WHAT happened in this Airbus A350 Cockpit?! | French Bee flight 711

an airbus a350 is a final protein for runway two five in paris or lee airport the first officer is part of flying and he's just disconnected the autopilot getting ready for a nice manual approach when suddenly from out of nowhere this warning sounds in the cockpit go around windshield ahead the captain immediately calls for a go around and initially the first officer responds to this but very soon it becomes clear that something is not right as things are starting to go very wrong inside of this cockpit stay tuned a huge thank you to skillshare for sponsoring this video french b flight 711 was a flight scheduled to fly from san francisco in the united states over towards paris orly in france the flights took place on the 4th of february 2020 and on board the flight was 206 passengers 10 cabin crew and three flight crew members now the reason the three flight crew members was the flight was scheduled to be more than 11 hours long and in that case you need an augmenting pilot so that all pilots during the flight could take a period of rest of about three hours each the pilot flying was going to be the first officer for this league and he reported that he was feeling good he had slept well prior to the flight and during the flight he selected the middle slot for his in-flight rest which meant that he actually got to sleep for a full one and a half hours during that hour flight the first officer was a 45 year old male he had 8 600 hours of total time and 1 200 hours on the airbus a330 and airbus a350 together with him acting as pilot monitoring on this flight was the captain he is a 41 year old male with 8 000 hours of total time and 2 000 hours on the airbus a350 and interestingly enough the captain had actually done a simulator session earlier on where he had flown together with this first officer and they had practice incapacitation particularly during takeoff but that's just an interesting kind of tidbit to remember the relief pilot was a 50 year old female pilot and she was sitting on the jump seat when this all occurred but her actions during the incident is still going to be important the destination airport that the crew was flying into paris orly has three active runways but the two that is going to be interesting for this particular incident is runway two five that was used for a rival aircraft with an ils approach and run with two four which was used for departing traffic because of the way that the runways were situated it meant that if an aircraft was doing an approaching runway two five and then had to do a missed approach it would potentially come into conflict with departing traffic from runway two four and because of that the missed approach procedure was built to mitigate that threat so if you had to do a misapproach procedure from a two-five you had to go straight ahead to 700 feet but not turning before the missed approach point and at 700 feet you need to initiate a left hand turn with a maximum of 185 knots to roll out on heading 199 degrees at a maximum altitude of 2000 feet now 2000 feet is a fairly low missed approach altitude it means that if you do a go around higher up than your minimums there's going to be a lot of things that you have to do in a very short time span and that's going to become really important here the first part of this flight was completely normal and uneventful so we're not going to pay too much attention to that instead we're going to focus on the approach which is where the action happened about 30 minutes prior to their estimated landing the first officer started setting up and briefing for the approach and when he looked through the weather the weather looked fine there was a cloud layer at 4500 feet there was some towering cumulus in the area and there was a fairly moderate to occasional strong wind from a northwesterly direction but nothing that would indicate any kind of threats at least from the weather to this approach instead the crew initiated their descent everything was normal they were handed over eventually to orly tower and the first officer started flying the normal instrument landing system ils approached him for runway to five they broke through the clouds at about 4500 feet which would have meant that they would have seen the runway in front of them and because it was all nicely stabilized the first officer decided that he wanted to hand flight approach a little bit to get a little bit of uh practice which is good especially for long-haul crews that maybe not hand fly as much he disconnected the outer pilot at about 1400 feet and only four seconds after that a predictive windshield warning was heard in the cockpit go around windshear ahead windshear ahead this took the flight crew by complete surprise because there was nothing in the weather that would indicate that a predictive windshield warning was to be expected the problem with the predictive windshield warning is that that warning is taken from the weather radar system and in some cases wind blowing over large buildings for example can give rise to what we call spurious predictive windshield warnings and there's actually notes in the manuals about that and if the weather is good enough the crew have the right to disregard that okay a predictive windshield warning is very different from an active windshield warning which is when the ground proximity warning system tells the crew that they're actually in a wind shear but in this case the crew was startled by the warning and the captain immediately asked for a go around the first officer complied with the go around request from the captain he advanced the trust lever into the toga mode which gives full go around trust he started to pitch up because remember he was flying manually at this point and he also asked for go around flaps to be set the captain responded to this he called to our traffic control that they were going around air traffic control came back and said okay go around follow the standard go around procedure to 2000 feet now things are starting to happen in a quite rapid succession because they went around at about 1350 feet remember the goron altitude is only 2000 feet so it's only about 600 feet to climb the first officer reduced the climb from toga back to the soft goron trust instead a soft core on trust is a mode that is used when there is not an immediate need for a very high climb rate it makes the go around maneuver slower and softer for everyone involved and it's designed to put trust it gives about 2 000 feet per minute rate of climb this was something that the captain specifically asked for the first officer now pitches for about eight degrees pitch up following initially