The Airbus safety magazine

#37

Safety
first
Safety first, #37 January 2024. Safety first is
published by Airbus S.A.S. - 1, rond point Maurice
Bellonte - 31707 Blagnac Cedex/France.
Editor: Yannick Malinge, Chief Product Safety Officer.
Concept Design by Airbus MultiMedia Studio
20232530. Reference: X00D16031905.
Photos by Airbus, P. Desrochers, G. Estragnat,
Safety first
The Airbus magazine contributing to the enhancement
A. Pecchi, Bockfilm - Bengt Lange, Master Films
- Jean-Baptiste Accariez, A. Domenjou and Kyle - of the safety of aircraft operations by increasing knowledge
stock.adobe.com. and communication on safety related topics.
This brochure is printed on Symbol Tatami White.
This paper is produced in factories that are accredited
EMAS and certi ed ISO 9001-14001, PEFC and
FSC CoC. It is produced using pulp that has been Safety first is published by the Product Safety department.
whitened without either chlorine or acid. The paper is
entirely recyclable and is produced from trees grown in It is a source of specialist safety information for the use
sustainable forest resources. of airlines who fly and maintain Airbus aircraft. It is also
The printing inks use organic pigments or minerals.
There is no use of basic dyes or dangerous metals
distributed to other selected organizations and is available
from the cadmium, lead, mercury or hexavalent on digital devices.
chromium group.
The printer, Art & Caractère (France 81500),
is engaged in a waste management and recycling Material for publication is obtained from multiple sources
programme for all resulting by-products. and includes selected information from the Airbus Flight
Safety Confidential Reporting System, incident and accident
investigation reports, system tests and fight tests. Material
is also obtained from sources within the airline industry,
studies and reports from government agencies and other
Editorial Team aviation sources.

Guillaume Javier Vanessa All articles in Safety first are presented for information
Estragnat Martinez Sadi
only and are not intended to replace ICAO guidelines,
standards or recommended practices, operator-mandated
requirements or technical orders. The contents do not
supersede any requirements mandated by the State of
Registry of the Operator’s aircraft or supersede or amend
Gwyneth Tim any Airbus type-specific AFM, AMM, FCOM, MMEL
Duggan Roach documentation or any other approved documentation.

Articles may be reprinted without permission, except where

copyright source is indicated, but with acknowledgement to
Airbus. Where Airbus is not the author, the contents of the
article do not necessarily reflect the views of Airbus, nor do
they indicate Company policy.
© Airbus S.A.S. 2024 – All rights reserved.
Proprietary documents.
By taking delivery of this Brochure Contributions, comments and feedback are welcome.
(hereafter “Brochure”), you accept on behalf of your Enquiries related to this publication should be addressed to:
company to comply with the following guidelines:
No other intellectual property rights are granted by
the delivery of this Brochure than the right to read it,
Airbus
for the sole purpose of information. Product Safety department (W)
This Brochure and its content shall not be 1, rond point Maurice Bellonte
modified and its illustrations and photos shall not be 31707 Blagnac Cedex - France
reproduced without prior written consent of Airbus.
This Brochure and the materials it contains shall safetycommunication@airbus.com
not, in whole or in part, be sold, rented, or licensed to
any third party subject to payment.
This Brochure contains sensitive information that is
correct at the time of going to press.
This information involves a number of factors that Visit us at safetyfirst.airbus.com
could change over time, affecting the true public or install the Safety first app:
representation. Airbus assumes no obligation to
update any information contained in this document or
with respect to the information described herein.
Airbus S.A.S. shall assume no liability for any damage
in connection with the use of this Brochure and of the
materials it contains, even if Airbus S.A.S. has been
advised of the likelihood of such damage.
 editorial
YANNICK MALINGE Dear Aviation Colleagues,
SVP & Chief
Product Safety Officer
Three of the most recent Safety first articles have highlighted events with unexpected,
or unintended, aircraft behavior. In such cases, reporting these events is essential to better
understand the cockpit conditions and human factors involved. This allows for the immediate
actions such as raising awareness and increasing the flight crew’s vigilance to detect these
potential problems.

Reported events also provide data needed for analysis and development of possible
enhancements that can further increase the resilience of the aircraft’s systems. This is why
the importance of reporting will be a topic in focus at our upcoming 28th Airbus Annual Flight
Safety Conference.

Airline speakers will provide testimony about how they empower and encourage their flight,
cabin, and maintenance crews to speak up and report events, even for an incident when
there were no operational consequences. We will also recall how Airbus manages in service
reports and practical illustrations of when reporting has made the difference and further
enhanced safety.

Whilst we may reflect on the good safety record of last year, the first week of 2024 provided
a stark reminder for why we must remain vigilant in all aspects of aviation safety. The images
of the JAL516 flight after a ground collision with the Japan Coast Guard aircraft was
an unfortunate realization of runway safety risks recently in focus for a number aviation
organizations globally. It is a call for timely action and to redouble our collective efforts
in addressing all such safety risks.

Thankfully, we can acknowledge the swift actions of the flight and cabin crew to effectively
evacuate all passengers from the aircraft, which highlights the importance of regular training,
practice and a strong safety culture. I also extend my sincere and heartfelt condolences
to the families and friends of the Japan Coast guard members who lost their lives.

Despite this very challenging start to the year, together with the Airbus Safety team, I pass
on our best wishes for a safe and prosperous year ahead.
Safety Publications
Safety first
The Airbus safety magazine

Available in app and website versions

Visit us at
safetyfirst.airbus.com

Statistical Analysis of
Commercial Aviation Accidents
 lso available in website version
A

Visit us at
accidentstats.airbus.com
 NEWS
The 28th Airbus Flight Safety Conference will be held in Bangkok,
18-21 March 2024
This event provides the opportunity for Airbus and its customers to exchange on how we can further strengthen
safety in our Air Transport System.
With the current rapid increase of passenger demand, our industry still has to face a number of safety challenges
to maintain its safety record. This is why the agenda of the conference will include a review of the risks, associated
mitigations, and best practices based on recent in-service events, including: dispatch challenges, runway safety,
severe weather and investigation updates. We will also focus on the importance of reporting with illustrative examples
given by airlines and Airbus presenters.
Growing our safety culture and building safety networks is essential for safety and so we encourage all our customers
to join us.

Airbus WIN
Worldwide Instructor News
FLIGHT OPERATIONS SUPPORT
AND TRAINING STANDARDS

A platform that provides Airbus Flight Instructors worldwide with videos, presentations
and other information from the Airbus Flight Operations and Training Standards department.
Available on

Website Androïd iOS

airbus-win.com app app
 Safety
first #37
OPERATIONS
P06
Inadvertent Autopilot Engagement
during Takeoff on A220 Aircraft

P14
Cockpit Control Confusion

Flight Operations
P22
Lightning Strikes

Cabin Operations

Ground Operations P36

Inappropriate V/S Target during
Maintenance Autoflight Mode Reversion
 OPERATIONS
Inadvertent Autopilot Engagement during Takeoff on A220 Aircraft

Inadvertent Autopilot
Engagement
during Takeoff
on A220 Aircraft
Several in-service events were reported to Airbus where the flight
crew inadvertently selected the autopilot while attempting to
engage the autothrottle during the takeoff roll. Inadvertent autopilot
engagement may result in early rotation that can lead to a tail
strike, inability to climb, runway overrun, or even loss of control.
The purpose of this article is to describe the circumstances leading
to this type of event with a case study and to provide details about
the procedure updates and planned product enhancements that
aim to prevent recurrence.

Check the latest version of this

article on safetyfirst.airbus.com
and on the Safety first app
for iOS and Android devices.
 Safety first #37 | January 2024 007

CASE STUDY
Event Description
An A220 aircraft was aligned on the runway and ready for a flap 2 and TO-3
derated takeoff. The computed takeoff speeds were 135 kt for V1, 137 kt for
VR, and 141 kt for V2. The autothrottle was armed (fig.1).

