EI493 - Incident: Lingus A320 at Dublin on Jan 14th 2025

An Aer Lingus Airbus A320-200, registration EI-DEE performing flight EI-493 from Faro (Portugal) to Dublin (Ireland), was descending towards Dublin about to turn onto final approach for runway 28L when the aircraft encountered an unusual attitude prompting the crew to initiate a missed approach. The aircraft began to climb again after reaching about 1900 feet, positioned for another approach and landed without further incident about 10 minutes later.

On Apr 11th 2025 the Irish AAIU reported they rated the occurrence an incident and opened an investigation describing the occurrence as: "Aircraft upset and level overshoot."

On Jul 31st 2026 the AAIU released their final report concluding the probable causes of the serious incident were:

While seeking to expedite a routing to the Final Approach Fix, an aircraft upset occurred, during which a bank angle of 44 degrees was reached, and on two occasions, the airspeed reduced below the minimum selectable speed (VLS).

Contributory Cause(s)

- The Commander’s belief that a direct routing to MAXEV would put the Aircraft in a position to fly a stable approach, on speed and at the correct altitude.

- The Commander’s decision to disconnect the autopilot, and fly the aircraft manually, resulted in degraded situational awareness.

- The Aircraft was high throughout the first approach.

- The Aircraft did not establish on the ILS during the first approach.

- The Flight Crew did not request extra track miles or entry into a holding fix.

The AAIB stated that they did not receive information about the occurrence until Mar 18th 2025: "On 18 March 2025, a Voluntary Occurrence Report was submitted to the IAA via the European on-line occurrence reporting portal. Following further enquiries, and upon receipt of an Air Safety Report (ASR) from the Operator, the AAIU commenced an Investigation."

The AAIB analysed:

Fatigue Analysis of Commander’s Roster

The Commander stated in interview that his preferred roster was to bid for late duties; however, his last two flight duty periods were earlies having been preceded by a ‘blank day’.

He also stated that he did not sleep well the night before his last duty day and that he did his best to manage his rest prior to reporting for duty. The Investigation obtained from the Operator a FAID analysis of the Commander’s roster. This indicated a peak FAID score of 47 prior to commencement of duty on the day of the occurrence, with the threshold for flight operations being a score of at or below 70. It should be noted that while the FAID score takes account of the ‘likely sleep opportunity’, it does not account for actual amount of sleep accrued, or the quality of that sleep.

The Occurrence Flight

The occurrence flight was part of a two-sector day with an early report time. The first sector, to LPFR, was flown by the FO, with the Commander acting as PM and arrived on stand approximately nine minutes ahead of schedule. The second sector, with the Commander as PF and the FO acting as PM, pushed back from its stand, taxied to the departure runway and took off at approximately 11:39 hrs. The scheduled departure time for this sector was 11:40 hrs with a scheduled time of arrival in EIDW at 14:40 hrs; therefore, the Flight Crew would not have been under any perceived or actual time pressure. As the aircraft climbed out of approximately 4,000 ft, the selected airspeed was 340 kt which is 10 kt less than the maximum operating speed of 350 kt. The maximum actual airspeed achieved below FL 100 was 336 kt before settling at 329 kt as the Aircraft approached FL 100. In the absence of CVR recordings, the Investigation cannot definitively say whether this high speed was requested by ATC; however, the Investigation found no evidence to indicate why ATC would have made such a request at that time and therefore it is considered unlikely.

The Aircraft subsequently established at its cruising Flight Level and continued on its route to EIDW. At 13:43 hrs, the Aircraft commenced its descent and routed towards ARVOK on the STAR for RWY 28L. Having contacted Dublin Approach Frequency, the Flight Crew was advised to maintain heading and when passing through FL 135, given an estimated track miles to touch down of 40 NM. In conjunction with flight management guidance computers, pilots of jet transport aircraft often use a rule of thumb, multiplying the first two digits of the FL by three, to estimate their required track miles to touch down.

In this case, the crew were given an estimate of 40 track miles when passing through FL 135, which, when using this rule of thumb would give an estimate of track miles required of 39 NM. However, this rule of thumb is dependent on several variables which include, inter alia, aircraft type, aircraft ground speed, aircraft weight, rate of descent and rate of deceleration to flap extension speeds.

The First Approach

At 13:56 hrs, the Aircraft was cleared to descend to an altitude of 3,000 ft and two minutes later, the FO transmitted that ‘we are available MAXEV if available’. This request by the FO would have been prompted by the Commander (as PF), who at this stage felt comfortable that if they got a direct routing to the Final Approach Fix, they would be in a position to fly a stable approach, on speed and at the correct altitude. The Controller acknowledged this request and instructed the Aircraft to ‘turn left heading North’.

At 13:59 hrs, the Controller cleared the Aircraft to descend to an altitude 2,000 ft and ‘when ready cleared to MAXEV and cleared ILS approach 28 Left’. The autopilot was disconnected by the Commander, a decision that was made in order to achieve full speed brake extension. The Aircraft began to track towards MAXEV and as it descended below 5,500 ft, it deviated to the right of this track, most likely in an attempt by the Commander to gain extra track miles before resuming its track towards MAXEV. As the Aircraft descended through 4,400 ft, ATC queried if extra track miles were required. The FO responded that they were going to go through the localiser and ATC asked them to ‘advise if you need any extra vectors’. The Aircraft did not actually go through the localiser but ended up parallel to, and left of it.

