Accident on 22 June 2003 at Guipavas (21) to the Bombardier Canadair CL-600 2B 19 registered F-GRJS operated by Brit Air

report summary f-js030622a

Full report available in PDF

 

SYNOPSIS

Date and time	Aeroplane
22 June 2003 at 21 h 51 [1]	Bombardier Canadair CL-600 2 B 19 "CRJ-100" Registered F-GRJS
Site of accident	Owner
Guipavas (29) (France)	Armor Lease
Type of flight	Operator
Public transport of passengers Scheduled flight AF 5672 Nantes – Brest	Brit Air
	Persons on board
	2 Flight Crew 1 Cabin Crew 21 passengers

Summary

On an ILS approach to runway 26 Left at Brest Guipavas aerodrome, the aeroplane deviated progressively to the left of the normal runway approach track. It passed above and then below the glide path and descended until it touched the ground 2,150 meters from the runway threshold, 450 meters from the extended runway centreline. The aeroplane struck several obstacles and caught fire.

Consequences:

	Persons			Equipment	3rd parties
	Killed	Injured	Unhurt
Crew	1	1	1	Destroyed	-
Passengers	-	4 *	17

* including three seriously

3 - CONCLUSIONS

3.1 Findings

• The crew and the controller possessed the requisite licenses and qualifications, which were valid.
• The aircraft had a valid Certificate of Airworthiness.
• The crew was undertaking a Nantes-Brest flight, the last stage of a rotation comprising Brest-Nantes-Strasbourg-Nantes-Brest legs.
• The crew was based in Brest and knew the procedures relating to the aerodrome.
• The aircraft took off from Nantes at 21 h 16 min with twenty-one passengers. It was about fifty minutes late, the delay having being carried over from the first leg.
• The Captain was pilot flying.
• Meteorological conditions at Brest worsened shortly before the takeoff from Nantes. The crew learned in flight of the deteriorating visibility at their destination.
• A NOTAM (Notice to Airmen) was in force, indicating that Category II and III approaches were unavailable at Brest Guipavas from June 2 to July 31, 2003; the crew were aware of this.
• The measured visibilities obtained before takeoff, during the flight, and during the approach were all greater than the requisite minima for a Category I approach.
• The aerodrome radio installations were in operational condition.
• The pre-descent briefing was not complete.
• The pilots communicated little during the approach and some announcements were omitted.
• The aircraft was “number two” on arrival.
• The approach Controller asked the crew to descend to four thousand then to three thousand feet and perform a holding pattern. She afterwards authorized descent to two thousand feet.
• The crew flew the approach on the PFD, without using the head-up system, in accordance with the operator's procedures.
• After the preceding aircraft had landed the Controller, seeing F-GRJS on the localizer centreline on the radar, and believing it to be stabilized, asked the crew to continue the approach before they had started the holding pattern.
• The crew began the approach after this clearance, which they read back.
• The readback was not received by the Controller.
• The automatic flight control system APPR mode was never active. The beginning of the approach was performed in HDG and VS modes.
• The wind, which veered progressively northwest then north during the descent, caused the aircraft to drift leftwards. This drift was not detected by the crew.
• The aircraft exited the localizer capture beam.
• The aircraft passed above the glide slope and the pilot selected the VS mode to recapture the slope. The crew's attention was focussed on managing the flight path in the vertical plane. During this time, the aircraft continued its leftward movement away from the localizer centreline.
• The aircraft captured the glide slope from above and the crew's attention then focussed on the horizontal flight path. The aircraft passed through the glide slope and remained below the latter until the impact with the ground.
• The captain initiated a right turn and disengaged the autopilot.
• Numerous “Glide slope” and “Sink rate” alarms were transmitted without any significant reaction from the crew.
• The Captain started the go-around at the decision altitude. The aircraft, off to the left of the runway centreline, was at about one hundred feet AGL. The speed was low (between 115 and 120 knots).
• The first meaningful pitch-up action on the elevators was recorded four seconds after the thrust command.
• The aircraft continued to descend, impacted the ground without violence, ran along the ground, and then impacted several obstacles that heavily damaged the cockpit. The aircraft came to a halt after about one hundred and fifty metres.
• The emergency beacon did not work.
• Fire broke out during the aircraft's ground run; it remained localized outside of the cabin.
• The Cabin Attendant ordered the passengers to evacuate before the fire destroyed the cabin.
• During the evacuation, one passenger opened an over-wing exit; the fire then penetrated into the cabin.
• Inspection of the various components of the pitch control system did not reveal any anomalies.
• The emergency services had problems in locating the wreckage. They arrived twenty-seven minutes after the accident.

3.2 Probable Causes

The causes of the accident are as follows:

• neglecting to select the APPR mode at the start of the approach, which led to non-capture of the localizer then of the glide slope;
• partial detection of flight path deviations, due to the crew's focusing on vertical navigation then on horizontal navigation;
• continuing a non-stabilised approach down to the decision altitude.

Lack of communication and co-ordination in the cockpit, and a change of strategy on the part of the Controller in managing the flight were contributing factors.

