On 26 September 2013, the crew of an Airbus A321 (TC-OBZ) being operated by Onur Air on an international passenger charter flight from Izmir to Deauville as OHY1985 lost positional awareness after being cleared to position to final approach at destination in day VMC by visual reference. EGPWS PULL UP Warnings were activated and a go around subsequently declared on short finals was then flown contrary to the standard missed approach procedure before a landing in the opposite direction was then achieved without further event.
The event was not reported to the French Civil Aviation Accident Investigation Agency but the next morning, the French Aviation Police (GTA) informed the BEA that a witness had seen an aircraft flying low over the sea the previous day. Examination of recorded radar data appeared to confirm such an occurrence and that it had involved the Onur A321. An Investigation was commenced the following day and after sight of the aircraft’s QAR data received after a request to the Turkish authorities eleven days after the event, the “seriousness of the incident was confirmed”. Non-reporting immediately after the occurrence resulted in relevant CVR data being overwritten. Data within the Mark 5 EGPWS memory was also available. Both pilots made statements to their airline and the Captain also submitted a Statement to the Investigation. The First Officer “claimed his retirement rights in the days following the incident (and) he refused to participate in the interviews proposed by the BEA”.
It was noted that the 35 year-old Captain, who had been PF for the flight, had 7,025 hours total flying experience which included 6,124 hours on type of which 1,347 hours had been in command, all of it after joining Onur Air two years previously. The 61 year-old First Officer had 8,043 hours total flying experience of which 2,008 hours were on type, all with Onur Air where he had been employed for 7½ years. Two controllers with similar qualifications were providing ATS at Deauville at the time of the event under investigation, both held English Language proficiency qualifications. It was noted that the Deauville TWR and APP positions are “grouped together” with one controller occupying a combined position as control tower manager and another similarly qualified controller responsible for “telephone co-ordination functions”.
With the flight cleared on a direct track to the runway 30 ILS approach IAF given by area ATC, the crew, who had briefed for an ILS approach to this runway based on the ATIS they had copied, were transferred to Deauville ATC and on first contact were advised that the runway in use had changed to runway 12. Since the only available instrument approach procedure for this runway was a GNSS procedure for which the crew were not qualified, they advised that they would make a visual approach which was approved. ATC then re-cleared the flight to the ‘DVR’ VOR which is situated 6nm southeast of the airport. The flight was subsequently cleared to turn right onto a left hand downwind leg. As the inbound aircraft neared the vicinity of the airport, ATC advised that a departing aircraft was backtracking the runway for departure and soon after this, the inbound aircraft crew, who had already selected the landing gear down and flaps 2, reported the field in sight and were cleared to continue descent below 3000 feet, their initial clearance limit, “at their convenience”. The crew then selected 1100 feet as a target altitude (this corresponded to the 1070 feet MDA for circling approach procedure to runway 12 for which clearance had not been given) and set the HDG bug to 300° and the target speed to 170 KIAS.
A couple of minutes later, ATC cleared the departing aircraft for takeoff and at that point, with the inbound aircraft downwind for runway 12 and clear of the departing aircraft climb out (position 4 in the illustration below), “the controllers’ attention then turned to the takeoff in progress (and) they no longer watched the manoeuvres of the Onur Air flight”. They had, however, advised that they would call the crew back to clear them to turn onto final approach. The ATC call came 20 seconds later when the inbound aircraft was at position 5 in the illustration and almost 1nm beyond the runway 12 displaced threshold and was to ask the aircraft to extend the downwind leg over the sea because of the departing aircraft. The AP was still engaged and the aircraft was approaching the selected altitude. After a further 30 seconds, with the aircraft now 2.3 nm from the runway threshold, ATC gave clearance for the inbound turn (position 6 in the illustration). The crew were visual with the sea surface and the coastline but no longer had the runway in sight. Selection of a descent rate of 650 fpm caused the AP to switch to VS mode as the aircraft began the left turn towards final approach. With the aircraft just below 1000 feet and just over 4 nm from the runway (position 7 in the illustration), the AP and both FDs were disconnected by the crew and full flap was selected.