the flight director mode because the flight director is still indicating how he's supposed to fly even though he's flying manually but very quickly he starts drifting slightly towards the right of the indicated track and because the flight directors knows that they're supposed to level off at 2000 feet they very quickly start indicating that he needs to both start pitching down in order to capture 2000 feet and also he needs to bring the thrust levels back from the soft gora mode into what's called a cl mode which basically engages the outer throttle and facilitates a level off but this doesn't happen instead the pitch remains at about eight degrees nose up and the flight director has continued to show that he needs to pitch down immediately and he also needs to turn slightly to the left to follow the missed approach track but none of this is happening at the same time the captain is retracting the landing gear he is continuing to retract the flaps but he realizes that something is off because as the flight director goes into what's called altitude star mode which is basically it's altitude acquire mode the captain calls this out he calls out speed and alt star which is the fma reading at the time but it doesn't get any response from the first officer instead the aircraft continues to climb with a climb rate of about 1800 feet per minute and both the captain and the relief pilot realizes that at this rate they are going to bust through the uh 2000 feet misapproach altitude and they call that out to the first officer but he does not respond to anything of this he just continues to climb with the same pitch up and without making any adjustments to his track what is happening to the first officer right now is likely what we call a partial incapacitation and we're going to talk much more about that later on in this episode but it's most likely caused by the sudden onset of very high workload that came out of absolutely nowhere but he did not expect it and it causes him to freeze up and to not hear anything and not react to normal stimuli at times 17 000 the aircraft busts through 2 000 feet and continues to climb and as it climbs to 2200 feet the altitude warning comes on and it sounds continuously in the cockpit about 24 seconds later the aircraft reaches 2750 feet and here the first inputs on the first officer's side stick is noted he starts to level the aircraft off and at the same time as he's doing this the captain pulls on the altitude knob on the mode control panel now when it does that it sends a signal to the aircraft that it needs to engage in descent mode to descend back to the 2000 feet that has been set on the motor control panel and it also tells the same to the outer throttle which is now in the cl mode so this means that the trust is now going back towards idle the flight directors are indicating a left descending turn but since the first officer is still flying manually nothing of this is happening the aircraft is continuing straight ahead now the aircraft passes overhead the threshold from where to five and air traffic control calls them up and tells them to turn left heading 180 degrees the captain responds to that saying that they have climbed up to 3 000 feet but they're now descending down to 2 000 feet again and that they're turning left heading 180. air traffic control responds to that and said that yes you have deporting traffic at about four miles ahead at your one o'clock position so now there is traffic that is coming up and into their direct flight path the captain reaches up and inputs 180 degrees on the mode control panel the flight directors are now starting to indicate that left hand turn towards 180 degrees instead of following the initial missed approach procedure but once again the first officer is not doing anything he is sitting there and they're now flying straight towards that conflicting traffic this is where the captain decides to take controls this is about 52 seconds after the aircraft had flown past the missed approach altitude the captain says my controls and he input autopilot number one by doing so the aircraft starts to turn to follow the flight directors but as the captain is doing this the first officer without saying anything to anyone reaches over and pulls out the speed brake what this does is that vls the velocity lowest selectable which is a minimum speed on the airbus goes up to 188 knots and the aircraft is currently at 175 knots so this gives a speed speed speed warning in the cockpit this catches the captain completely out of surprise and he does what any pilot would do when they hear that kind of warning he puts the trust up to toga to get as much thrust as possible out of the engine and he starts inputting forward on his side stick when he does so the fact that he's increasing the thrust means that the speed brakes that were extended now automatically retract but since this speed brake lever is still out and the speed brakes are not out this causes a conflict in the computer and it generates a master caution warning which just adds to the workload of the captain also the fact that he is pitching forward on the side stick disconnects the outer pilot that he had just connected and it removes the flight director so he's now flying without flight directors and in a perceived low speed situation with a master caution warning ahead of him so you can imagine that the stress of the captain would be really high right now traffic control now once again calls them up and tells them to continue that turn onto heading 180 degrees to avoid the traffic but there's no response from the flight crew it's very likely that the captain is just inundated with the workload at this point the aircraft is now descending with a fairly high descent rate 2 200 feet per minute and at time 170 126 they once again crossed through their missed approach altitude of 2 000 feet this is also where they get into the closest proximity to the departing traffic from a 2-4 they get within 1.69 nautical miles and about 75 feet vertically and that triggers an stca a short-term conflict alert in the air traffic control tower but in the cockpit they're unaware of this it's not close enough for the tcas to issue a resolution advisory um it's just in the control tower that they realize how close these aircraft are to each other the captain undershoots the target altitude but about 150 feet and you can see that he is even putting on his side stick to try to level the aircraft off remember that he still doesn't have any flight directors so it's not flying very accurately at this point and throughout this maneuver the augmenting pilot that's sitting on the jump seat have been calling the flight crew to please engage