1 The flight crew moved the thrust levers forward to initiate takeoff. 2 The autothrottle
engaged at approximately 31 kt and the takeoff thrust (81.5% N1) was reached
at approximately 40 kt. 3 At 62 kt, the autothrottle unexpectedly disconnected, (fig.1)
accompanied by the “AUTOTHROTTLE” aural alert. Illustration of the event - part 1

4 At 106 kt, the flight crew wanted to re-engage the autothrottle but they pressed
the autopilot AP switch instead of the AT switch on the Flight Control Panel (FCP).
5 The CONFIG AP EICAS alert triggered at 110 kt (VR- 27 kt), but without
the associated “CONFIG AUTOPILOT” aural alert as the “AUTOTHROTTLE”
aural alert was still repeating. With the AP engaged, the aircraft started to rotate.
6 At 115 kt (VR-22 kt), the PF disconnected the autopilot and briefly applied
OPERATIONS
Inadvertent Autopilot Engagement during Takeoff on A220 Aircraft

66% backstick input before releasing the sidestick to neutral. 7 At 119 kt (VR-
18 kt), the aircraft pitch reached 10.7 ° and the strut of the main landing gear
decompressed. 8 1s later, the landing gear was compressed again and the
(fig.2) aircraft pitch reduced slightly to 7.5 °. The captain (PM) pushed the thrust levers
Illustration of the event - part 2 to MAX and the first officer applied 50% backstick inputs.

9 The landing gear decompressed again when the aircraft reached 129 kt
(VR-8 kt) and began to climb. 10 The aircraft reached 151 kt (V2 + 10kt) at 100 ft
(fig.3) RA. The flight crew deactivated the repetitive “AUTOTHROTTLE” aural alert
Illustration of the event - part 3 and continued the flight.
 Safety first #37 | January 2024 009

Event Analysis
Inadvertent selection of the autopilot

When the autothrottle unexpectedly disconnected during the takeoff roll,

the flight crew tried to manually reengage it using the autothrottle switch, but they
inadvertently pressed the autopilot switch instead. This caused the autopilot
to be engaged with the aircraft still on ground.

Autopilot commanded rotation

The autopilot commanded a pitch-up when it was inadvertently activated on the

ground to reach the flight guidance pitch target. This caused the aircraft to rotate
too early when the aircraft was still 27 kt below VR.

No “CONFIG AUTOPILOT” aural alert

The “CONFIG AUTOPILOT” aural alert did not sound, because the repetitive
“AUTOTHROTTLE” aural alert was still active when the CONFIG AP EICAS
alert was triggered.

Reduced Tailstrike Margin

During the event, at step 7 , the aircraft pitch attitude was 10.7° when the
aircraft was still on the ground, which corresponds to a tailstrike margin as low
as 1 to 2 ft.

OPERATIONAL CONSIDERATIONS

The A220 FCOM and AFM were updated and the red OEB 001 was published
to provide procedures and information to flight crews with the aim to raise
awareness and prevent any unintentional selection and engagement of the
autopilot during the takeoff roll if attempting to select and engage the autothrottle.

No autothrottle selection during takeoff roll

The flight crew must not attempt to select and engage the autothrottle during
the takeoff roll. This will reduce the risk of unintentional selection of the autopilot
switch.

As a reminder, the autothrottle selection pushbutton on the FCP is inhibited

above 60 kt when the HOLD Mode activates and remains inhibited until reaching
400 ft AGL.
OPERATIONS
Inadvertent Autopilot Engagement during Takeoff on A220 Aircraft

Managing autothrottle disconnect during takeoff

A220 FCOM 2 “Normal Procedures - Normal takeoff / High wind takeoff,
Step (3) Autothrottle“ was updated to provide flight crews with a procedure
if the autothrottle disconnects during the takeoff roll.

Autothrottle disconnect below 60kt

If the autothrottle disconnects below 60 kt, the flight crew must abort takeoff.

Autothrottle disconnect above 60 kt

• In the case of a TO or FLEX takeoff, the thrust levers must be set to MAX
to continue the takeoff.

• In the case of a derated takeoff (TO-1, TO-2, or TO-3):

- If the N1 of both engines matches the N1 target, the flight crew can continue
the takeoff

- If the N1 of either or both engine(s) does not match the N1 target, the flight
crew must abort the takeoff.

When stabilized in climb (not below 400 ft)

After the aircraft is established on a stabilized climb above 400 ft, the flight crew
can reengage the autothrottle as required. For derated thrust or FLEX takeoff,
they must confirm that the autothrottle is selected on.

AFM update
The AFM was updated to add a warning in the limitations section for the
autopilot. It states that “Autopilot engagement during takeoff roll can result
in premature rotation, possibly leading to tail strike, inability to climb or
loss of control. Immediate crew intervention is required.”
 Safety first #37 | January 2024 011

Training
The Operations Training Transmission A220-OTT-22-00-001 Rev 00 (dated
14-July-2023) recommends that Operators and Training Organizations:

• Reinforce flight crew knowledge on:

- The importance of reviewing OEBs together during preflight

- The content of the red OEB “INADVERTENT AUTOPILOT ENGAGEMENT

DURING TAKEOFF”

- The temporary AFM and FCOM 2 takeoff normal procedure “Autothrottle

disconnect during takeoff”

• Highlight the importance of the role of Pilot Monitoring.

INFORMATION
Further information can be found in the following documents:

• FOT A220-FOT-22-00-001 dated 09-NOV-22 “ATA 22 – A220 Inadvertent

Autopilot Engagement During Takeoff” available on the A220World portal

• TCCA Emergency AD CF-2022-64

• FAA Emergency AD 2022-25-51

• A 220 Red OEB-001.01 Inadvertent Autopilot Engagement During

Takeoff published on 28-March-2023

• A220 AFM - Limitations, Autopilot

• A220 FCOM – Normal Procedures - Normal takeoff / High Wind Takeoff,

Step (3) Autothrottle

• A220-OTT-22-00-001 Rev 00 dated 14-July-2023A

OPERATIONS
Inadvertent Autopilot Engagement during Takeoff on A220 Aircraft

PRODUCT ENHANCEMENTS

Airbus will introduce the following enhancements to prevent inadvertent

engagement of the autopilot when the aircraft is still on the ground and improve
flight crew awareness to prevent any errors.

Modification to inhibit autopilot

To prevent autopilot engagement during the takeoff roll, the Primary Flight Control
Computer (PFCC) will be upgraded to inhibit AP engagement during takeoff and
until 6 seconds after liftoff. This modification will be introduced in PFCC standard
009, planned for Q2 2024.

Enhancement of the autothrottle disconnection logic

The autothrottle disconnect logic is also being updated to address the issues
that cause it to disconnect during the takeoff roll. A first set of improvements will
be introduced with the next 8A3 avionics software and further improvements
are currently being developed.

