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    Air Pilots - Commercial Air Transport: Safety Briefing Note 03

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    Léa Mercier
    The document discusses rarely used normal flight procedures and the importance of training for them. It provides an example where a go-around was initiated after touchdown but thrust was not increased, resulting in a runway excursion. The summary recommends operators and pilots take steps to ensure familiarity with infrequently used procedures through risk assessment, data monitoring, and supplemental training.

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    Air Pilots - Commercial Air Transport: Safety Briefing Note 03

    Uploaded by

    Léa Mercier
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    The document discusses rarely used normal flight procedures and the importance of training for them. It provides an example where a go-around was initiated after touchdown but thrust was not increased, resulting in a runway excursion. The summary recommends operators and pilots take steps to ensure familiarity with infrequently used procedures through risk assessment, data monitoring, and supplemental training.

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    The document discusses rarely used normal flight procedures and the importance of training for them. It provides an example where a go-around was initiated after touchdown but thrust was not increased, resulting in a runway excursion. The summary recommends operators and pilots take steps to ensure familiarity with infrequently used procedures through risk assessment, data monitoring, and supplemental training.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5 views2 pages

    Air Pilots - Commercial Air Transport: Safety Briefing Note 03

    Uploaded by

    Léa Mercier
    The document discusses rarely used normal flight procedures and the importance of training for them. It provides an example where a go-around was initiated after touchdown but thrust was not increased, resulting in a runway excursion. The summary recommends operators and pilots take steps to ensure familiarity with infrequently used procedures through risk assessment, data monitoring, and supplemental training.

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    The Honourable Company of Air Pilots is the largest City of London Livery Company and the only one

    with a
    global membership. London Livery Companies are charitable specialist professional and trade bodies which,
    where relevant, seek to contribute their entirely independent and impartial expertise to their areas of interest.
    The Air Pilots Commercial Air Transport Team is directly supported by a large network of Company Members
    who review and validate our draft publications before issue.

    If you would like to receive copies of new Safety Briefing Notes direct by email - or stop receiving them -
    please advise this to catcsg1@airpilots.org All published Notes which continue to be relevant can be
    consulted at or downloaded from https://www.airpilots.org/CATSafetyBriefingNotes/

    AIR PILOTS - COMMERCIAL AIR TRANSPORT


    SAFETY BRIEFING NOTE 03
    [Issued 02 MARCH 2021]

    RARELY USED NORMAL PROCEDURES


    The Context
    The majority of Normal Procedures will be used often and it can be expected that pilots will have
    no difficulty following them. If the possible need to use those which are only rarely used can be
    anticipated, then this can be covered in prior, suitably focused, briefings. However, in a few cases,
    checklist-based normal procedures will typically begin with a memory based sequence of actions to
    be correctly accomplished in unanticipated circumstances and without delay. This is particularly
    true of a go-around other than one commenced because of an absence of the required visual
    reference on reaching DA/MDA. A go-around commenced soon after touchdown will, for most
    pilots, be a relatively rare if not a very rare occurrence. Experience has shown that situations like
    this are particularly prone to unintended deviation from applicable procedures. This can often be
    attributed in part to a combination of surprise at the onset of the situation and lack of any recent
    and directly relevant full flight simulator training covering the sequence involved.

    An Example: failure to successfully initiate a go-around after touchdown


    In August 2016, a Boeing 777-300 flight crew attempted to commence a go around shortly after a
    manual touchdown at Dubai when it became clear that touchdown had occurred sufficiently beyond
    the runway threshold that a long landing was in prospect. However, despite taking action in
    response to an ATC call as they climbed, they did not confirm that the necessary thrust had been
    set until it was too late to prevent a loss of flight path control and runway impact followed. Although
    all occupants successfully evacuated without any fatalities, the already damaged aircraft was then
    destroyed by fire.
    The Investigation1 attributed the attempt to go-around without setting the thrust required to achieve
    this to both pilots’ unfamiliarity with the initiation of a go-around after touchdown in the
    circumstances it was necessary. However, it also noted their failure to follow several required
    procedures which could have supported early recovery of control and a successful transition to the
    intended go-around state. The aircraft operator’s normal go-around procedure for the aircraft type
    required the A/T to remain engaged for all flight phases including approach and landing when, with
    weight on wheels sensed, it then reverts automatically to ‘IDLE’ mode and the TO/GA switches are
    disabled. This condition then remains unless the thrust levers are manually advanced for a go-
    around, in which case the A/T annunciated mode changes to ‘THR’ and the thrust levers move
    accordingly.

