Afriqiyah A332 at Tripoli on May 12th 2010, impacted ground short of runway
Last Update: March 1, 2013 / 16:59:15 GMT/Zulu time
Incident Facts
Date of incident
May 12, 2010
Classification
Crash
Aircraft Registration
5A-ONG
Aircraft Type
Airbus A330-200
ICAO Type Designator
A332
On Feb 28th 2013 Libya's Civil Aviation Authority (LCAA) have released their final report (Appendix 1, Appendix 2, Appendix 3) concluding the probable causes of the crash were:
A final approach carried out in common managed guidance mode should have relieved the crew of their tasks. The limited coordination and cooperation between the two crew members, especially the change into vertical selected guidance mode by the PF, probably led to a lack of a common action plan.
The lack of feedback from the 28 April 2010 flight, flown by the same crew on the same aircraft, did not allow them to anticipate the potential risks associated with managing non-precision approaches.
The pilotsÂ’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
During the go-around, the crew was surprised not to acquire visual references. On one hand the crew feared exceeding the aircraftÂ’s speed limits in relation to its configuration, and on the other hand they were feeling the effects of somatogravic illusion due to the aircraft acceleration. This probably explains the aircraft handling inputs, mainly nose-down inputs, applied during the go-around. These inputs were not consistent with what is expected in this flight phase. The degraded CRM did not make it possible for either crew member to identify and recover from the situation before the collision with the ground, even when the TAWS warnings were activated close to the ground.
Based on elements from the investigation, the accident resulted from:
- The lack of common action plan during the approach and a final approach continued below the MDA, without ground visual reference acquired.
- The inappropriate application of flight control inputs during a go- around and on the activation of TAWS warnings,
- The lack of monitoring and controlling of the flight path.
These events can be explained by the following factors:
- Limited CRM on approach that degraded during the missed approach. This degradation was probably amplified by numerous radio-communications during the final approach and the crewÂ’s state of fatigue,
- Aircraft control inputs typical in the occurrence of somatogravic perceptual illusions,
- Inappropriate systematic analysis of flight data and feedback mechanism within the AFRIQIYAH Airways.
- Non adherence to the company operation manual, SOP and standard terminology.
In addition, the investigation committee found the following as contributing factors to the accident:
- Weather available to the crew did not reflect the actual weather situation in the final approach segment at Tripoli International Airport.
- In adequacy of training received by the crew.
- Occupancy of tower frequency by both air and ground movements control.
The captain (57, ATPL, 17,016 hours total, 516 hours on type) was pilot monitoring, the first officer (42,ATPL, 4,216 hours total, 516 hours on type) was pilot flying, the augment first officer (37, CPL, 1,866 hours total, 516 hours on type) was occupying the observer seat.
The aircraft had been vectored for a NDB approach to runway 09, weather information indicated winds were calm, visibility was 6000 meters, temperature 19 degrees C, dew point 17 degrees C. Upon contacting tower the flight was cleared to continue the approach and instructed to report runway in sight.
The aircraft was configured to gear down, flaps 3 and was descending at 144 KIAS while descending through 1400 feet, when the first officer called the landing checklist.
The creww selected the go-around altitude (2000 feet) into the master control panel as well as a flight path angle of -3 degrees, the captain of the preceding aircraft called the accident captain by his first name on radio and reported patches of fog on short final, the captain thanked.
The aircraft crossed the NDB at 1020 feet MSL.
At 720 feet, 100 feet above MDA, an automatic call "hundred above" sounded, the captain commanded "continue", at that point the crew had not reported "runway in sight" to tower, the first officer repeated "continue".
20 seconds later, the aircraft descended through 490 feet (280 feet radio altitude) the terrain awareness and warning system (TAWS) sounded "Too Low, Terrain", the captain commanded "go-around", the first officer acknowledged, the autopilot was disconnected, the thrust levers pushed into the TOGA detent, the first officer provided nose up inputs, the attitude began to increase from 2.1 degrees nose up and the aircraft began to climb and reached 670 feet MSL at 12.3 degrees nose up attitude about 3 seconds after the thrust levers were placed in the TOGA detent, the flaps were set to position 1 and the gear was retracted. From that moment the flight data recorder recorded nose down inputs for the final 21 seconds.
17 seconds after the go-around was initiated the TAWS called "Don't sink!", the captain pressed the priority switch and took control of the aircraft providing a sharp nose down input while the first officer provided a full nose up input at the mechanical stop of the stick, 2 seconds later the aircraft impacted ground at position N32.6616 E13.1146 and 262 feet MSL at a rate of descent of 4400 feet per minute and 260 knots over ground. The aircraft was destroyed, only one of the occupants survived.
On the ground a step down transformer, a house, several eletrical poles and some trees were damaged.
The LCAA reported that the same crew carried out another NDB approach to runway 09 on the same aircraft on April 28th 2010. That approach had never been stabilized, a go-around was initiated 70 feet above MDA, three substantial pitch oscillations reaching from 2 degrees nose down to +25 degrees nose up and two flap speed exceedances occurred after the go-around was initiated, the aircraft subsequently positioned for an eventless ILS approach to runway 27.
