reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2013 A321 Over-run Lyon France

Brief account : 

The crew made a Category 1 (CAT I) ILS approach to runway 36R at Lyon Saint-Exupéry Airport. The weather conditions were such that low visibility procedures (LVP) were in place. On passing the stabilisation height at 1,000 ft, the speed of the aeroplane was 57 kt above the approach speed. At 140 ft, an inappropriate increase in thrust by the autothrust maintained the aeroplane at high speed.

The flare was long and the aeroplane touched the runway at 1,600 metres past the 36R threshold. The aeroplane overran the runway and came to rest approximately 300 metres after the opposite threshold.

Crew-related factors : 

The crew in this event were fatigued after almost 15 hours on duty and the operator was criticised for many of its practices that resulted in the crew pairing. They had difficulty communicating with each other - the Captain was Greek and the F/O Spanish, and neither was fluent in the other's language or in conversational English. The Captain was newly promoted and had only 425 hours command time; the First Officer was PF and was very inexperienced with only 600 hours total.

The weather was not good: during the descent they were advised of low visibility procedures being in use with 1100m visibility and cloud at 100ft. The PF thought that a Cat 2 approach would be required, but the Captain (PM) said it would not be. There was a significant tailwind, which was discussed by ATC with preceding aircraft crews but in French, so not understood by either pilot. The pressure altimeters were set with a 10mb (300ft) error. 

The F/O's briefing as PF did not cover all aspects especially the landing, and he had some difficulty in managing the aircraft on the descent, resulting in the aircraft being high and fast on the approach. The report noted that "During the approach, the workload gradually increased. The changes in configuration had to be managed simultaneously with rapidly changing parameters. The presence of a strong tailwind caused closing on the runway faster than usual. The numerous contacts with the controllers often interrupted tasks. Finally, the frequent requests made by the PF to the PM significantly increased the latter’s workload. The PM seems to have reversed his priorities at 2,000 ft AGL. When the PF called for configuration 2, the PM gave priority to responding to an ATC request. This choice delayed the reduction in speed of the aeroplane at a key moment. The PM also seemed to have partially taken over the PF function, and thus found himself in a work overload situation. To cope with it, he gradually relaxed the monitoring of the aeroplane parameters and was no longer able to fully play his role as PM".

The Captain could see the runway from about 7 miles out and despite not meeting stable approach criteria the aircraft arrived at DH fairly close to the desired position and configuration: the F/O disconnected the autopilot at 200ft leaving autothrust engaged. However, at 150 ft an "anomaly" in the autothrust caused a gradual increase in thrust from idle to 70% thrust. The aircraft crossed the threshold at 60 ft and during the landing the pilots were aware of much decreased visibility at the end of the runway.The thrust increase would not have been detectable by any advance of the thrust levers as there is no tactile feed back to the PF who was primarily focused outside. This increased the speed by 5 kts and the landing distance by about 500 m.

 The Captain became concerned that the aircraft was "floating" and made conflicting sidestick inputs to the F/O. The resulting prevailing input was nose-up until the wheels touched down approximately 18 seconds after crossing the threshold.

The report was critical of the airline and its supervision for creating the circumstances the crew found themselves in, which led to a situation where the crew did not even consider a go-around. 

As far as procedures are concerned, a major issue is whether the F/O should have been responsible for all the duties he had as PF in these conditions, including the landing. The aircraft behaviour with a faulty autothrust system would have been hard for an inexperienced pilot to deal with. The division of responsibilities was such that both pilots became overloaded, and again no-one was in a position to observe the thrust anomaly which must have contributed to the miss-handling of the flare that led to the Captain's intervention, but a major factor must also have been the mental comitment to landing after such a long duty.         

Type: 
A321
Where: 
Lyon France
Expected weather: 
Instrument
Pilot in charge: 
F/O under direction
Early transition: 
No
Go-around : 
No
Damage: 
Minor or none
PicMA potential: 
Major
Year: 
2013
Time: 
Night
Deterioration: 
No
Vert Guidance: 
G/S
Both Head Up: 
No
LoC: 
No
Operator: 
Hermes
Fully prepared: 
No
Actual Weather: 
Low Cloud
Autopilot : 
Y
CCAG: 
High