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|
Attributes | |
ACN | 793369 |
Time | |
Date | 200806 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl bound lower : 900 agl bound upper : 1200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : go around |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument pilot : multi engine |
Experience | controller non radar : 3 controller radar : 16 flight time last 90 days : 160 flight time total : 9875 flight time type : 3600 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : regained aircraft control |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
On this leg I was the PF the first officer was the PNF. We had been cleared for a visual approach to runway 33L at ZZZ. The WX was good and I was letting the autoplt fly us inbound and downslope on the ILS. At about 7-8 mi out the tower warned us that a truck and men were working quickly to get debris (dead animal) cleared off the runway. He said he didn't know if they would be done in time so there was the chance he might have to abort the approach. He asked us to fly our lowest approach speed possible. I do this with full flaps and gear down. At approximately 3 mi and 900 ft AGL; tower said something like 'air carrier X sorry but this isn't gonna work; turn left to a heading of 190.' 3 seconds later the controller said 'and air carrier X climb and maintain 2000 ft.' at the very instant of his first 6 words I leveled the plane by engaging the vertical speed zero FCU button. The autoplt and autothrottle worked together to stop the downslope trajectory and bring up the engines to more power. Then I commenced the turn using the autoplt. Next I used the FCU to dial in and engage an autoplt climb to 2000 ft. The engines advance and the plane begins a climb. All airline pilots train for go around's that pass over the field. This was very much a non standard maneuver. At a low altitude we were being broken off the approach. Though our low altitude gets one's attention; it really is not that big a deal as now all we do is go about flying the airplane. The first officer seemed spring loaded for action. He asked me 'is this a go around?' as his l-hand was on the flap lever. I said 'no;...we aren't doing a go around over the field.' first officer 'do you want go around flaps?' captain 'no.' a few seconds go by and I ask for gear by saying the SOP 'positive rate; gear up.' first officer lifts the gear lever. Now we are in the climb and about 1100-1200 ft AGL. I say the SOP phrase 'go around flaps' which in this plane means that retract the flaps one step. In our current confign this would be from full flaps to flaps 3 degrees. The PNF is to make the SOP call out 'speed checked; flaps 1' after looking at the ECAM. He didn't make this callout. I am generally looking forward and working the FCU to fly. In my lower vision I see the left side pfd tape jump up (it ties in with the flap lever) and our speed is now presenting as quickly approaching the area of a stall. I quickly grab the stick; shove the nose forward and the autoplt kicks off. I grab the thrust levers and push them forward for more power. I try to level the bank some and perform something similar to an upset recovery procedure. The first officer was thinking the same thing as he had also pushed the nose forward. (Dual inputs was called out by the warning system.) my eyes take 1 second to look at the central engine gauges and I see that the flaps have been commanded to their lowest detent which now will be a setting of flaps 1+F. The first officer had inappropriately moved the flaps from the fullest setting past 2 detents and F one. This causes us to lose lift on the wings of a heavy swept-wing aircraft. The plane is herky-jerky; this isn't pretty but the alpha floor protection system did not activate. We descend what I guess was 200-300 ft. I scoop it out; we fly to heading; we are put back into the line up and we land. Once at the gate the first officer doesn't offer any reflections; thoughts; apologies; opinions until I initiate conversation on the break out. In general he just comments that 'that whole thing was screwy.' I have since communicated with him and he won't participate in conversation to review the flying particulars of the incident. Conclusion: the first officer moved the flap lever to an uncommanded position. He did not make the SOP callout while doing this. I had to take aggressive action to avoid approaching a stall regime. Why? I don't know. I am continuing to pursue the matter with department heads and the pilot himself. Possibly the first officer had his brain saturated with the typical go around procedure; but even so he did this wrong. Also; we have had to do more than the usual number of flaps 3 degree takeoffs lately at ZZZ due to construction on runway 28. Possibly he had that profile in his brain where we move the flaps from F3 to F one. But if he was thinking that he still did it wrong cause we aren't allowed to do this until at least 1500 ft AGL. Either way his brain was not calm; he got flustered; and/or his SOP procedural verbal and profile knowledge was weak. Exact analysis would show that aerodynamic safety properties of flight were not transgressed. The plane flew. I asked flight attendants later what they thought and they didn't comment that the breakout was overly worrisome with deck angle or engine sounds. But this could have gone differently. (Alpha floor; etc) the first officer is human and he made a mistake. The flight was not as smooth as airline flying should be. The PF had to do lots of quick stressful action due to the PNF's mistake.
