Emirates A388 at Moscow on Sep 10th 2017, go around from about 400 feet AGL 8nm before runway
Last Update: April 16, 2020 / 17:17:13 GMT/Zulu time
Date of incident
Sep 10, 2017
Dubai, United Arab Emirates
Moscow Domodedovo, Russia
ICAO Type Designator
Position and Altitude data transmitted by the aircraft's transponder suggest the aircraft was tracking about 190 degrees magnetic when the aircraft initiated the go around at about 1000 feet MSL about 8nm before the runway threshold, which translates to about 400 feet AGL with the aerodrome elevation at 180 meters/592 feet MSL.
The airline told The Aviation Herald on Sep 18th 2017, that the occurrence is being investigated by United Arab Emirates' Civil Aviation Authority GCAA, the airline apologizes that due to the investigation no further details can be provided.
The GCAA have already sent a first preliminary reply indicating the communication department is about to respond to the questions.
On Sep 19th 2017 the GCAA reported that the occurrence of the A380 descending below the glideslope on approach to runway 14R at Moscow Deomodedovo Airport was rated a serious incident and is being investigated by UAE's Air Accident Investigation Sector (AAIS). There were no injuries and no damage to the aircraft.
On Sep 22nd 2017 the GCAA stated to other accident investigation bodies: "During the approach, the aircraft descended to 400 ft, approximately 7.5 Nm inbound on the runway while attempting to intercept the ILS for landing. The EGPWS alerted the pilots and the crew aborted the landing. A second approach was unsuccessful and aborted. The aircraft landed safely on the third approach." The occurrence was rated a serious incident and is being investigated by the GCAA's AAIS.
Russia's Rosaviatsia (Civil Aviation Authority) have not yet replied to the inquiry by The Aviation Herald.
According to Russia's news agency Interfax the aircraft was cleared to descend to 500 meters (editorial note: heights in meters QFE are given by ATC below transition altitude, above transition altitude altitudes in feet are provided) however descended too fast and below the assigned height.
On Apr 16th 2020 the GCAA released their final report concluding the probable causes were:
The Air Accident Investigation Sector determines that:
- The descent below the cleared altitude on the first approach can be explained by an erroneous flight crew perception that the Aircraft would capture the 3° glideslope from above and by insufficient coordination between the flight crewmembers. After the Co-pilot carried out the glide interception from above procedure, he focused on the horizontal position of the aircraft to establish on the localizer and neither of the two pilots maintained a correct awareness of the Aircraft vertical position.
- The cause of the discontinued approach on the second approach was the selection by the flight crew of a waypoint using the DIR TO function and after a relatively long discussion between them due to:
+ the unavailability of the flight plan on the ND, as the FMS1, reset after the go-around, was not reconfigured by re-sequencing the flight plan as per SOP; and
+ the Aircraft oscillation around the localizer course.
The Air Accident Investigation Sector identifies the following contributing factors to the Incident:
- The expectation of the Co-pilot that Radar Control might not provide the flight crew with vectors to intercept the localizer at an angle of 45 degrees or less when the Aircraft was on the base leg (90-degrees to the final approach track). The provided radar vectors inside the final approach point (FAP) together with the instruction to maintain relatively high speeds until the Aircraft was almost abeam of the initial approach fix (IAF), and the Co-pilot expectation, resulted in an unusually high workload in a dynamic approach phase.
- The glide interception from above procedure was performed when the Aircraft had not yet established on the ILS localizer for runway 14R. This was not in accordance with the SOP.
- During the period of when the glide interception from above procedure was performed and the go-around, the Aircraft position was initially outside the azimuthal coverage of the ILS glideslope signal, and when the Aircraft came within azimuthal coverage, it was outside the elevation coverage of the glideslope signal. Consequently, invalid glideslope deviation indications were displayed to the flight crew.
- Before performing the glide interception from above procedure, the erroneous flight crew representation of the Aircraft position gave them the perception that they were being vectored to a tight approach and that the Aircraft would capture the glideslope from above, led the pilot flying:
+ to refer only to the glideslope deviation indication to determine the Aircraft vertical position instead of considering and crosschecking any other available indications (pressure altitude, vertical and navigation displays, and the DME distance table in the approach chart) which would have enabled him to reconsider and validate the Aircraft position;
+ to descend below the cleared altitude and to modify the heading vectors issued by the Air Traffic Controller.
