF; I reached over and immediately disconnected the automatic brakes with the switch. At this point in time I thought we had an automatic brake malfunction. After explaining the abrupt stop to passenger and flight attendants; we continued to the gate. During the taxi in; the first officer told me he had inadvertently selected maximum automatic brakes when he meant to select 'terrain on' switch. We had the WX radar on for arrival; he switched off the WX radar and was attempting to turn on the 'terrain on' switch. He told me he must have selected the maximum automatic brakes just before the landing gear was extended. All checklists and normal callouts were accomplished and cockpit discipline was very good. I did not catch the automatic brake light being illuminated during the normal checks. I did confirm gear down; flaps down; and landing memo green. After completing the shut down procedures; we did an inspection of wheels and tires and had the wheels chocked; then released brakes. Brake temperatures reached 480 degrees on one of the brakes. No damage was noted on wheels and tires. I called maintenance airframe controller and told him exactly what happened; he said no further maintenance action was required. The first officer told me he thought fatigue had contributed to his mistake. It was our first leg together and I did not notice any fatigue. Lessons learned; expect the unexpected and always cross check automatic brake selection. Why did airbus not include an ECAM caution warning when maximum automatic brakes are selected in flight? Callback conversation with reporter revealed the following information: the captain was very surprised after the fact that the ECAM did not annunciate the selection of maximum brakes. At his air carrier; maximum automatic brake is prohibited. The question then is; if selected and use is prohibited; why not alert on selection prior to landing. He believes that the first officer's accidental maximum selection instead of terrain radar on; was merely complacency or fatigue. Supplemental information from acn 659409: human factors was a factor; it was a long day.
Original NASA ASRS Text
Title: AN A320 FO INADVERTENTLY SELECTED MAX AUTO BRAKES BEFORE LNDG. THE CREW DID NOT REALIZE MAX BRAKING WAS SELECTED UNTIL IT WAS APPLIED DURING LNDG.
Narrative: AFTER A STABILIZED; NOT RUSHED APCH; AND A SMOOTH LNDG; MAX AUTO BRAKES ENGAGED AFTER SPOILER DEPLOYMENT. AS THE PF; I REACHED OVER AND IMMEDIATELY DISCONNECTED THE AUTO BRAKES WITH THE SWITCH. AT THIS POINT IN TIME I THOUGHT WE HAD AN AUTO BRAKE MALFUNCTION. AFTER EXPLAINING THE ABRUPT STOP TO PAX AND FLT ATTENDANTS; WE CONTINUED TO THE GATE. DURING THE TAXI IN; THE FO TOLD ME HE HAD INADVERTENTLY SELECTED MAX AUTO BRAKES WHEN HE MEANT TO SELECT 'TERRAIN ON' SWITCH. WE HAD THE WX RADAR ON FOR ARR; HE SWITCHED OFF THE WX RADAR AND WAS ATTEMPTING TO TURN ON THE 'TERRAIN ON' SWITCH. HE TOLD ME HE MUST HAVE SELECTED THE MAX AUTO BRAKES JUST BEFORE THE LNDG GEAR WAS EXTENDED. ALL CHKLISTS AND NORMAL CALLOUTS WERE ACCOMPLISHED AND COCKPIT DISCIPLINE WAS VERY GOOD. I DID NOT CATCH THE AUTO BRAKE LIGHT BEING ILLUMINATED DURING THE NORMAL CHKS. I DID CONFIRM GEAR DOWN; FLAPS DOWN; AND LNDG MEMO GREEN. AFTER COMPLETING THE SHUT DOWN PROCS; WE DID AN INSPECTION OF WHEELS AND TIRES AND HAD THE WHEELS CHOCKED; THEN RELEASED BRAKES. BRAKE TEMPS REACHED 480 DEGS ON ONE OF THE BRAKES. NO DAMAGE WAS NOTED ON WHEELS AND TIRES. I CALLED MAINT AIRFRAME CTLR AND TOLD HIM EXACTLY WHAT HAPPENED; HE SAID NO FURTHER MAINT ACTION WAS REQUIRED. THE FO TOLD ME HE THOUGHT FATIGUE HAD CONTRIBUTED TO HIS MISTAKE. IT WAS OUR FIRST LEG TOGETHER AND I DID NOT NOTICE ANY FATIGUE. LESSONS LEARNED; EXPECT THE UNEXPECTED AND ALWAYS CROSS CHK AUTO BRAKE SELECTION. WHY DID AIRBUS NOT INCLUDE AN ECAM CAUTION WARNING WHEN MAX AUTO BRAKES ARE SELECTED IN FLT? CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT WAS VERY SURPRISED AFTER THE FACT THAT THE ECAM DID NOT ANNUNCIATE THE SELECTION OF MAX BRAKES. AT HIS ACR; MAX AUTO BRAKE IS PROHIBITED. THE QUESTION THEN IS; IF SELECTED AND USE IS PROHIBITED; WHY NOT ALERT ON SELECTION PRIOR TO LNDG. HE BELIEVES THAT THE FO'S ACCIDENTAL MAX SELECTION INSTEAD OF TERRAIN RADAR ON; WAS MERELY COMPLACENCY OR FATIGUE. SUPPLEMENTAL INFO FROM ACN 659409: HUMAN FACTORS WAS A FACTOR; IT WAS A LONG DAY.
Data retrieved from NASA's ASRS site as of January 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.