If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user

 Actions

MD83, vicinity Nantes France, 2004

From SKYbrary Wiki

Summary
On 21 March 2004, an MD-83 operated by Luxor Air, performed an unstabilised non-precision approach (NPA) to runway 21 at Nantes Atlantique airport, at night and under IMC conditions, which resulted in near-CFIT and a go around contrary to the standard missed approach procedure.
Event Details
When March 2004
Actual or Potential
Event Type
Controlled Flight Into Terrain (CFIT), Human Factors
Day/Night Night
Flight Conditions IMC
Flight Details
Aircraft MCDONNELL DOUGLAS MD-83
Operator Luxor Air
Domicile Egypt
Type of Flight Public Transport (Passenger)
Origin Luxor International Airport
Intended Destination Nantes/Atlantique
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Missed Approach
APR
Location - Airport
Airport vicinity Nantes/Atlantique
General
Tag(s) Approach not stabilised,
Non Precision Approach,
Event reporting non compliant,
Inadequate Aircraft Operator Procedures,
Inadequate ATC Procedures
CFIT
Tag(s) Into terrain,
Lateral Navigation Error,
Vertical navigation error
HF
Tag(s) Distraction,
Ineffective Monitoring,
Manual Handling,
Data use error,
Procedural non compliance,
Inappropriate crew response - skills deficiency
Outcome
Damage or injury No
Aircraft damage None"None" is not in the list (Minor, Major, Hull loss) of allowed values for the "Aircraft damage" property.
Injuries None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Injuries" property.
Fatalities None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Fatalities" property. ()
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness,
Air Traffic Management
Investigation Type
Type Independent

Description

On 21 March 2004, an MD-83 operated by Luxor Air, performed an unstabilised non-precision approach (NPA) to runway 21 at Nantes Atlantique airport, at night and under Instrument Meteorological Conditions (IMC) conditions, which resulted in near-Controlled Flight Into Terrain (CFIT) and a go around contrary to the standard missed approach procedure.

Luxor Air Nantes

Synopsis

This is an extract from the official report of the incident published by the Bureau d'Enquêtes et d'Analyses (BEA) pour la Securite de l’Aviation Civile, France:

“…the crew was cleared to descend towards 3,000 ft, and was then cleared for approach…The airplane was then on a 330° heading on autopilot in NAV mode (GPS navigation). The co-pilot selected VOR/LOC mode to intercept the 043° radial inbound on the NTS VOR. The airplane was configured for landing and the Captain told ATC…that he planned to descend from three thousand feet to five hundred feet then..[1 minute later]that the airplane was established on the approach radial.

Note that the MDA is 500 feet but the approach includes a series of step-down fixes, see the approach plate below:

LFRS Approach plate. Reproduced from the Official Report.

The crew then noticed, on the navigation instruments, that there was a variation of about 0.8 NM between the airplane’s route and the localizer radial. The VOR CAP indicator was displayed on the FMA. The co-pilot changed the autopilot to HDG SEL to intercept the radial with a selected heading of about 250°.

8 NM DME away, a short time before the airplane crossed the radial, the Captain asked the co-pilot to continue on that heading in order to go around a stormy area that he thought he had identified on the weather radar…The airplane made its descent at an average rate of descent of a little less than 1,000 ft/min5.08 m/s
. The crew reported suffering significant turbulence during this phase.

…the controller intervened to say that the airplane seemed to him to be too low. The Captain asked the co-pilot to select ALT HOLD and told the controller that he was maintaining five hundred feet. In addition, the co-pilot decided to go back towards the radial with an 80° left turn via the HDG SELECT mode. Coming out of the turn, the airplane probably broke through the cloud layer and a [ground] witness then noticed that it was starting a go-around…the Captain announced the go-around to the controller.

[at 6 DME the aircraft should have been at a minimum altitude of 1730 feet]

The airplane climbed towards three thousand feet. As it was passing through the radial on a 170° heading, the controller informed the crew that they could start descending again. The Captain answered that he preferred to perform the [standard] approach again. The controller vectored them and gave them the altitude cues during the descent.

Radar data and radio communications - click on the image to enlarge.
Reproduced from the Official Report.

The second approach and the landing were uneventful.

The Cause of the serious incident was given as:

The direct cause of the incident was a combination of different factors that led the crew to abandon standard operating procedures:

  • the incorrect interpretation of meteorological data from the weather radar;
  • lack of knowledge of protected areas and, more generally, lack of skill in VOR DME procedures;
  • improvising an action (deviation from the procedure) without any defined or shared plan of action.

The following is stated as contributory factors to the serious incident:

  • lack of training in Crew Resource Management by the operator;
  • the weakness of the operator’s feedback structure;
  • discomfort and stress due to meteorological conditions;
  • the crew's perception of the meteorological conditions, which both led to an erroneous interpretation of the weather radar data and, further, led them to fail to take into account the effects of the wind on the descent profile;
  • the difficulty in checking and cross-checking from the time the crew deviated from the final approach path;
  • a deviation within the air traffic control organisation between the established procedures and practice, which led to some non-published approach paths;
  • lack of synergy between the controller and the crew;
  • a probable hypo vigilance phenomenon on the part of the controller, who was alone at his work station at the time.

The Report's recommendations, beginning on page 49, also focus on institutional and organisational issues including the airline operator and the air traffic control service provider (see Further Reading).

Related Articles

Further Reading

For further information see the full serious incident report published by BEA.