4 - SAFETY RECOMMENDATIONS

4.1 Procedures in Force

At the time of the accident, Brit Air procedures did not call for an announcement when passing through the stabilization height. Such an announcement leads crews to establish a common strategy regarding continuation or missing the approach. Additionally, when issued by the PNF, it may encourage the latter to propose a go-around. The investigation also showed that the Brit Air Operations Manual made no connection between instructions on GPWS alarms and those relating to the stabilization height.

Consequently, the BEA recommends that:

• the DGAC study the possibility of generalizing a procedure relating to passing through stabilization height, consistent with procedures relating to GPWS alarms.

The Brit Air Operations Manual is somewhat inconsistent, in particular with regard to the stabilization height and go-around actions.

Consequently, the BEA recommends that:

• Brit Air ensure that the content of its Operations Manual is consistent.

4.2 Flight Crew Training

The investigation showed an absence of awareness by Brit Air pilots regarding the low-speed characteristics of the CRJ-100. A similar observation had already been made in Canada following a December 1997 accident. Bombardier has put in place a balked-landing training program, but the latter constitutes only a partial answer to this awareness requirement.

Consequently, the BEA recommends that:

• the DGAC introduce awareness-training on the low-speed operating characteristics of the CRJ-100, and other aircraft presenting comparable characteristics during go-around, into its training programs;
• the DGAC inform foreign regulatory bodies of the above recommendation.

The investigation showed that training for CRM trainers was not subject to specific approval by the DGAC, and that end-of-training skills were not checked.

Consequently, the BEA recommends that:

• the DGAC, in association with its foreign counterparts, put in place a training-approval regime concerning training of CRM trainers.

The SFI functions of the Co-pilot and a small number of other pilots based at Brest could have contributed to the inadequate communication and co-ordination between the crew.

Consequently, the BEA recommends that:

• the DGAC ensure the incorporation of such factors in CRM training.

4.3 Display of LOC and GLIDE Information

The option selected by Bombardier and Rockwell Collins for the display of localizer and glide information on the CRJ-100 PFD was to present the two items on the same screen but on two separate instruments, as permitted by the regulations. Utilization of an instrument such as the HGS, combining the two items, could have allowed the crew to detect non-capture of the localizer sooner.

Consequently, the BEA recommends that:

• the EASA study the possibility of imposing the combining of localizer and glide information on instruments used for the approach phase.

4.4 Interface between Crew and Air Traffic Control

The investigation highlighted the fact that the Controller, motivated by the desire to assist the crew, had changed strategy and cleared for approach belatedly. This could have contributed to precipitation in the cockpit during the preparation of the aircraft and the beginning of the approach.

It is therefore considered desirable for a multidisciplinary think-tank to evaluate the operational consequences on pilots of proposals from ground control and that the results of this study are made known to controllers. The BEA recently recommended “the DGAC introduce the notions of ground/crew resource management into the training and practice routines of controllers and pilots. Feedback data could be used effectively to this end”. This recommendation would appear to address the above issue.

An announcement of the type “report when established on the localizer” could have helped the crew to realize they had not captured the localizer. Similarly, procedures associated with use of the radar could have helped the Controller to realize that the final phase of the approach was not taking place normally.

Consequently, the BEA recommends that:

• the DGAC study the possibility of extending to precision approaches, not preceded by radar guidance, the instruction to report back when the aircraft is established on its final approach flight path;
• the DGAC take measures to clarify utilisation of radar, and limitations of same, in particular for the surveillance function.

4.5 Evacuation

Due to the stress associated with the accident, the Cabin Attendant did not think to use the megaphone during the evacuation, and forgot to take the first-aid kit when leaving the aircraft. She could not remember the number of passengers aboard, and could not be certain that all had actually disembarked from the aircraft.

Consequently, the BEA recommends that:

• the DGAC study the introduction into training and practice sessions for cabin crew of near-real situational simulations.
• Moreover, carrying a megaphone aboard the CRJ-100 is not mandatory.

Consequently, the BEA recommends that:

• the DGAC impose carrying a megaphone when the presence of a cabin attendant is required by regulations.

During the evacuation, one passenger opened an over-wing exit. Fire then penetrated the cabin. Opening an emergency exit without first verifying for possible outside hazards may in certain cases prove detrimental to safe evacuation.

Consequently, the BEA recommends that:

• the DGAC study the possibility of specifying the checks to perform prior to opening of emergency exits, for example, by use of pictograms on exits themselves, or through the available cabin safety instructions, in order to prevent opening of said exits in the event of outside hazards.

4.6 Flight Recorders

Exchanges in the cockpit were recorded solely on the cockpit area microphone. The poor quality of this recording did not enable a full reconstitution of cockpit communications.

Consequently, the BEA recommends that:

• the DGAC impose the use of headset microphones in the climb and descent phases, or at the very least, below the transition level or altitude, in compliance with paragraph 6.20 of Annex 6 to the Convention on International Civil Aviation.

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[1]  Except where otherwise noted, the times shown in this report are expressed in Universal Time Coordinated (UTC). Two hours should be added to obtain the legal time applicable in metropolitan France on the day of the accident.