Air France A321 at Marseille on Mar 10th 2011, &quot;Alpha Floor&quot; activation on approach
Last Update: May 22, 2015 / 19:25:01 GMT/Zulu time
The French BEA released their final report in French concluding the probable cause of the incident were:
Wrong selection of flaps and slats, not detected by the flight crew, followed by inadequate pitch commands resulting in decrease of the aircraft's energy state, which was not immediately recognized and led to the activation of "Alpha Floor" Protection.
Inadequate preparation during the arrival briefing contributed to the inadequate management of workload during the simultaneous swing over and aircraft configuration.
The BEA complained that the cockpit voice recorder recordings were not available. Their report therefore was based only on testimony by the crew and flight data recorder.
The BEA annotated that the distance to threshold runway 13L was about 600 meters less than to threshold runway 13R.
The BEA analysed that the disengagement of the autopilot and autothrust increased the workload when the swing over was to be conducted simultaneously with the configuration of the aircraft for landing, when the commander instructed the first officer to extend the landing gear, activate the secondary flight plan for runway 13L. The first officer reported in his recollection he is not sure whether he was instructed to also set flaps to 3 or not. The BEA stated that the rapid succession of instructions may have caused the pilot monitoring to act mechanically without control, the rapid transition from a rather relaxed work load situation to high workload may have caused the inadvertent retraction of flaps rather than the extension to the landing setting.
The pilot flying was looking out of the cockpit windows while positioning the aircraft from the extended centerline runway 13R to the extended centerline of runway 13L. When he checked the instruments again he saw 170 KIAS, which would have been consistent with the flap configuration 2, which he thought was set. However, the speed was indicated below minimum speed, the captain believed this was an erroneous indication and thus did not take action to increase thrust and adjust the pitch. The warning "SPEED! SPEED! SPEED!" warning of the low energy state did not activate because the flaps were in position 0.
The BEA reported the operator took immediate safety actions in order to prevent a recurrence now requiring in their standard operating procedures that upon the instruction to set flaps the pilot monitoring needs to call out "speed check" in order to have both crew focus on the correct speeds, then after verifying at correct speed the first officer would, at the same as moving the flaps lever, announce "FLAPS X" before the flaps reached that position which would reduce the chances of interruption and execution of wrong selections. The operator also points out adequate use of automation to reduce workload even during visual approaches.
This article is published under license from Avherald.com. © of text by Avherald.com.
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