Lessons Learned

Technical Related Lessons

During approach and landing, one pilot must conduct continuous visual monitoring of airplane airspeed and flight path.  (Threat Category:  Incorrect Piloting Technique)

  • In this accident, a visual approach was being conducted, and the runway was in sight.  However, the flightcrew elected to fly the approach with the flight director and autothrust system engaged.  Confusion over flight director mode changes led to both pilots concentrating on the functioning of the autoflight system, and for the pilot flying to neglect his duties to monitor and maintain airspeed and progress toward the runway (flight path.)   

Common Theme Related Lessons

Failures or breakdowns in flightcrew communication or discipline can have catastrophic results.  The pilot flying must assure execution of requests/commands, and appropriate followup must be accomplished. (Common Theme:  Human Error)

  • Flight 605 was conducting a visual approach to Bangalore.  The airplane manufacturer recommended that during a visual approach, both flight directors be turned off.  However, during the initial stages of the approach, the flight directors were on, and were providing flight path guidance.  As the airplane passed through 5000 feet, the pilot flying (PF) requested that the altitude on the FCU be reset to the go around altitude of 6000 feet.  Rather than set 6000 feet as requested, the pilot monitoring (PM) asked if the PF would rather use vertical speed for the next portion of the approach, and never did set 6000 feet on the FCU.  Compounding the error, the PF did not verify whether or not 6000 feet had been set.  Later in the approach, the investigation believes that the pilot monitoring (PM) also set 3300 feet (the minimum descent altitude for a VOR DME approach), and did not inform the PF of this change.  Finally, near the end of the approach, the pilot flying asked for the flight directors to be turned off.  This led to a discussion about the PF having already turned his flight director off, but had not turned off the pilot monitoring's flight director.  Ultimately, the PM did not turn his flight director off, and the pilot flying did not verify that it was off.  The Indian Court of Inquiry concluded that if any one of the actions requested by the pilot flying had been carried out, the accident would not have occurred.  The failure of the PM to respond to the PF’s requests, and the pilot flying’s failures to verify that his requested actions had been accomplished, led to the accident.

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