the autopilot to try to reduce the workload and to get more help from the automatics it seems like at this point the first officer kind of wakes up a little bit from his paralysis because he clearly heard that the augmented pilot was asking for the autopilot to be engaged but because he is still not really fully in the situation he just reaches over and engages the autopilot number two without telling the captain that he's doing so the captain looks down on this fma and doesn't understand why all of a sudden an autopilot is engaged and the modes on the fma is saying that it's in vertical speed minus 650 feet per minute and also that the heading select has been engaged but not on 180 degrees that he had selected earlier but at the heading that they were when the autopilot was engaged up 228 degrees the captain now just reaches over and engages autopilot one again and then states very clearly in the cockpit everyone's silent i am the only one giving orders on the surface that might sound very harsh but if you think about it up until this point there's been complete pandemonium in this cockpit there's been people pushing buttons that shouldn't have pulling levers and on several occasions the hands of both pilots have been crossing each other as they were pushing buttons on the motor control panel that has to stop and the way that the captain is doing this by making a clear order is kind of aimed at restoring order making sure that everyone knows who's flying and who's doing what and to kind of calm things down and get this aircraft back in under control again but that is doing this the aircraft is still descending and it reaches a minimum altitude of 1550 feet before the captain once again disconnects the autopilot but making inputs on his side stick this time to get the aircraft to start climbing adding trust again the aircraft is climbing back up and pulling the altitude knob to reset the flight directors into a climb mode at this point he also calls that traffic control and tells them that he is indeed turning left heading 180 according to their instructions air traffic control responds with saying thank you for the information traffic is very close i suggest that you turn quickly and he responds to this air traffic control also tells him that he can continue to climb to 3 000 feet now there's no response once again from the captain when they cleared him for this so they call him again reminding him that he's clear to 3 000 feet this time he reads it back and during the climb the speed increases to 281 knots which is pretty fast and he has also a fairly high climb speed but this time he levels off in time he brings the speed back to 220 knots and he gets the autopilot engaged once again and before i continue what happens after this here is a short word for my sponsor i also want to take a few seconds here to say a special thank you to the sponsor of this episode which is skillshare now i know that you are watching this because you are a curious person a lifelong learner someone who constantly wants to improve and understand the world around you better and in that case skillshare is definitely something that you should be checking out okay they have thousands of high quality video courses and pretty much anything that you can imagine a course that i'm using myself at the moment is five minutes creativity with jasmine cheyenne where she gives kind of hands-on tips on how to chisel out a few minutes to be creative every single day and it's something that i personally really need but there are also courses in you know storytelling creative photography or even how to use your own home simulator to improve and prepare before you start your private pilot license so if you think peter that sounds amazing well then the 1000 first of you guys who clicks on this link here below will get one month of premium skillshare absolutely for free so click the link and start exploring your curiosity today this whole sequence from when the aircraft got the predicted windshield warning until the aircraft was stabilized again at three thousand feet it took only four minutes okay i'm sure that it felt like an eternity for the crew that was involved as the crew had stabilized itself at 3 000 feet the first officer kind of got back into it again and he said that he felt fine and that he could resume the role of pilot monitoring to take the radio and the captain accepted that they went in and they did an uneventful landing on runway 2-5 after another eyeless approach but how come that something like this could happen in the first place what happened to the first officer and what can be done to make sure it doesn't happen again when the report of this incident came to the attention of the air incident investigators they realized quite quickly that this was a very serious incident you had several altitude busts which is defined to when an aircraft depart from its cleared altitude with more than 300 feet on top of that potential piloting capacitation and a air prox to another traffic and low speed alert so they started looking into what had led up to this how come that it went this far and they divided it into the role of the captain the role of the first officer but also the role of the airport now when it came to the first officer he said that he didn't feel fatigued or anything but that he was extremely surprised when the predictive windshield warning occurred and that when he started the go around maneuver he he kind of well into something that felt like slow motion he didn't hear the call outs or the warnings from neither the aircraft or his colleagues and everything was kind of like in a daze until after the actual incident was almost over he had no recollection of pulling the speed brake lever or why he engaged the second autopilot without telling his colleague but why would the first officer react this way because of a go around i mean he would have briefed it about 40 minutes earlier in his approach briefing and isn't this something that pilots should be ready to take on at any given point well here is where some statistics about go around is actually quite important so a go around happens typically between two to four times every 1000 flights and what that means is that for a medium haul pilot like myself that equates to about one go around per year but for a long haul pilot that means that he or she will be doing a go-around maybe once every five to ten years so in reality it is an extremely unlikely thing that will happen especially when the weather is expected to be good so that would mean that the first officer in this case would have been seeing the runway straight ahead he's disconnected which by the way means that he's flying manually which