VARA AT72 at Brisbane on Apr 2nd 2017, incorrect landing configuration results in EGPWS warning

Last Update: September 5, 2017 / 15:08:27 GMT/Zulu time

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Photo of VARA Virgin Australia Regional Airlines VH-FVL, ATR ATR-72-200 — VARA Virgin Australia Regional Airlines VH-FVL, ATR ATR-72-200 (Photo credit: Alec BHX/KKC / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Apr 2, 2017

Classification
Incident

Airline
VARA Virgin Australia Regional Airlines

Flight number
VA-1670

Departure
Moranbah, Australia

Destination
Brisbane, Australia

Aircraft Registration
VH-FVL

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A VARA Virgin Australia Regional Airlines Avions de Transport Regional ATR-72-212A, registration VH-FVL performing flight VA-1670 from Moranbah,QL to Brisbane,QL (Australia), was on final approach to Brisbane's runway 19 when the crew received a EGPWS "TOO LOW FLAPS" warning, detected an incorrect flap setting and went around. The aircraft positioned for another approach to runway 19 and landed safely about 20 minutes after the go around.

Australia's ATSB rated the occurrence a serious incident and opened an investigation (editorial note: the ATSB provided the time stamp as 09:30 EST instead of 09:30 UTC/19:30 EST).

On Sep 5th 2017 the ATSB released their final report concluding the probable causes of the serious incident were:

- During the approach, the first officer moved the flap lever up from flap 15 to flap 0, instead of from flap 15 to flap 30 as intended. This resulted in an unstable approach.

- The crew did not identify the incorrect flap setting until the ground proximity warning system alerted them to an incorrect configuration, likely due to workload.

The ATSB reported that the flight had progressed normally until final approach, flaps had been extended to 15 degrees, the captain was pilot flying. Descending through 1700 feet the captain called for flaps 30, the first officer completed a radio call with ATC, moved the flaps lever and adjusted the V-speeds calling out "V Approach Set", then started reading a checklist.

The crew noticed however that the aircraft was not performing as expected, the captain needed to adjust attitude and engine torque to control the speed, the speed became too high, the first officer called out "Speed". Both crew had no recollection as to whether the stabilized approach criteria were checked and called out passing 500 feet, the approach was continued. At 173 feet the EGPWS called out "TOO LOW FLAP". The captain immediately initiated a go around, during the subsequent climb the captain called for flaps 15, check power and the first officer responded accordingly. After establishing a positive rate of climb the gear was retracted. ATC vectored the aircraft for a right base, at that time the first officer indicated he might have left the flaps lever at 15 degrees. The aircraft landed safely on second approach, the captain decided to stand both crew down and not continue for the next two sectors.

According to the quick access recorder the flaps were moved from 15 degrees to 0 degrees at 1700 feet AGL, at that height the aircraft commenced the turn to join final.

The ATSB annotated that the stall speed for flaps 0 was 106 KIAS, the Vapp was computed and set to 104 KIAS. The minimum speed on approach was recorded at 114 KIAS descending through 507 feet AGL.

The ATSB reported the captain recalled seeing the first officer reaching out for the flaps lever after instructing flaps 30 but was too busy handflying the aircraft to monitor the movement. The first time the captain became aware the flaps had been set to 0 was during review of a flight animation produced by the operator.

The first officer recalled that he was checking the flaps position indicator after moving the flaps handle and saw movement, but obviously erroneously assumed the flaps were moving to 30 degrees when they began to move towards 0 degrees.

The ATSB analysed:

The approach and landing is known to be a phase of flight with a high workload due to the number of tasks to be completed in addition to monitoring the flight path. During the approach, as the aircraft was turning, the first officer was responding to a radio call and completing a checklist. It is likely that the first officer inadvertently selected the flap lever up from 15 to 0, instead of down to 30, and did not crosscheck the flap indicator before moving on to the other tasks. This inadvertent action led to an increase in the aircraft’s airspeed, which the flight crew recognised, but at the time were unable to ascertain why. The incorrect flap setting was not detected and a go around initiated after a ground proximity warning alerted the crew to an incorrect configuration at 173 ft.

Due to the high workload in managing the aircraft’s performance on approach, the crew did not detect the aircraft’s speed was exceeding the stabilised approach criteria of VAPP + 10 kts or that the aircraft was incorrectly configured with flap 0. Although at 507 ft, the airspeed was 114 kts, which was within the stabilised approach criteria with the VAPP set at 104 kts, at 358 ft, the airspeed had increased to 128 kts, which was outside the stabilised approach criteria.

Since the incorrect flap setting was not detected by the crew on approach, had they managed to slow the aircraft to the VAPP of 104 kts for flap 30, they would have been 2 kts below the stall speed for the actual flap setting (106 kts).