Final Report B738 (7T-VJM), vicinity Paris Orly France, 6 December 2019

Final Report B738 (7T-VJM), vicinity Paris Orly France, 6 December 2019

Publication info
Author
BEA France
Category
Accident Reports Human Factors Controlled Flight Into Terrain Loss of Control
Date of publication
13/10/2021

On 6 December 2019, a Boeing 737-800 below Decision Altitude on an ILS approach at Paris Orly was unexpectedly instructed to go-around in day VMC without explanation. The go around was mishandled and the aircraft began to descend after initially climbing which triggered EGPWS Warnings and controller alerting before recovery was achieved. It was suspected that surprise at the go-around and the early climbing turn required may have initiated the crew’s mismanagement of automated flight path control with further surprise leading to failure to revert to manual control when they no longer understood the automated system responses to their inputs.

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