DCA11IA040

the captain's failure to properly recognize and manage the abnormal condition, resulting in it escalating to an in-flight emergency.

According to flight data recorder (FDR) data, the Avionics Smoke warning was active at the time the recording began. Since the caution was inactive at power up, it was most likely caused from contaminants detected before the airplane was powered up. Based on this, when the crew arrived at the airplane, they should have had three primary cues alerting them of an Avionics Smoke event, including: a master caution light illuminated amber; an amber AVIONICS SMOKE warning on the upper Electronic Centralized Aircraft Monitor (ECAM); and Blower and Extract fault lights and Gen 1 Line smoke light illuminated amber on the overhead panel. In addition, when they viewed the status page of the ECAM (as required per the captain's Cockpit Preparation checklist), VENT BLOWER and VENT EXTRACT would have been listed under inoperative systems. It is unlikely that airline personnel would have cleared or canceled this warning without communicating this information with the crew, and the crew stated that they did not cancel the warning. Had the warning been inadvertently cleared or cancelled, the overhead panel lights would have remained illuminated and vent blower and vent extract would have remained inoperative systems. Because the cockpit voice recorder (CVR) did not contain any discussion related to any Avionics Smoke event while on the ground, or after takeoff prior to about 1500 feet (during which time both crewmembers responded with surprise), it is unlikely that the crew had previously seen the warning but purposefully ignored the available cues. It is also possible that the crew did not see the cockpit indications since the captain did not complete at least one step of his cockpit preparation checklist–pushing the recorder ground control switch. Because of this, the CVR and FDR did not begin until the time that the APU started, when it should have started much sooner in the sequence of preflight events. So, the investigation was not able to determine whether the crew completed other checklist items that should have alerted them to the Avionics Smoke warning. Finally, investigators were unable to find any condition in which the caution could be recorded on the FDR but not displayed to the crew. Therefore, although the incident flight crew was not aware of the Avionics Smoke event prior to takeoff, investigators could not determine the reason for this. At 7:10:08.7, the captain began the after takeoff checklist. Item 3 of that checklist is "ECAM memo…checked." When completing this step, the captain detected the Avionics Smoke event on the upper ECAM. Primary cues available were the Avionics Smoke procedure and an amber LAND ASAP message. Although the crew were surprised when they noticed the alert message, there was no corresponding master caution aural warning during this time, which confirms that the Avionics Smoke alert had been active prior to takeoff. The captain then delegated crew duties, assigning the first officer as the pilot flying and indicated that he would complete the ECAM. At 07:10:30.8, the captain began the Avionics Smoke ECAM procedure and stated, "perceptible smoke", referring to the first conditional statement of the procedure "if perceptible smoke". Airbus stated that completion of the Avionics Smoke procedure is dependent on "direct detection by the crew [and] secondary detection by a detector which is considered as a help." Detection by crew can be by sight or smell. According to the procedure, "If perceptible smoke" is a conditional statement and if the crew did not detect smoke, they were not to continue the procedure. After the incident the first officer stated that if Avionics Smoke was detected by the sensor, then there was Avionics Smoke and he was not going to question that. About 38 seconds after the flight crew became aware of the Avionics Smoke warning, the captain stated, "hey you lost your autopilot too." The FDR indicated that the crew received an autothrust message. CVR data suggests that the captain became very apprehensive about the situation. The flight crew concluded that the failure of the autopilot meant that their situation was deteriorating and they needed to land the airplane promptly. Likely adding to the captain's apprehension was the LAND ASAP [i.e. as soon as possible] message displayed on the ECAM. Although an amber LAND ASAP message was presented, discussions with UAL instructors and pilots indicated that, to a pilot, land ASAP means land ASAP, regardless of color. After the incident, the captain stated that during his last proficiency training session, in-flight fires were emphasized. Specifically, pilots were told that delaying landing by a few minutes could be the difference between a successful landing and loss of an aircraft, such as Swissair [flight 111, that occurred September 2, 1998] and Valujet [flight 592, that occurred May 11, 1996]. The captain said, "he did not want this to be the next Valujet." The captain continued with the Avionics Smoke procedure but did not do so with the necessary thoughtfulness and made several missed steps. For example, the procedure states action item "EMER ELEC PWR…MAN ON" followed by the conditional statement "WHEN EMER GEN