ASN Wikibase Occurrence # 233559
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Narrative:The crew took off from Bamako, Mali, on 12 March 2012 at 23 h 59 heading for Paris Charles de Gaulle (CDG) Airport. On arrival, the ATIS indicated that the low visibility procedure (LVP) was in force. The crew prepared themselves for a CAT III precision approach.
|Fatalities:||Fatalities: 0 / Occupants: |
|Aircraft damage:|| None|
|Location:||near Paris-Charles de Gaulle Airport (CDG/LFPG) -
|Nature:||Passenger - Scheduled|
|Departure airport:||Bamako Airport (BKO/GABS)|
|Destination airport:||Paris-Charles de Gaulle Airport (CDG/LFPG)|
|Investigating agency: ||BEA|
|Confidence Rating:|| Accident investigation report completed and information captured|
The aeroplane was stable at FL90 at about 30 NM from the threshold of runway 08R. Autopilot 1 was engaged in HDG and ALT mode. The autothrottle (ATHR) was engaged in SPEED mode. The speed was stable at 250 kt in accordance with the controller’s request. The crew was in contact with CDG approach. They were cleared to intercept localizer 08R.
At 04:40, the controller cleared the crew to descend to FL80 and five seconds later the aeroplane, stable at FL90, passed above the 3° glide path. The crew was then cleared to descend to FL60. They selected an altitude of 6000 ft on the FCU and the autopilot mode changed to OP DES. The autopilot captured the localizer 08R signal (LOC) and then the LOC mode engaged. When the aeroplane descended to 7220 ft, and was 17.5 NM from the threshold, or about 1275 ft above the glide path, the controller requested that a speed of more than 200 kt be maintained. The aeroplane’s speed was about 250 kt. The crew read back and requested to continue the descent. The controller apologised for his omission then cleared the crew to descend to 3000 ft to intercept the 08R ILS.
The crew selected 220 kt and 3000 ft. The OP DES mode remained active. The aeroplane speed and rate of descent decreased which resulted in increasing the deviation from the glide path. The crew extended the airbrakes. When the aeroplane speed reached the target speed of 220 kt, the rate of descent increased again to a value of -1840 ft/min.
At 10 NM from the runway threshold and at an altitude of 5500 ft, the approach controller requested that the crew maintain a speed of more than 160 kt and that they contact the tower. He did not inform the tower controller that the aeroplane was above the glide path. The crew selected a speed of 210 kt then 183 kt and wing slats/flaps configuration 1. Again, the rate of descent decreased and the aeroplane deviated from the 3° glide path.
The crew contacted the tower and indicated that they were 9 NM out. The aeroplane was at an altitude of 4950 ft (1750 ft above the glide path). The controller initially cleared the crew to continue the approach. The latter read back "Cleared to land 08 right...". The controller indicated that he then checked that the CAT III ground services were clear then confirmed clearance to land.
The crew selected slats/flaps configuration 2 and retracted the airbrakes. About one minute later, they re-extended the airbrakes, set the G/S mode using the APPR switch and engaged autopilot 2. The glide deviation displayed on the PFD indicated to the crew that they were approaching the glide path from above. The aeroplane was 4 NM from the runway threshold, at about 3700 ft (that is 2100 ft above the glide path at 3°) and was located in an ILS signal sidelobe.
About 30 seconds later, the crew extended the landing gear. The glide path capture mode (G/S) was activated when the aeroplane was 2 NM from the runway threshold at 2850 ft (that is about 1600 ft above the glide path at 3°). The ATHR changed to SPEED mode. The pitch attitude increased from 1° to 26° in 12 seconds. The PNF stated that he had called out the difference in the pitch attitude when the chevrons appeared. When the aeroplane pitched up, the speed dropped from 163 kt to 130 kt, the vertical speed changed from – 1600 ft/min to + 3300 ft/min. When the pitch attitude reached 26°, the crew disconnected both autopilots and the PF made a pitch down input almost down to the stop. The pitch attitude and vertical speed decreased. The crew retracted the airbrakes. The throttle levers were in the IDLE position. The speed was 143 kt and the ATHR disengaged. About 30 seconds later, autopilot 1 was engaged, the levers were repositioned on the CL setting and the ATHR was activated. The PF explained that he engaged autopilot 1 to perform a go-around on automatic. The LOC and G/S modes were active and the ATHR was in SPEED mode. The speed was 147 kt. The aeroplane was directly above the runway threshold at an altitude of about 2700 ft. The pitch attitude then decreased from 2° to -5° and the aeroplane descended.
The PF stated that he realised that the modes displayed on the FMA were not appropriate. He then disengaged the AP 8 seconds after having activated it and then displayed a pitch attitude of about 6° and placed the throttle levers in the TOGA setting at an altitude of about 2000 ft.
The crew made a second approach and landed without further difficulties.
This serious incident was due to:
- Inadequate monitoring of the aeroplane’s flight path by the controller and by the crew during the CAT III precision approach under radar vectoring;
- The crew’s decision to continue the approach after the FAP when the aeroplane was above the glide path.
The following factors contributed to it:
- The absence of visual reference points on the controllers’ radar screen for glide path interception at altitudes lower than 5,000 ft.
- The crew’s use of an unsuitable method to intercept the glide path from above.
- The autopilot’s capture of an ILS signal from a sidelobe, which generated an excessive increase in pitch attitude.
Flight crew and controller fatigue may have contributed to the occurrence of this serious incident.
| || |
|Investigating agency: ||BEA |
|Status: ||Investigation completed|
|Download report: || Final report|
Other occurrences involving this aircraft
|22 Jul 2011
||Noth of the Antilles
|23 Dec 2014
||Antananarivo-Ivato Airport (TNR/FMMI)
|11 Mar 2017
||Bogotá-Eldorado Airport (BOG/SKBO)
|Runway excursion. |
|28 Nov 2017
||Updated [Narrative, Photo, Accident report, ]|
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