ASN Wikibase Occurrence # 269248
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| Date: | Wednesday 20 October 2021 |
| Time: | 19:51 LT |
| Type: |  Bombardier CRJ-1000EL |
| Owner/operator: | HOP! |
| Registration: | F-HMLD |
| MSN: | 19007 |
| Fatalities: | Fatalities: 0 / Occupants: 102 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | near Nantes Airport -
 France
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | Lyon Saint-Exupéry Airfield (LYS/LFLL) |
| Nantes Atlantique Airport (NTE/LFRS) | |
| Investigating agency: | BEA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Hop! flight AF1632, a CRJ-1000, descended too low during the approach to runway 21 at Nantes Atlantique Airport , France.
Before starting the RNP approach for runway 21, the air traffic controller cleared the crew to descend to 3,000 ft with a QNH of 1002. The crew read back QNH 1021. During the final approach, the Minimum Safe Altitude Warning (MSAW) was activated.
The approach was continued and the aircraft landed uneventfully.
Contributing factors
The following factors may have contributed to the altimeter setting error:
• a high workload and the F-HMLD crew being excessively focused on the weather conditions associated with the ongoing storm, to the detriment of the application of the standard procedure, which included checking the consistency of the QNH value provided by the ATC against another source of information;
• the APP controller being distracted due to an imminent conflict in another sector of his area of responsibility for which he was preparing the resolution. As a consequence, the controller did not identify that the crew incorrectly read back the altimeter setting.
The following factors may have contributed to the non-detection of the erroneous final path:
• the inherent limitations of the Baro-VNAV function in the event of an altimeter setting error;
• the absence of appropriate safety measures in such situations - in particular, the “consistency check” procedure based on the radio altimeter value appears to be ineffective given the operational context at this point of the flight;
• the controller’s radar display using the standard altimeter reference to indicate the aircraft altitudes.
The following factors may have contributed to the reaction time to the MSAW:
• the QNH not being mentioned when the controller conveyed the warning;
• the word “immediately” not being used in the controller’s warning message;
• the surprise effect experienced by the crew.
Accident investigation:
 |
|
Sources:
https://www.bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-bombardier-crj-1000-registered-f-hmld-operated-by-air-france-hop-on-20-10-2021-near-nantes/
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 29-Oct-2021 08:52 | harro | Added |
| 29-Oct-2021 09:06 | harro | Updated [Time, Aircraft type, Operator, Narrative] |
Corrections or additions? ... Edit this accident description
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