ASN Wikibase Occurrence # 166254
Last updated: 22 February 2017
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Narrative:The Air Canada Rouge Airbus A319 was operating as flight AC1804 from Toronto, Canada, to Montego Bay, Jamaica, with 131 passengers and 6 crew members on board. At approximately 14 minutes before touchdown, the aircraft was cleared for a non-precision approach to runway 07 at the Montego Bay Airport. The approach became unstable and the aircraft touched down hard, with a vertical load factor of 3.12g. The landing subjected the main landing gear to very high loading. The aircraft was subsequently inspected and the main landing gear shock absorbers were replaced as a precaution.
|Owner/operator:||Air Canada Rouge|
|C/n / msn:|| 697|
|Fatalities:||Fatalities: 0 / Occupants: 137|
|Airplane damage:|| Minor|
|Location:||Montego Bay-Sangster International Airport (MBK/MJKS) -
|Nature:||International Scheduled Passenger|
|Departure airport:||Toronto Pearson International Airport (YYZ/CYYZ)|
|Destination airport:||Montego Bay-Sangster International Airport (MBK/MJKS)|
|Investigating agency: ||Transportation Safety Board (TSB) - Canada |
Findings as to causes and contributing factors
1. The flight crew's selection of a higher target speed before the final approach fix resulted in an increased-thrust and high-airspeed condition. This condition contributed to the crew's confusion and misunderstanding of what the aircraft was doing, and resulted in their mismanagement of the configuration sequence.
2. The inadvertent flight control unit selection resulted in a second high-airspeed and increased-thrust condition. The aircraft deviated above the approach profile between the final approach fix and the 500-foot arrival gate, and a flaps-3 overspeed alarm sounded. In response, the pilot flying disengaged the autothrust.
3. The timing of the operational discussion as the aircraft descended past the 500-foot arrival gate may have diverted the attention of the pilot monitoring from his duties, causing an essential task (a “Stable” call) to be missed. As a result, the flight crew missed an opportunity to recognize an unstable approach.
4. The pilot flying made the “Stable” call when the aircraft was not stabilized, as its airspeed was high, the landing checks were incomplete, and the thrust was at idle. As a result, the flight crew continued an unstable approach.
5. Management of the aircraft's energy condition diverted the flight crew's attention from monitoring and controlling airspeed during the descent. As a result, the aircraft passed the final approach fix arrival gate at a high airspeed and with a flaps configuration that was not in accordance with the standard operating procedures.
6. While on short final approach, the airspeed decayed well below final approach speed (VAPP), placing the aircraft in an undesired aircraft state at a very low altitude.
7. When the flight crew recognized the undesired aircraft state, the late addition of engine power was insufficient to arrest the descent rate, resulting in a hard landing.
8. The flight crew did not adhere to the standard operating procedures, which required the monitoring of all available parameters during approach and landing. With both flight crew members focused on the airspeed conditions and aircraft configuration delays, the instability of the approach was not identified and a go-around was not conducted.
9. Air Canada Rouge did not provide flight crews with simulator training in recognizing an unstable approach leading to a missed approach. As a result, the occurrence flight crew did not recognize the multiple deviations in airspeed and thrust or the deficiencies in coordination and communication, and they continued the approach well beyond the stabilization gates.
10. Air Canada Rouge did not include autothrust-off approach scenarios in each recurrent simulator training module, and flight crews routinely fly with the automation on. As a result, the occurrence flight crew was not fully proficient in autothrust-off approaches, including management of the automation.
Findings as to risk
1. If flight crews do not conduct thorough briefings, including missed-approach briefings, they may not have a common action plan or set priorities, resulting in reduced crew coordination, which might compromise the safety of flight operations.
2. If flight crews are distracted by other operational and non-operational activities and do not follow standard operating procedures, critical tasks associated with flying the aircraft may be delayed or missed.
3. If flight crews do not adhere to standard procedures and best practices that facilitate the monitoring of stabilized approach criteria and excessive parameter deviations, there is a risk that threats, errors, and undesired aircraft states will be mismanaged.
4. If an air operator's standard operating procedures (SOP) are not consistent with its stable approach policy, there is a risk that flight crews will continue an approach while deviating from the SOPs, resulting in an unstable approach.
5. If standards for flight crew training in relation to automation proficiency (Commercial Air Service Standards 725.124) are not explicit with regard to frequency, there is a risk that air operators will exclude critical elements from recurrent training modules and that flight crews might not be proficient in all levels of automation.
Official accident investigation report
|investigating agency: ||Transportation Safety Board (TSB) - Canada |
|report status: ||Final|
|report number: ||A14F0065|
|report released:||9 January 2017|
|duration of investigation: ||2 years and 8 months|
|download report: ||
||Updated [Total fatalities, Location, Destination airport, Source, Damage, Narrative]|
||Updated [Narrative, Photo, ]|