F900 / BT36, Bremgarten Germany, 2018
F900 / BT36, Bremgarten Germany, 2018
Summary
On 28 April 2018, a Dassault Falcon F900B came into close proximity with a Beech B36T Bonanza at the uncontrolled VFR-only aerodrome at Bremgarten during its tailwind approach to runway 23 made without contacting the designated Flight Information frequency as the other aircraft was on approach to runway-in-use 05 and in contact with Flight Information. The Beech pilot took avoiding action by turning north and climbing in order to avoid a collision. The Falcon 900 crew had not prepared for the approach which was then unstabilised with late gear extension and multiple EGPWS ‘SINK RATE’ warnings annunciated.
Flight Details
Aircraft
Type of Flight
Public Transport (Non Revenue)
Flight Origin
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Descent
Flight Details
Aircraft
Type of Flight
Not Recorded
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Missed Approach
General
Tag(s)
Approach not stabilised,
Aircraft-aircraft near miss
HF
Tag(s)
Procedural non compliance
LOS
Tag(s)
Near Miss,
Uncontrolled Airspace
Outcome
Damage or injury
No
Non-aircraft damage
No
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Aircraft Operation
Safety Recommendation(s)
Group(s)
None Made
Investigation Type
Type
Independent
Description
On 28 April 2018, a Dassault Falcon F900EX (I-TARH) being operated by the Chicago Jet Group on a positioning flight from Catania to Bremgarten with just the flight crew on board positioned onto a tailwind final approach to runway 23 at destination in day VMC without contacting the AFISO. It then continued an unstabilised approach which generated multiple EGPWS warnings to a landing which forced a Beech B36T Bonanza (D-EBCF) on short final to the runway in use 05 to break off its approach and initiate avoiding action overflying the F900 as it touched down by 225 feet.
Investigation
An Investigation of ATC communications was carried out by the German Federal Bureau of Accident Investigation (BFU). The F900 was not fitted with a FDR nor required to be but the 2 hour CVR was “seized” but relevant data was only found on channels 2 (right seat pilot) and 4 (area microphone) and this was successfully downloaded. Useful recorded ATC radar data from Strasbourg was provided by the French ANSP and recorded R/T communications (in German) were provided by Bremgarten and (in English) by Zurich ACC, the last frequency worked by the F900 before landing at Bremgarten.
The F900 flight crew consisted of a 52 year-old Captain with an FAA-issued ATPL (airline transport pilot licence) who had a total of 13,015 hours flying experience of which “about 2,235 hours” were on type and a 43 year-old Co-pilot, also with an FAA-issued ATPL, who had a total of 12,610 hours flying experience of which 1,652 hours were on type. The 70 year-old Beech 36TC pilot held a German-issued PPL and had recorded a total of 2,902 hours flying experience up to a date four weeks after the investigated event had occurred.
What Happened
With the Beech 36TC already in contact with the Bremgarten AFISO and established on final approach for the runway in use 05, the Dassault F900, with the Captain acting as PF, called on a no longer used Bremgarten frequency (122.0 MHz) that it was on final approach to runway 23 prefacing the call with “Bremgarten Control”. This call was made one minute before the subsequent touchdown. Twenty five seconds after this, the F900 gear warning was annunciated followed approximately 15 seconds later - 10 seconds before touchdown - by four EGPWS ‘Sink Rate’ warnings. The landing checklist was completed at 100 feet agl after which the PF first noticed the opposite traffic - the Beech 36 - and exclaimed “guy is coming right at us”. The Beech 36 pilot saw the F900 and decided that an immediate avoidance manoeuvre was appropriate and initiated a climb and then a left turn which resulted in him overflying the F900 as it touched down.
It was noted that as Bremgarten was only approved for use by aircraft with an MTOW not exceeding 20 tonnes, the intended use of the aerodrome by a Falcon 900EX (MTOW 22,226kg) required that an exceptional authorisation must be issued in advance by the appropriate regulatory authority, in this case, the Stuttgart Roads and Traffic Regional Council acting in accordance with the German Federal Aviation Act and the sections 18 & 24 of the German Aviation Regulation. This had been done and permitted the specific aircraft advised to make one landing and one take off during the period 28-30 April 2018.
The approximate ground tracks of both aircraft superimposed on the Bremgarten Chart. [Reproduced from the Official Report]
Why It Happened
The context for the potentially dangerous operation of the F900 was examined by the Investigation. It was found that despite the relatively long en-route flight time of the F900, no attempt whatsoever had been made by its crew to prepare for their arrival at Bremgarten in advance of arriving in its vicinity - had they consulted the published ‘Visual Operation Chart’ for Bremgarten, they would have had AFIS frequency to hand. Their IFR flight plan was terminated with Zurich ACC in the vicinity of the ‘HOC’ DVOR located approximately 26nm south of Bremgarten about 4 minutes before the subsequent landing after which the flight requested and was given the Bremgarten frequency - initially incorrectly as the old frequency 122.0 MHz but then corrected this to 124.030 MHz (to which it had been changed from 1 January 2018 and a NOTAM issued). Permission to leave the ACC frequency followed.
One minute earlier, the flight crew had noticed that the wrong arrival aerodrome had been selected in the FMS and this had been corrected by the Captain who then gave an approach briefing including a landing distance calculation for runway 05. The Copilot attempted to contact Bremgarten and said the flight was “currently 5 miles to the south east inbound to land on runway 23” but used the incorrect frequency. Approximately 30 seconds later, the PF requested the initial approach flap setting and the Copilot asked if the speed brakes could be retracted again but was told not.
About 75 seconds prior to landing, prompted by a gear status warning, the PF called for landing gear down and told the Copilot to “observe the airspace” as he flew the aircraft towards the runway 23 final approach. The Copilot then asked the Captain if they were going to land on runway 05 in which case they would have to turn downwind to which the Captain replied that he intended to land on runway 23. The Copilot followed this with “we are going to land 23 with tailwind?” and received the response “it‘s a crosswind”. An updated approach briefing for runway 23 was not performed. On short final, the Copilot called again on the incorrect frequency to advise that the flight was on final approach to runway 23. As the landing checklist was completed around 100 feet agl, the Captain finally saw the opposite direction aircraft straight ahead and having seen it begin to climb continued to touchdown. The Beech 36TC pilot saw the other aircraft and in agreement with the AFISO, he began a climb.
Four Contributory Factors were formally identified as:
- Insufficient airspace observation by the Falcon 900B flight crew.
- Selection of an invalid radio frequency by the Falcon 900B crew as a result of insufficient pre-flight preparation.
- Insufficient Crew Resource Management within the Falcon 900B crew - the Captain failed to make a timely brief on the planned landing direction.
- The Falcon 900 pilots’ self-generated time pressure caused by the Captain’s spontaneous decision to change the landing direction which led directly to a late configuration of the aircraft for landing and resulted in an unstabilised approach.
The Final Report of the Investigation was completed on 11 May 2022 and released later the same month. No Safety Recommendations were made.