“CONFIG AUTOPILOT” priority over

“AUTOTHROTTLE” aural alert
EICAS software will be upgraded to give higher priority to takeoff configuration
warning messages, such as “CONFIG AUTOPILOT”, or when other CONFIG
takeoff alerts are posted, even if the AUTOTHROTTLE aural alert is not silenced.
This improvement should also be available in the 8A3 avionics software.
 Safety first #37 | January 2024 013

Flight crews should be aware of the consequences of inadvertent

CONTRIBUTORS: selection of the autopilot during the takeoff roll, which may lead to a
risk of tail strike, inability to climb, runway overrun, and possible loss of
ALI FARHAT
control. A220 FCOM procedures were updated and AFM limitations
A220 Senior Engineering
Specialist Autoflight were added to help flight crews learn from the experience of previously
Design Office reported events and prevent this kind of event from recurring.
SÉBASTIEN FITTE This should be reinforced by all operators applying the applicable
A220 Engineering Specialist recommendations, including the need for the flight crew to review
Design Office applicable OEBs together during preflight and the importance of the
SEBASTIEN GUAY Pilot Monitoring role. Product enhancements, modifications, and
A220 Engineering updates will be implemented as additional safety features that will
Specialist Principal inhibit autopilot engagement during the takeoff roll, increase the
Design Office robustness of the autothrottle monitoring, and improve the priority
SUNNY GUPTA sequencing of aural alerts.
Accident/Incident Investigation
Product Safety
MATTHIAS MAEDER
A220 Chief Technical Pilot
GUILLAUME REIX
A220 Engineering
Specialist - Indicating
Design Office

With thanks to
Josep BOADA-BAUXELL
from A220 engineering,
Adrien CHEN from
A220 Product Safety,
Jimmy AVGOUSTIS from
A220 Flight Operations
Support and Albert MAZZIA
from Training and Flight
Operations Support
 OPERATIONS
Cockpit Control Confusion

Cockpit
Control
Confusion
Inadvertent use of the wrong cockpit
control instead of the intended control
is a potential situation that pilots may
encounter on any aircraft type. This kind
of error can occur with even the most
experienced pilots and this article explores
what factors can influence and lead to this
type of occurrence.
The resilience of the aircraft systems
to cope with such an error provides
effective safety barriers to prevent serious
events. The aim of this article is also to
raise awareness of the potential causes
and effects of cockpit control confusion
incidents and provide information about
best practices, which can help pilots
to reduce the risks that may lead to
operational and safety consequences.

Check the latest version of this

article on safetyfirst.airbus.com
and on the Safety first app
for iOS and Android devices.
 Safety first #37 | January 2024 015

CASE STUDY

Event Description
The First Officer, who was Pilot Flying (PF), called the ground crew operating the
towbarless pushback vehicle connected to the A319, to state that they were
cleared for pushback and engine start. The ground crew called to release the
brakes and the First Officer set the PARKING BRK handle to OFF. The flight crew
completed the “Before Start” checklist and a few moments after the aircraft
began to move, the First Officer called out “starting engine one”. The Captain
acknowledged the First Officer’s call. The First Officer then inadvertently set the
PARKING BRK handle to ON causing the aircraft to abruptly stop. The sudden
stop caused the nose landing gear to jump out of the tow clamp of the towbarless
pushback vehicle and it became lodged on top of the vehicle platform with
the nosewheel deflected at more than 90 degrees (fig.1). Two cabin crew
members, who were performing the safety demonstration at the time of the
incident, received minor injuries. The passengers and crew exited the aircraft
using steps positioned at the rear cabin door, with no further injuries.

Event Analysis
(fig.1)
Parking Brake Handle vs. Engine Mode Selector Picture of the event
(Source: Operator)
During the engine start sequence, the PF inadvertently set the PARKING BRK
handle to ON instead of setting the ENG MODE selector to IGN/START. Both
controls are located on the pedestal. The PARKING BRK handle needs to be
pulled, turned in the clockwise direction to ON, and released. The ENG MODE
selector also needs to be turned in the clockwise direction to IGN/START.
Both controls are used in the pushback and start sequence by either: (fig.2):

• Setting the PARKING BRK handle to OFF before pushback, and setting it back
to ON when pushback is complete, and then setting the ENG MODE selector
to IGN/START to start the engine, or

• Setting the PARKING BRK handle to OFF before pushback, then setting
the ENG MODE selector to IGN/START to start the engine during pushback,
and setting the PARKING BRK handle back to ON when pushback is complete

(fig.2)
The pushback/engine start
sequence may vary depending
on the situation
OPERATIONS
Cockpit Control Confusion

Many pilots position their hand on the PARKING BRK handle without making
any visual check before moving it as they know very well the specific shape of
the PARKING BRK handle on the pedestal and the specific action of pulling and
turning to move it.

CAUSES OF COCKPIT
CONTROL CONFUSION

Situations and Context

The cockpit control confusion situation described in this article occurred in
normal operational conditions. Situations that cause high workload, additional
stress, and cognitive overload for flight crews can lead to human errors. This is,
however, not necessarily the case for cockpit control confusion incidents.
In these cases, it is not due to a lack of knowledge and skills of the flight crews.
In fact, even the most experienced pilots on current type can experience cockpit
control confusion and so there are other contributing factors.

Humans create routines

Humans evolved by optimizing capabilities, and when a skill is acquired and
frequently used in the same environment, the human brain creates routines. This
human ability for pattern seeking and automatically performing actions allows
us to preserve our brain’s cognitive resources, making it possible to focus on
something else when performing routine actions. For example, flight crews can
often perform instantaneous monitoring of the aircraft in normal flight conditions
whilst communicating with air traffic control.

Skill-Based Errors
Behaviors based on routines, or so-called “skill-based behaviors”, are when
humans perform automatic actions with low conscious control on how they are
performing them. According to aviation human factors expert, James Reason*,
there are two types of skill-based errors:

• Lapses: when an action is missed

• Slips: when an action is performed incorrectly

*Reason, James. Human error. Cambridge university press, 1990.

Inadvertently using a cockpit control instead of another in normal situations is

a “slip”. Although performed incorrectly, the intention of the action was correct.
The momentary absence of attentional control and active thinking when
performing the action caused the error and it is not related to a lack of skills
or knowledge.

KEYPOINT
Cockpit control confusion incidents are skill-based errors or, “slips”, where the
intention is correct, but there is a failure of execution. These incidents happen
when a pilot is acting without conscious control over their actions.
 Safety first #37 | January 2024 017

Contributing Factors
Routines

Cockpit control confusion situations are often encountered on the most

frequently used controls, because routines are more developed on those
controls. This is why cockpit control confusion is more often observed with
experienced pilots performing well-known procedures.

Human Factors

Other contributing factors for slips are fatigue, overconfidence, and

momentary distractions such as pilot preoccupation or an unexpected (fig.3)
interruption when performing a well-known sequence of actions or a flow EXPED and APPR pushbutton
pattern. Anticipation of the action is also a contributing factor. For example, on the FCU of an A320 aircraft
when a pilot habitually rests their hand on the control before activating it, this 100 1000 UP
indicates that the pilot’s mind is already committed to performing the next action PUSH
with that control even if a different control action is called for. This can result in METRIC TO
ALT LEVEL
the inadvertent use of that cockpit control. OFF
DM
Shape & Position of the Controls
EXPED APPR
There are reported cases of confusion between the expedite (EXPED)
pushbutton and the approach (APPR) pushbutton (fig.3). The EXPED and
APPR pushbuttons are located next to each other on the FCU panel, and they
have a similar shape and action to select.

Similarly on the A220 aircraft, there are reported cases of control confusion
between the autopilot (AP) pushbutton-switch and the autothrottle (AT)
pushbutton-switch. For more information about this example, refer to the
Safety first article on “Inadvertent Autopilot Engagement During Takeoff on
A220 aircraft”.

In the case of cockpit control confusion, a pilot performs a skill without conscious
control over their action, therefore, even controls with different shapes and
locations in the cockpit can still be confused. For example, there are reported
cases of control confusion between the landing gear lever (located on the main
instrument panel) and the flaps lever (located on the pedestal).

Proximity Factors

When a control is positioned closer for the pilot to reach, then it is more likely
to be subject to cockpit control confusion. For example, when PFs are in the
left seat they are more likely to experience a skill-based error or slip, related to
the EXPED pushbutton, because it is located on the left side of the FCU panel.
When Pilots Monitoring (PMs) are in the right seat they are more likely to
experience cockpit control confusion related to the flaps lever because it is
located on the right of the pedestal.
OPERATIONS
Cockpit Control Confusion

Challenges
The lack of attentional control and active thinking when performing the action
that caused the error is not due to the lack of skills or knowledge, and therefore,
cockpit control confusion or slips, cannot be mitigated by conventional training.