- As the Aircraft was descending below 500 meters QFE, the duration of the Radar Controller’s instruction to the flight crew “not to descend further” was lengthy and the phraseology used was non-standard for an urgent instruction,
- As the flight crew prepared for the second approach, a multi-waypoint sequencing in a row of the flight plan occurred when the crew performed a lateral revision of the flight plan using the DIR TO CRS IN pushbutton as per the SOP at a location where several waypoints satisfied the FMS geometrical waypoint sequencing rules. A real time computation issue caused an automatic reset of FMS1.
- After the multi-waypoint sequencing of the flight plan and the FMS1 auto-reset during the second attempted approach, the flight crewmembers omitted to reconfigure the FMS by inserting (adjusting the sequencing of the flight plan) the runway 14R ILS approach. The flight crew did not anticipate that omitting this action, aiming at providing the missed approach route should a go-around need to be performed, would jeopardize the capture of the localizer by the AFS system.
The GCAA reported the captain (54, ATPL, 18,000 hours total, 2,615 hours on type) was pilot monitoring, the first officer (39, ATPL, 7,280 hours total, 700 hours on type) was pilot flying.
The GCAA reported the aircraft reached a minimum height of 395 feet AGL during the first approach. On this approach the aircraft never aligned with the localizer nor did it intercept the glidepath.
The GCAA reported that both FDR and CVR were read out, however, only the FDR contained useful data of the incident flight The CVR contained the data of the return flight to Dubai.
The GCAA summarized the first approach:
After passing the Aksinyino (AO) NDB, ATC was providing radar vectoring to EK131 to establish th Aircraft on the runway 14R instrument landing system (ILS). On the base leg, the vectors provided were approximately parallel to the initial approach fix (IAF) – intermediate fix (IF) line as shown in figure 4. The AMTAM waypoint was the IAF point, as illustrated on the ILS 14R chart (figure 4). The flight path of the Aircraft was approximately 2.9 nautical miles shorter to the runway than the localizer interception path through the AMTAM waypoint, as shown on the chart.
At 1751:30, the Radar Controller offered EK131 a descent to 500 meters on a QFE setting (about 2,230 feet on QNH7 setting) at the flight crew’s discretion in order to establish on the localizer. The Commander agreed to descend the Aircraft to 500 meters. At this time, the Aircraft was on a heading of 220 degrees and levelled off at 3,250 feet pressure altitude, and the airspeed was 169 knots.
At 1751:38, the selected altitude setting was changed from 3,300 to 2,300 feet. The Radar Controller acknowledged that the Aircraft was descending to 500 meters and the controller repeated the clearance for the runway 14R ILS on the present heading of 220 degrees to establish the localizer. The Radar Controller requested EK131 to maintain 170 knots as long as possible to avoid minimum separation with traffic behind the Aircraft. EK131 commenced the descent in “open descent” mode.
At 1752:08, the Radar Controller informed the flight crew that there was no separation issue, and no speed limit instruction was given to the Aircraft. This was acknowledged by EK131. At this time, EK131 was maintaining a 220-degree heading and descending through 3,016 feet pressure altitude at 170 knots airspeed. The selected heading was changed gradually from 220 degrees to approximately 212 degrees, and the Aircraft started to turn left.
At 1752:24, the 170 knots airspeed selected mode was changed to speed managed mode. The target speed was now 143 knots. Consequently, the airspeed reduced gradually.
At 1752:30, the landing gear was down and in locked condition, the slats/flaps were at ‘configuration 3’, and the speed-brake lever was in the ‘arm’ position, as configured before. Nine seconds after the airspeed managed mode was set, at 1752:33, the speed managed mode was set back again to selected mode with an airspeed of 170 knots. The airspeed reached a minimum of 158 knots, and it then increased gradually to the selected airspeed.
At 1752:47, as the Aircraft was about to capture 2,300 feet pressure altitude (1,840 feet radio altitude), the selected altitude setting was changed from 2,300 feet to 3,000 feet (about 700 feet above the initial go-around altitude of 2,240 feet pressure altitude). At this time, the Aircraft was maintaining a heading 212 degrees and descending through 2,320 feet pressure altitude. Three seconds later, the vertical speed setting was selected to a 2,000 feet per minute rate of descent.
