Canada Rouge A319 at Montego Bay on May 10th 2014, hard landing at +3.12G

Last Update: January 11, 2017 / 10:58:23 GMT/Zulu time

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Incident Facts

Date of incident
May 10, 2014

Classification
Report

Flight number
AC-1804

Aircraft Registration
C-FZUG

Aircraft Type
Airbus A319

ICAO Type Designator
A319

An Air Canada Rouge Airbus A319-100 on behalf of Air Canada, registration C-FZUG performing flight AC-1804 from Toronto,ON (Canada) to Montego Bay (Jamaica) with 131 passengers and 6 crew, performed a VOR/DME approach to runway 07 after discovering that the ILS was not available at that time (the NOTAM had been included in the crew briefing but had been overlooked by the crew). The captain (about 10,000 hours total experience, 4,200 hours on type), pilot flying, rebriefed - following the initial briefing for an ILS approach - the VOR/DME approach with the first officer (about 12,000 hours total, 475 hours on type), pilot monitoring, but did not include the go-around procedure or the specific missed approach procedures. The captain however advised he intended to use a managed approach. The aircraft intercept the final approach about 9.6nm out, flaps were set to 1 at time, the aircraft maintained 3000 feet at about 200 KIAS with the autopilot (Modes: NAV and FINAL DES) and autothrust engaged. The captain ordered the landing gear down while slowing the aircraft. About 7.7nm from the threshold (the aircraft should have been configured to flaps 3 already) the crew selected the managed speed from 200 to 134 knots and the aircraft was descending through 2440 feet and a short time later crossed the Final Approach Fix at 2000 feet (proper altitude) and 188 KIAS. 5.2nm from the threshold the captain disengaged the autopilot, the aircraft was descending through 1780 feet and 186 KIAS. 5nm before the runway threshold, at 188 KIAS 2 knots above flap 3 selection speed, the captain ordered flaps to 3, the first officer selected the flaps to 3, recognized the speed error, and reselected the flaps to 2, then responded to an ATC radio tranmission clearing the aircraft to land. The crew subsequently pulled the ALT selector know, the selected altitude in the FCU was 2000 feet, the aircraft thus changed from tracking flight path angle to Open Climb, the autothrust accelerated the engines, due to the autopilot disengaged the aircraft did not pitch up and the speed increased. 4.5nm from the runway threshold at 185 KIAS and 1530 feet MSL the aircraft levelled off temporarily, the first officer moved the flaps lever to position 3, the airspeed increased further to 193 KIAS, a master warning indicating flaps overspeed activated and a chime repeatedly sounded. The crew changed the flight path angle to 3.2 degrees again, which activated SPEED mode on autothrust and TRK and flight path angle tracking on the flight mode announciators. The first officer again selected flaps 2, the captain disengaged autothrust. 6 seconds after selecting flaps 2 the first officer selected flaps 3 again, the aircraft descended through 1420 feet at 182 KIAS, thrust levers at idle and rate of descent of 300 fpm. The captain advised they were too high and he was correcting, the rate of descent increased to 1400 fpm, the aircraft established on the PAPI glide path about 1.9nm before the runway threshold. At 1.5nm before the runway threshold at 155 KIAS at 500 feet AGL the crew acknowledged they were back on profile. The GPWS sounded "four hundred". 4 seconds later the captain called 500 feet stable approach including one hundred above, minimums, runway in sight", the aircraft was 1nm before the threshold descending through 370 feet AGL at 146 KIAS (12 knots above Vapp), engines at idle thrust. About 0.5nm before the threshold the airspeed reduced through Vapp at 200 feet AGL at 570 fpm rate of descent. About 0.2nm before the threshold nose up inputs were recorded as the aircraft descended through 80 feet AGL at 123 KIAS at 650 fpms and 9.9 degrees Angle of Attack. At 40 feet AGL the airspeed had dropped to 115 KIAS, the pitch was 9.9 degrees nose up at 13.9 degrees angle of attack, the automated aural "thirty" call sounded, the thrust levers were placed to maximum takeoff thrust, the engines responded but spooled up by only 4% until the touch down occurred, the touchdown occurred about 125 feet past the runway threshold at the maximum of 15.3 degrees angle of attack, 7.7 degrees nose up, 108 KIAS and a vertical load of +3.12G. The aircraft rolled out without further incident and taxied to the apron.

