On 16 October 2012, a Bombardier CRJ 700 (F-GRZE) being operated by Air France subsidiary Brit Air on scheduled domestic passenger flight from Paris Orly to Lorient under callsign BZ 937QL overran the runway during a night landing in normal ground visibility at Lorient by 200 metres damaging ground installations in the process. The aircraft sustained significant damage and an emergency evacuation took place but there no injuries to the 57 occupants.
An Investigation was carried out by the French BEA and was aided by successful download of the Flight Data Recorder (FDR) (although this did not record the applied brake pressure) and the 30 minute Cockpit Voice Recorder (CVR). It was found that both members of the flight crew had significant experience on the aircraft type involved.
The Automatic Terminal Information Service (ATIS) information broadcast by the French Navy-operated aerodrome 20 minutes prior to the accident indicated that a precision approach radar to runway 07 should be expected, that the runway was “wet with puddles” and that the wind velocity was 170°/18 knots with the lowest cloudbase 1000 feet aal. Shortly after thus, the controller advised the wind velocity as 160°/17 knots gusting to 26 knots as a significant and severe squall passed through the area of the aerodrome. They also advised of visibility reduced at times to between 2000 and 3,000 metres in rain and advised that the previous landing aircraft had reported aquaplaning.
The crew, with the aircraft commander designated as PF, to request an Instrument Landing System (ILS) approach to runway 25 which they “believed to be compatible with the prevailing crosswind and gusts advised by ATC” and this was approved. The applicable VApp was calculated as 140 KIAS and a flap 30 landing was briefed. Passing 1000 feet agl, the applicable stabilised approach criteria were satisfied and the crew became visual with the runway at approximately 800 feet aal. However, the speed gradually increased reaching more than 10 knots in excess of VApp “without the crew seeming to notice” and the callouts and mandatory go-around required by Brit Air SOPs in case of such subsequent de-stabilisation did not occur.
The aircraft crossed the threshold of the 2230 metre-long runway at a height of 54 feet agl and at a speed of 154 KIAS with a tailwind component subsequently found to have been 4 knots. Thrust reduction to flight idle was made over the TDZ with the aircraft at 17 feet agl but it then floated for approximately 800 metres before an unintentionally ‘soft’ touchdown was made with the aircraft at 140 KIAS and with only 1100 metres of runway remaining. Maximum reverse thrust was applied but “the remaining distance did not allow the crew to stop before the end of the runway” and the aircraft overran the end at a groundspeed of 66 knots. The left wing hit the localiser antennae before the aircraft came to a stop in a grass field approximately 200 metres beyond the end of the paved runway surface. The order to evacuate was given by the flight crew and used the left front door and the two over wing exits.
The PF subsequently reported having had difficulty in estimating the altitude of the aeroplane because of the absence of runway centreline lighting and the FDR showed that multiple inputs had been made on the controls at this time in an attempt to keep the aircraft on the runway centreline. He reported afterwards having focussed on control of the aircraft “because he did not know how far from the threshold he was landing”. The crew were unaware that the landing was long and “at no time did they envisage a go-around”.
It was noted from the CVR that “extra-professional conversations were exchanged during the flight, specifically below FL 100 during the descent” and had affected flight deck monitoring and the proper use of Checklists. There was also evidence of fatigue on what was the fifth and final sector of the day’s flying duty for both pilots.
It was found that the pilot training regime in place at the time of the accident had “made it impossible for crews to understand some of the threats facing them during operations”. Although pilot recurrent ground training had recently been changed to add a TEM element, the same had not been done for simulator sessions. In addition, at the time of the accident, only the aircraft commander had received the revised ground training and so the accident aircraft crew was therefore “not predisposed to apply it”. It was also noted that simulator sessions did not include night-time scenarios and that “simulation of runway contamination is not possible on the simulators used”. The overall effect was considered to be that Brit Air crews “were therefore not trained to react to certain degraded conditions that they might encounter in operations”.
The oversight of operational safety at Brit Air was also examined and it was concluded that processes were inadequate and that “the operator had no accurate perception of the safety performance of its operations”.
It was noted that Lorient Naval Base was classified by Brit Air as a Category C aerodrome but neither ground training nor Part C of the Operations Manual provided crews with information on the specific details of the poorly-visible runway markings and the location of known water retention areas on runways. It was also found that there was local awareness of both these problems and corrective action had been planned but not implemented at the time of the accident.
