Serious incident Boeing 777-328ER F-GSQJ,
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ASN Wikibase Occurrence # 277129
 
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Date:Tuesday 5 April 2022
Time:c. 07:51 UTC
Type:Silhouette image of generic B77W model; specific model in this crash may look slightly different    
Boeing 777-328ER
Owner/operator:Air France
Registration: F-GSQJ
MSN: 32852/510
Year of manufacture:2005
Fatalities:Fatalities: 0 / Occupants: 292
Aircraft damage: None
Category:Serious incident
Location:Paris-Charles de Gaulle Airport (CDG/LFPG) -   France
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:New York-John F. Kennedy International Airport, NY (JFK/KJFK)
Destination airport:Paris-Charles de Gaulle Airport (CDG/LFPG)
Investigating agency: BEA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Air France Flight AF011, a Boeing 777-300ER, was going around Paris-CDG Airport when the pilots experienced difficulties controlling the flight path.
The captain on the flight was the Pilot Monitoring (PM), the co-pilot, in the right seat, was the Pilot Flying (PF).

During the descent, the crew prepared for an ILS approach to runway 26L. The meteorological conditions were the following: wind 230, 8 kt, visibility 3000 m, cloud ceiling 300 ft, temperature 9° C, QNH 1013.
On final, the aircraft was established on the localizer and glideslope ILS beams. At 07:49 UTC, the crew were cleared to land. They configured the aircraft for landing, the selected speed was 140 kt. The crew then carried out the Landing checklist. At 07:50:20, when the aircraft was at an altitude of 1670 ft, the PF continued the approach in manual flight: he disconnected the autopilot (AP), leaving the auto throttle (AT) and the flight directors (FD) activated. He then made inputs on the controls for around 15 seconds. The aircraft followed the movement of the controls and stayed on the ILS path, the left and right roll being less than 2°. In the subsequent ten seconds, there were less inputs on the wheel. The co-pilot than made inputs on the control column and wheel with a greater frequency, the amplitude was still small, the aircraft followed the commands, the left and right roll being less than 3°. At 07:51:06, the co-pilot expressed his astonishment with respect to the aircraft’s bank angle. The roll inputs were amplified and the average position of the wheel was at around 6° to the left. The aircraft turned left with a small bank angle. The captain voiced his surprise with respect to the deviation from the flight path.
At 07:51:12, when the aircraft was at an altitude of 1115 ft, banked 7° to the left, with the wheel oriented 16° to the left, the crew carried out a go-around. Up until the go-around, the flight path had remained within the operator’s stabilization criteria. The recorded parameters show that the two pilots then simultaneously made inputs on the controls.
In the following second, the position of the wheel reached a maximum value of 27° to the left. One second later, the roll reached a maximum value of 15° to the left and the nose-up attitude was 12°.
At 07:51:16, the captain commented that the plane was going left. The control columns were then desynchronized for 14 seconds due to opposing forces. The captain held the control column in a slightly nose-down position while the co-pilot made several, more pronounced, nose-up inputs. Two brief episodes of wheel desynchronization were also observed.
At 07:51:20, the go-around switches were pushed again increasing the thrust to the maximum thrust available.
At 07:51:23, the pitch reached a maximum value of 24°.
At 07:51:25, the co-pilot called out 'Positive climb' and retracted the landing gear. The configuration warning was displayed and the associated aural warning (siren) sounded because the landing gear was retracted while the flaps were still in the landing position.
The two pilots continued to simultaneously make inputs on the controls. The captain made more pronounced nose down inputs for a few seconds.
At 07:52:06, the captain was the sole person making inputs. The crew completed the go-around actions.
The crew analysed the situation without perceiving the antagonistic inputs made on the controls and the desynchronizations of the control channels. They considered that they could use the AP again and carry out a new approach.
The co-pilot became the PF again. The captain informed the controller that there had been a problem on the flight controls and asked to join the final for runway 27R. The approach and landing took place without further incident at 08:13 UTC.
No failure warning was activated during the occurrence. No anomaly was observed on the aircraft.


