ASN Wikibase Occurrence # 363706
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Date: | Friday 30 December 2011 |
Time: | |
Type: | Bombardier CRJ-200LR |
Owner/operator: | Armavia |
Registration: | EK20018 |
MSN: | 7499 |
Fatalities: | Fatalities: 0 / Occupants: |
Aircraft damage: | None |
Category: | Serious incident |
Location: | near Nice-Côte d'Azur Airport (NCE/LFMN) -
France
|
Phase: | Approach |
Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
Departure airport: | Yerevan Airport (EVN/UDYZ) |
Destination airport: | Nice-Côte d'Azur Airport (NCE/LFMN) |
Investigating agency: | BEA |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:The crew performed a flight between Yerevan (Armenia) and Nice (France), with a planned night arrival.
At the beginning of the approach to Nice, the controller informed the crew that the "VORa runway 04L" procedure was in effect. He then told them that the wind was from 160° at 18 kt and asked if they agreed to continue the approach for runway 04L. The crew accepted. They were then authorized to intercept the 175° radial of the VOR CGS and to carry out the "VORa runway 04L" approach (see point of the trajectory below).
Shortly after, the aircraft crossed the radial without intercepting it. The controller asked the crew to turn to a heading of 030°. The crew did not acknowledge this instruction and requested the latest wind information. The controller used emergency phraseology to instruct them to turn to a heading of 090° and informed them that the procedure in effect was now "VORb runway 22R" (point). He then asked if they could increase speed to 220 kt and to call back when ready to start the approach. The crew was authorized to reduce speed to 160 kt.
Around 6:20 PM, the crew announced they were ready for the approach. The controller then instructed them to initially turn to a heading of 060°, and two minutes later to turn to a heading of 310° and intercept the 089° radial of the VOR AZR (point).
He then asked if they were established on the 089° radial (point). The crew confirmed and reported descending to 1,500 ft. At the FAF, they initiated the descent and flew below the published glide path.
After initial contact with the LOC controller, he asked the crew to continue the approach. The controller was then occupied managing an aircraft taking off.
About 10 NM from the DME AZR, the aircraft descended below the procedure minimums (1,500 ft) and then deviated right of the final approach axis. The MSAW(1) alert was triggered a few seconds later and lasted 41 seconds; the aircraft was flying at a heading of 300°, which is a 30° deviation from the approach axis, and was still descending.
The APW(2) alarm was triggered eleven seconds after the MSAW alert and lasted for 1 minute and 18 seconds. The LOC controller used emergency phraseology to instruct the crew to turn left to a heading of 270° (point); the crew acknowledged. The aircraft's rate of descent reached 1,700 ft/min. The controller reiterated his message and informed the crew that they were mistaking the bay. The aircraft then reached 550 ft. The crew turned left and began to ascend (point), and the MSAW alert stopped.
Asked by the controller, the crew indicated they wished to abort the approach to attempt another one.
As the aircraft climbed back to 1,150 ft, the controller instructed the crew to turn to a heading of 180° and maintain altitude, then to turn to a heading of 140° (point). At the same time, the APW alert stopped. The controller instructed to climb to 3,000 ft, then reiterated his request with emergency phraseology (point).
The controller then asked to contact the approach controller to attempt a new "VORb runway 22R" approach. During this attempt, the crew crossed the 089° axis without intercepting it. The controller asked them to turn to a heading of 230° for interception, which the crew acknowledged. The APW alert was triggered again while the aircraft was north of the 089° axis. The controller used emergency phraseology, asking to turn to a heading of 240° for interception. The crew acknowledged, corrected the trajectory, and reported the field in sight. The controller asked them to turn to a heading of 270° and to remain on frequency. The aircraft deviated again to the right of the published trajectory. The controller instructed the crew to turn to a heading of 260° and informed them to expect a visual approach. After ensuring that the crew had the runway in sight, the controller asked them to resume navigation and contact the tower frequency. The MSAW alert was triggered again briefly for three seconds as the aircraft flew over Cap Ferrat at 1,200 ft. The crew landed on runway 22R.
CONCLUSION
The incident was due to the inadequate execution of the approach by the crew, whose resources may have been saturated by the management of the runway change and the complexity of the published approach procedure.
The controller's reaction following the activation of the APW alarm prevented a more serious event. However, his failure to perceive the MSAW alarm contributed to the late detection of the deviation from the aircraft's trajectory.
Accident investigation:
|
| |
Investigating agency: | BEA |
Report number: | BEA e-18111230 |
Status: | Investigation completed |
Duration: | 1 year and 8 months |
Download report: | Final report |
|
Sources:
https://bea.aero/en/investigation-reports/notified-events/detail/quasi-collision-avec-le-sol-lors-de-lapproche-finale-de-nuit-remise-de-gaz/ Location
Revision history:
Date/time | Contributor | Updates |
18-Mar-2024 20:10 |
ASN |
Added |
18-Mar-2024 20:11 |
ASN |
Updated [Total occupants, Location, Nature, Departure airport] |
18-Mar-2024 20:12 |
ASN |
Updated [Departure airport] |
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