Changing the design of a cockpit control that is very familiar to many thousands
of pilots can be counterintuitive, and it is not possible to cover all cockpit control
confusion cases.

The Importance of Reporting

The aircraft systems are very resilient to inadvertent use of cockpit controls,
pilots will react quickly to correct their error, and there is often no operational
consequence. It may not seem necessary for the flight crew to report the
cockpit control confusion incident, but it is important to better understand
the contributing factors and identify the possible mitigations. That is why it is
so important for airlines to foster a speak-up culture and just and fair policy,
that encourages pilots to report such events.

KEYPOINT
Given the challenges faced to reduce the number of cockpit control confusion
incidents, it is important for flight crews to report such events. The more cases
that are reported, the more accurate the analysis and identification of trends
will be, allowing for the most effective mitigations.
 Safety first #37 | January 2024 019

PREVENTIVE ACTIONS
Reporting cockpit control confusion events, analyzing trends, developing best
practices, and raising awareness among pilots is the most effective means of
prevention. Some operators have reinforced this by creating additional callouts
for their flight crews when carrying out routine tasks in the cockpit.

Recognized best practices are described in the Flight Crew Techniques Manual
(FCTM) of all Airbus aircraft (A300-600, A310, A320 Family, A330/A340 Family,
A380, A350, A220) in the “Cockpit Philosophy” chapter.

The main recommendations for flight crews are:

• Do not rest your hands on controls.

• Do not anticipate actions by putting your hands on the controls before
you need to.

• Perform a visual check on the control before using it. Even if you are focused
on the PFD you should look at the controls before using them.

• Check the result of the action, which is essential.

• Break the automated loop and raise the level of active thinking and attention.
Use the standard callouts and use additional callouts, if necessary.

Examples of additional callouts from an Operator:

• During the Engine Start procedure, the PF points to the ENG MODE selector
and calls “ENG MODE SELECTOR” before using it.

• Before using the flaps, the PM puts their hand on the lever and calls out “Flaps”
before moving the lever and calling out the flap position.

• Before using the landing gear, the PM puts their hand on the lever and calls
out “Gear” before moving the lever and calling out “Up” or “Down”.

These additional callouts reduced the number of inadvertent uses of the parking
brake handle instead of the ENG MODE selector, and the inadvertent flaps
selection or landing gear selection, by increasing the attentional focus of the
flight crew. However, the risk remains that such “attention-getters” can also
become routine.

BEST PRACTICE
During training sessions, instructors should be vigilant to identify cockpit
control confusion and debrief the flight crew to raise their awareness of this
behavior. This is more likely to occur during recurrent training and is less often
seen during initial training sessions.
OPERATIONS
Cockpit Control Confusion

INFORMATION
For more information on cockpit control confusion, the video “Understanding
and Managing Cockpit Control Confusion in Operations” is available on the
Airbus Worldwide Instructor News (WIN) website.

Thank you to both easyJet and KLM for their contribution to this article.
With effective speak-up cultures and just and fair policies, flight crews were
empowered to report several incidents that were studied to better understand
the circumstances that contributed to cockpit control confusion. This allowed
for more precise and targeted recommendations to reduce the risk of cockpit
control confusion for all flight crews.
 Safety first #37 | January 2024 021

The human mind creates routines for acquired skills in an effort to save
CONTRIBUTORS: cognitive resources for other tasks. When pilots are performing routine
tasks in the cockpit, they may occasionally lose attentional control
FLORENCE BURATTO
over the actions they are performing. This can lead to a cockpit control
Human Factors Expert
for Flight Operations confusion scenario.
Customer Support
Fatigue, overconfidence, distraction, and anticipation are some
IAN GOODWIN of the contributing factors to cockpit control confusion. A lack of
Safety Enhancement Manager attentional control and active thinking when performing the action
Product Safety causes the error, and not a lack of skills or knowledge. Cockpit control
MICHEL RICHARME confusion can happen on any aircraft type and to any pilot, regardless
Synthetic Flight Instructor of their experience. It can be the case that more experienced pilots
Customer Support are even more likely to have cockpit control confusion due to the
LAURENT SPAGGIARI longer time they have spent performing repetitive and routine tasks.
Human Factors Expert The most effective mitigation means are to always check the control
for Safety Enhancements
Design Office before acting on it and to always check the result of the action.
Reporting cockpit control confusion events, analyzing trends, raising
MARTIN NIJHOF (KLM
awareness, and sharing best practices are other mitigation means
ROYAL DUTCH AIRLINES)
to also take into account. Recommendations for pilots to prevent
Senior Flight Safety
Investigator/Senior Risk Analyst cockpit control confusion are available in the FCTM for all Airbus
aircraft (A300-600, A310, A320 Family, A330/A340 Family, A380,
CAPT. JEROEN
WOOLDERINK (EASYJET)
A350, and A220). The key point for pilots is to consciously maintain
Flight Operations Safety
their focus on each action they perform. Operators who have also
Captain developed additional callouts for their flight crews observed a
reduction in the number of reported cockpit control confusion events.

The aircraft systems are resilient to many of the effects from cockpit
control confusion. Their protections offer an effective safety barrier to
prevent more serious situations from occurring. It is a timely reminder
to apply the golden rules for pilots and always “take action if things
do not go as expected.”
 OPERATIONS
Lightning Strikes

Lightning Strikes
Each in-service aircraft is struck by lightning at least
once per year, on average. Even if the level of energy
of lightning strikes is high, their effects on an aircraft
are limited.
This article explains the lightning phenomenon and why
aircraft are prone to lightning strikes. It describes how
aircraft are designed to limit the effects of a lightning
strike and ensure that the safety of the flight is not
impaired. It also recalls several safety precautions
to take in flight and on the ground, and what must
be done when an aircraft is struck by lightning.

Check the latest version of this article

on safetyfirst.airbus.com
and on the Safety first app
for iOS and Android devices.
 Safety first #37 | January 2024 023

LIGHTNING PHENOMENON

Within storm clouds, thermal convection causes collisions between ice particles
resulting in the transfer of electrons between them. This process leads to the
accumulation of electrical charges inside the cloud. When the electrical tension
between these charged areas reaches a critical point, it overcomes the insulating
properties of the air that separates them, resulting in a lightning discharge.
(fig.1). Lightning can happen 1 between cloud and ground, 2 inside a cloud,
or 3 between two clouds. Earth experiences an average of approximately (fig.1)
44 lightning strikes every second. Typical types of lightning
 OPERATIONS
Lightning Strikes

Lightning bolts

A lightning bolt initiates with a column of ionized air (fig.2) that generally 1 starts
from the negative part of the cloud and moves towards the positively charged area.
This column is called a ‘leader’. As it nears the positively charged area, 2 secondary
leaders develop from it. 3 When the two leaders come into contact with each other,
an electrical current flows to neutralize the opposite electrical charges accumulated
in the two areas.

There are often several successive discharges in a single lightning bolt. The discharge
current can reach 200 000 A and the temperature inside the lightning channel can
reach 30 000 °C. Cloud-to-ground lightning bolts are usually the most powerful.

Worldwide distribution of lightning strikes to ground

The average worldwide frequency is 3 lightning strikes per square km per year
(strike/km²/yr). However, there is a strong disparity of this value depending
(fig.2)
on the location on the planet. Based on a National Aeronautics and Space
Lightning initiation
Administration (NASA) study, the regions more prone to lightning strikes are
Central Africa and South America with more than 20 strikes/km²/yr and more
than 70 strikes/km²/yr in Central Africa, reaching 158 strikes/km²/yr in Congo. In
comparison, oceanic areas have a frequency of less than 1 strike/km²/yr reaching
less than 0.1 strike/km²/yr in the polar regions and South Pacific area (fig.3).