At 1752:51, the Radar Controller instructed EK131 to maintain the 220 degrees heading to approach the final approach point (P) at 500 meters, and to contact the Tower on 118.6 megahertz (MHz). The controller provided the QNH of 1015 mbar/hectopascal. The flight crew did not reply to the Radar Controller. At this time, the Aircraft was maintaining a 212-degree heading and descending through 2,236 feet pressure altitude. The airspeed was 162 knots and still increasing gradually to 170 knots.
At 1753:01, the selected heading was changed gradually from 212 to 210 degrees. The Aircraft was now descending through 2,044 feet pressure altitude, and the airspeed had reached the selected 170 knots.
At 1753:08, the Radar Controller instructed the flight crew to maintain 500 meters height at QFE 994 (QNH 1015), and to stop further descent. The Radar Controller repeated this instruction three times. He informed EK131 that the transponder indicated a height of 290 meters and the runway elevation was 180 meters. As the Radar Controller started this communication with the Aircraft, the flaps lever position was changed from configuration ‘3’ to ‘full’. At this time, the Aircraft was maintaining a 210 degree heading, descending through 1,720 feet pressure altitude (1,205 feet radio altitude), and the airspeed was 174 knots. At 1753:26, the selected altitude was set to 3,100 feet from 3.000 feet.
At 1753:29, the selected vertical speed setting was changed from -2,000 feet per minute to +2,500 feet per minute.
At 1753:31, the Commander contacted the Radar Controller declaring a go-around.
At almost the same time, takeoff/go-around (TOGA) thrust was activated and engine thrust started to increase. The Aircraft was banking to the left through a heading of 197 degrees while descending through 1,084 feet pressure altitude (504 feet radio altitude), and the airspeed was 173 knots.
At 1753:33, the enhanced ground proximity warning system (EGPWS) issued alerts while the Aircraft was still banking to the left, turning through the 197 degree heading and descending through 1,048 feet pressure altitude (474 feet radio altitude), at an indicated airspeed of 172 knots and a distance of 7.3 nautical miles from runway 14R threshold.
The EGPWS alerts began with a two second “glideslope” caution, followed by a terrain awareness and display (TAD) ”Terrain ahead-pull up” warning which lasted for six seconds and ended with a further EGPWS “glideslope” alert lasting one second. The minimum radio altitude reached was 395 feet above ground level, while the EGPWS alerts were active.
The Radar Controller instructed EK131 to continue on its present 200-degree heading, and to climb to 900 meters QFE (3,550 feet QNH). While the Aircraft climbed through 2,128 feet pressure altitude, the controller instructed the flight crew to change heading to 180 degrees. The Radar Controller requested the reason for the go-around and the Commander replied that the approach had been unstable.
The aircraft performed a second approach, turned onto final approach course descending from 3300 feet MSL through 3100 feet MSL, when the captain anounced they were going around. The aircraft levelled off at 2600 feet MSL and maintained 2600 feet (600 meters QFE) without selecting TOGA. The go around target altitude was 600 meters QFE. The captain explained the approach was unstable.
The aircraft was vectored for a third approach, established on localizer and glidepath and landed without further incident.
The GCAA analysed the first approach in a very lengthy way spanning 23 pages. The key statements are:
At 1752:26, when the position of the Aircraft was abeam the AMTAM waypoint, following the noisy signal phase, the displayed glideslope deviation indicated that the Aircraft was above the 3-degree ILS glideslope, while the actual Aircraft height was approximately 580 feet below the theoretical 3-degree glideslope.
At approximately 1752:57, the displayed glideslope deviation indicated that the Aircraft was on profile, and continued descending below the profile. The actual Aircraft height was approximately 850 feet below the theoretical 3-degree glideslope when the glideslope deviation indication indicated that the Aircraft was on profile. Following this, the actual Aircraft height continued to decrease.
the Aircraft was descending passing 2,560 feet pressure altitude (2,072 feet radio altitude), with a target of 2,300 feet pressure altitude, and the ‘altitude hold’ mode was armed. The airspeed was decaying through 163 knots (the target speed was 143 knots in a speed-managed mode). The localizer and glideslope modes were already armed. The landing gear was ‘down and locked’, and the flaps were set to ‘configuration 3’.
