Aeroflot A320 near Oslo on Dec 19th 2008, descended below minimum safety altitude
Last Update: June 12, 2013 / 14:09:46 GMT/Zulu time
Incident Facts
Date of incident
Dec 19, 2008
Classification
Incident
Airline
Aeroflot
Aircraft Type
Airbus A320
ICAO Type Designator
A320
AFL211 had a crew with limited experience from approaches to Gardermoen. The relatively large amount of information in the given clearances and additionally several changes to the active runway prior to landing, were factors which resulted in misunderstandings which again led the crew to “fall behind†when attempting to get the airplane established on the ILS approach. When the aircraft quickly approached the final approach, the crew became stressed at a time when the focus should be directed at flying the aircraft, not making changes in the aircraft's systems e.g. changing the active landing runway. Although not desirable, flight crew will at times be in a situation at lower altitudes where cockpit tasks beyond focus at flying are a necessity. In order to reduce the risk of spatial disorientation, one option could be that Pilot Flying (PF) continues to fly the aircraft and asks Pilot Monitoring (PM) to execute any changes to the aircraft systems.
Based on the actual track and the distance to terrain when AFL211 was at its lowest altitude, the AIBN believes that a risk of controlled flight into terrain (CFIT) was present but not imminent. When at its lowest altitude of 2,540 ft, it would have required approximately one minute of level flight before it would be in conflict with rising terrain ahead. Although the recovery was late and slow, once initiated it was positive to the point where the First Officer elected not to intervene more aggressively.
It is not uncommon for air traffic services to initiate quicker and shorter approaches than normal to process traffic more efficiently. Flexibility to achieve efficient traffic processing is desirable, but must not be at the expense of safety. There is a point where flexible and efficient traffic processing reaches a limit which may threaten safety. Crews which regularly take off and land at an airport will probably handle last-minute changes better than crews which seldom have been at the airport. The challenge for the individual air traffic controller is then to have an understanding of what the individual crew can handle.
Established work methodology should not be deviated from, for example changing the landing runway when the aircraft is less than 30 NM out should not happen unless the crew accept the change. In this case, at the final change of landing runway, the crew could have been offered new vectors instead of being notified of a new landing runway.
Regardless of factors that could have been changed by air traffic control, the commander has the overall responsibility for safe flying. The commander wanted to abort the approach when the final change was announced, but chose to continue the approach due to time pressure. The commander became disoriented which resulted in an incorrect response when the aircraft passed cleared altitude and continued with a high descent rate before correct recovery was initiated. This incident demonstrates that it can be a challenge for crews to recognize exposure to spatial disorientation which again most likely will result in a delayed corrective action.
Air traffic control expects that any crew will report unable if they cannot comply with a given clearance. AIBN believes that in this incident both ATC and the crew had time to solve the misunderstandings prior to AFL211 approaching the localiser. It is both parties responsibility to ensure precise communication.
The AIBN reported the captain (54, ATPL, 16,170 hours total, 1,035 hours on type) was pilot flying, the first officer (35, CPL, 1,400 hours total, 800 hours on type) was pilot monitoring.
ATIS indicated during approach, that visibility was 10km+, however there was a visibility reduction to 3500 meters in the west and temporary visibility of 800 meters in fog. Runway 19R was active.
The captain briefed the ILS CAT I approaches for both 19L and 19R and also took into account the possibility of a CAT II approach. Runway 19R was put as primary runway into the FMS. After being handed off to approach control the crew was advised to expect landing on runway 19L, the crew changed the FMS to 19L. The crew overheard information transmitted to other aircraft that low visibility procedures were in use at Gardermoen Airport, which created uncertainty on the flight deck as the designated low visibility runways would be 01R and 19R. SU-211 was never directly informed however.
Upon hand off to final approach the crew was advised that they were now vectored for an ILS approach to runway 19R due to weather: "Aeroflot two one one good evening descend 5 000 feet, turn left heading 280, prepare now for 19 right, 19 right the localizer frequency 111.3 due weather conditions". The crew read back: "Descending 5 000 feet, heading 280 cleared ILS 19 left". The controller did not challenge the readback but continued with instructions to other aircraft.
A minute later the controller repeated that runway 19R had to be used due to weather, this time the crew picked up on the again changed runway assignment, they were about 4nm short of intercepting the localizer 19R with about 20 track miles to fly to touchdown. Flaps were set at position 1, the aircraft was maintaining 210 knots IAS (maximum 230 KIAS for the configuration).
The captain did not feel comfortable with the resulting situation and considered to request vectors for a new approach. Due to the very busy radio frequency and the fact, that the aircraft was rapidly approaching the intercept to localizer 19L, time pressure arose, the captain thus decided to reprogram the FMS to runway 19R and continue the approach. Following standard operating procedures the captain handed controls to the first officer while reprogramming the FMS. He needed two attempts to get the change to runway 19R accomplished, but did not recognize that this already was indication of mental overload and high stress levels. He subsequently took control again and armed approach mode for the ILS intercept.
The aircraft was already so close to the extended runway center line, that the autopilot went into localizer capture almost immediately, the aircraft went through the localizer at an angle of nearly 90 degrees, the autopilot banked the aircraft intensively to the left with sideslip involved. When the captain raised his head after completing the FMS inputs, he had thus the illusion that the aircraft was aggressively pitching up instead of rolling left, instinctively disengaged the autopilot and pushed the side stick fully forward in order to counter the perceived pitch up motion. The commander recognized he was disoriented and aborted the approach, autopilot and autothrottle were disconnected, the aircraft at that point was at 4380 feet MSL, 30 degrees left bank and rate of descent of 2200 fpm, the bank increased to 35 degrees and the rate of descent increased to 5800 feet per minute, the airspeed increased prompting the first officer to call "speed speed", the first officer did not recognize the captain's lack of response as indication of incapacitation and therefore did not intervene by taking control. The flight data recorder showed however that the first officer provided nose up stick inputs on two occasions, while the captain began to pull the aircraft out of the dive. The EGPWS activated "TERRAIN AHEAD". The captain steered the aircraft wings level and climbed the aircraft back to 4000 feet, the flight data recorder showed the aircraft had descended to 2540 feet on its lowest point, the airspeed had reached 260 KIAS, 30 knots above the flaps 1 limit. The air traffic controller noticed the altitude deviation just prior to the aircraft beginning to climb again and instructed the aircraft to climb back to 4000 feet, the aircraft disappeared from his radar so that the controller believed an accident had happened until the aircraft appeared again on radar much to the relief of the controller.
The aircraft subsequently positioned for another approach and landed without further event. A flap overspeed inspection did not find any damage or malfunction.
Eurocontrol had issued recommendations to flight crew to not accept runway changes below FL100 unless the possible runway change had been briefed and prepared already. Eurocontrol argues that late runway changes increase workload of flight crew and lead to rushed, unstable approaches, flying the wrong go-around, not intercepting the final approach in time (especially critical on airports with parallel approaches) and to errors in performance calculations leading to runway excursions.
Incident Facts
Date of incident
Dec 19, 2008
Classification
Incident
Airline
Aeroflot
Aircraft Type
Airbus A320
ICAO Type Designator
A320
This article is published under license from Avherald.com. © of text by Avherald.com.
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