(fig.3)
Worldwide lightning distribution from 1995 to 2003 with color range indicating the average annual number of lightning flashes per square kilometre.
Credits: National Oceanic and Atmospheric Administration (NOAA) Science and National Aeronautics and Space Administration (NASA).
 Safety first #37 | January 2024 025

AIRCRAFT AND LIGHTNING

STRIKES

Using the 3 strikes/km²/yr average value and an average aircraft surface of 300 m²,
an aircraft should theoretically be struck by lightning once every 1 000 years.
The operational reality is that an in-service aircraft will be struck by lightning on
average once a year, or every 3 000 flight hours. This is 1 000 times the projected
value above.

This difference can be explained by the fact that an aircraft will tend to attract
lightning in flight when it is in the proximity of a storm’s high electrical field (fig.4).

If a lightning leader initiates close to an aircraft 1 , some lightning leaders will also
initiate from the aircraft extremities (e.g. nose cone, wing tips, vertical tailplane)
toward the lightning leader 2 .

If one aircraft leader joins with the lightning leader, the aircraft becomes part of the
lightning channel 3 , and continuing leaders initiate from the other extremities of
the aircraft toward the positively charged area (ground) 4 .

When one of these leaders nears this positively charged area, 5 new leaders (fig.4)
initiate from it and 6 create lightning when joining the main leader. How lightning strikes an aircraft.
OPERATIONS
Lightning Strikes

Aircraft design considerations

All large aircraft must be designed and certified to withstand lightning strikes
without sustaining significant damage to their structure or effects on their systems
that would adversely affect safety for the remainder of the flight. This includes
protection of the airframe structure against the direct effects of lightning, and the
protection of the electronic circuitry versus lightning current induced effects.

Conductive structure

The aircraft structure is designed to conduct the electrical current induced by a

lightning strike. For composite fuselages or components, integrated conductive
(fig.5)
metallic foils and metallic strips are used to ensure this.
Metallic foil integrated into
composite structure (left),
conductive metallic strips All components of the aircraft structure (metallic or composite) must be bonded
on the radome (centre), and together with bonding leads or with fasteners to ensure electrical continuity (fig.5).
bonding leads ensure electrical
continuity between structural This will enable the lightning current to travel through the aircraft structure without
components (right). creating significant damage.

Direct effects of a lightning strike are normally limited to the damage caused by the
lightning strike at its initial point of contact. The observable effects of a lightning
strike include:

• Metallic components: Burns, pitting, holes, and melt marks on the aircraft
skin or structure, structural deformation, heat damage, and paint discoloration.

• Composite components: Paint discoloration, skin punctures, fiber damage

(including fiber tufts or fiber delamination), loss or damage of copper foil mesh
and metallic strips.
 Safety first #37 | January 2024 027

As the aircraft moves during the strike, and due to the pulsating discharge of
the electrical current, the lightning attachment points (on entry or exit) can move
along the surface of the aircraft creating the so-called multiple “swept strokes” (fig.6)
Example of “swept strokes”
(up to 20 strokes) (fig.6). They can also remain fixed on the rearmost parts of the
and “hang-on” attachment
aircraft (known as a “hang-on” attachment point), which is a single attachment points shown on an A320 aircraft
point sustaining several discharges. with the initial entry point of the
lightning current on the nose cone
and an exit point on the left side
The level of damage at the attachment points depends on the intensity of the of the horizontal tailplane.
lightning strike.

Aircraft Lightning Attachment Zones

Lightning attachment zones are identified depending on the probability and type
of lightning attachment on the aircraft structure (fig.7).

(fig.7)
Lightning attachment zones
shown on an A320 aircraft
(AMM extract)
OPERATIONS
Lightning Strikes

Protection against the indirect effects of lightning strikes

Electromagnetic fields related to a lightning strike can cause unwanted transient

voltages and currents in the aircraft wiring and its systems. As required by the
regulations, aircraft must be designed so that there is no perturbation of a critical
or essential system in the case of a lightning strike that could temporarily or
permanently affect its operation. The level of protection given to a particular system
depends on the likelihood of the system being affected by lightning and the impact
that a loss of this system would have on the safety of the flight.

Protection from the indirect effects of lightning strikes is ensured by:

• System redundancy

• Physical and electrical segregation of the redundant systems

• Electromagnetic protection on the electrical harness where required, using

differential transmission lines, shielding and over-shielding, and specific routing
rules

• Electrical isolation or use of lightning surge arrestors specified inside equipment

ports depending on their potential exposure to lightning strike effects

• Management of corrupted data by system software.

INFORMATION
Detailed information on the lightning phenomenon and its effect on aircraft
can be found in the “Lightning Protection of Aircraft Handbook” created by
Franklin A. Fisher and J. Anderson Plumer, available for download on the FAA
Technical library.

The standard ED-91A - Lightning Zoning and the SAE Aerospace Recommended
Practice (ARP) ARP5414B - Aircraft Lightning Zone, provides information on
lightning strike zones and guidelines for locating them on particular aircraft.

Lightning Protection FAA Technical

of Aircraft Handbook library
 Safety first #37 | January 2024 029

LIGHTNING STRIKE PREVENTION

& SAFETY PRECAUTIONS

Most of the reported lightning strike events on aircraft usually occur in flight
between 5 000 ft and 15 000 ft, or when the aircraft is on the ground.

Lightning Avoidance In-flight

Flight crews should take advantage of all available means to avoid lightning
conditions such as weather forecasts, use of the onboard weather radar, and
ATC guidance. (fig.8)
FCOM illustration of the Honeywell
Certain weather radars are equipped with a lightning prediction function that weather radar RDR-4000 with
1 rain echo attenuation indication,
provides additional indications to the flight crew of areas within a storm where an 2 lightning prediction, and 3 hail
aircraft may be more prone to lightning strikes (fig.8). prediction icons ikes an aircraft.

INFORMATION
Information on the use of weather radar and storm avoidance can be found in:

• A220 FCOM1 (section 16-06) and A320/A330/A340/A350/A380 FCTM Aircraft

Systems/weather radar

• Safety first article “Optimum use of weather radar” published in July 2016

• Airbus WIN video “Operational Use of the Weather Radar” published

in November 2017

Optimum use Operational Use

of weather radar of the Weather Radar
OPERATIONS
Lightning Strikes

Safety Precautions when on Ground

In the case of a storm with lightning activity when the aircraft is parked or stored
outside for maintenance activities, the maintenance and ground servicing
personnel should apply specific safety precautions to limit the consequences of
a potential lightning strike.

Aircraft electrical grounding (earthing)

Grounding (earthing) the aircraft reduces the risk of injury to personnel and risk of
damage to the aircraft in the case of a lightning strike. If the aircraft is not grounded,
the lightning current can exit from any point of the aircraft structure. This is normally
close to the landing gears where it can cause significant damage and a risk of
serious injury. Any ground servicing equipment (e.g. platforms, access stairs, cargo
loaders, ground service carts, cargo loaders, and pushback vehicles) that may
be in contact with an aircraft that is not grounded when it is struck by lightning,
may also be damaged.

A grounding cable with less than 500 mOhm of resistance and with a minimum
cross section of 22 mm2 (0.034 in2) must be attached to one of the aircraft
grounding points.

Suspension of maintenance and servicing activities

Maintenance or ground servicing operations should be stopped pending the

end of the storm and lightning conditions. Even if the aircraft is grounded, the
resulting shockwave created by a lightning strike can cause injuries to ground
personnel. Anyone working in the vicinity of the aircraft should not touch metal
parts equipment or any other item connected to the aircraft.

Disconnection of all external equipment

Disconnection of external equipment (e.g. external power supply, air conditioning

carts, and other ground servicing vehicles) prevents damage in the case of a
lightning strike.

In lightning conditions, ground operators should disconnect or remove their

headsets and communicate with the crew in the cockpit using standard
hand signals.

