reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2011 B777 LoC in Go-around Paris France

Brief account : 

During a Cat 3 approach at the crew's home base, a brief Master Caution occurred with a land status change for which the PNF called for a go-around. The Captain (PF) applied full thrust and pulled on the control column. The autopilot remained coupled and the aircraft accelerated down the glideslope. 

Both pilots subsequently applied control column pressure disengaging the autopilot. After reaching a minimum altitude of 63ft, the aircraft was subjected to large pitch and speed changes before the crew recovered control.  

The investigation was based on FDR and crew reports as the CVR was erased by mistake.   

Crew-related factors : 

Both pilots and a relief pilot were experienced on type. A Cat 3 autoland was planned due to the weather: prevailing RVRs were of the order of  400m in fog with light winds. 

At 320ft radio an EICAS mode downgrade "No Land 3" occurred with a brief Master Caution, and the LAND 3 status changed to LAND 2.    

The relief pilot called out “warning” and the PNF called out “go-around”. 8 seconds after the first warning the PF advanced the thrust levers to the stop in two seconds. He did not press the Go-around switches but instead disconnected the auto-throttle (AT). Simultaneously, a nose-up input by the PF on the control column was recorded but it was not strong enough to disconnect the autopilot. The radio height was now 250 ft.

The aircraft now accelerated down the glideslope trimming and pitching nose down. THe PNF started retracting the flaps,  Both pilots then applied nose up force, disconnecting the autopilot and causing a 1.84g pitch up, followed by conflicting pilot inputs .

The exact sequence of oscillations is not clear from the report but the lowest height reached was 63 ft. radio. 

It is clear that the Captain as PF had become convinced by sight of the visual cues considerably above the Cat 3 DH that he would be able to land. Consequently, when other crew members called for a go-around because of instrument indications, he was faced with a significant mental conflict at a critical point in the approach. In resolving it, he made actions and inputs which were not appropriate to either his original mental model or the new one. 

If PicMA had been in use, the pilot flying at the time of the go-around call would have been the First Officer. The F/O was fully prepared to carry out a go-around, and would not have been exposed to the visual cues.  The Captain, while he may still have considered that the visual scene was adequate for landing, would probably not have over-ridden the go-around call.     

Type: 
B777-200
Where: 
Paris France
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
Yes
Go-around : 
Below DH/A
Damage: 
Minor or none
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