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ASN Wikibase Occurrence # 201846
Last updated: 12 December 2017
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Date:15-MAY-2015
Time:01:37 LT
Type:Silhouette image of generic A319 model; specific model in this crash may look slightly different
Airbus A319-132
Owner/operator:Skytraders
Registration: VH-VCJ
C/n / msn: 1880
Fatalities:Fatalities: 0 / Occupants: 23
Other fatalities:0
Airplane damage: None
Category:Serious incident
Location:25 KM from Melbourne-Tullamarine Airport, VIC (MEL/YMML) -   Australia
Phase: Approach
Nature:Domestic Non Scheduled Passenger
Departure airport:Perth Airport, WA (PER/YPPH)
Destination airport:Melbourne-Tullamarine Airport, VIC (MEL/YMML)
Investigating agency: ATSB
Narrative:
An Airbus A319 aircraft, registered VH‑VCJ and operated by Skytraders Pty Ltd, was positioning to commence an approach to runway 16 at Melbourne Airport. Following the receipt of a clearance to descend the aircraft to 3,000 ft, the pilot flying (PF) made a number of autoflight mode selections. These mode selections led to the autothrust system disengaging and the engines entering the thrust lock condition. The PF’s actions to correct the condition resulted in an unexpected increase in thrust.

In response to the thrust increase, the PF made a number of pitch-down inputs and retarded the thrust levers. The pitch-down inputs, when combined with the increased thrust, resulted in the aircraft developing a high rate of descent with an accelerating airspeed. The aircraft descended below the cleared altitude and a Terrain Avoidance and Warning System (TAWS) alert activated. The PF responded to the alert by declaring an intent to ‘go around’ and advanced the thrust levers to full power. When the engines responded with increased power, the PF again reacted with pitch-down inputs. A further two TAWS alerts activated before the PF reversed the descending flight path and started to climb the aircraft.

Contributing factors
- The pilot flying inadvertently selected the EXPED pushbutton instead of the APPR pushbutton, and, in an attempt to correct the error, pressed the A/THR pushbutton, creating a thrust lock condition.
- In attempting to remove the thrust lock condition, the pilot flying pressed the instinctive disconnect pushbutton but did not move the thrust levers to match the locked thrust setting. As the thrust was locked at idle while the thrust levers were set to climb thrust, this resulted in an unexpected, significant thrust increase.
- The pilot flying likely experienced pitch-up illusions during two rapid thrust increases and responded to these illusions with pitch-down sidestick input.
- Pitch-down inputs by the pilot flying, combined with a very high thrust setting, resulted in a very high rate of descent with rapidly increasing airspeed. This led to the breach of the cleared minimum descent altitude, as well as triggering a number of Enhanced Ground Proximity Warning System alerts.
- The rapidly changing aircraft state led to the crew experiencing a high workload. This was likely to have limited their capacity to identify mode changes and to respond to the aircraft’s undesired high airspeed and rate of descent.
- The pilot monitoring’s ability to identify and influence the rapidly changing situation was likely affected by the non-routine actions of the pilot flying, the reduced communication between flight crew and an apparent focus on the flap speed exceedance as the aircraft started to accelerate.

Sources:

https://www.atsb.gov.au/media/5773700/ao-2015-048_final.pdf

Accident investigation:
cover
Investigating agency: ATSB
Status: Investigation completed
Duration: 2 years and 6 months
Accident number: AO-2015-048
Download report: Final report

Images:


Revision history:

Date/timeContributorUpdates
25-Nov-2017 19:46 harro Added
25-Nov-2017 19:48 harro Updated [Source]

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