A radar plot of the Aircraft at approximately 8.1 NM from the threshold shows a descent through 3,900 ft. Had the Aircraft been established on the localiser at this distance, the Aircraft would have been required to lose approximately 1,400 ft of altitude over 1 NM to be at MAXEV (7.1 NM from threshold) at the published altitude of 2,500 ft. This would have required aggressive manoeuvring; therefore, the Investigation concludes that the Aircraft was high on the approach. It is also likely that the Commander, who was manually flying the aircraft, may have overcompensated for the effect of the wind during this turn in an attempt to establish on the localiser. Furthermore, the METAR for EIDW indicated a broken cloud layer at 900 ft which, during this phase of the approach, would have made visual contact with the airport environment challenging.

The FO described this phase of the approach as similar to being in ‘no man’s land’. This is understandable as the localiser and glideslope indexes would have displayed fly right and fly down indications respectively. Given that the FCU altitude was set at 2,000 ft, a discontinued approach may have been an option to recover the situation. However, it is likely that the Commander was becoming task-saturated, and the FO, in an attempt to recover the situation, suggested an orbit manoeuvre to the Commander, who agreed, following which the FO requested a left hand orbit from ATC. A right hand orbit was approved and the Aircraft commenced a steep turn to the right and over flew MAXEV at approximately 3,200 ft.

During this turn, a bank angle of 44 degrees was reached, which would have required lateral pressure on the sidestick without automatic pitch trim. The FO, who was the Pilot Monitoring, alerted the Commander to the excessive bank angle which was subsequently corrected. As the Aircraft turned on to an easterly heading, it was in OP DES mode with idle thrust commanded and the FD bars were engaged; therefore, the FD would have given a pitch down command to maintain the target airspeed of 139 kt. However, this command was not followed and the airspeed decreased below this speed and towards the VLS. In response to this decrease in airspeed, the Commander, who was still manually flying the Aircraft, selected Conf 3 and Conf FULL, a task normally performed by the PM when requested by the PF. It is likely that the Commander was alarmed by this speed decay and to expedite flap extension, performed this task himself. However, when a PF also performs the functions of the PM, it can have a negative impact on effective Crew Resource Management and may leave the other flight crew member with a sense of being uninvolved in the operation of the flight.

The airspeed continued to decrease and dropped below VLS. Consequently, in accordance with system logic, the autoflight low speed protection activated, the current flight guidance modes and the FD bars were removed, and the autothrust reverted to speed mode to recover the target speed. At approximately the same time and in response to the speed decay, the Commander moved the thrust levers to the TOGA position and the FDs re-engaged with SRS and GA TRK guidance. The autothrust was disengaged, the landing gear was selected up and the flaps were retracted to Conf 3. The FO requested a level off altitude of 3,500 ft, which was approved by ATC. The Aircraft continued to climb and the airspeed reduced below the VLS again, before it increased. The Aircraft climbed to a maximum altitude of 4,200 ft before it descended again. The Flight Crew was provided with radar vectors for a second ILS approach, and touchdown occurred on RWY 28L at 14:11 hrs.

Human Factors

The Investigation notes the contents of the Manufacturer’s Golden Rules for Pilots and its emphasis on Fly, Navigate and Communicate. The PM must assist the PF and actively monitor flight parameters, call out any excessive deviation, and resolve any uncertainty. The FO, who was the PM, maintained his situational awareness and was able to call out the excessive bank angle during the orbit manoeuvre.

The Investigation notes that the FCTM guidance on manual flight is for both pilots to agree on a course of action based on individual assessments and for crews to use the appropriate level of automation at all times. The optimum use of the autopilot helps flight crews with workload management and also relieves ‘the PF from routine handling tasks and thus allowing time and resources to enhance his/her situational awareness or for problem solving tasks’. The Commander stated in interview that not having the autopilot engaged may have ‘removed my SA [Situational Awareness]’. During interview, the FO stated that he may have suggested to the Commander that the autopilot was available, but the Aircraft continued to be flown manually. This decision to continue in manual flight was likely due to an incorrect perception that the auto flight system was not functioning correctly (speed reduction below VLS with autothrust engaged and FD disengagement).

Subsequent to the occurrence, the Operator published an FCI designed to make crews aware of issues associated with the conduct of visual orbits. The Operator stated that getting into a high and or fast situation may be because of an earlier loss of situational awareness and that trying to recover the situation ‘by conduct of an orbit may lead to a further degradation of the situation and situational awareness of the crew’. The Investigation also notes the Operator’s procedure for regaining the vertical profile is to request entry into a published hold or to request additional track miles from ATC.

Aircraft Upset

According to the Aircraft Manufacturer, ‘An aircraft upset may involve pitch and/or bank angle divergences and may lead to inappropriate airspeeds for the conditions.’ A normal turn on the Aircraft type is a bank angle of less than 33 degrees. In this case, a bank angle of 44 degrees was reached. Furthermore, the Aircraft experienced two events in which the airspeed reduced below the VLS and the Aircraft’s speed protection system activated; therefore, the occurrence is classified as an aircraft upset. The Investigation notes that these divergences from the desired Aircraft state were unintentional and the situation was recovered through pilot intervention.

Related Flight: EI493, Aer Lingus News