Created Friday, Aug 27th 2021 17:33Z, last updated Friday, Aug 27th 2021 17:33Z
An Orange2fly Airbus A320-200 on behalf of SalamAir, registration SX-ODS performing flight
OV-104 from Dubai (United Arab Emirates) to Muscat (Oman), was on approach to Muscat's runway 26R in the right hand turn to final while descending through about 1840 feet AGL, when the captain, pilot flying, selected idle thrust, however, autothrust disconnected. On final the captain handed control of the aircraft to the first officer. With the autothrust remaining disconnected the aircraft's speed reduced to 116 KIAS at 290 feet AGL, at which point Alpha Floor activated, almost simultaneously TOGA was selected. The aircraft continued to descend to 210 feet AGL before climbing again. The captain took control again and continued the approach for a safe landing.
On Nov 21st 2019 Greece's AAIASB reported the occurrence was rated a serious incident and is being investigated by the AAIASB.
In 2021 the AAIASB released their final report concluding the probable causes of the serious incident were:
Root Cause(s)
- Poor CRM on the part of both Pilots is the root cause.
- Non-complying with SOP’s on all phases of the initial and final approach and verbal confirmation from both Pilots.
- The handover of controls below 1000 ft without the a/c being fully stabilized (IDLE THRUST).
- CM2, as testified, not being trained to control the speed with Auto Thrust disconnected.
Contributing Factors
Loss of situation awareness is the main contributing factor.
No or poor CRM as CRM encompasses a wide range of knowledge, skills and attitudes including, communication, situational awareness, problem solving, decision making and teamwork. CRM is concerned with the cognitive and interpersonal skills to manage the flight within an organised system. Cognitive skills are defined as the mental process used for gaining and maintaining situational awareness for solving problems and for making / taking decision.
The captain (13,522 hours total, 73 hours on type) was pilot monitoring, the first officer (1,489 hours total, 328 hours on type) pilot flying.
The AAIASB analysed:
At the end of initial approach, being radar vectored, at 2560 ft and IAS 196 kts Flaps 1 was selected. At 2260 ft IAS 186kts the Commander disconnected the Auto pilot and took over control of the Aircraft.
Final Approach
At 1840 ft turning right on final for RW 26R the Commander selected idle thrust and thus the Auto Thrust was disconnected.
At 1810 ft the landing gear was selected down.
At 1470 ft IAS 182kts Flaps 2 was selected.
At 1080 ft on final on the ILS flaps 3 was selected at 167 kts.
At 1000ft IAS 154kts full flaps was selected.
At 930ft IAS 144kts the control of the Aircraft was handed over to the F/O.
Thereafter with the thrust levers at idle and auto thrust disconnected:
At 800 ft (800 RA) with IAS 142 kts (VAPP + 8), V/S - 1080ft/min on G/S on LOC. Speed trend Decreasing.
At 700 ft (700 RA) with IAS 138 kts (VAPP + 4), V/S -1080ft/min on G.S. on LOC. Speed trend Decreasing.
At 600 ft (600 RA) with IAS 137 kts (VAPP + 3), V/S -900ft/min 1dot below G/S on LOC. Speed trend Decreasing.
At 500 ft (500 RA) with IAS 130 kts (VAPP - 4), V/S -720ft/min 1 dot below G/S ½ dot right of LOC. Speed trend Decreasing.
At 400 ft (377 RA) with IAS 117 kts (VAPP – 17), V/S - 840ft/min 1 dot below G/S ½ dot right of LOC. Speed trend Decreasing.
At 300 ft (282 RA) with IAS 116 kts (VAPP – 18), V/S -1300ft/min full scale deflection below G/S ½ dot right of LOC.
At 290 ft (256 RA) with IAS 116 kts (VAPP – 18), V/S - 1300ft/min. TOGA thrust was applied.
Minimum recorded altitude was 210 ft and pitch at 14.77° up. At that time ALPHA FLOOR was activated and FMA was reading TOGA SRS GA TRK. The initial pitch up is recorded with the righthand side stick and the aircraft started climbing and the speed picking up. The CM1 intervened on his side stick at 240 ft (162 RA) IAS 127 kts (DUAL SIDE STICK ACTIVATED) the Aircraft levelled off and the thrust went back to idle with indication 1 dot below G/S and on the LOC.
Landing
The threshold was crossed at 70 ft and a normal landing was performed by the Commander on RW 26R with no further events reported or recorded.
Landing roll
No events reported or recorded.
Related Flight:
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