The flight path of the aircraft derived from QAR data with positions referenced in the above text by a number sequence. [Reproduced from the Official Report]
The final approach to runway 12 up to the beginning of the go around showing the EGPWS ‘Terrain Ahead PULL UP’ (Warning 1) and the subsequent Mode 1 ‘Sink Rate’ (Warning 2). [Reproduced from the Official Report]
However, descent continued and as the turn onto final approach was completed, the aircraft was flying towards the coastline still descending and at an altitude not far above the cliffs ahead which were almost 500 feet amsl and at a similar height to the airport ARP of 472 feet amsl. As a result of this, an EGPWS “TERRAIN AHEAD” alert was activated for approximately 8 seconds with the aircraft at position 8 in the illustration. The Captain responded by making a nose-up input on his side stick which corresponded to about one third of the available maximum travel which changed the aircraft pitch attitude from 0.5° nose down to 12° nose-up. However, this did not stop the aircraft descending and an EGPWS Hard Warning “TERRAIN AHEAD PULL UP” of similar duration followed almost immediately at position 8 in the illustration). This time, as the aircraft reached its minimum height of 528 feet amsl (which corresponded to just 49 feet above the airport ARP when 3 nm from the runway threshold), the Captain reacted by a further increase of around one third of available maximum side stick travel nose-up input and this caused the aircraft pitch attitude to increase sufficiently for the aircraft to begin climbing. The crew reported that only then had they regained visual contact with the runway and having seen that they were left of the centreline, a corrective right turn was initiated.
Having safely crossed the coastline, the climb then continued above the 3.5° PAPI guidance before descent towards the runway commenced approximately 1½ nm from the runway threshold from an altitude of just over 1,100 feet. A further corrective alignment was made to finally establish on the runway extended centre using a 33° bank to the left. This manoeuvre triggered an EGPWS Mode 1 ‘SINK RATE’ Alert which prompted the Captain to discontinue the approach and the First Officer advised ATC that this was because they had lost sight of the runway due to the sun. They requested and obtained clearance for a visual approach on runway 30 following which the aircraft flew over the runway at a height of 300 ft and made a right turn onto a south easterly heading and upon reaching 1,100 feet then began a left turn onto a final approach to runway 30 and landed.
The two controllers on duty at the time stated that they had observed the Onur Air flight as it entered the downwind leg and kept it in sight until “the end of its downwind leg” after which “their attention then shifted to the aircraft taking off”. Later, the supporting controller reported having seen the aircraft “approaching, at a very low altitude, off-centre in relation to the runway and with a pitch-up attitude” and had informed his colleague who agreed to the crew’s subsequent request to re-position for a landing on runway 30. He reported having considered that "he should not interfere with the control of the flight and that the pilot was in the best position to choose an option”. Both controllers stated that they had not been “aware of the seriousness of the event and did not consider it necessary to notify it”.
The crew stated that “at no time did they feel that they were in danger of a collision with the terrain, all the more so because they thought they were being visually or radar monitored and that their flight path was protected”. They also added that “only the appearance of the TAWS alerts had made them aware of the aircraft's situation in the vertical plane and of the need to correct its flight path”.
Applicable Onur Air and ATC Procedures
It was noted that aircraft handling SOPs relevant to the approach contained in the Operations Manual were consistent with the corresponding Airbus procedures. These included a requirement that a visual approach must be conducted at a downwind leg altitude of 1500 feet aal without the AP and without the FD and with systematic use of external visual references. On turning base at the equivalent of 45 seconds in still air past the landing threshold, descent should be commenced and the landing gear extended with a mandatory go around if final approach is not stabilised at 500 feet aal.
It was also noted that, in the case of a Class ‘D’ CTZ such as the one at Deauville, “unlike ICAO documentation, French Air Traffic Regulations do not explicitly state that the aerodrome controller must conduct a visual watch of all the aircraft in the circuit” and that “the AIP does not specify a difference between the French regulations and ICAO Doc 4444 with respect to the monitoring and visual watching of aircraft in the aerodrome circuit”.
The Causes of the Serious Incident were formally documented as follows:
- an incomplete transition from the Circling Approach procedure to the Visual approach procedure. The crew kept the MDA as their target altitude during the downwind leg;
- a loss of awareness of the aircraft's situation in the vertical plane. The crew commenced and continued the descent under the final approach slope. However, when flying over the sea, crews may have a tendency to fly too low because the external visual references are insufficient to accurately estimate height;
- the crew and the ATC interpreted the flight path which the aircraft was to follow to reach the downwind leg differently. The controller expected a flight path corresponding to a visual approach while the crew initiated a Circling procedure.
Relevant Safety Action taken by Airbus in March 2016 was noted to have been the amendment of the FCOM in respect of daylight TAWS/EGPWS ‘red’ alerts removing pilot discretion on whether to respond with TOGA thrust and maximum pitch up. It was also noted that although it was not a consequence of the investigated event, European regulations make the inclusion of pilot training for GNSS procedures during initial training for an Instrument Rating compulsory by 25 August 2020 at the latest.
One Safety Recommendation was made as a result of the Investigation as follows:
- that the EASA draws the attention of airlines to the need to take into account in their risk-mapping, the skills that may in practice be required during visual approaches, according to the airports they serve. [Recommendation 2018-003]
The Final Report was published on 6 September 2018.