is not something long-haul cruise would be doing that often anyway and all of a sudden from out of nowhere you have this predictive windshield warning that would have just thrown him out of his pace and then immediately the captain calls for a go around and in the back of his head he just remembers that this is a very complicated go around with an early turning altitude and with the speed restriction and stuff and all of this together can lead to something that we call a cognitive incapacitation that means that the overflow of workload and sudden onset of okay what's happening and i need to this i need to remember that just basically makes the brain temporarily shut down and i see this fairly often when i'm training new pilots in the simulator where the workload becomes too high or where you have a sudden onset of stress that they did not expect so this happens from time to time so this would fall under something called subtle incapacitation and a subtle incapacitation is really hard to diagnose for the remaining pilot because what we practice in the simulator generally is what we call a total incapacitation that's when the other pilot stops functioning completely either due to a heart attack for example or just fainting and of course when that happens it's very clear what you need to do right you need to take control of the aircraft you need to control of the all of the switches that see that they're in the right order you need to use automatics you need to call a mayday to air traffic control because you're now the only pilot working and you need to call in some cabin crew to help you and to try to help the pilot who is incapacitated so that's all very very clear but in this case the first officer was still there he was still inputting on the controls it just didn't make any sense what he was doing and in that case it becomes even more important that the remaining pilot take the control and calls that out very clearly and also in the case of the airbus uses the button on the side stick and holds that in for 40 seconds because that will give priority to whoever is holding in the button and it will also disengage the side stick on the opposite side and it's made for exactly this kind of circumstance now when it came to the captain he also said that he was very very surprised by the predictive windshield warning and when he called the goron he was also surprised by the fact that the first officer wasn't really following the procedure he was still inputting on the controls but there was definitely something wrong but because this was a subtle link excitation it was hard for him to diagnose it hence it took longer for him to take over the controls he said basically that it felt like a simulator scenario but in real life where you had pilot incapacitation altitude busts um traffic close by low speed alert everything happening at once the investigation team heard this and they came with a recommendation that startled training should be included in future pilot simulator training they know that the simulator training that pilots are doing at the moment even though it's varied most pilots kind of know what's going to happen so it would be very beneficial to introduce a startle factor at some point during the training program so that the pilots would know how they react when something like that happened and also get guidance on how to do it better in the future they also refer to what's known as the airbus golden rules which is if you find yourself in a situation like this one fly the aircraft aviate navigate communicate two use autopilot at an appropriate level to give a little bit of support three always know what your fma is telling you you know understand your fma and three take action if things are not going as expected on top of this the investigation team also went into paris orly and had a look at the missed approach procedure because of the very low level of altitude and the complexity of having to level off at a low altitude while you were most likely in a turn at lower than normal speed and they gave a recommendation to look at the feasibility of increasing the goron altitude from 2000 feet to 3 000 feet to make that go around just a little bit more user friendly for the pilots and that's something that i full-heartedly agree with another thing that the investigation team thought might be a good idea to implement is to maybe do a bit of a short recap of the approach briefing just prior to actually intercepting the localizer and glide slope so to do kind of okay so we're coming in here now in case we have to go around remember that it's just straight ahead 700 feet left turn 185 not to climb to 2000 feet which by the way is a really low level off so be ready for that something quick and concise like that would probably just kind of recap it for both pilots so that they're aware of it and also remind them that a go-around is a possibility in any approach that you do even if the weather looks like it's really good now to answer the question that i know undoubtedly would come did these pilots receive any reprimands did they lose their jobs are they still flying the answer to that is i don't know and my guess would be that they're probably still flying after a little bit of retraining potentially the reason i don't know is because that's not given in the final report okay the reason that a incident final report like this is being issued is so that we the pilots out there can learn from it that we can see what other people have done and the investigation team can see if there's any way to get to the root cause of what caused this and fix it so that the flying becomes even safer than it already is that's everything that the investigation team want to do and that's also what i want to do with these videos now if you want to see a video about a 737 that ended up flying through a brick wall then check out the video up here i would also love to hear your comments what what you would have done differently if you were in the captain's position put that into the comments below remember the acronym class and have an absolutely fantastic day bye-bye

Channel: Mentour Pilot

Views: 1,321,986

Keywords: French Bee, Airbus, Airbus A350, Paris Orly Airport, Aircraft incident, aircraft accident investigation, aircraft accident documentary, aircraft accident investigation video, aircraft accidents due to human error, aircraft accidents 2021, mentour pilot 737 max, mentour pilot crash, air crash investigation 2021, air crash investigation, Pilot life, Go around, Pilot incapacitation, French Bee 711, French Bee flight, french bee flight 711, flight report french bee

Id: LAtcrdJqJDc

Length: 26min 33sec (1593 seconds)

Published: Sat Oct 02 2021