Incident Boeing 737-8AS (WL) EI-EMK, Thursday 29 January 2015
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Date:Thursday 29 January 2015
Time:14:20 LT
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8AS (WL)
Owner/operator:Ryanair
Registration: EI-EMK
MSN: 38512/3272
Year of manufacture:2010
Fatalities:Fatalities: 0 / Occupants: 172
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Bergerac-Roumanières Airport (EGC/LFBE) -   France
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:London/Stansted (EGSS)
Destination airport:Bergerac-Roumanières Airport (EGC/LFBE)
Investigating agency: BEA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The crew made a regular commercial flight from London Stansted Airport to Bergerac-Roumanière Airport. ILS and DME equipment at the destination was unavailable and the captain deduced from the approaches listed that RNAV (GNSS) approaches were not authorized for them.
The crew began the timed approach NDB Y for runway 28. During this procedure, when approaching the approach turn, the crew lowered the aircraft below the minimum safe altitude in V/S mode. An MSAW alarm was triggered in the Aquitaine-Approach control room. The descent continued for almost two minutes in a turn, in IMC, until the E-GPWS TERRAIN alert was activated. The airplane was then more than 8 NM from the runway threshold, to the left of the final approach axis, at an altitude of 1054 ft and a radio altiude of 842 ft. The crew aborted the approach; the “PULL UP” alarm activated at the same time.

Contributing factors
The incident occurred while performing an NDB approach without DME equipment, probably without external visual references.
The first preparation of the approach was probably incomplete or not precise. The clearance given by the controller, although it concerned the procedure that the crew thought theyhad prepared, seems to have called into question their action plan and obliged them to reprogramme the FMS.
This late modification probably meant that the crew did not have enough time to agree with each other about what guidance mode was to be used. This resulted in the captain’s confusion with respect to the horizontal path actually being followed by the aeroplane.
Faced with these doubts, rather than opting for a holding pattern or returning to a conventional management of the procedure, this state of confusion led him to request the anticipated start of descent, below the safe altitude. The following factors may have also contributed to this manoeuvre:
- The captain’s concerns, notably with respect to the noise nuisance in his headset which he perceived as extremely uncomfortable, and his concerns as to the first officer’s participation.
- The first officer’s small amount of experience in this type of approach, which, at the very least, did not enable him to perceive the inconsistency in the request given by the captain.
The following factors may have contributed to the descent being continued below the safe altitude for nearly two minutes until the activation of the E-GPWS “TERRAIN” alert, even after the activation of a MSAW:
- The two pilots’ situational awareness which was at that time seriously impaired.
- The controllers’ lack of knowledge of the NDB procedures which meant that they did not effectively monitor the aeroplane’s path.
- The absence at Bergerac of a MSAW system (or a remote MSAW display) and, failing this, the absence of emergency coordination procedures between Aquitaine-Approach and Bergerac on the activation of a MSAW.

Accident investigation:
cover
  
Investigating agency: BEA
Report number: 
Status: Investigation completed
Duration: 5 years and 5 months
Download report: Final report

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-du-boeing-b737-800-immatricule-ei-emk-exploite-par-ryanair-survenu-le-29012015-en-approch/

Revision history:

Date/timeContributorUpdates
26-Jun-2020 17:04 harro Added
08-Sep-2020 17:05 harro Updated [Narrative, Accident report, ]

Corrections or additions? ... Edit this accident description

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