FO OF A319 MAKES NUMEROUS AUTOFLT MANAGEMENT AND MENTAL ERRORS ON APCH CULMINATING IN MANUALLY DESCENDING WHILE THE AUTOTHRUST SYSTEM WENT TO CLIMB THRUST AS PROGRAMMED. FLAP OVERSPEED RESULTS.
Synopsis
FO OF A319 MAKES NUMEROUS AUTOFLT MANAGEMENT AND MENTAL ERRORS ON APCH CULMINATING IN MANUALLY DESCENDING WHILE THE AUTOTHRUST SYSTEM WENT TO CLIMB THRUST AS PROGRAMMED. FLAP OVERSPEED RESULTS.
Narrative
I WAS THE PF. ARR AND DSCNT WENT SMOOTHLY AS PLANNED. APCH CTL HAD US ON A VECTOR FOR THE ILS RWY 22L. WHEN APCH ASKED US IF WE HAD THE ARPT IN SIGHT; I LOOKED UP AND SAW A RWY WHERE I EXPECTED IT TO BE WITH THE APPROPRIATE APCH LIGHTING SYS AND I GAVE THE CAPT A THUMBS-UP. HE TOLD ATC THAT WE HAD THE ARPT IN SIGHT AND THEY CLRED US FOR A VISUAL APCH. THE CAPT ASKED ME IF I WANTED TO GO DIRECT ROUGE INTXN (7.5 MI OUT ON THE RWY 22L LOC) AND I INDICATED THAT I DID. ONCE WE WERE SET UP DIRECT ROUGE; OUR AUTOMATION MODES WERE: THR IDLE (180 KTS SELECTED) OP DES (2300 FT SELECTED); AND NAV (DIRECT ROUGE). I ALSO ARMED APCH MODE AND ACTIVATED AUTOPLT #1 (ARMED LOC AND GS MODES). SOMEWHERE AROUND THIS TIME; WE HAD SELECTED FLAPS 1 DEG. A FEW SECONDS LATER; IT APPEARED TO ME THAT WE WERE APCHING THE CTRLINE TO FINAL APCH TO THE RWY. SINCE I WAS AWARE THAT DTW WAS CONDUCTING SIMULTANEOUS APCHS TO PARALLEL RWYS AND ALSO THAT THE AIRBUS IS CAPABLE OF OVERSHOOTING THE COURSE CTRLINE; I PULLED THE HDG KNOB AND BEGAN TURNING THE ACFT TOWARD THE RWY TO HELP PREVENT A POSSIBLE OVERSHOOT. SHORTLY THEREAFTER; THE CAPT ASKED 'WHERE ARE YOU GOING?' I LOOKED DOWN AT MY NAV DISPLAY AND REALIZED THAT WE WERE STILL SEVERAL MI FROM OUR RWY CTRLINE; AND WHAT I HAD THOUGHT WAS OUR RWY WAS IN FACT A RWY AT ANOTHER ARPT (WILLOW RUN) WHICH RAN ALMOST PARALLEL TO OUR RWY (LAW OF EXPECTATION). UPON REALIZING THIS; I SELECTED A HDG THAT WOULD TAKE US BACK TO INTERCEPT THE LOC TO OUR RWY; THIS TIME RIGHT ABOUT THE FAF (HULKA). AT THE END OF THIS MANEUVER; MY AUTOMATION MODES WERE: SPD (STILL 180 KTS); VS-700 (MODE REVERSION 2300 FT STILL ARMED); AND HDG WITH LOC AND GS STILL ARMED. NOW ON OUR WAY TO INTERCEPT THE TRUE RWY (A LITTLE SHAKEN BY THE EVENT); I SAW THAT WE WERE GOING TO INTERCEPT THE LOC JUST INSIDE THE HULKA FIX ABOVE THE GS; SO I ASKED FOR FLAPS 2 DEGS AND SPUN THE ALT KNOB TO A HIGHER ALT THAN WE WERE; THUS PREVENTING A LEVELOFF BEFORE INTERCEPTING THE GS. I BELIEVE IT WAS RIGHT ABOUT THIS POINT THAT I PERFORMED THE MOST INEXPLICABLE ERROR: INSTEAD OF SELECTING A HIGHER VS (STILL AT -700); I PULLED THE ALT KNOB. I BELIEVE AT THE TIME THAT I HAD FORGOTTEN THAT I HAD ALREADY SELECTED A HIGHER ALT. I WAS EXPECTING THE AUTOMATION TO GO TO THR IDLE; OP DES. IN FACT; IT WENT TO THR CLB; OP CLB. AT PRECISELY THIS TIME; THE ACFT FLEW THROUGH THE LOC COURSE AND FELT LIKE IT WAS LEVELING OFF; SO INSTEAD OF FIGHTING WITH THE FCU; I SIMPLY DISCONNECTED THE AUTOPLT AND BEGAN MANUALLY NAVING