Although it was clear that there had been water on the runway at the time of the accident landing, depth of the water was not determined. It was concluded that the landing distance required on a wet runway was less than the LDA but that the landing distance on a contaminated runway was greater than the LDA. Given the late touchdown it was considered that the actual landing performance of the aeroplane was compatible with a water-contaminated runway.
The Investigation formally concluded that the Cause of the Accident was “the crew deciding not to reject the landing although they were not aware either of the degree to which runway conditions were contaminated or of the remaining length of runway available”. It was further concluded that:
“Continuing the landing can be explained by insufficient situational awareness (linked to crew performance degraded by fatigue and routine and unfamiliarity with safety margins and inadequate TEM training) and to an approach to safety by the Operator that did not encourage crews to question their plan of action”.
Seven Contributory Factors were also identified as follows:
- The crew’s under-estimation of the meteorological conditions;
- Operational instructions that were sometimes unclear or contradictory, thereby undermining teamwork;
- The characteristics of runway 25, which were also not documented in the Brit Air Operations Manual;
- The organisation of aerodrome operations that contributed to the deviations identified concerning runway 25 not being corrected in a timely manner;
- A lack of common phraseology that would guarantee crews and controllers to have a shared comprehension of the true condition of the runway;
- The organisation of training and checks that prevented the operator from recognising and improving its safety performance;
- Incomplete integration of the risks of fatigue by the airline.
Safety Actions taken as a result of the accident were recorded as including the following:
Brit Air has:
- Required that landings in suspected wind shear conditions on this aircraft type must be made with flaps 45°
- Required that touchdowns must occur as near as possible to the aiming points with a tolerance of 300 metres
- Modified pilot ground training to rectify identified deficiencies
Bombardier has published a Flight Operations Note (FON) to remind crew that when landing the CRJ-700/705/900/1000 in suspected or known wind shear, require normal landing in the flaps 45° configuration.
Lorient Naval Air Base has completed repainting of the runway markings.
Fifteen Safety Recommendations were made as a result of the Investigation as follows:
- that DGAC ensure that this safety information be known to all aerodrome operators, including those under the Ministry of Defence, that operate aerodromes for use by civil aviation [Recommendation FRAN-2013-068]
- that DGAC link renewal of its approvals to the good condition of ground markings [Recommendation FRAN-2013-069]
- that EASA study, for aerodromes used by commercial civil aviation, the mandatory installation of additional ground facilities to improve night flight support systems for pilots on runways approved for Cat I precision approaches [Recommendation FRAN-2013-070]
- that in the meantime, DGAC make the installation recommended in "Safety Information" no2012/02 mandatory for all operators of aerodromes for use by civil aviation. [Recommendation FRAN-2013-071]
- that DIRCAM (the Directorate of Naval Air Safety) and DGAC jointly ensure that the French Navy General Staff takes steps to make it possible to improve drainage and to eliminate areas of water retention all over runway 25 in the shortest possible time. [Recommendation FRAN-2013-072]
- that in the meantime, DGAC put in place TEM awareness programmes for holders of an AOC. [Recommendation FRAN-2013-074]
- that DGAC check that operators holding an AOC take TEM into account in their Safety Management System. [Recommendation FRAN-2013-075]
- that DGAC ensure that operators holding an AOC put in place systems allowing representative assessment and follow-up of the proficiency level of their crews. [Recommendation FRAN-2013-076]
- that DGAC ensure that the measures implemented within the framework of an SMS are adapted to prevent fatigue and, where appropriate, to mitigate its effects. [Recommendation FRAN-2013-077]
- that Brit Air revise the process of checking and updating documentation and improve both the lead times for changes and the overall consistency of the various items of documentation [Recommendation FRAN-2013-078]
- that Brit Air ensure that Part C of their Operations Manual indicates the features of runways, notably information about their ground markings (details and condition) and surface condition. [Recommendation FRAN-2013-079]
- that DGAC ensure, in the context of its oversight actions, that all operators (of aircraft and aerodromes) and ATC service providers take into account, in the context of their SMS and operations, the lessons learned from the symposia organised by the DGAC. [Recommendation FRAN-2013-080]
- that DGAC check that operators of aerodromes and of aircraft holding an AOC evaluate the recommendations of the European Action Plan (EAPPRE) through their own SMS. [Recommendation FRAN-2013-081]
- that DSAC (the Civil Aviation Safety Directorate) and DIRCAM study the possibility of extending, to military aerodromes that handle civil traffic, the requirements for certification and safety management applicable to civil aerodromes with equivalent traffic. [Recommendation FRAN-2013-082]
The Final Report was published in English translation on 18 March 2014 following initial publication in French on 16 October 2013.