Adherence to local regulations

When available, the operators must review and follow the local airport or airline
policy and procedures for managing safety when there is lightning and storms.
 Safety first #37 | January 2024 031

INFORMATION
More information and guidelines can be found in the International Air Transport
Association (IATA) documentation:

IATA Airport Handling Manual, (AHM) 462 “Safe Operating Practices In Aircraft
Handling”, section 11; 11.3 Weather Terms and Definitions; 11.5 Severe Weather
Forecasting; 11.6 Severe Weather Notification; 1.6.2 Notification Methods;
11.7.3 Thunderstorm/Lightning; 11.8 Thunderstorm/Lightning Safety.

IATA Ground Operations Manual, (IGOM) 3.3 Adverse Weather Conditions

OPERATIONS
Lightning Strikes

MANAGING LIGHTNING STRIKES

When lightning strikes an aircraft, a specific process must be applied to detect any
damage caused by the strike, evaluate the damage, and perform the necessary
repair before returning the aircraft back into service.

Informing Maintenance of a Lightning Strike Event

In the case of a lightning strike, the flight crew must make a logbook entry
to inform maintenance personnel of the event, so that they can perform the
appropriate inspection and necessary repairs. The flight crew should provide as
much information as possible such as the landing gear position when the strike
happened, a description of any system malfunction during or after the strike, and
a list of the ECAM (EICAS for A220) alerts that may have been triggered.

Inspection of the aircraft for damage

Preparation of the inspection

The maintenance personnel should gather all the information provided by the flight
crew about the event and print a Post Flight Report (PFR) to analyze any effect
on the aircraft systems.

Choice of inspection

It is possible to choose between several types of post lightning strike inspection

(except for A220 and A300 aircraft). This enables flexibility depending on airline
operations, time constraints, human resources, availability of ground support
equipment, etc.

Standard post-lightning strike Inspection

The standard inspection after a lightning strike is divided into several phases. The
first phase being initial damage detection consisting of a thorough inspection of
the entire surface of the aircraft and testing certain systems. The following phases
are additional checks to be performed further to damage detection.

Quick Release Inspection (QRI)

The Quick Release Inspection (QRI) allows the operator to perform a reduced
inspection to release the aircraft in a shorter time frame, and postpone the full
standard inspection for a limited number of flight cycles when time and logistics
permit. The QRI is only available for A300-600, A310, A320 family, A330, A340,
A350, and A380 aircraft.

The QRI consists of inspecting the areas that are most prone to lightning strikes
and testing certain systems. If no damage is found during the QRI, the aircraft
can be dispatched for up to 50 or 200 Flight Cycles (FC) depending on the aircraft
type. A full standard lightning strike inspection must be performed on the aircraft
before the end of this grace period. If a new lightning strike occurs during the grace
period, a new QRI must be performed, but the grace period applicable before a
full inspection remains the 50 or 200 FC from the initial lightning strike event.
 Safety first #37 | January 2024 033

1-flight-back inspection (2 FC)

This alternative was added in the A320 family AMM to enable further flexibility
and allows a maximum of 2 FC (ferry or revenue flight) to return the aircraft to
an airfield with sufficient manpower and logistics to perform a standard or quick
release inspection. However, this procedure is not applicable if one of the following
conditions occurred:

• The flight crew reported a lightning flash with the sound of detonation

• The flight crew decided to divert the flight after a lightning strike event in flight

• There were Injuries to passengers and/or crew members caused by the lightning
strike event.

The 1 flight back inspection consists of:

• A visual Inspection of the Air Data/Inertial Reference System (ADIRS) probes and
sensors (at touching distance)

• A visual inspection of the flight control surfaces (from a 3m platform or passenger

entry stairs)

• A functional check of the aileron and elevator servo controls

• A functional test of the flight control surfaces.

The 1-flight-back inspection was made available for A350 aircraft in the 01-NOV-
2023 revision and is under study for A330, A340, and A380 aircraft.

Inspection A300-600/ A320 A330/A340

A220 A300 A350 A380
Type A310 Family Family
Standard
YES YES YES YES YES YES YES
inspection

QRI 50 FC 200 FC 200 FC 200 FC 200 FC

Quick
N/A N/A Note: If a new lightning strike occurred during the grace period,
Release
Inspection the grace period remains 200 FC or 50FC from the time
of the initial lightning strike event
1 Flight
N/A N/A N/A YES Under Study YES Under Study
Back (2 FC)
OPERATIONS
Lightning Strikes

Damage Evaluation & Repair

Damage due to lightning strikes should be repaired using an approved repair as per
(fig.9) local authority regulations. Airbus recommends using the SRM or ASR (for A350)
SRM for Mechanics (SRM4M) or ASRP (for A220) to evaluate and repair the damage. SRM/ASR/ASRP repairs
application for Android and iOS are certified to be capable of withstanding additional lightning strikes.

Damage outside of the SRM/ASR/ASRP limits

When the lightning strike damage is outside of the SRM/

ASR/ASRP limits, it is necessary to obtain repair instructions
either from Airbus via a Repair and Design Approval Form
(RDAF) or a Repair Engineering Order (REO) for A220 aircraft,
or via an instruction provided by an EASA PART 21 approved
organization.

To obtain the Airbus RDAF/REO, the operator or repair

organization should prepare a damage assessment as
required in SRM/ASR/ASRP.

INFORMATION
The “SRM for Mechanics” (SRM4M) mobile application provides a quick and
easy way to use the SRM for A320 family aircraft.

Report lightning strike events to Airbus

Airbus analyzes any reported lightning strike events in order to further increase
knowledge in this domain. Operators and repair organizations are encouraged
to report lightning strike occurrences to Airbus even if no damage is found on
the aircraft after the inspection. Operators can also participate in the forums and
working groups organized by Airbus. For example, Airbus hosts a Lightning Strikes
Expert Forum in order to exchange experience about managing lightning strikes
with all operators. An SRM working group (except A220) also meets regularly since
2014 to exchange experience about structural repair topics.

INFORMATION
Further information can be found in the AMM/MP, SRM/ASR/ASRP documents
available on the AirbusWorld portal and in the following published documents:
• OIT 999.0066/15
• O IT 999.0003/20 ATA 51 – STRUCTURAL REPAIR MANUALS AND
AIRCRAFT STRUCTURAL REPAIR MANUALS CONTINUOUS
IMPROVEMENTS
• Safety first #18 - Safe Operations with Composite Aircraft
• FAST #22 - Lightning Strikes and Airbus Fly-By-Wire Aircraft
 Safety first #37 | January 2024 035

Aircraft are often struck by lightning. Aircraft manufacturers must

CONTRIBUTORS: demonstrate that their aircraft remain safe after a lightning strike.

AUDREY BIGAND Flight crews should avoid areas with lightning conditions as much
Expert - EMH as possible by using weather forecasts, onboard weather radar,
& Lightning Direct Effects and ATC guidance.
CHIA-CHI CHEN
When an aircraft is parked or stored outside in lightning conditions,
Abnormal Events Engineer
it is important to apply precautionary measures such as electrically
- Overall A/C
In-Service Engineering grounding the aircraft, pausing ground or maintenance operations,
and disconnecting any external equipment. It is also important that all
ALEXANDRE GREKOV
operators are familiar with the local airport regulations and procedures
A220 Customer Services /
SMS Safety Officer for severe storms and lightning events, and have their own policies in
place for their flight crews, maintenance crews, and ground crews.
DOMINIQUE GRISEL
Cargo Guidance For every lightning strike event, it is essential for flight crews to make
Manager BCV SMS an accurate logbook entry and for maintenance crews to adhere to
Representative the AMM/MP/AMP procedures to perform inspection and damage
ROBERT KEBEL assessment. Any repair must be done using the SRM (ASR on
EMC and Lightning Protection A350 and ASRP on A220).
Expert
Operators should report all their lightning strike events to Airbus, even
CHRISTELLE KUTYLA if there is no damage found in the post lightning strike inspection.
EMH Specialist This will provide data that contributes to further enhancing industry
RENAUD PUJOL knowledge on the subject.
HO SRM Development

With Thanks to Diego

ALONSO TABARES from
Airport Operations Expert,
Olivier DUROU from
Particular Risk Analyses
Expert, Ian GOODWIN
from Product Safety
 OPERATIONS
Inappropriate V/S Target during Autoflight Mode Reversion

Inappropriate
V/S Target
during Autoflight
Mode Reversion
Two cases of inappropriate V/S target during
an autoflight reversion to V/S mode after a go-
around were recently reported to Airbus. In both
cases, the inappropriate V/S target resulted in a
pitch down command of the autopilot with high
thrust. The flight guidance used the previously
selected V/S value set during the preceding
ILS glide slope intercept from above as a
V/S target for the mode reversion.
This article describes one of these events
in detail and explains the conditions that caused
this autoflight behavior. It provides operational
recommendations to flight crews to prevent
and detect this situation. It also lists the system
enhancements that were launched to avoid the
use of an inappropriate V/S or FPA target during
a mode reversion of the flight guidance.

