Serious incident Airbus A321-231 TC-OBZ, Thursday 26 September 2013
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Date:Thursday 26 September 2013
Time:10:18
Type:Silhouette image of generic A321 model; specific model in this crash may look slightly different    
Airbus A321-231
Owner/operator:Onur Air
Registration: TC-OBZ
MSN: 811
Year of manufacture:1998
Total airframe hrs:38700 hours
Cycles:25500 flights
Engine model:IAE V2533-A5
Fatalities:Fatalities: 0 / Occupants: 227
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:5,6 km WNW of Deauville-Saint Gatien Airport (DOL) -   France
Phase: Approach
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Izmir-Adnan Menderes Airport (ADB/LTBJ)
Destination airport:Deauville-Saint Gatien Airport (DOL/LFRG)
Investigating agency: BEA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Onur Air flight OHY 1985 departed Izmir, Turkey, on a charter flight to Deauville, France. The captain was Pilot Flying (PF) and this was his first flight to Deauville.
The flight crew prepared for an ILS approach for landing on runway 30 as the ATIS information indicated that this was the runway in use. This subsequently changed to runway 12. On first contact with the Deauville Approach controller at 10:07, the crew was informed that the active runway had changed and that another aircraft was preparing to take off ahead of them.
The controller suggested a runway 12 GNSS approach. However, the flight crew was not qualified for GNSS approaches. The crew radioed that they were preparing for a visual approach, but they prepared for a circle-to-land procedure.
When the controller requested to report downwind, the PF interpreted this message as an instruction to turn right. From that point on, the crew no longer followed standard procedures but mixed the circle-to-land procedure and visual the approach.
The flight descended to the MDA of 1100 ft AAL during the downwind leg and then continued the descent into the last turn under the glidepath for the final.
At 10:18:44, the TAWS "terrain ahead" alarm sounded for about eight seconds. The PF reacted by initially applying a pitch-up command. The aircraft attitude changed from 0.5° to 12° nose-up. At 10:18:52, a second "Terrain ahead pull up"-alarm sounded for approximately seven seconds. At this time, the aircraft was at a minimum recorded altitude of 528 ft (49 ft above the aerodrome) and 3 NM from the runway threshold. The PF reacted by reapplying a further pitch-up command. The attitude of the aircraft increased towards 16°.
The aircraft climbed again and the crew regained visual contact with the runway and realized that they were to the left of the centreline. As the aircraft, still climbing, approached the coast, the PF began a turn to the right. The controller saw the aircraft in an unusual attitude and asked: "One nine eight five, you are going around ?".
The crew responded that they were landing. The Tower controller then radioed: "Cleared to land, zero seven zero degrees, five to eight knots." The aircraft passed over the glide path indicated by the PAPI lights.
At about 1.5 NM from the threshold and at an altitude of 1,144 ft, the PF resumed the descent, decreasing the attitude to -1° to nose-down, and began the last left turn by banking the aircraft to 33° to align with the runway centreline. A TAWS "sink rate" alarm was then triggered for approximately three seconds.
The PF then contacted the controller, stating: "Onurair one nine eight five, (*) request circle to land for runway three zero, we are not able to land in 12 now."
The captain then explained on the frequency that they lost visual contact with the runway because of the sun. He requested and obtained clearance for a visual approach to runway 30.
The read back of the controller's clearance was done by the PF and PNF simultaneously.
The aircraft passed over the runway at a height of 300 feet. The crew retracted the flaps to position 3 and the PF began a right turn after passing the Deauville Airport. The aircraft climbed to a height of 1100 feet on a heading of 150 degrees and then began a left turn to align on runway 30. At the end of the turn, the crew selected the flaps in the full extended position and the TAWS glideslope alarm activated for approximately two seconds. At 10:23:28, the aircraft landed on runway 30.

The controllers did not observe the aircraft's track on final. A TAWS warning caused the crew to climb to a safe altitude from which they continued the approach.

Causes of serious incident
The crew announced a visual approach on the radio but prepared for an MVL procedure. When the controller requested the crew to call back at the beginning of the downwind leg, the PF interpreted this message as an order to turn right. From this point on, the crew no longer followed a standard procedure but mixed up the MVL procedure with the visual approach procedure. They descended to the MDA (1,100 ft AAL) in the downwind leg and then continued the descent in the final turn under the final approach slope. The minimum recorded altitude was 528 ft (i.e. 49 ft above the aerodrome) at a distance of 3 NM from the runway threshold.
The serious incident was caused by:
- an incomplete transition from the MVL procedure to the visual approach procedure. The crew kept the MDA as their target altitude in 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 represented 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 an MVL procedure.
The controllers did not watch the aircraft's flight path on the final approach. The crew's response to the occurrence of TAWS alerts probably prevented a collision with the coast.

Accident investigation:
cover
  
Investigating agency: BEA
Report number: tc-z130926
Status: Investigation completed
Duration: 4 years and 6 months
Download report: Final report

Sources:


History of this aircraft

Other occurrences involving this aircraft

29 September 2005 JA102A All Nippon Airways - ANA 0 90 km ESE of Chubu International Airport non
20 May 2018 TC-OBZ Onur Air 0 Volgograd International Airport (VOG/URWW) min
Loss of pressurization

Location

Images:


photo (c) BEA; Deauville-Saint Gatien Airport (DOL); 26 September 2013

Revision history:

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