2015 A319 loss of situation awareness Bristol UK
After planning an ILS approach, the crew were asked if they wished to use the reciprocal runway due to a wind shift. They accepted this as also being more expeditious and requested a visual final, using partial navigation display information for orientation.
During the course of this, the aircraft position was misjudged and a go-around was flown from a position some way off the centre-line, where the aircraft was close to a populated area, This was on a hill which gave a minimum clearance of under 500 ft. The aircraft then landed safely on the original runway.
There is no information on crew aspects in the report, nor a CVR transcript. However this incident is a good example of premature abandonment of instrument information for misleading visual cues due to "benign" conditions. In this case the Captain (PF) made a late change which threw away the briefed approach, but did not replace it. The co-pilot was not now aware of how the Captain intended to fly the approach, so was not properly able to monitor it.
In the event the F/O (PM) identified that some lights on the ground were in an inappropriate position, realised that the Captain was now scanning for external cues and called for a go-around just as the Captain decided the visual references were not correct and also initiated a go-around.
The report says: "The Captain probably did not update his 5 nm range ring from that set earlier centred on the threshold of Runway 09, and its subsequent use for situation awareness may have caused him to position too close in to the threshold of Runway 27. Both crew members then lost situational awareness, but neither communicated this to the other until the co-pilot called for a go-around. The fact the go-around altitude was not set until the go-around had commenced indicates either the landing checklist had not been completed or that it had not been completed satisfactorily".
If PicMA had been the SOP,
1) although the Captain may have elected to cancel the instrument approach, he would have had more opportunity to evaluate exactly where the aircraft was, and to reset the precautionary display of a 5 mile final point for the new runway while the F/O continued on the planned instrument routing.
As it was, having seen some visual cues, as PF he immediately disconnected the autopilot, autothrust and flight directors, without adequately communicating what he intended to do. Both pilots then essentially became entirely reliant on visual cues which were open to misinterpretation.
2) the fact that the landing checklist had not been completed at the point where the Captain wanted to take control would have perhaps triggered more caution in both pilots.