Original NASA ASRS Text
Title: AN A320 CAPT DESCRIBES A GO AROUND PROCEDURAL ERROR RESULTING IN A NEAR STALL CONDITION.
Narrative: ON THIS LEG I WAS THE PF THE FO WAS THE PNF. WE HAD BEEN CLRED FOR A VISUAL APCH TO RWY 33L AT ZZZ. THE WX WAS GOOD AND I WAS LETTING THE AUTOPLT FLY US INBOUND AND DOWNSLOPE ON THE ILS. AT ABOUT 7-8 MI OUT THE TWR WARNED US THAT A TRUCK AND MEN WERE WORKING QUICKLY TO GET DEBRIS (DEAD ANIMAL) CLRED OFF THE RWY. HE SAID HE DIDN'T KNOW IF THEY WOULD BE DONE IN TIME SO THERE WAS THE CHANCE HE MIGHT HAVE TO ABORT THE APCH. HE ASKED US TO FLY OUR LOWEST APCH SPD POSSIBLE. I DO THIS WITH FULL FLAPS AND GEAR DOWN. AT APPROX 3 MI AND 900 FT AGL; TWR SAID SOMETHING LIKE 'ACR X SORRY BUT THIS ISN'T GONNA WORK; TURN L TO A HDG OF 190.' 3 SECONDS LATER THE CTLR SAID 'AND ACR X CLB AND MAINTAIN 2000 FT.' AT THE VERY INSTANT OF HIS FIRST 6 WORDS I LEVELED THE PLANE BY ENGAGING THE VERT SPD ZERO FCU BUTTON. THE AUTOPLT AND AUTOTHROTTLE WORKED TOGETHER TO STOP THE DOWNSLOPE TRAJECTORY AND BRING UP THE ENGS TO MORE PWR. THEN I COMMENCED THE TURN USING THE AUTOPLT. NEXT I USED THE FCU TO DIAL IN AND ENGAGE AN AUTOPLT CLB TO 2000 FT. THE ENGS ADVANCE AND THE PLANE BEGINS A CLB. ALL AIRLINE PLTS TRAIN FOR GAR'S THAT PASS OVER THE FIELD. THIS WAS VERY MUCH A NON STANDARD MANEUVER. AT A LOW ALT WE WERE BEING BROKEN OFF THE APCH. THOUGH OUR LOW ALT GETS ONE'S ATTN; IT REALLY IS NOT THAT BIG A DEAL AS NOW ALL WE DO IS GO ABOUT FLYING THE AIRPLANE. THE FO SEEMED SPRING LOADED FOR ACTION. HE ASKED ME 'IS THIS A GAR?' AS HIS L-HAND WAS ON THE FLAP LEVER. I SAID 'NO;...WE AREN'T DOING A GAR OVER THE FIELD.' FO 'DO YOU WANT GAR FLAPS?' CAPT 'NO.' A FEW SECONDS GO BY AND I ASK FOR GEAR BY SAYING THE SOP 'POSITIVE RATE; GEAR UP.' FO LIFTS THE GEAR LEVER. NOW WE ARE IN THE CLB AND ABOUT 1100-1200 FT AGL. I SAY THE SOP PHRASE 'GAR FLAPS' WHICH IN THIS PLANE MEANS THAT RETRACT THE FLAPS ONE STEP. IN OUR CURRENT CONFIGN THIS WOULD BE FROM FULL FLAPS TO FLAPS 3 DEGS. THE PNF IS TO MAKE THE SOP CALL OUT 'SPD CHKED; FLAPS 1' AFTER LOOKING AT THE ECAM. HE DIDN'T MAKE THIS CALLOUT. I AM GENERALLY LOOKING FORWARD AND WORKING THE FCU TO FLY. IN MY LOWER VISION I SEE THE L SIDE PFD TAPE JUMP UP (IT TIES IN WITH THE FLAP LEVER) AND OUR SPD IS NOW PRESENTING AS QUICKLY APCHING THE AREA OF A STALL. I QUICKLY GRAB THE STICK; SHOVE THE NOSE FORWARD AND THE AUTOPLT KICKS OFF. I GRAB THE THRUST LEVERS AND PUSH THEM FORWARD FOR