Before selecting the airspeed to 170 knots, the flight crew were concerned that they were being vectored inside the final approach point (FAP/ P). The vectoring brought the Aircraft 2.9 nautical miles closer to the runway threshold, compared to the ILS 14R approach chart (figure 4) distance.
The flight crew expected the Aircraft to be at a distance of less than eight nautical miles from the threshold. In this case, the Aircraft would have been high on intercepting the glideslope when reaching the final approach leg. The Commander felt that the Aircraft was not in a comfortable position to turn and intercept the glideslope.
After setting the speed to ‘managed’ mode, the Co-pilot estimated that a higher airspeed than the target speed was required in order to expedite descent while in open descent mode. His perception of the need for a higher airspeed led him to select the airspeed to 170 knots.
Seven seconds later after 170 knots was selected, the altitude capture mode engaged indicating that the Aircraft had almost reached the selected 2,300 feet pressure altitude. At this time, the Aircraft was descending passing through approximately 2,470 feet. The displayed ALT* mode (in green) was indicated on the FMA for about seven seconds.
The 170 knots in selected mode did not have contribution to the descent below the vertical profile ...
Approximately 14 seconds after the Co-pilot set the airspeed selected mode to 170 knots, at 1752:47, the selected altitude was increased from 2,300 to 3,000 feet, and thereafter the vertical speed was selected to -2,000 feet per minute.
As per procedure design, the selected altitude of 3,000 feet on the AFS CP was above the actual Aircraft altitude, which resulted in disengagement of the altitude capture mode and engagement of the vertical speed selected mode. At that time, the Aircraft was descending passing through 2,320 feet pressure altitude. The Aircraft should have been levelled off at 2,300 feet QNH (500 meters QFE), as instructed by ATC, but instead the Aircraft continued to descend since the glide interception from above procedure had been used.
The altitude target was selected above the Aircraft actual altitude as per glide interception from above procedure in order to prevent an inadvertent altitude capture engagement that would have destabilized the capture of the ILS glideslope (G/S) signal. It also prevents an attitude excursion in the case of a go-around initiation.
When the Co-pilot set the selected altitude to 3,000 feet, the pressure altitude on his primary flight display indicated 2,316 feet, and the altitude capture mode was still displayed on the FMA, giving him an opportunity, as the pilot flying, to remember the 2,300 feet QNH clearance as instructed by the Radar Controller, and to delay the application of the glide interception from above procedure. The altitude capture mode became disengaged and the display disappeared from the FMA after the selected altitude was set to 3,000 feet.
The Investigation believes that the Co-pilot referred only to the glideslope deviation indication displayed on the PFD that indicated more than one dot above the ILS glide profile (figures 27 and 28), while the ILS glideslope signal was not yet reliable and accurate. Had the Co-pilot referred to other vertical indications, it is most likely that he would not have performed the glide interception from above procedure. Therefore, the Investigation believes that before the Co-pilot decided to perform the procedure, he did not confirm the actual Aircraft vertical position by referring to other indications such as the pressure altitude, navigation and vertical display, and the approach procedure chart.
The vertical display (VD) was also available since both navigation displays (NDs) were in ARC and ROSE-NAV modes. Therefore, the Co-pilot could have referred to the VD to verify the actual Aircraft vertical position.
According to the FCOM, prior to commencing the glide interception from above procedure, the Aircraft should be established on the ILS localizer. When the Co-pilot performed the procedure actions, the Aircraft had not yet established on the localizer.
The Commander stated that he did not recognize the Co-pilot’s announcement about his (Co-pilot’s) actions as he attempted to carry out the glide interception from above procedure.
During the time between the Radar Controller’s first instruction and his second communication, the Commander was confronted with a significant workload including:
- the need to change the radio communication frequency to the Tower control;
- understand the change of heading to 210 degrees, which was not as instructed;
- the Co-pilot’s announcement of the glide interception from above procedure that the Commander did not understand, if indeed such an announcement was declared by the Co-pilot;
- the second Radar Controller’s communication, which required a reply from the Commander; and
- the request to set the flap lever from ‘3’ to ‘full’ position from the Co-pilot, which occurred within the six-second period, or between Radar Controller’s second communication and the Commander’s reply.
