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speed 210 kt was exceeded. At this moment the Captain made a control input on the side stick
forward to 11º, which resulted in further increase in the nose-down pitch, the descent rate and the
indicated airspeed. A control input on the side stick that resulted in an increase in right bank was
also recorded. Simultaneously with the control inputs on the side stick, the pedals were moved to
a position of -3.4º…-4º, and the lateral G went up 0.02…0.04.
At 22:12:47 the GPWS Alarm sounded, and at the same time the co-pilot’s phrase: “Level off”
was recorded. Altitude decreased to 1358 ft (414 m), the indicated airspeed increased to 211 kt
(392 km/h), the pitch angle decreased to 11…12º nose down, and the roll angle increased to
37…39º. The aircraft descent rate was -20…-22 m/s. At this moment the co-pilot intervened and
moved the side stick to the left stop position (20º) to counter the increasing right bank, while the
Captain continued making control inputs to increase the right bank. Apparently the co-pilot was
trying to counter the bank only. However, while moving the side stick sideways to the stop
position, he had made forward control inputs on it as well (a “parasitic” input produced by high
sideward forces applied to the side stick in the stop position) (Attachment 2, Fig. 4,7 and 8).
While intervening, the co-pilot had not pressed the take-over pushbutton, therefore both pilots’
control inputs were added and averaged. Such dual piloting is prohibited by the A320 FCOM. At
that time the actions of the two pilots were not coordinated. The Captain twice moved the side
stick half-way backwards , possibly, reacting to the EGPWS, but at the same time the co-pilot
was inadvertently making nose-down inputs, which might have led the Captain to believe that the
aircraft response to the control inputs in the pitch channel was not adequate.
48
Note: During the onset and development of the abnormal situation the co-pilot did not comply
with the duties of non-flying pilot during a go-around phase as stipulated in the FCOM.
In particular, he did not inform the Captain of the pitch angle values below 10 degrees
pitch up and of the descent rate, when it developed.
Note: The DUAL INPUT warning was not activated because of its lower priority compared to
the EGPWS warning.
Note: As was shown by outcomes of experiments on the flight simulators and by the results of
mathematical simulations provided by Airbus specialists, after autopilot disengagement
and change-over to manual control, aircraft movement was entirely determined by
deflection of the control surfaces and the engine modes. Aerodynamic and thrust
performance of the aircraft corresponded to the characteristics of the aircraft type.
There were no external influences on the aircraft (wind shear, etc.)
The backward movement of the Captain’s side stick to -11º was accompanied by its sideways
movement to the right to -16º. At the same time the pedals were moved to -4.8º, and the lateral G
went up 0.1…0.11.
Neither of the pilots fully fulfilled the FCOM requirements for crew actions in case of
EGPWS activation stipulated in the QRH “EMERGENCY PROCEDURE” Section. Flying at
night or in difficult weather conditions requires an immediate response to this warning, in
particular to move the side stick backward and hold it in this position, as well as to set the takeoff
power mode. The crew’s attention might also have been distracted by a long 20-second
message from the controller regarding a change in the approach procedure, which was recorded
by the CVR along with the EGPWS and CRC warnings sounding in the background. The
controller sent the message in accordance with the controller’s operational manual, after the crew
contacted him.
It should be noted that in the course of the investigation of the accident to the A320 A40-EK that
occurred during go-around at Bahrain airport on 23 August 2000, the Investigation Commission
also noted inadequate actions by the Captain, who moved the side stick forward and held it there,
despite the EGPWS warning sounding for a long time. In that case the crew response to the CRC
warning that was sounding at the same time was also correct (flaps retraction).
At 22:12:49 the preset vertical speed became equal to 25.4 m/s. The change in the preset value
was connected with automatic activation of the VS MODE, with the autothrust switched to the
speed-hold mode. In the case where the autopilot is disengaged, the manual control disagrees
with the command bars and the aircraft speed reaches the VFE value plus 4 kt, the mode is
changed automatically in order to prevent
　
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