MORE PWR. I TRY TO LEVEL THE BANK SOME AND PERFORM SOMETHING SIMILAR TO AN UPSET RECOVERY PROC. THE FO WAS THINKING THE SAME THING AS HE HAD ALSO PUSHED THE NOSE FORWARD. (DUAL INPUTS WAS CALLED OUT BY THE WARNING SYS.) MY EYES TAKE 1 SECOND TO LOOK AT THE CENTRAL ENG GAUGES AND I SEE THAT THE FLAPS HAVE BEEN COMMANDED TO THEIR LOWEST DETENT WHICH NOW WILL BE A SETTING OF FLAPS 1+F. THE FO HAD INAPPROPRIATELY MOVED THE FLAPS FROM THE FULLEST SETTING PAST 2 DETENTS AND F ONE. THIS CAUSES US TO LOSE LIFT ON THE WINGS OF A HVY SWEPT-WING ACFT. THE PLANE IS HERKY-JERKY; THIS ISN'T PRETTY BUT THE ALPHA FLOOR PROTECTION SYS DID NOT ACTIVATE. WE DSND WHAT I GUESS WAS 200-300 FT. I SCOOP IT OUT; WE FLY TO HDG; WE ARE PUT BACK INTO THE LINE UP AND WE LAND. ONCE AT THE GATE THE FO DOESN'T OFFER ANY REFLECTIONS; THOUGHTS; APOLOGIES; OPINIONS UNTIL I INITIATE CONVERSATION ON THE BREAK OUT. IN GENERAL HE JUST COMMENTS THAT 'THAT WHOLE THING WAS SCREWY.' I HAVE SINCE COMMUNICATED WITH HIM AND HE WON'T PARTICIPATE IN CONVERSATION TO REVIEW THE FLYING PARTICULARS OF THE INCIDENT. CONCLUSION: THE FO MOVED THE FLAP LEVER TO AN UNCOMMANDED POS. HE DID NOT MAKE THE SOP CALLOUT WHILE DOING THIS. I HAD TO TAKE AGGRESSIVE ACTION TO AVOID APCHING A STALL REGIME. WHY? I DON'T KNOW. I AM CONTINUING TO PURSUE THE MATTER WITH DEPT HEADS AND THE PLT HIMSELF. POSSIBLY THE FO HAD HIS BRAIN SATURATED WITH THE TYPICAL GAR PROC; BUT EVEN SO HE DID THIS WRONG. ALSO; WE HAVE HAD TO DO MORE THAN THE USUAL NUMBER OF FLAPS 3 DEG TKOFS LATELY AT ZZZ DUE TO CONSTRUCTION ON RWY 28. POSSIBLY HE HAD THAT PROFILE IN HIS BRAIN WHERE WE MOVE THE FLAPS FROM F3 TO F ONE. BUT IF HE WAS THINKING THAT HE STILL DID IT WRONG CAUSE WE AREN'T ALLOWED TO DO THIS UNTIL AT LEAST 1500 FT AGL. EITHER WAY HIS BRAIN WAS NOT CALM; HE GOT FLUSTERED; AND/OR HIS SOP PROCEDURAL VERBAL AND PROFILE KNOWLEDGE WAS WEAK. EXACT ANALYSIS WOULD SHOW THAT AERODYNAMIC SAFETY PROPERTIES OF FLT WERE NOT TRANSGRESSED. THE PLANE FLEW. I ASKED FLT ATTENDANTS LATER WHAT THEY THOUGHT AND THEY DIDN'T COMMENT THAT THE BREAKOUT WAS OVERLY WORRISOME WITH DECK ANGLE OR ENG SOUNDS. BUT THIS COULD HAVE GONE DIFFERENTLY. (ALPHA FLOOR; ETC) THE FO IS HUMAN AND HE MADE A MISTAKE. THE FLT WAS NOT AS SMOOTH AS AIRLINE FLYING SHOULD BE. THE PF HAD TO DO LOTS OF QUICK STRESSFUL ACTION DUE TO THE PNF'S MISTAKE.
Data retrieved from NASA's ASRS site as of May 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.