reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2013 ATR72 G_A LOC CFIT Pakse Laos

Brief account : 

The ATR72 made a step-down VOR/DME approach in a thunderstorm with a minimum altitude of 600 ft set the altitude selector, almost 400 ft below the correct MDA. Just below this altitude the approach was aborted. The Captain disconnected the autopilot, but followed the Flight Director which captured the 600ft altitude. The aircraft was pitched down and reached 60 ft RA with 37 degrees right bank, prior to a pitch up of 25 degrees with a steep climb. This was then followed by a nose down to impact.  

Crew-related factors : 

Only an abbreviated report is available in English, but the following points emerge. The cross-cockpit authority gradient was very high: the Captain was 57 and quite experienced but the 22 year old F/O had only 400 hours total time and only qualified as an ATR copilot some 10 days earlier. The approach was apparently conducted without adequate briefing and the Captain may have suffered some somatogravic illusions leading to the loss of control.

If PicMA had been the company SoP:  

1) the F/O is unlikely to have set the altitude capture below the MDA unless specifically ordered to by the Captain

2) the Captain would have had more opportunity to assess the deteriorating conditions during the approach  

3) even at the improper low quasi-MDA, on deciding on a missed approach the Captain would not have had to revert from seeking outside cues to being PF on instruments, reducing vulnerability to somatogravic illusions and subsequent loss of control.

Type: 
ATR72-600
Where: 
Lakse, Laos
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
Unknown
Go-around : 
Below DH/A
Damage: 
Serious
PicMA potential: 
Major
Year: 
2013
Time: 
Day
Deterioration: 
Yes
Vert Guidance: 
None
Both Head Up: 
No
LoC: 
Yes
Operator: 
Lao Airlines
Fully prepared: 
Yes
Actual Weather: 
Thunderstorm
Autopilot : 
Y
CCAG: 
High