Air France A320 at Tel Aviv on Apr 3rd 2012, approach to stall on turning final results in Alpha Floor and flaps overspeed
Last Update: December 20, 2013 / 17:34:38 GMT/Zulu time
The French BEA released their final report in French (English version released on Dec 20th 2013) concluding the probable cause of the serious incident was:
The RNAV Visual Approach to runway 26 was proposed to all arriving aircraft indiscriminately. The lack of RNAV Visual Approach training at Air France at the time of the occurrence caused the captain fail to anticipate possible problems during the approach briefing, that the first officer might encounter during the unusual approach. In addition, the lack of understanding of how open descent, open climb and autothrottle work with the crew believing the autoflight systems would still ensure maintaining correct airspeed led to lack of monitoring of airspeed. The lack of identification of such risk factors led to the aircraft entering the turn to final in low energy state, given its configuration and the nose up inputs the speed warning and Alpha Floor activated.
The BEA reported the captain (58, ATPL, 20,000+ hours total, 9,800+ hours on type) was pilot monitoring and the first officer (27, 500 hours total, 200 hours on type) was pilot flying.
The BEA analysed that following the feeling that they were too high and too fast very early into the approach the first officer applied full configuration very early into the approach, while the manuals recommend to apply full configuration only once established on final approach.
The investigation could not determine why the first officer applied nose up inputs during the turn to final opposed to the flight director indications. These inputs triggered the speed warning and activation of Alpha Floor, neither pilot detected the resulting TOGA Lock and situational awareness degraded.
The BEA analysed that the aircraft subsequently went into overspeed. In a reflex to the overspeed warning the first officer retarded the thrust levers to idle, which disengaged the autothrottle and thus removed the TOGA Lock and permitted the engines to spool down, neither pilot had still detected the TOGA Lock condition.
The investigation determined that there was lack of understanding of the automation modes and their consequences and recommended to provide training with focus on understanding open descent in the approach. A second safety recommendation was issued to the Civil Aviation Authority of Israel to only apply RNAV visual approaches to approved operators.
This article is published under license from Avherald.com. © of text by Avherald.com.
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