THE ACFT TO THE RWY. THE CAPT ASKED ME 'WHAT ARE YOU DOING NOW?' (COMPLETELY UNDERSTANDABLE) TO WHICH I REPLIED 'I'M JUST GONNA FLY IT TO THE RWY.' LOOKING BACK; I GUESS I DIDN'T UNDERSTAND WHAT HIS CONCERN WAS; BUT NOW I KNOW THAT WHAT WE WERE DOING WAS DSNDING SOMEWHAT RAPIDLY WHILE THE AUTOTHRUST WAS STILL IN THR CLB MODE. ALMOST IMMEDIATELY; WE WERE GETTING THE CONTINUOUS REPETITIVE CHIME; FLASHING MASTER WARNING LIGHTS; AND THE AIRSPD WAS WELL INTO THE BARBER POLE. IT WAS ONLY THROUGH THE CAPT'S QUICK THINKING IN SELECTING A LOWER AIRSPD (130 KTS) THAT WE DIDN'T GO FURTHER INTO THE OVERSPEED REGIME. SHORTLY THEREAFTER; WE MANAGED TO GET THE ACFT ON PROFILE AND LANDED WITHOUT FURTHER INCIDENT. THE ACFT WAS WRITTEN UP AND INSPECTED. THE NEXT DAY; THE MECH WHO PERFORMED THE INSPECTION TOLD ME THAT HE HAD FOUND NO DAMAGE RESULTING FROM THE INCIDENT. I CAN EASILY SAY THAT THIS HAS BEEN THE MOST EMBARRASSING MOMENT IN MY SHORT YET REWARDING CAREER AT ACR X. ALL I CAN SAY IS THAT A LONG DAY OF COMMUTING; TAKING A BADGE TEST; RUNNING ERRANDS; AND HAVING MANY THINGS ON MY MIND CONSPIRED AGAINST ME TO MAKE A STRING OF RUDIMENTARY AND EASILY AVOIDABLE MISTAKES; RESULTING IN THE EXCEEDANCE OF AN ACFT LIMITATION. I TAKE 100% RESPONSIBILITY IN THIS OCCURRENCE. IN THE DAYS (AND NIGHTS) FOLLOWING THIS EVENT; I HAVE THOUGHT OF MANY THINGS I COULD HAVE DONE TO HAVE PREVENTED THIS OCCURRENCE: 1) XCHK MY NAV DISPLAY. IF I HAD ONLY DONE THIS; THE ACFT WAS SET UP PERFECTLY TO NAV TO ROUGE; INTERCEPT THE LOC AND GS. ALL I WOULD HAVE HAD TO HAVE DONE WAS CONFIGURE THE ACFT. HAD I LOOKED AT MY NAV DISPLAY; I WOULD HAVE KNOWN THAT THE RWY AT WILLOW RUN WASN'T OURS AND NOT STARTED US DOWN THE PATH. 2) SET A HDG TO INTERCEPT THE LOC OUTSIDE THE MARKER. THE FAF (HULKA) IS THE LAST POINT ALONG THE LOC COURSE WHERE YOU KNOW THE ALT OF THE GS (2300 FT). IF I HAD SIMPLY GONE OUTSIDE OF HULKA; I WOULD HAVE KNOWN THAT AS LONG AS I MADE IT TO 2300 FT BEFORE HULKA; I WOULD INTERCEPT BOTH THE LOC AND GS THERE AND WOULD HAVE HAD PLENTY OF TIME TO CONFIGURE. 3) BE ABSOLUTELY POSITIVE WHAT THE RESULTS OF EACH ACTION WILL BE BEFORE I DO IT. IF I WOULD'VE TAKEN 1 SECOND TO CONSIDER WHAT WOULD HAPPEN WHEN I PULLED THE ALT KNOB; I WOULD HAVE DONE SOMETHING DIFFERENT; SUCH AS SELECTING A HIGHER VERT SPD; DISCONNECTING THE AUTOPLT; OR EVEN GOING AROUND WHEN THE APCH STARTED GETTING UGLY. 4) PAY ATTN TO MY FMA'S. WHEN I PULLED HDG TO LINE UP ON WILLOW RUN; I KNEW THAT VERT MODE WOULD REVERT TO VERT SPD AT WHATEVER OUR VERT SPD WAS AT THE TIME (-700). IF I HAD LOOKED AT MY FMA'S IMMEDIATELY AFTER WRONGLY PULLING THE ALT SELECTOR; I WOULD'VE SEEN THE THR CLB OP CLB AND KNOWN THAT WAS NOT WHAT WE WANTED AND REACTED ACCORDINGLY (FIX FCU OR DISCONNECT AUTOPLT AND AUTOTHROTTLES). UNFORTUNATELY; AT THE TIME; I WAS FIXATED OUTSIDE THE COCKPIT AND ON THE RWY.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.