320 Go

A320 Go-Around with inappropriate mode
selection
A320 & A319 events
Presented by
Marc Baillion / Director of Flight Safety
17th Flight Safety Conference
Content
Reminder: Thrust Levers are also mode selectors

Approach
Go Around
Operational considerations
Page 2
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
21-24 March 2011
21-24 March 2011
FBW Thrust Levers are also mode selectors
FBW Thrust Levers

besides their thrust control function
are also mode selectors

They have MULTIPLE additional functions e.g.
Engaging the common modes when TOGA is set

Sequencing the FMS flight plan into the missed approach
procedure when TOGA is set
Page 3
Content

Approach
Go Around
Page 4
21-24 March 2011
21-24 March 2011
First Event
Synopsis
During a scheduled passenger service, an A320 performed a
missed approach in foggy conditions during which it reached a
minimum 38ft radio altitude
Official investigation
Page 5
Approach conditions
ILS approach CAT 1
Day condition 0900E 2500 FG BKN003
A320
64 tons
S/F FULL
L/G DN
VAPP 138kt
Airport elevation 433ft
Missed approach altitude : 4000ft selected
Page 6
21-24 March 2011
Approach
Captain Pilot Flying (PF)
AP1+2 engaged in G/S LOC
LAND mode engaged automatically below 400ft
A/THR engaged and active in SPEED mode

VAPP 138kt selected
No visual reference at minima (DH = 200ft)

Crew decided to Go Around
Page 7
21-24 March 2011
DFDR Animation
Page 8
21-24 March 2011
Content

Approach
Go Around
Page 9
21-24 March 2011
21-24 March 2011
Go Around
At 220ft: Thrust levers moved to just above FLX/MCT, and then
retarded to FLX/MCT
A/THR de-activation
AP 1+2 were still engaged in LAND mode
At 115ft: CONF 3
At 70ft: EGPWS DONT SINK alert
PF pulled the stick (2/3 of full back stick)
AP disconnection
Master warning and AUTOLAND warning triggered
Lowest radio altitude of 38ft

Page 10
21-24 March 2011
Go Around
At 200ft: L/G UP and thrust levers to CLB
AFS still in LAND mode
A/THR active
At 300ft: AP1 transiently engaged

At 600ft: AP1 transiently engaged and thrust levers pushed to
TOGA
Page 11
DFDR Animation
Page 12
21-24 March 2011
Content

Approach
Go Around
Page 13
21-24 March 2011
21-24 March 2011
Second Event
Synopsis:
During a scheduled passenger service, an A319 performed a
missed approach in misty conditions during which it reached a
minimum 75ft radio altitude, L/G UP, CONF 3
Official investigation
Page 14
Approach conditions
ILS Approach CAT 1
Day condition 3000 BR SCT002 BKN003
A319
53,9 tons (MLW 61 tons)
S/F FULL
L/G DN
Vapp 124 kt (VLS + 9)
Airport elevation 390ft
Missed approach altitude: 2000ft selected
Go Around briefing: Soft Go Around
Page 15
21-24 March 2011
Approach
Captain Pilot Flying
Manual flight with FDs ON
LAND mode engaged automatically below 400ft
ATHR disconnected
No contact at minimum (DH = 200ft)
Go Around initiated at 200ft
Page 16
21-24 March 2011
DFDR Animation
Page 17
21-24 March 2011
Content

Approach
Go Around
Page 18
21-24 March 2011
21-24 March 2011
Go Around
At 200ft: PF advanced thrust levers progressively to FLX/MCT
detent in 5s
PF simultaneously increased pitch to 6 Nose Up

A/C remained in LAND MODE
A/C (still manually flown) stopped descent at 150ft RA
CONF 3 selected at 150ft
Page 19
Go Around
At 170ft: AP1 engaged & L/G selected UP
Thrust Levers were still in FLX/MCT detent
AFS still in LAND mode commanded pitch down to regain the
glide,
At 180ft: PF moved thrust levers to CLB detent