    Discussion
    Although the operator provided recurrent training considerably in excess of minimum regulatory
    requirements which included go-arounds commenced after touchdown following a manual
    approach, this exercise was being conducted with the A/T and the Flight Directors off and pre
    briefed as a demonstration that manually advancing the thrust levers would be necessary. This
    meant that there was a significant difference from the way this situation would be encountered
    during normal operations, in particular that the usual way to set TO/GA thrust for any go around is
    by pressing the corresponding thrust lever switches.

    1
    http://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachm
    ents/125/2016-Published%20Final%20Report%20AIFN-0008-2016-UAE521%20on%206-Feb-2020.pdf
    In this case, the investigators found no evidence that the difference between the way the thrust
    levers work in the case of A/THR on current Airbus types and A/T on Boeing types played any part
    in what happened. However, where pilots have changed their current type rating in either direction,
    there is a potential for reversion to their former type to affect the pilot interface with the thrust
    levers when unexpected situations arise suddenly. More generally, scenarios such as that in the
    example above serve to illustrate the importance of both clear and appropriate procedures and
    training which enables all pilots to respond appropriately to any infrequently encountered normal
    scenario which arises unexpectedly and requires a prompt response relying on little-used memory
    actions and cross checks. Important checks do need to be called and confirmed to avoid omission.
    Other examples of go-arounds which may also be encountered unexpectedly include one
    commenced in IMC or at night well before reaching the DA/MDA and loss by one pilot of the
    previously acquired visual reference when below DA/MDA. An example of the former occurred at
    London Stansted UK in February 2019 where issues with the control of the aircraft when a night
    go-around was commenced from 2000 feet worsened the loss of separation against a departing
    aircraft2. An example of the latter occurred in Brunei in July 2014 when an A320 approach was
    continued after the handling pilot lost their previously acquired visual reference below DA and the
    other pilot took over and continued to a runway excursion landing on the basis that he could “make
    out” a line of white lights which turned out to be runway edge lights3.

    Safety Recommendations
    To Aircraft Operators
     Although operating procedures supplied by aircraft manufacturers provide a sound basis,
    aircraft operators should carefully review them against the demands which will be placed on
    them as applied to their particular combination of crew experience and route flying.
     A risk assessment of all Normal Procedures which may need to be only infrequently used
    should be made, paying special attention to those procedures which begin with memory
    recall actions. Any appropriate risk mitigations should then be put in place and, like all risk
    assessments, then periodically reviewed to confirm their continued efficacy.
     Care is needed to ensure crews have sufficient understanding of the relationship between
    potentially critical Normal Procedures and the automated systems on which they are based
    and that corresponding training reflects normal rather than abnormal circumstances.
     Any risk which can be informed by Operational Flight Data Monitoring should use it to track
    performance against procedure and capture relevant data for review. Situations where
    rarely used Normal Procedures have been - or should have been - used should be
    considered as a risk exposure measure.
     If, because of regulatory requirements which must be satisfied, it proves difficult to fit in
    adequate full flight simulator practice of rarely-used Normal Procedures which require a
    rapid response and memory recall, alternative ways in which your pilots can be supported,
    such as the use of part-task training devices and classroom or online learning, should be
    considered.
    To Pilots
     Not all pilots are fortunate enough to fly for operators like the one involved in the example
    event described above who provide training beyond regulatory minima. Even if you are, it is
    worth recognising that delivering pilot training on the response to rarely used normal
    scenarios as frequently as you personally would perhaps prefer may be a challenge. You
    may therefore want to supplement it by ensuring you regularly and critically review rarely
    used normal procedure checklists for situations which can occur unexpectedly.
     If the initial or recurrent aircraft type training provided does not give you the confidence that
    you could necessarily competently respond to any situations where the solution is a rarely-
    used Normal Procedure initiated by memory recall, you may wish to supplement it by
    regularly thinking through such sequences - a process that has sometimes been described
    as ‘armchair flying’.
     Unless the content of an ATC call is safety critical, the early stages of any go around or the
    response to any other critical flight phase is a time to prioritise in the order ‘Aviate -
    Navigate - Communicate’. This priority may, in the illustrative example provided, have
    increased the chances that both pilots would have prioritised confirmation that the
    appropriate thrust, pitch attitude and trim had been set.

    2
    https://assets.publishing.service.gov.uk/media/5d9f2d0ee5274a5959410736/Airbus_A320_OE-
    IHD_and_Saab-Scania_SS340B_G-LGNK_11-19.pdf
    3
    https://www.skybrary.aero/bookshelf/books/4104.pdf

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