Contributing factors
During the ILS approach to runway 26L, without external visual references, in manual flight, the PF expressed his surprise regarding the aeroplane’s bank angle and flew a missed approach a few seconds later.
On the PF verbalizing his surprise about the aeroplane’s bank angle, the captain, PM, placed his hand on the wheel at the same time as the pilot aborted the approach. It is possible that the co-pilot then felt an unusual resistance in the controls when he pulled on the control column to reach the go-around pitch attitude. Already surprised by the bank angle before aborting the approach and feeling an unusual resistance in the controls, he possibly increased his pull input and the aeroplane’s pitch attitude became too steep.

The captain then acted, most probably by reflex action, on the control column to reduce this pitch attitude without taking back the controls and making the procedure call-out, based on the principle of only one pilot having the controls. The two pilots then simultaneously made inputs on the controls. The pitch controls were desynchronized for 12 s due to opposing forces. Two brief episodes of roll desynchronization were also observed. During this phase, there was considerable confusion, as neither pilot was aware that he was fighting the other, with the captain initially attributing the extra load in the controls to a jammed control.
The controls were synchronized again after the captain explicitly called “push push”.
When the captain made the standard "I have the controls” call-out (designed to inform the other pilot of the transfer of tasks between the PF and the PM), about 53 s after the approach had been aborted, the forces recorded on the right-hand control column became zero and the flight path was stabilized. After recovering control of the flight path, the crew carried out a new approach to runway 27R without further incident.
The investigation was not able to identify the factors which contributed to affecting the co -pilot’s sensations. He had believed that it would be difficult to maintain a stabilized approach.
The following factors may have contributed to the simultaneous inputs on the controls:
• the PM’s reflex action on the controls during the banked go-around, probably linked to the deflection of the wheel and the unusual pitch attitude;
• failure to formalise the transfer of control;
• the absence of any warning about the effects of simultaneous actions on the controls in the manufacturer's and operator's documentation for this type of aeroplane;
• the lack of information on the possibility of desynchronization of the controls in the event of opposing inputs in the documentation available to pilots;
• a lack of knowledge about the systems resulting from this lack of information;
• the conviction that simultaneous inputs on the controls would be quickly perceived by crews on this type of aeroplane.

METAR:

Weather reported about the incident time (0751Z):
LFPG 050800Z 24008KT 3000 BR BKN003 09/08 Q1013 TEMPO BKN002
LFPG 050730Z 23009KT 3000 -RA BR BKN003 09/08 Q1013 TEMPO BKN002
LFPG 050700Z 23008KT 3000 -RA BR BKN003 08/08 Q1013 TEMPO BKN002

Accident investigation:
cover
  
Investigating agency: BEA
Report number: BEA2022-0138
Status: Investigation completed
Duration: 1 year and 9 months
Download report: Final report

Sources:

Twitter
https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-boeing-777-registered-f-gsqj-operated-by-air-france-on-05-04-2022-at-paris-charles-de-gaulle/
https://bea.aero/fileadmin/user_upload/BEA_-_Press_Release_270422.pdf
https://www.flightradar24.com/data/flights/af11#2b62b2c9
https://www.airfleets.fr/ficheapp/plane-b777-32852.htm
https://globe.adsbexchange.com/?icao=394a09&lat=49.008&lon=2.681&zoom=10.2&showTrace=2022-04-05&trackLabels

Images:



Graph (c): BEA France

Media:

Revision history:

Date/timeContributorUpdates
05-Apr-2022 17:25 Iceman 29 Added
05-Apr-2022 17:26 Iceman 29 Updated [Source, Photo]
05-Apr-2022 18:33 Iceman 29 Updated [Date]
05-Apr-2022 18:59 harro Updated [Time, Aircraft type, Destination airport, Narrative]
05-Apr-2022 19:01 harro Updated [Source]
06-Apr-2022 09:09 Iceman 29 Updated [Embed code]
06-Apr-2022 09:09 Iceman 29 Updated [Embed code]
07-Apr-2022 01:57 RobertMB Updated [Cn, Embed code]
07-Apr-2022 06:38 Anon. Updated [Narrative]
15-Apr-2022 15:55 harro Updated [Source, Narrative]
27-Apr-2022 17:09 harro Updated [Total occupants, Source, Narrative]
27-Apr-2022 18:01 harro Updated [Photo]
16-Jan-2024 17:53 harro Updated [Other fatalities, Embed code, Narrative, Accident report]

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