Check the latest version of this article

on safetyfirst.airbus.com
and on the Safety first app
for iOS and Android devices.
 Safety first #37 | January 2024 037

CASE STUDY

Event Description
An A320 aircraft was descending toward its destination airport in IMC and the flight
crew prepared for an ILS approach. Late clearance from air traffic control meant
that the aircraft was high. The aircraft captured the localizer, but was above the
ILS glide slope (fig.1).

1 At 3 500 ft, the aircraft was in OP DES I LOC mode with AP, FD, and autothrust
ON. The selected altitude was 3 000 ft, the speed brakes were fully deployed, and
speed was selected at 174 kt. Flaps configuration was CONF 2 and the landing
gear was down.

2 At approximately 3 400 ft, the ALT* mode engaged.

3 At 3 200 ft, the flight crew retracted the speed brakes and twice attempted
to engage the V/S mode by pulling the V/S/FPA knob, but the ALT* mode
reengaged 1 s after each attempt.
(fig.1)
4 At 3 000 ft, the ALT mode engaged and the aircraft leveled off. Event description (1 of 3)
OPERATIONS
Inappropriate V/S Target during Autoflight Mode Reversion

5 The flight crew then pulled the V/S/FPA knob to engage the V/S mode and
selected a V/S value of -2 600 ft/min on the FCU. The aircraft began to descend.

6 At approximately 2 300 ft (1 600 ft RA), the aircraft was still too high above
the glide slope and the flight crew pushed the thrust levers to TOGA to initiate
a go-around with the autopilot engaged. The aircraft started to climb toward
the 3 000 ft altitude that was still selected on the FCU. The NAV mode engaged
(fig.2) shortly after and 7 the PF moved the thrust levers back to the CLB detent
Event description (2 of 3) at approximately 2 700 ft.

8 The ALT* mode engaged at approximately 2 500 ft. 9 The flight crew immediately
increased the altitude target from 3 000 ft to 5 000 ft on the FCU. As a result, the
flight guidance reverted to V/S I HDG modes with associated alerts (triple-click
sound, white box on FMA, and FD bars flashing for 10s). The aircraft pitch began
to decrease. It climbed up to approximately 2 950 ft and then started to descend
and accelerate. At 2 800 ft, the aircraft vertical speed reached -2 600 ft/min
and remained constant until 10 the flight crew manually took over by pulling the
sidestick. The aircraft reached 2 100 ft (1 400 ft RA) and started to climb again.

(fig.3) The flight crew later reengaged the autopilot and successfully performed a second
Event description (3 of 3) ILS approach.
 Safety first #37 | January 2024 039

Event Analysis
Reversion to the previously selected V/S value

When the flight crew increased the selected altitude from 3 000 ft to 5 000 ft on
the FCU in step 9 , the ALT* mode was engaged. This triggered a reversion
to the V/S mode as per flight guidance logic. Since the V/S value was modified
shortly before the go-around, it was still in the memory and displayed on the
FCU. This led the V/S mode to use this previously selected value instead of the
current aircraft V/S. We will describe this inappropriate behavior later in this article.

Flight crew reaction

It took more than 30 s from the mode reversion to V/S - 2600 in step 9 ,
and 24 s from the start of the pitch down, for the flight crew to realize that the
aircraft did not respond as expected.

AUTOFLIGHT SYSTEM BEHAVIOR

The event described above is due to a combination of two functions of the flight
guidance system: The V/S or FPA preselection function and the reversion to
V/S or FPA modes.

V/S or FPA Target Preselection

The V/S or FPA target preselection enables the flight crew to preselect a V/S
or FPA target to be prepared to activate the associated flight guidance mode when
appropriate. To do so, when the flight crew selects a V/S or FPA target on the
FCU, this preselected value is stored in the memory and remains displayed
on the FCU for 45 s (10 s on A300, A310, and A300-600 aircraft) to activate
the guidance mode later.
 OPERATIONS
Inappropriate V/S Target during Autoflight Mode Reversion

INFORMATION
The duration of the V/S or FPA preselected value stored in the memory was increased from 10 s (on A300, A300-600,
A310 aircraft) to 45 s for the A320 family, A330, A340, A350, and A380 aircraft. It enables the flight crew to 1 preselect
an FPA value earlier while the aircraft flies toward the Final Descent Point (FDP) during an approach using FPA guidance,
in order to 2 anticipate the engagement of the FPA mode when the aircraft reaches the FDP.

(fig.3)
Preselection of the FPA value is used during approach using FPA guidance

Mode Reversion to V/S or FPA modes

The flight guidance automatic mode reversion to V/S or FPA modes is a logic
designed to maintain the current aircraft trajectory when the altitude selection by
the flight crew is inconsistent with the objectives of the current guidance mode.
In the event described in this article, the reversion was triggered by changing the
target altitude while the autopilot was in the ALT* altitude capture mode.

FCOM DSC-AUTO FLIGHT - FLIGHT GUIDANCE - AP/FD MODES - V/S

/ FPA MODE provides all the conditions for reversion to V/S or FPA modes.

An Inappropriate Combination
During a reversion to V/S or FPA modes, the flight guidance V/S or FPA target
usually synchronizes with the current aircraft V/S or FPA in order to maintain the
aircraft trajectory. However, if a V/S or FPA value is selected on the FCU and
if the mode reversion happens within 45 s (10 s on A300-600 and A310 aircraft),
the flight guidance V/S or FPA target synchronizes with this selected value.

This inappropriate combination of the V/S or FPA target preselection function

with the mode reversion function may cause inappropriate behavior of the flight
guidance as seen in the previous example.
 Safety first #37 | January 2024 041

The shorter time that the preselected value on A300-600 and A310 aircraft is
stored in the memory significantly reduces the probability of mode reversion to
the selected value within 10 s after the selection.

Several scenarios can lead to this inappropriate behavior, but not all aircraft are
concerned due to some differences in their guidance logic.

Scenario 1: Go-around during glide slope intercept from above (A300-600,

A310 and A320 family aircraft only)

The most common scenario where the flight crew may face this issue is a
go-around during or after a glide slope intercept from above, as in the example
described earlier in this article. 1 A V/S value is preselected, 2 V/S mode is
engaged and 3 the V/S may be adjusted. 4 A go-around is then performed.
5 If the mode reversion happens within the 45 s after the V/S value preselection
or last V/S modification, the inappropriate behavior will occur.
(fig.5)
Only A300-600, A310, and A320 family aircraft are concerned. On A330, A340, Scenario 1: Go-around during
glide slope intercept from above
A350, and A380 aircraft, the V/S or FPA preselected value is canceled as soon (A300-600 A310, and A320 family
as the V/S or FPA is engaged. aircraft only)
OPERATIONS
Inappropriate V/S Target during Autoflight Mode Reversion

Scenario 2: Go-around before glide slope intercept from above (before

engaging V/S mode)

In this case, 1 a negative V/S value is preselected in anticipation of a glide

slope intercept from above due to possible late ATC clearance. 2 When cleared
for approach, the flight crew presses the APPR pushbutton and G/S* mode
engages, followed by G/S mode. 3 A go-around is performed. 4 If a mode
reversion happens less than 45 s after the V/S preselection, the preselected
negative V/S value is used.
(fig.6)
All aircraft are concerned by this scenario, except A220 aircraft and A350 aircraft
Scenario 2: Go-around before
glide slope intercept from above that are equipped with PRIM 14.1. (because the V/S or FPA selected value is reset
(before engaging V/S mode) at go-around engagement with PRIM 14.1).

