Accident on 22 June 2003 at Guipavas (21)
to the Bombardier Canadair CL-600 2B 19
registered F-GRJS operated by Brit Air
report summary f-js030622a

Full report available in PDF

 

SYNOPSIS

Date and time

Aeroplane

22 June 2003 at 21 h 51 [1]

Bombardier Canadair CL-600 2 B 19 "CRJ-100"

Registered F-GRJS

   

Site of accident

Owner

Guipavas (29) (France)

Armor Lease

   

Type of flight

Operator

Public transport of passengers

Scheduled flight AF 5672

Nantes – Brest

Brit Air

 

Persons on board

 

2 Flight Crew

1 Cabin Crew

21 passengers

Summary

On an ILS approach to runway 26 Left at Brest Guipavas aerodrome, the aeroplane deviated progressively to the left of the normal runway approach track. It passed above and then below the glide path and descended until it touched the ground 2,150 meters from the runway threshold, 450 meters from the extended runway centreline. The aeroplane struck several obstacles and caught fire.

Consequences:

 

Persons

Equipment

3rd parties

 

Killed

Injured

Unhurt

   

Crew

1

1

1

Destroyed

-

Passengers

-

4 *

17

   

* including three seriously

3 - CONCLUSIONS

3.1 Findings

3.2 Probable Causes

The causes of the accident are as follows:

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.

4 - SAFETY RECOMMENDATIONS

4.1 Procedures in Force

At the time of the accident, Brit Air procedures did not call for an announcement when passing through the stabilization height. Such an announcement leads crews to establish a common strategy regarding continuation or missing the approach. Additionally, when issued by the PNF, it may encourage the latter to propose a go-around. The investigation also showed that the Brit Air Operations Manual made no connection between instructions on GPWS alarms and those relating to the stabilization height.

Consequently, the BEA recommends that:

The Brit Air Operations Manual is somewhat inconsistent, in particular with regard to the stabilization height and go-around actions.

Consequently, the BEA recommends that:

4.2 Flight Crew Training

The investigation showed an absence of awareness by Brit Air pilots regarding the low-speed characteristics of the CRJ-100. A similar observation had already been made in Canada following a December 1997 accident. Bombardier has put in place a balked-landing training program, but the latter constitutes only a partial answer to this awareness requirement.

Consequently, the BEA recommends that:

The investigation showed that training for CRM trainers was not subject to specific approval by the DGAC, and that end-of-training skills were not checked.

Consequently, the BEA recommends that:

The SFI functions of the Co-pilot and a small number of other pilots based at Brest could have contributed to the inadequate communication and co-ordination between the crew.

Consequently, the BEA recommends that:

4.3 Display of LOC and GLIDE Information

The option selected by Bombardier and Rockwell Collins for the display of localizer and glide information on the CRJ-100 PFD was to present the two items on the same screen but on two separate instruments, as permitted by the regulations. Utilization of an instrument such as the HGS, combining the two items, could have allowed the crew to detect non-capture of the localizer sooner.

Consequently, the BEA recommends that:

4.4 Interface between Crew and Air Traffic Control

The investigation highlighted the fact that the Controller, motivated by the desire to assist the crew, had changed strategy and cleared for approach belatedly. This could have contributed to precipitation in the cockpit during the preparation of the aircraft and the beginning of the approach.

It is therefore considered desirable for a multidisciplinary think-tank to evaluate the operational consequences on pilots of proposals from ground control and that the results of this study are made known to controllers. The BEA recently recommended “the DGAC introduce the notions of ground/crew resource management into the training and practice routines of controllers and pilots. Feedback data could be used effectively to this end”. This recommendation would appear to address the above issue.

An announcement of the type “report when established on the localizer” could have helped the crew to realize they had not captured the localizer. Similarly, procedures associated with use of the radar could have helped the Controller to realize that the final phase of the approach was not taking place normally.

Consequently, the BEA recommends that:

4.5 Evacuation

Due to the stress associated with the accident, the Cabin Attendant did not think to use the megaphone during the evacuation, and forgot to take the first-aid kit when leaving the aircraft. She could not remember the number of passengers aboard, and could not be certain that all had actually disembarked from the aircraft.

Consequently, the BEA recommends that:

Consequently, the BEA recommends that:

During the evacuation, one passenger opened an over-wing exit. Fire then penetrated the cabin. Opening an emergency exit without first verifying for possible outside hazards may in certain cases prove detrimental to safe evacuation.

Consequently, the BEA recommends that:

4.6 Flight Recorders

Exchanges in the cockpit were recorded solely on the cockpit area microphone. The poor quality of this recording did not enable a full reconstitution of cockpit communications.

Consequently, the BEA recommends that:


[1]  Except where otherwise noted, the times shown in this report are expressed in Universal Time Coordinated (UTC). Two hours should be added to obtain the legal time applicable in metropolitan France on the day of the accident.