The flight crew were unaware that the Aircraft had descended below 500 meters.
The Commander was attending to the workload listed. The high workload resulted in the Commander not replying to the Radar Controller’s initial instructions, and his only action was to set the flap lever to ‘full’.
Since the radio frequency had not yet been changed to the Tower control frequency, the Radar Controller was still able to alert the flight crew to the situation. Should the frequency have been changed to the Tower frequency, it might have resulted in a more serious outcome since the time at which the first contact would have made with the Tower could not be predicted, and the Tower Controller would have needed some time to comprehend the true Aircraft situation, including its vertical position.
The ICAO envelope of glideslope signal coverage is basic knowledge for an
instrument rated pilot. Guidance for runway 14R ILS was provided in a LIDO chart, and in the FCOM. It is also referenced in the Manufacturer’s pilot development program (PDP), which was mandatory for new pilots joining the operator. However, there was no evidence that either flight crewmember was aware of the ICAO envelope of glideslope signal quality. The angle of the Aircraft-runway threshold axis relative to the runway centerline axis (psi angle of figure 33) was approximately 18.5 degrees, which was more than 8 degrees. Based on the flight path, the Aircraft passed 8 degrees psi at about 1753.25, which means the flight crew might have needed to wait for another 38 seconds from the time the selected altitude was set to 3,000 feet (initiation of the glide interception from above procedure), in order to obtain normal quality of glideslope signal as per ICAO envelope.
The Investigation believes that the Commander, as the pilot monitoring, was concentrating on communications with ATC to such an extent that his situational awareness of what was occurring in the cockpit and of the actual Aircraft state was significantly degraded. He was aware of the airspeed and he proposed setting ‘managed mode’, and he expected that the Aircraft would intercept the glideslope from above, as he believed that the Aircraft was too high, since he referred to the glideslope deviation indication. However, he did not challenge the Co-pilot as to the Co-pilot’s application of the glide interception from above procedure. The Commander, probably, relied on the Co-pilot to an extent that he degraded his own situational awareness, especially in relation to the Aircraft state. He focused more on communications and in helping the Co-pilot to configure the Aircraft for the approach and landing when requested by the Co-pilot.
Neither pilot was aware that the Aircraft was descending below 500 meters QFE until the instruction ‘not to descend further’ came from the Radar Controller. On receiving this instruction, the Commander then decided to initiate an immediate go-around. He declared his intention to the Radar Controller approximately three seconds after the “not to descend” instruction.
At 1753:11, the Radar Controller instructed EK131 to stop its descent. The Radar Controller’s transmission of this instruction lasted for approximately 17 seconds. As this communication started, the flap lever was set to ‘full’. In addition, in the middle of the communication, the selected heading was changed from 210 to 188 degrees, which was carried out by the Co-pilot.
The Investigation believes that, within these 17 seconds, it was the Commander, who realized the true situation regarding the Aircraft vertical position, which was already less than 500 meters above ground level. Later, the Co-pilot understood the situation because the Commander urgently directed ‘select ALT’ twice.
Based on the FDR data, ATC transcript, and the Co-pilot’s statement, the
Commander queried the Co-pilot about the selection of altitude hold mode during the final part of the Radar Controller’s instruction. The Co-pilot then realized that the Commander’s query was urgent. This caused the Co-pilot to press the ALT pushbutton approximately three seconds before the Radar Controller’s instruction ended in order to stop the descent by levelling off the Aircraft. At this time, the Aircraft was descending passing 707 feet radio altitude with a rate of descent approximately 2,000 feet per minute.
This means that, until this time, the Co-pilot was not paying attention to the Radar Controller’s last instruction and he was most likely only aware of the Aircraft’s heading to establish on the ILS establishment. The Co-pilot only became aware of the urgency of the situation when the Commander asked him to select ‘altitude hold’ mode.