Scenario 3: Mode reversion due to the loss of an approach mode

In this scenario, 1 a V/S or FPA value was preselected, as it was for scenario
2, and 2 Approach mode is engaged when cleared by ATC. A mode reversion
happens during the next 45 s after the preselection due to a loss of approach
mode for reasons such as:

• G/S or F-G/S , APP DES or FINAL APP mode disengagement (e.g. loss
of ILS signal, MMR failure, loss of flight plan, etc.)

• LOC or F-LOC or NAV mode disengagement

• The flight crew selects a target altitude higher than the actual aircraft altitude on
FCU in DES or OP DES mode.
 Safety first #37 | January 2024 043

In this case, the effect on the trajectory is generally limited due to an already (fig.7)
descending trajectory. It may be more difficult for the flight crew to detect Scenario 3: Mode reversion due
the behavior. to the loss of an approach mode

Scenario 4: Visual manual approach using HUD

When performing a visual manual approach using the Head Up Display (HUD),
the flight crew may select the FPA value corresponding to the final approach path
on the FCU as a guidance (fig.8).

If a go-around is performed the FD will come ON and SRS mode will engage.
If a mode reversion happens within 45s after the last selection of the FPA value,
the guidance mode will revert to V/S mode using V/S value corresponding to the
FPA selected value, typically around -700 ft/min for a -3° FPA.
(fig.8)
Selection of the FPA during
a visual approach using FPA mode
can also lead to the unintended
behavior if a mode reversion
happens within the next 45 s.
OPERATIONS
Inappropriate V/S Target during Autoflight Mode Reversion

OPERATIONAL CONSIDERATIONS

Flight crews can identify an occurrence of an inappropriate V/S target during

autoflight mode reversion thanks to several cues.

Aural and visual alerts

When a reversion to V/S or FPA mode occurs, the triple-click (except on A300-
600 and A310 aircraft), FD flashing and guidance mode boxing on the FMA triggers
to attract the attention of the flight crew who can check the reversion parameters.

Understand your FMA at all times

Careful monitoring and understanding of the FMA, as stated in the “Airbus Golden
Rules for Pilots” will enable the flight crew to detect the reversion to V/S or FPA
mode, and detect any inappropriate V/S or FPA target value.

Effect on the pitch

An unexpected pitch command by the autopilot can also be the sign of an

(fig.9) inappropriate V/S or FPA target after a mode reversion. Note that in scenario
Several cues enable the flight 3 described above (mode reversion due to the loss of an approach mode),
crew to detect an inappropriate
V/S target during an autoflight
the unexpected autopilot pitch command may be limited and, therefore,
mode reversion difficult to perceive.

Importance of the Pilot Monitoring

The pilot monitoring plays an important role in detecting the issue and alerting
the pilot flying when the pilot flying does not detect the inappropriate behavior.

Take action if things do not go as expected

If the inappropriate behavior occurs, the flight crew should take appropriate action
as per the golden rules.
 Safety first #37 | January 2024 045

SYSTEM ENHANCEMENT

System enhancements are available, or will be made available on most of the

concerned aircraft to prevent the inappropriate combination of the V/S or FPA
Target Preselection function with the Mode Reversion function.

Enhancement 1: Reset of the V/S or FPA Preselected

Value after V/S or FPA Mode Engagement
Whenever a V/S or FPA target is preselected in the FCU, if the flight crew engages
V/S or FPA mode, the preset value is used for the guidance and is reset when
the V/S or FPA mode engages. It prevents the use of a preselected value in a
subsequent reversion to V/S or FPA as in the example described in this article
but also in other phases of flight.
(table 1)
This modification is already installed on A330, A340, A350 and A380 aircraft
Availability of the reset of the V/S
(table 1). It is planned to be introduced on A320 family aircraft. No availability or FPA preset value after V/S
date was defined at the time of authoring of this article. or FPA mode engagement

A300/
A320
Aircraft A300-600/ A330 A340 A380 A350 A220
Family
A310
To be Already Already Already Already
Availability Not planned N/A
defined installed installed installed installed

Enhancement 2: Reset of the V/S or FPA Preselected

Value at Go-around Engagement
This modification cancels any V/S or FPA preset value when the flight crew
performs a go-around. This prevents the use of an inappropriate V/S of FPA value
if V/S or FPA mode was not engaged before the go-around.
(table 2)
This enhancement was already implemented on A350 aircraft in PRIM P14.1
Availability of the reset of the V/S
standard certified in December 2022. The enhancement will be introduced on or FPA Preselected value at
A320 family, A330, and A380 aircraft (table 2). go-around engagement

A300/
A320
Aircraft A300-600/ A330 A340 A380 A350 A220
Family
A310
Planned
To be on FMGEC Planned for PRIM P14.1
Availability Not planned Not planned N/A
defined H8+ PRIM P14 (DEC 2022)
(Q1 2025)
OPERATIONS
Inappropriate V/S Target during Autoflight Mode Reversion

Enhancement 3: Reset of the V/S or FPA Preselected

or Selected Value in the Case of a Reversion to V/S
or FPA Mode
This enhancement ensures that the current V/S or FPA is used during a mode
(table 3) reversion so that the current trajectory is maintained.
Reset of the V/S or FPA
preselected or selected value
in the case of a reversion This enhancement is planned to be installed on A320 family, A330, A350, and A380
to V/S or FPA mode aircraft (see table 3).

A300/
A320
Aircraft A300-600/ A330 A340 A380 A350 A220
Family
A310
Planned for
To be To be Planned for
Availability Not planned Not planned PRIM P14 N/A
defined defined PRIM P15
(Batch 8)
 Safety first #37 | January 2024 047

V/S or FPA Target Preselection and Mode Reversion to V/S or FPA

CONTRIBUTORS:
mode are two useful functions of the flight guidance system. However,
THIERRY BOURRET
in certain circumstances, their combination may create inappropriate
Autoflight and Flight
behavior of the flight guidance. System enhancements are available,
Operation Senior expert or will be made available on most of the concerned aircraft to prevent
Design Office the inappropriate combination of the two functions.
JEAN FOISNEAU The role of the pilot monitoring is especially important to support
Aircraft Safety the pilot flying in detecting when an inappropriate reversion to V/S
Enhancement Manager
or FPA mode occurs. The warning to listen and look for are the
Design Office
triple-click (except on A300-600 and A310 aircraft), FD flashing,
MAXIME LANSONNEUR and guidance mode boxing on the FMA. These cues get the attention
Director Safety - Training of the flight crew who can check the reversion parameters and take
and Flight Operations
Customer Support action if needed.

GILBERT SAVARY To “understand the FMA at all times” and “take action if things do
Director Flight Operations not go as expected” are two of the Airbus Golden Rules for Pilots
and Training Standards that are very relevant to avoid the effects of inappropriate V/S target
Customer Support during autoflight mode reversion.
With thanks to Daniel
LOPEZ FERNANDEZ
from Product Safety,
Laurent MOURE and
Fabien PERRIN from the
A300/A310 Engineering,
Thomas GOBEAUT
and Marc LE-LOUER
from the A300/A310 Flight
Operations Support.