At 120ft: EGPWS warning SINK RATE triggered
Descent rate approx. 1400ft/min
PF disconnected AP and pulled almost full back stick

A/C minimum height 75ft RA, L/G UP in Conf 3, CAS 180kt
Page 20
21-24 March 2011
21-24 March 2011
Go Around
At 110ft: VFE exceedance, Master warning triggered
At 500ft: Thrust levers retarded to IDLE
At 900ft: AP1 transiently re-engaged while AFS still in LAND
mode
AFS commanded pitch down to regain the glide

Thrust levers moved to CL detent
PF disconnected the AP and pulled the stick
At 1600ft: AP1 briefly re-engaged twice

Both FDs were disengaged and re-engaged in V/S HDG 1s later
Page 21
DFDR Animation
Page 22
21-24 March 2011
Content

Approach
Go Around
Page 23
21-24 March 2011
21-24 March 2011
TOGA Selection
PF did not correctly move the thrust levers to the TO/GA
position when carrying out the missed approach procedure (both
events)
The relatively low missed approach altitude resulted in the

decision to adapt the procedure (A319 event)
Apply TOGA in the proper way by pushing

the thrust levers quickly to the mechanical stop
Page 24
Monitor Basic Flying Parameters

Monitor the basic flying parameters:
Pitch ~15!
Thrust
Positive vertical speed
Page 25
21-24 March 2011
AP Engagement
Check FMA before connecting AP
Connect AP only when FDs showing the intended flight path
Page 26
21-24 March 2011
21-24 March 2011
Check Lists
A320 event: the aircraft operator had changed the SOP for the
go-around
FMA check was moved from 3rd to 9th line in the check list
A319 event: FMA check was removed from the check list
completely but referenced as general rule in another document
Page 27
21-24 March 2011
Check Lists
According to the investigation board official reports of both
events, changes to the check lists may have resulted in the flight
crew being unaware of the flight mode status
Operators need to take great care when

changing or omitting items from check lists
Page 28
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document. This document and all information contained herein is the sole property of AIRBUS S.A.S. No intellectual property rights are granted by the
delivery of this document or the disclosure of its content. This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS S.A.S. This document and its content shall not be
used for any purpose other than that for which it is supplied. The statements made herein do not constitute an offer. They are based on the mentioned assumptions and are expressed in good faith. Where the supporting
grounds for these statements are not shown, AIRBUS S.A.S. will be pleased to explain the basis thereof.
AIRBUS, its logo, A300, A310, A318, A319, A320, A321, A330, A340, A350, A380, A400M are registered trademarks.
Page 29

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A320 Go-Around with inappropriate mode

17th Flight Safety Conference

Reminder: Thrust Levers are also mode selectors

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

FBW Thrust Levers are also mode selectors

FBW Thrust Levers

are also mode selectors

Engaging the common modes when TOGA is set

17th Flight Safety Conference

Reminder: Thrust Levers are also mode selectors

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

A/THR engaged and active in SPEED mode

No visual reference at minima (DH = 200ft)

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

Reminder: Thrust Levers are also mode selectors

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

Lowest radio altitude of 38ft

17th Flight Safety Conference

21-24 March 2011

At 300ft: AP1 transiently engaged

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

Reminder: Thrust Levers are also mode selectors

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

Reminder: Thrust Levers are also mode selectors

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

PF simultaneously increased pitch to 6 Nose Up

17th Flight Safety Conference

At 180ft: PF moved thrust levers to CLB detent

PF disconnected AP and pulled almost full back stick

21-24 March 2011

17th Flight Safety Conference

21-24 March 2011

AFS commanded pitch down to regain the glide

At 1600ft: AP1 briefly re-engaged twice

17th Flight Safety Conference

21-24 March 2011

17th Flight Safety Conference

Reminder: Thrust Levers are also mode selectors