One second later, the Co-pilot rotated the altitude knob to 3,100 feet and pulled the knob, which engaged the ‘open climb’ mode only for one second, then he pulled and rotated the vertical speed knob from -2,000 to +2,500 feet per minute. The last action resulted in ‘vertical speed’ mode and ‘speed’ mode engagement. Immediately after this, the Commander decided to initiate a go-around and the Co-pilot then commenced the go-around by pushing the thrust levers to the TOGA detent, and then moving the thrust levers back to the FLEX MCT detent four seconds later, which initiated a soft go-around. Hence, the speed reference system managed mode, navigation mode, and manual go-around soft mode became engaged as were displayed on the FMA.
When the go-around was initiated, the Aircraft was descending and passing through 504 feet radio altitude with a rate of descent approximately 1,600 feet per minute.
The elapsed time from the Commander’s decision to carry out a go-around and the initiation of the go-around was approximately three seconds, after the end of Radar Controller’s instruction to stop any further descent.
At the time of the initiation of the go-around, the localizer track mode and/or localizer capture mode did not engage and so neither the glideslope track nor the glide slope capture modes. This was in line with the system design logic, which decreased the risk of a glideslope capture mode or glideslope track mode engagement when the Aircraft position was outside the ICAO envelope where the glideslope signal quality could not be assured.
The system logic ensured that the glideslope capture occurred within the lateral limits of the ICAO envelope where the glideslope beam quality was adequate. In this case, the Aircraft was below the minimum elevation coverage of the ICAO envelope (below 0.45 è, è is the 3 degrees of ILS glideslope path angle), however, the Aircraft was within the lateral limits of the envelope. This caused the localizer capture mode and/or localizer track mode to fail to engage.
Approximately two seconds later after initiating the go-around, the glideslope alert appeared for approximately two seconds, followed by a “Terrain ahead, pull up” aural warning that lasted for six seconds and finally for one second a further “Glideslope” alert.
The localizer deviation indications on both PFDs were far from the axis (+/- 2 dots), and the Aircraft was below 1,000 feet, which triggered the “Descent below glideslope (mode 5)” cautionary alert, and therefore the “Glideslope” aural alert sounded and the visual alert appeared on the PFD.
The terrain awareness display (TAD) warning alert had priority over the glideslope ‘mode 5’ cautionary alert. In this case, the TAD cautionary alert did not appear before the TAD warning. This condition occurred, most probably, due to the edge of the TAD caution envelope being overlaid by the edge of the TAD warning envelope to ensure that warnings take precedence over cautions. The TAD warning triggered the activation of the “Terrain ahead, pull up” aural alert and the ‘Terrain’ visual alert on both NDs.
The minimum radio altitude of the Aircraft was 395 feet above the ground level while the alerts (caution and warning) were active. This means that the Aircraft had an altitude loss of approximately 109 feet after initiation of the go-around.
UUDD 102030Z 20003MPS 170V230 9999 -SHRA SCT050CB 14/12 Q1015 R88/010095 NOSIG
UUDD 102000Z 20003MPS 9999 -SHRA FEW046CB 14/11 Q1015 R88/010095 NOSIG
UUDD 101930Z 21003MPS CAVOK 14/11 Q1015 R88/010095 NOSIG
UUDD 101900Z 21003MPS 170V230 CAVOK 14/11 Q1015 R88/010095 NOSIG
UUDD 101830Z 18003MPS CAVOK 14/11 Q1015 R88/010095 NOSIG
UUDD 101800Z 18004MPS CAVOK 15/11 Q1015 R88/010095 NOSIG
UUDD 101730Z 18004MPS 9999 FEW040 15/12 Q1015 R88/010095 NOSIG
UUDD 101700Z 19003MPS 9999 FEW040 15/12 Q1016 R88/010095 NOSIG
UUDD 101630Z 18003MPS CAVOK 15/12 Q1016 R88/010095 NOSIG
UUDD 101600Z 17003MPS CAVOK 17/12 Q1015 R88/010095 NOSIG
UUDD 101530Z 17003MPS CAVOK 18/12 Q1015 R88/010095 NOSIG
UUDD 101500Z 18003MPS CAVOK 20/12 Q1016 R88/010095 NOSIG
Date of incident
Sep 10, 2017
Dubai, United Arab Emirates
Moscow Domodedovo, Russia
ICAO Type Designator
This article is published under license from Avherald.com. © of text by Avherald.com.
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