AVAIL:" and action item "GEN 2…OFF". In this instance, the captain should have turned on the emergency electrical power (i.e., deployed the RAT13), and then when emergency generator power was available turned off generator 2. Data show that the captain did not manually deploy the RAT prior to turning off generator 2. As a result, when generator 2 was turned off prematurely, there was a brief disruption in the power supply and the airplane entered the emergency electrical configuration. The EMER ELEC procedure and a red LAND ASAP message appeared on the ECAM. This configuration caused the RAT to automatically deploy which restored electrical power to the airplane after about 6 seconds. The airplane remained in the emergency electrical configuration. Therefore, the captain became apprehensive about the Avionics Smoke event and hastily performed the ECAM procedure resulting in the airplane entering the emergency electrical configuration. At 7:12:51.5, the first officer alerted the captain that he had no instruments. Two seconds later the captain took control of the airplane and told the first officer to call the flight attendants. The flight crew did not adequately transfer control of the airplane – the first officer did not brief the captain on the status of the airplane and the captain did not brief the status of the emergency procedures. Over the next two and a half minutes the crew focused primarily on contacting the flight attendants and did not discuss completing the EMER ELEC procedure. About 30 seconds later, the flight crew lowered the landing gear without restoring power to the airplane, per the EMER ELEC procedure, and the airplane began operating on battery power. As a result, the CVR recording ended and no further communications in the cockpit were available with the exception of ATC communications. Completion of the EMER ELEC procedure would have restored power to generators 1 and 2 prior to landing gear extension and maintained electrical power to the airplane. After the incident, the captain said when they lowered the landing gear, operating on battery power was not on his mind. After touchdown, reverser 2 did not deploy, and the airplane veered to the left and exited the runway. The flight crew was not aware that reverser 2 was an inoperative system based on the electrical configuration of the airplane. Had the first officer checked the ECAM status per the Approach Descent Checklist, the inoperative system would have been identified. However, this was not completed likely due to the time constraints. After landing, engine status cues would have alerted the first officer that reverser 2 did not deploy and he should have informed the captain. While it is unknown if the first officer monitored engine status and mad

HISTORY OF FLIGHT On April 4, 2011, at about 0725 central daylight time (CDT), United Airlines flight 497, an Airbus 320-232, N409UA, departed the left side of runway 19 while conducting an emergency landing due to an avionics smoke warning at the Louis Armstrong New Orleans International Airport (MSY), New Orleans, Louisiana. An emergency evacuation was conducted. There were no injuries to the 104 passengers or five crew members and the airplane sustained only minor damage. The flight was a 14 Code of Federal Regulations part 121 regularly scheduled passenger flight and had originally departed MSY destined for San Francisco International Airport, San Francisco, California. The first officer (FO) was the pilot flying for the flight and the captain was the pilot monitoring. According to flight crew statements and recorded data, the incident flight takeoff began at 0708. At about 0710:10, the cockpit voice recorder (CVR) recorded the captain began the after takeoff checklist and stated, "…wait a minute what do we got here." The captain then states, "okay ECAM I got the uh— uh you got the jet. I got this." The CVR then records the captain beginning the Avionics Smoke ECAM checklist procedure. The FO stated that about that time he became aware of an "avionics smoke" warning electronic centralized aircraft monitoring (ECAM) message and the captain stated that he noticed a "yellow" autothrust ECAM message. The FO reported he pushed the autothrust (ATHR) button on the mode control panel (MCP), but this did not succeed in re-engaging the autothrust. The captain said the autothrust message was followed by a red "LAND ASAP" ECAM message accompanied by the electrical page synoptic display and the "AVIONICS SMOKE" ECAM procedure. The FO leveled the aircraft at 5,000 feet in instrument meteorological conditions (IMC) and retarded the thrust levers to slow the aircraft. The captain stated that the first item on the avionics smoke ECAM procedure was to don oxygen masks, but that he and the FO agreed not to don the masks because there was no smell of smoke. The captain did not recall seeing any conditional statements or a timer in the ECAM procedure. At about 0711:22, the captain stated "line one off" followed by "okay emergency electrical power man on when uh emergency generator available. gen two off." Concurrent with the second generator being switched off, the flight data recorder stopped recording and there was about a six second power interruption of the CVR. When the CVR resumed recording, the captain is discussing the ram air