Common Themes

Human Error

The Accident Report stated that "the probable cause of the accident may be expressed specifically as follows:- "Failure of the pilots to monitor speed during final approach, probably because they diverted their attention to find out the reason for the aircraft going into idle/open descent mode rather than realising the gravity of the situation and responding immediately towards proper action of moving the throttles even after the Radio altitude call-outs of "Four Hundred", "Three Hundred", and "Two Hundred" feet, in spite of knowing that the plane was in idle/open descent mode."

  • These factors are indicative of human error in monitoring critical aircraft flight parameters and also in interfacing with the aircraft autoflight/autothrottle system. The autoflight system was erroneously placed in an incorrect mode and the crew did not detect the resultant loss of airspeed resulting from the incorrect autoflight mode. Several human errors were made on final approach - setting an incorrect autoflight mode, making autoflight mode changes on final approach, setting a lower altitude on the Flight Control Unit (FCU) (potentially due to selecting the incorrect FCU knob), not turning off Flight Directors, not being on a stabilized approach on final, not monitoring critical flight parameters, and not detecting and correcting a large airspeed deviation from final approach speed.

Back to top