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CRJ1, vicinity Brest France, 2003

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Summary
On 22 June 2003, a Bombardier CRJ100 being operated by Brit Air flew an inaccurate night ILS approach and impacted terrain over a mile from the runway during an attempted unsuccessful go-around at Brest Guipavas Airport.
Event Details
When June 2003
Actual or Potential
Event Type
Controlled Flight Into Terrain (CFIT), Fire Smoke and Fumes, Human Factors
Day/Night Night
Flight Conditions IMC
Flight Details
Aircraft BOMBARDIER Regional Jet CRJ-100
Operator Brit Air
Domicile France
Type of Flight Public Transport (Passenger)
Origin Nantes/Atlantique
Intended Destination Brest/Bretagne Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Missed Approach
APR
Location - Airport
Airport vicinity Brest/Bretagne Airport
CFIT
Tag(s) Into terrain,
Lateral Navigation Error,
IFR flight plan
FIRE
Tag(s) Post Crash Fire
HF
Tag(s) Distraction,
Ineffective Monitoring,
Data use error,
Procedural non compliance,
Inappropriate crew response - skills deficiency
Safety Net Mitigations
Malfunction of Relevant Safety Net No
GPWS Available but ineffective
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Non-aircraft damage Yes
Injuries Few occupants
Fatalities Few occupants ()
Off Airport Landing Yes
Causal Factor Group(s)
Group(s) Aircraft Operation,
Air Traffic Management
Safety Recommendation(s)
Group(s) Aircraft Operation,
Air Traffic Management
Investigation Type
Type Independent

Description

On 22 June 2003, a Bombardier CRJ100 being operated by Brit Air flew a inaccurate an unstabilised ILS approach to runway 26L at destintion at night and in IMC and impacted terrain following unsuccessful attempt at a go-around. The accident site was 2,150 meters from the runway threshold and 450 meters from the extended runway centreline. The aircraft struck several obstacles and caught fire. One of the 24 occupants died and four others were injured.

The Investigation

An Investigation was carried out by the French BEA. Their Report gives a summary of the events immediately after the decision of the crew to go-around:

"The Captain's announcement “Go around” at 21 h 51 min 16 sec occurred when the aeroplane arrived at the decision altitude, just after the GPWS/TAWS “One hundred” announcement and the Co-pilot stating “I've nothing in front”.

One second later, the engine parameters began to increase: there was therefore an immediate throttle input following the announcement. The first significant upward elevator deflection occurred three seconds after the beginning of the thrust increase. Given the nose-down pitching moment produced by the thrust increase, and loss of elevator efficiency due to low airspeed, the amplitude of the nose-up action was not sufficient to bring the aeroplane into an ascending flight path. The aeroplane pitch decreased from 0° to - 5°. That was where the first noise of impact was heard, at 21 h 51 min 22 s. The flaps and landing gear remained in the same configuration.

It is difficult to know what happened precisely in the cockpit during this sequence. The Co-pilot stated that as he had the impression that the Captain was passive, he had pushed on the TOGA button, moved the throttles and tried to modify the aeroplane's pitch by pulling back on the control column. The Co-pilot very probably had some input on the controls, but certainly later than he remembered. He stated that he made a rapid throttle input after activating the TOGA mode. However, this mode had been activated about four seconds after the start of the thrust increase. It is therefore likely that the throttle input was made by the Captain, partially or completely, and that the Co-pilot, when he intervened, may have completed the movement or indeed could have had the impression of pushing levers that were already in the full thrust position.

Causal and Contributory Factors

The outcome of the approach was attributed to inappropriate airraft management. According to the Report the causes of the accident were 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."

Safety Recommendations

The BEA recommended that:

  • "the DGAC [General Directorate for Civil Aviation] study the possibility of generalizing a procedure relating to passing through stabilization height, consistent with procedures relating to GPWS/TAWS alarms.
  • Brit Air ensure that the content of its Operations Manual is consistent.
  • 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 DGAC, in association with its foreign counterparts, put in place a training-approval regime concerning training of Crew Resource Management trainers.
  • the DGAC ensure the incorporation of such factors in CRM training.
  • the European Aviation Safety Agency (EASA) study the possibility of imposing the combining of localizer and glide information on instruments used for the approach phase.
  • 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.
  • the DGAC study the introduction into training and practice sessions for cabin crew of near-real situational simulations.
  • the DGAC impose carrying a megaphone when the presence of a cabin attendant is required by regulations.
  • 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.
  • 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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