turbine (RAT) and that the airplane is in emergency electrical configuration. The FO then lost his flight instrument displays and began using the captain's primary flight display for altitude, heading and airspeed. A short time later, the captain took control of the airplane. The FO said that once the captain had taken control of the airplane, he stated that he thought they were in the emergency electrical configuration but he didn't know what the ECAM steps were for that configuration. He said he did not follow up on the ECAM actions, and he did not use the Quick Reference Checklist (QRC) while in flight. The first officer then tried to alert the flight attendants (FA), but he said he "did not hear the bell" when he called and the FAs did not respond. He used the pedestal handset to call the FA's, but he got no response. He then opened the cockpit door and told the FAs that they were in an emergency and would be landing immediately. The pilots both stated in interviews that they did not conduct an approach briefing, tune the navigation radios, enter an approach in the FMGC, check the ECAM status page, use the flight manual to determine what systems were affected or lost, conduct an approach descent checklist, conduct an overweight landing checklist, determine the applicable approach speed or landing distance from the FMGC or flight manual, or attempt to repower the electrical system. The captain later said that there was no time to do these things because of the severity of the emergency. The captain said he knew he would be in direct law with no antiskid or nose wheel steering, but he did not recall telling the first officer this. He estimated that the approach speed should be 160 knots, based on the takeoff V2 of 147 knots, rounded up for wind additive. He said that normal landing distance was 3,500 to 4,000 feet and was confident the airplane would stop on the runway. Both pilots stated that they wanted to keep the approach speed above 140 knots in order to avoid stalling the ram air turbine (RAT). The captain told ATC that they would need a vector back to the airport and requested "the longest runway." ATC advised that runway 10, which was 10,104 feet long, was still closed due to the equipment on the runway, but that airport personnel were attempting to clear the runway. At about 07:16:03, as the flightcrew lowered the landing gear, the CVR stopped recording. The captain stated that he could hear the tower on the radio talking to the operations personnel working on runway 10 and he realized that they would not be able to clear that runway in time for the flight to land. The captain then told ATC "we've lost all our instruments, we need a PAR." The captain stated during his interview that he had attitude and compass information but no localizer, and that the screens started to fade during the approach. ATC told the flight that they would provide a no-gyro surveillance approach. The captain did not advise the FO as he continued the descent through the cleared altitude of 2000 feet. The FO stated that he did not recall if they were cleared to descend out of 2000 feet. According to the ATC recording, the crew reported they "we're at 1000 feet now and we've got water contact, where are we from the airport?" The controller replied that he was at 330 degrees from the airport and said on their present heading they would be "set up for the shoreline 19." After some additional communication with ATC, the captain said "I've got it" and the controller replied "wind 180 at 16 gusts to 20, cleared to land." The captain stated that he landed with full flaps and used the PAPI for vertical guidance. The captain stated that he landed on the centerline, approximately 1,500 feet down the runway. He also state that he "got on the brakes," used full reverse, and used right rudder to keep the airplane in the center of the runway. The FO stated that on touchdown the cockpit door swung open and that he turned and shouted "remain seated, remain seated." He said that when the engines came out of reverse the captain went to the tiller but the aircraft pulled to the left. The captain had said "I can't control it," and "we're going to evacuate." The airplane continued to veer to the left and the captain indicated he stepped harder on the right brake pedal. The airplane departed the left side of runway 19 approximately 5000 feet from the threshold at a low speed, and the nose gear sank into the soft groundoff the side of the runway. Once the aircraft came to a stop, the flightcrew used the QRC to conduct the evacuation. The captain set off the evacuation signal and the first officer then silenced it. The first officer said the 1R slide did not inflate and he yelled "go the other way." He went down the 1L slide and began helping the passengers get away from the airplane. The captain came out a few minutes later with a megaphone, which he used to direct the passengers away from the aircraft. INJURIES TO PERSONS: There were no injuries to the 104 passengers, which included 3 children and 1 infant lap child, two flight crew, or three flight attendants. DAMAGE TO AIRCRAFT: Post incident inspection of the airplane revealed no evidence of fire or smoke in the avionics compartment, ducts, or anywhere on the airplane. The nose landing gear bracket and weight-on-wheels switch as