The Canadian TSB released their final report concluding the probable causes of the occurrence (the TSB did not state, whether the occurrence was rated accident, serious incident or incident) were:

Findings as to causes and contributing factors

- The flight crew’s selection of a higher target speed before the final approach fix resulted in an increased-thrust and high-airspeed condition. This condition contributed to the crew’s confusion and misunderstanding of what the aircraft was doing, and resulted in their mismanagement of the configuration sequence.

- The inadvertent flight control unit selection resulted in a second high-airspeed and increased-thrust condition. The aircraft deviated above the approach profile between the final approach fix and the 500-foot arrival gate, and a flaps-3 overspeed alarm sounded. In response, the pilot flying disengaged the autothrust.

- The timing of the operational discussion as the aircraft descended past the 500-foot arrival gate may have diverted the attention of the pilot monitoring from his duties, causing an essential task (a “Stable” call) to be missed. As a result, the flight crew missed an opportunity to recognize an unstable approach.

- The pilot flying made the “Stable” call when the aircraft was not stabilized, as its airspeed was high, the landing checks were incomplete, and the thrust was at idle. As a result, the flight crew continued an unstable approach.

- Management of the aircraft’s energy condition diverted the flight crew’s attention from monitoring and controlling airspeed during the descent. As a result, the aircraft passed the final approach fix arrival gate at a high airspeed and with a flaps configuration that was not in accordance with the standard operating procedures.

- While on short final approach, the airspeed decayed well below final approach speed (VAPP), placing the aircraft in an undesired aircraft state at a very low altitude.

- When the flight crew recognized the undesired aircraft state, the late addition of engine power was insufficient to arrest the descent rate, resulting in a hard landing.

- The flight crew did not adhere to the standard operating procedures, which required the monitoring of all available parameters during approach and landing. With both flight crew members focused on the airspeed conditions and aircraft configuration delays, the instability of the approach was not identified and a go-around was not conducted.

- Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach. As a result, the occurrence flight crew did not recognize the multiple deviations in airspeed and thrust or the deficiencies in coordination and communication, and they continued the approach well beyond the stabilization gates.

- Air Canada Rouge did not include autothrust-off approach scenarios in each recurrent simulator training module, and flight crews routinely fly with the automation on. As a result, the occurrence flight crew was not fully proficient in autothrust-off approaches, including management of the automation.

Findings as to risk

- If flight crews do not conduct thorough briefings, including missed-approach briefings, they may not have a common action plan or set priorities, resulting in reduced crew coordination, which might compromise the safety of flight operations.

- If flight crews are distracted by other operational and non-operational activities and do not follow standard operating procedures, critical tasks associated with flying the aircraft may be delayed or missed.

- If flight crews do not adhere to standard procedures and best practices that facilitate the monitoring of stabilized approach criteria and excessive parameter deviations, there is a risk that threats, errors, and undesired aircraft states will be mismanaged.

- If an air operator’s standard operating procedures (SOP) are not consistent with its stable approach policy, there is a risk that flight crews will continue an approach while deviating from the SOPs, resulting in an unstable approach.

- If standards for flight crew training in relation to automation proficiency (Commercial Air Service Standards 725.124) are not explicit with regard to frequency, there is a risk that air operators will exclude critical elements from recurrent training modules and that flight crews might not be proficient in all levels of automation.

The TSB reported that the aircraft did not sustain any structural damage, however, both left and right main gear were exposed to high load exceedance. The aircraft was permitted to ferry to Miami,FL (USA) with gear down, where both left and right shock absorbers were replaced as recommended by the aircraft manufacturer.

The TSB analysed:

Before departure, the flight crew did not notice the Notice to Airmen (NOTAM) explaining that the instrument landing system (ILS) for Runway 07 was not available. As a result, they initially performed an approach briefing for the inoperative ILS approach. Following a call from air traffic control (ATC) enquiring about their selected approach, a second approach briefing for the very high frequency omnidirectional range with associated distance measuring equipment (VOR/DME) Runway 07 approach was conducted. Neither briefing included the aircraft go-around procedure or the specific published missed-approach procedure, which form part of the first approach briefing of the day according to company procedures. In this occurrence, the flight crew was not under any time pressure. It is possible that, given the visual meteorological conditions, a go-around was deemed unlikely, and this may have reduced the perceived importance of the required briefings.

