Incident Overview

Date: Wednesday 1 October 2014
Aircraft Type: Embraer ERJ 190-100 STD (ERJ-190STD)
Owner/operator: KLM Cityhopper
Registration Number: PH-EZV
Location: Amsterdam-Schiphol International Airport (AMS) – ÿ Netherlands
Phase of Flight: Landing
Status: Minor, repaired
Casualties: Fatalities: 0 / Occupants: 90
Component Affected: The Embraer 190 aircraft’s flight control system, specifically the autopilot and the flight management system (FMS) which were involved in the automated landing procedure. The pilot?s actions, including the lack of a flare and the sustained descent rate, directly impacted the aircraft?s trajectory and landing characteristics.The Embraer 190 aircraft’s flight control system, specifically the autopilot and the flight management system (FMS) which were involved in the automated landing procedure. The pilot?s actions, including the lack of a flare and the sustained descent rate, directly impacted the aircraft?s trajectory and landing characteristics.
Investigating Agency: Dutch Safety BoardDutch Safety Board
Category: Accident
The flight from Prague experienced a significant and unexpected landing due to a misinterpretation of the flight control system during an ILS CAT I approach. The pilots, operating an Embraer 190, initiated a pre-planned automated landing procedure, which was subsequently overridden by a critical error. The initial briefing emphasized a controlled automated landing, but the pilot?s actions ? including a lack of flare, a sustained descent rate, and a failure to react to potential issues ? led to a hard landing. The crew?s reliance on FMA indications, rather than a genuine assessment of the aircraft?s configuration, contributed to the error. The incident highlights a critical failure in situational awareness and the potential for automated systems to deviate from planned procedures, especially in complex atmospheric conditions.The flight from Prague experienced a significant and unexpected landing due to a misinterpretation of the flight control system during an ILS CAT I approach. The pilots, operating an Embraer 190, initiated a pre-planned automated landing procedure, which was subsequently overridden by a critical error. The initial briefing emphasized a controlled automated landing, but the pilot?s actions ? including a lack of flare, a sustained descent rate, and a failure to react to potential issues ? led to a hard landing. The crew?s reliance on FMA indications, rather than a genuine assessment of the aircraft?s configuration, contributed to the error. The incident highlights a critical failure in situational awareness and the potential for automated systems to deviate from planned procedures, especially in complex atmospheric conditions.

Description

The flight departed from Prague at 06:20 hours, five minutes before the planned departure time. According to the crew nothing of note occurred during the take-off, climb or cruise flight. According to the captain, approach and landing at Schiphol Airport were prepared prior to top of descent. At that time the current weather at Schiphol Airport had been received via ATIS. The weather indicated the need to perform an ILS CAT I approach. The captain stated that the airplane was prepared for an ILS CAT I approach followed by an automatic landing. This procedure is seldom flown in operational practice and was therefore comprehensively discussed by the two pilots prior to the descent. Both pilots stated that this briefing was clear and that there was no need to consult the manuals. The first officer stated that during the briefing it was emphasised that this would be the first ILS CAT I approach followed by an automatic landing in limited visibility conditions for both pilots since completing conversion training on the Embraer 190. While descending through FL160, the flight crew began programming the FMS in preparation for an approach and landing on runway 36R. Having contacted the Schiphol Approach controller, the pilot flying flew the airplane to final approach based on radar vectors. The autopilot was set to follow the final approach path and the speed was controlled by autothrottle. While the airplane was flying on the final approach course and upon intercepting the glide slope, the landing gear was lowered and flaps were set to position 3. At 1400 feet, the flaps were set to the FULL position. At 1100 feet, speed was reduced to the calculated approach speed of 124 knots. At 1000 feet the airplane was prepared for landing on runway 36R. The crew stated that no incorrect or abnormal indications about the aeroplane’s configuration were observed during the final approach. The crew assumed that the airplane was correctly configured for the intended automatic landing. The captain stated that he saw the runway from a distance of approximately 4 NM (7.4 kilometres). At that time the airplane was flying at an altitude of approximately 1200 feet. The first officer, in turn, stated that he could see the runway before the aircraft had passed an altitude of more than 500 feet. At that time the airplane was flying slightly to the left of the final approach path. Soon after, this was corrected by the autopilot. At low altitude, the first officer again noticed a slight leftward displacement. The captain stated that at approximately 50 feet above the runway he noticed that the airplane was continuing to fly towards the runway at a constant rate of descent and did not perform a flare. The aeroplane’s pitch remained at a constant 1.6 degrees above the horizon. In an attempt to reduce the aeroplane’s rate of descent the captain pulled back on the control column at a low altitude. The autopilot disengaged at a height less than 9 feet (3 metres) above the runway. The tractive force on the control column at that moment was twice as high as during a normal manual landing. The airplane made a hard landing. After the main landing gear touched the ground the aeroplane’s pitch increased further to 8.6 degrees before the nose wheel was landed. The first officer stated that he was concerned that the airplane had sustained damage as a result of how hard the landing was. Therefore, while rolling-out on the runway he asked the captain if he could still steer the aeroplane; the Captain replied in the affirmative. After the landing the Captain informed the passengers and taxied to the aircraft stand. After the flight arrived at the aircraft stand and the engines were shut down, the central maintenance computer on board the Embraer 190 printed a warning that the airplane had touched down with a vertical acceleration that was 2.78 g. Engineering personnel were informed about the hard landing so that the airplane could be inspected. The inspection by engineering personnel revealed that the airplane had been damaged. An operating rod of the left-hand main landing gear door was damaged and an operating rod of the innermost right-hand wing flap was bent. CONCLUSIONS: The crew were incorrectly under the impression that they had configured the aircraft for an automatic landing. The indications of the automatic pilot did not lead the pilots to suspect that the aircraft was actually configured for a manual landing. The FMA indications that they saw during the approach were what they were used to seeing. Moreover, the aircraft was in a valid configuration, which meant no error messages were generated. As a result, both pilots had no reason to think that the aircraft was not flying in the correct mode for an ILS Category I approach followed by an automatic landing. The aircraft did not perform a landing flare and made a hard landing. The fact that the Cockpit Voice Recorder was no longer available has had adverse effects on reconstructing events and gaining insight into the crew’s considerations prior to the hard landing. The crew’s recollections of the incident have faded and/or may have been influenced by more recent flight experiences. The procedures for reporting incidents described in the airline’s operations manual leave room for interpretation regarding which incidents should be reported and what follow-up actions are required. This results in the loss of important sources of information for the investigation of incidents.

Primary Cause

Incorrect interpretation of the flight control system and a failure to adequately react to the pilot?s overridden automation, leading to a hard landing.Incorrect interpretation of the flight control system and a failure to adequately react to the pilot?s overridden automation, leading to a hard landing.

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