The LCAA analysed, that the first officer performed an incomplete approach briefing mentioning only the arrival runway, NDB approach runway 09 and low autobrakes, however did not mention what automation modes were intended to be used during the approach or the missed approach procedure. The LCAA continued: "Following this, the crew continued the approach preparation and the approach checklist seemed to be performed, but without any formal callouts: the only item called out by the crew was the altimeter setting."
The LCAA anaysed that after the first officer had selected FPA mode: "the pilots no longer seemed to share the same strategy for conducting the final approach:
- The CaptainÂ’s strategy was to carry out the final approach in common managed guidance mode, which involved a continuous descent final approach down to the MDA (about 1 NM from the runway threshold for the approach procedure to Locator 09) and then to the runway threshold, at an altitude of 50 ft.
- The co-pilot intended to carry out the approach in selected vertical guidance mode, which involved a final approach with a possible level at MDA until the MAPt."
The LCAA continued: "it is almost certain that the weather conditions (as indicated by the previous crew), the lighting conditions and the actual position of the aircraft in relation to the runway threshold when approaching the minima (2.6 NM and an altitude of 420 ft when “Continue” was called out) did not enable acquisition of the external visual references required to continue the approach below the MDA." Further: "On the Captain’s “Continue” callout, which seems to demonstrate the latter’s awareness of the MDA approach, the co-pilot (PF) probably assumed that the Captain had acquired outside visual references."
The LCAA analysed: "The co-pilotÂ’s (as PF) hesitation in conducting a go around without explicit approval from the captain might indicate that the CRM principles had not been fully implemented. One of these principles is that although the captain is the superior and has ultimate responsibility in the cockpit, the other crew members should feel at liberty to contribute their own opinions, suggestions and to show initiative."
The LCAA went on to analyse that the first officer obviously was ready to go around, upon the captain calling the go-around it is thus likely the first officer disconnected the autopilot, set the thrust levers to TOGA and provided nose up inputs.
The LCAA analxyed: "The go-around was initiated without undue haste. At this stage, the actions of the two crew members indicate that they shared a common goal, but within a very short period of time some items of the go-around procedure were not called out (the “positive climb” and “FMA” callouts). The Captain, as PNF, did not make the appropriate callouts (deviation detection) and the co-pilot questioned him on several occasions, indicating the need for a more active participation of the PNF in a dynamic flight phase to apply the go-around procedure. It is likely that the Captain did not expect to have to abort the final approach and the “TOO LOW TERRAIN” warning destabilized him."
The LCAA stated: "After switching from FULL configuration to configuration 3 onwards, i.e. four seconds after the autopilot disconnection, the co-pilot began to apply nose-down inputs on his side stick, resulting in a decrease in the pitch attitude of the aircraft to a negative pitch. These inputs are consistent with the high pitch attitude he could have perceived (see 1.16.1), typical of a somatogravic perceptual illusion occurring in the absence of outside visual references and monitoring of the artificial horizon. The co-pilot would have maintained nose-down inputs as long as he was feeling this effect, the pitch attitude perceived being relatively constant and greater than the theoretical pitch attitude during a go-around."
The LCAA analysed that the captain provided stick inputs at the same time similiar to the first officer's inputs and in the same direction, the magnitude of the inputs insufficient to trigger the "dual input" automatic warning. "This distracted the captain from his task of monitoring the flight data and also that it led to ambiguity about who was in control of the aircraft. Loss of control over the flight path after the go around may have been the inadvertent result of the absence of clarity about who was flying the aircraft."
At that time the airspeed indication rose close to the red/black area indicating flap overspeed, the first officer called for flaps.
The LCAA analysed: "When the TAWS “DON’T SINK” alert was triggered, the Captain applied a sharp nose-down input on his side stick, which could be explained either by: The persistence of the somatogravic perceptual illusion. In this case, when selecting the speed on the FCU and CONF 1 the Captain necessarily moved his eyes, which may have affected his perception of the situation; Or through a reaction to the black and red strip scrolling down on the speed tape, leaving “virtually” the yellow horizontal line materializing the current speed under the lower part of the black and red strip."
"The Captain maintained his nose-down input on the side stick after taking over priority. At this time the co-pilotÂ’s input on the side stick was to the pitch-up stop. It indicates that the copilot at this stage was aware of the aircraft flight path but did not know that his input on the side stick was inhibited by the Captain who had taken over control."
The LCAA analysed with respect to the relief pilot: "While it was confirmed that the 3 pilots were in the cockpit at the time of accident and the relief pilot has no assigned duty below FL200, However if he was occupying the third crew member seat, he would have access to monitor the flight instrument but investigation committee did not find any evidence of the relief pilot announcement or any notice made by him to the flight crew of the deviation from the assigned approach path probably he was looking out side for a visual ground reference."
With respect to the go-around on April 28th 2010 the LCAA analysed: "Although go around and TAWS alerts are reportable events but the execution of GO-AROUND and TAWS alerts on April 28 2010 flight were not reported by the crew to the ATC nor to the company accident prevention advisor (APA)."
Incident Facts
Date of incident
May 12, 2010
Classification
Crash
Aircraft Registration
5A-ONG
Aircraft Type
Airbus A330-200
ICAO Type Designator
A332
This article is published under license from Avherald.com. © of text by Avherald.com.
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