The TSB continued analysis:

As the aircraft passed the FAF arrival gate, it met all of the stabilized approach criteria in the company policy. The aircraft had regained the approach profile, and its vertical speed was acceptable. The aircraft was tracking appropriately laterally. However, its airspeed was much higher than that specified by the SOPs, and its flaps were set to 1 instead of 3. Therefore, although the stabilized approach criteria were met, the airspeed and flap setting were contrary to the SOPs. If an air operator’s SOPs are not consistent with its stable approach policy, there is a risk that flight crews will continue an approach while deviating from the SOPs, resulting in an unstable approach.

The inadvertent FCU selection resulted in a second high-airspeed and increased-thrust condition. The aircraft deviated above the approach profile between the FAF and the 500-foot arrival gate, and a flaps-3 overspeed alarm sounded. In response, the PF disengaged the autothrust, which he called out to the PM.

The TSB analysed the "stable approach":

The PM initiated the flap-selection check after the PF had disengaged the autothrust and the PM had configured the aircraft with flaps 3. At the “Autothrust” item of the checklist, the check was interrupted by a discussion about the missed-approach altitude and was subsequently not completed. These 2 operational events occurred as the aircraft descended past the 500-foot arrival gate (100 feet above minimums), and a call of “Stable” was not made. The timing of the operational discussion as the aircraft descended past the 500-foot arrival gate may have diverted the attention of the PM from his duties, causing an essential task (a “Stable” call) to be missed. As a result, the flight crew missed an opportunity to recognize an unstable approach.

When the aircraft was on final approach, at 400 feet, the flight warning computer (FWC) annunciated “four hundred.” Following the FWC annunciation, the PF made the stable call of “hundred above, stable, minimums.” However, the PF made the “Stable” call when the aircraft was not stabilized, as its airspeed was high, the landing checks were incomplete, and the thrust was at idle. As a result, the flight crew continued an unstable approach. The aircraft had returned to the approach vertical profile, which was likely what the PF recognized as stable.

The TSB analysed the hard touchdown:

The flight crew did not recognize that the airspeed was decaying as the aircraft approached the runway, nor that the autothrust was off. While on short final approach, the airspeed decayed well below VAPP, placing the aircraft in an undesired aircraft state at a very low altitude. The PF applied full nose-up side-stick input, and the angle of attack (AOA) reached maximum levels. As a result, during the flare, the aircraft’s AOA protection system engaged, reducing the pitch angle. The protection system functioned as designed, and as a result no significant nose-up elevator movement occurred, although full nose-up side-stick input had been applied before touchdown.

The crew were unaware of the low-energy state just before touchdown, as they believed that the autothrust was on. At 50 feet before touchdown, the flight crew suddenly realized that airspeed had been decaying and applied full manual thrust (i.e., maximum take-off thrust); however, in the time remaining before touchdown, the thrust increased by only 4%. When the flight crew recognized the undesired aircraft state, the late addition of engine power was insufficient to arrest the descent rate, resulting in a hard landing.
Aircraft Registration Data
Registration mark
C-FZUG
Country of Registration
Canada
Date of Registration
BcApmiqkgnlgeqAlb Subscribe to unlock
Certification Basis
PAcg ggefkbqigAnlpljbdke p b pqlkhklbhnki nq Subscribe to unlock
TCDS Ident. No.
Manufacturer
Airbus
Aircraft Model / Type
A319-114
ICAO Aircraft Type
A319
Year of Manufacture
Serial Number
Aircraft Address / Mode S Code (HEX)
Maximum Take off Mass (MTOM) [kg]
Engine Count
Engine Type
Main Owner
CA qbgk fmhnAgAcg eAjbkAjfichqqjd npjmdmcfkpfijmegpicjfAicgpjkgnmjgmkclhldpk Subscribe to unlock

Aircraft registration data reproduced and distributed with the permission of the Government of Canada.

Incident Facts

Date of incident
May 10, 2014

Classification
Report

Flight number
AC-1804

Aircraft Registration
C-FZUG

Aircraft Type
Airbus A319

ICAO Type Designator
A319

This article is published under license from Avherald.com. © of text by Avherald.com.
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