reducing "Crew-caused"
approach and landing

Pilot-in-charge Monitored Approach

2014 A320 CFTT Naha Japan

Brief account : 

During a daytime IMC PAR (Precision Approach Radar "talkdown") approach the Captain descended the aircraft early. Following the F/O's late recognition of the situation, GPWS and ATC alerts, a go-around was initiated with a minimum altitude of 242 ft about 4 miles short of the runway. 

Approaches to this runway require an extended period of at least 5 miles level flight at only 1000ft, to avoid conflict with traffic at nearby airfields. The CVR was not available but the FDR was correlated with ATC and EGPWS recordings for the investigation.

Crew-related factors : 

Both crew members were experienced, but there may have been some culture or language  issues: some reports indicate that the Captain was an Argentinian male and the copilot a Japanese female. Having initially prepared for a VOR approach as per ATIS, the Captain realized that the weather was deteriorating and like preceding aircraft requested a PAR approach.

The Captain (PF) had incorrectly pre-set a somewhat high descent rate of 900fpm in the V/S window. It appears he mistakenly activated it and called for flaps to "full" at the start of the talk-down about 5.7 miles out, instead of at the correct descent point at 3 miles, without making required call-outs for FMA changes. 

Neither pilot recognised the pitch change or engine noise changes associated with the star of the descent. During the next 45 seconds there were only 11 seconds when no PAR instructions were being received.

The report noted that the Captain was concentrating on the radar guidance. He had not made a PAR approach for 5 years and never in an A320. The Captain as P/F did not recognise that he had started descent at the wrong point, and no vertical guidance was being provided.

At that point the F/O was also performing the landing checklist: she commented that the V/S set was "too low" (probably meaning excessive), but both pilots apparently believed the autopilot was still holding the aircraft level.

It also appears that both pilots were at least partly involved in seeking visual cues rather than instrument monitoring as both commented that they had not seen the surface during the approach and go-around.  

It was evident that the F/O's workload was high as the PAR transmissions occupied 80% of the time, making completion of the landing checklist difficult while also configuring the flaps. She did then alert the Captain with "too low" warnings at 450 and 400 ft, and the Captain pushed the V/S button at 310 ft to arrest the descent.

9 seconds later following both GPWS and ATC alerts a go-around was initiated at 242ft. Neither pilot apparently registered the GPWS however, and the go-around was flown on autopilot and not as a "PULL UP" escape.  

Overall it appears that the Captain's concentration on the requirement of flying the PAR resulted in his loss of overall situation awareness, while the F/O's prioritisation of tasks similarly degraded her overall awareness. To quote a report from a different but somewhat similar event 40 years earlier, "The commander’s overall supervision of the approach was adversely affected by his personal preoccupation with the control of the aircraft.... the system of monitoring used did not function properly at a time when the cockpit workload was high."

If the crew had been using a PiCMA procedure,

1) it is less likely that an incorrect setting of the V/S mode would have been allowed to go unremarked.  

2) If the F/O had similarly initiated descent at the start of the lateral part of the talkdown, it is less likely that as pilot in charge the Captain would have prioritised the flap setting and checklist over the flight path of the aircraft.  

Naha Japan
Expected weather: 
Pilot in charge: 
Early transition: 
Go-around : 
At or above DH/A
PicMA potential: 
Vert Guidance: 
Both Head Up: 
Peach Aviation
Fully prepared: 
Actual Weather: 
Low Cloud
Autopilot :