reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2011 B772 Cat 3 Loss of Control Paris France

Brief account : 

At 320ft RA during a Cat 3 approach planned for an autoland, a "No Land 3" EICAS message + Master Caution occurred, with the A/P status changing to >LAND 2< . This was not initially reacted to by the PNF (F/O), but the relief pilot called out "warning". The PNF then called for a Go-around in accordance with the company SOP. The Captain (PF) did not press the TOGA switches but pushed the autothrust disconnect buttons instead. He fully advanced the thrust levers and pulled on the control column.  However the autopilot remained engaged and coupled to the glideslope. Consequently the aircraft accelerated with increasing nose down pitch. 

The PNF initially concentrated on the G/A reconfiguration, and the relief crew member called the pitch discrepancy from correct G/A attitude. Both pilots then applied nose-up control inputs, pulling 1.84G and disconnecting the autopilot at a minimum Radio Altitude of 63 ft. achieving a maximum pitch angle of 19 deg.  

Subsequently the Captain applied nose down inputs while the F/O applied nose up and a second high G oscillation occurred. The gear was finally selected up some 25 seconds after the initial g-around call, at a height of 870ft. and the aircraft positioned for a second Cat 3 autoland. 

Crew-related factors : 

From his subsequent statements it was clear that the Captain's attention had been outside the cockpit and he had seen the ground at 250ft. The Captain PF's desire to land, reinforced by this, conflicted with the need for a go-around.

The report noted that "Having visual references and, knowing that the landing was possible, his plan of action was to land. The NOLAND3 warning, making mandatory a go-around, led to confusion and to a change in his plan of action. He thus progressively moved the throttle levers forwards". 

The F/O initially did not react to the warning and called for the G/A after prompting by the relief pilot. He did not apparently get a response or command from the PF before retracting the flaps. "It seems that the PNF focused his resources more on progress in retracting the flaps (which takes about ten seconds) than on monitoring flight parameters." 

It appears that once he had seen some visual cues the Captain (PF) was totally unprepared for a go-around. The "startle factor" of the F/O's go-around call seemed to lead to some sort of reflex to push the thrust levers and pull on the wheel rather than carry out any of the actual appropriate actions, which had been the subject of training only 3 weeks earlier.  

This sequence was repeated in 2013 with a B757, where the Captain's actions were analysed by a human factors expert who reported "‘The Captain was visual with the runway on a coupled ILS final approach, with every expectation of continuing to land. After many times of experiencing this situation the captain’s brain (unconsciously), brings to readiness a motor response to squeeze the right thumb in order to disconnect the A/T, because that is what normally happens at this point – in order to commence visual landing off the approach. This might also have been consciously anticipated (he was soon intending to do so). In the second after the go-around instruction, the captain is preparing the action and is only consciously aware that he “needs to do something with his thumb”. Unfortunately his thumb is almost certainly covering or touching the right A/T button as well as being unconsciously primed to disengage the A/T. The primed response (disengaging the A/T), is extremely similar to the required response (pushing the GA buttons). Given the physical thumb position and the highly sensitized action of disengaging the A/T with the thumb (due to [contextual] priming), this error was relatively likely to occur….’

The precise detail of the company's Cat 3 autoland procedure for this type is not stated (i.e. Decision Height / No DH / Alert Height) operation so the exact application of PicMA to it therefore unknown. However if the crew had been using a PicMA- based procedure it is unlikely that this event would have occurred. On seeing the downgrade  

1) The F/O would have been PF, and been mentally "primed" to respond to a go-around at any point in the approach.

2) He would not have been exposed to the external cues, and not have had to re-adjust either visually or mentally from "visual" to instrument flight.

Type: 
B777-200
Where: 
Paris CDG
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
No
Go-around : 
At or above DH/A
PicMA potential: 
Major
Year: 
2011
Time: 
Day
Deterioration: 
No
Vert Guidance: 
G/S
Both Head Up: 
No
LoC: 
Yes
Operator: 
Air France
Fully prepared: 
Yes
Actual Weather: 
Fog
Autopilot : 
Y
CCAG: 
Normal