PA46, Courchevel France, 2019

Summary: 

On 8 February 2019, a Piper PA46-350P overran the landing runway at Courchevel and collided with a mound of snow which caused significant damage to the aircraft but only one minor injury to a passenger. The Investigation noted that the experience of the Captain was inadequate but the investigation effort was primarily focused on the risk which had resulted from a commercial air transport flight being conducted without complying with the appropriate regulatory requirements for such flights and without either the passengers involved or the State Safety Regulator being aware of this.

Event Details
When: 
08/02/2019
Event Type: 
Day/Night: 
Day
Flight Conditions: 
VMC

32878

Flight Details
Type of Flight: 
Public Transport (Passenger)
Flight Origin: 
Intended Destination: 
Take-off Commenced: 
Yes
Flight Airborne: 
Yes
Flight Completed: 
No
Phase of Flight: 
Landing
Location - Airport
Airport: 
General
Tag(s): 
Approach not stabilised, Copilot less than 500 hours on Type, Deficient Crew Knowledge-handling, Inadequate Aircraft Operator Procedures, Ineffective Regulatory Oversight, PIC less than 500 hours in Command on Type, Safety pilot present, Deficient Pilot Knowledge
HF
Tag(s): 
Inappropriate crew response - skills deficiency, Procedural non compliance
RE
Tag(s): 
Overrun on Landing, Excessive Airspeed, Late Touchdown
Outcome
Damage or injury: 
Yes
Aircraft damage: 
Minor
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): 
Aircraft Operation
Investigation Type
Type: 
Independent

Description

On 8 February 2019, a Piper PA46-350P (F-GUYZ) being privately operated for commercial air transport purposes on a non-scheduled IFR domestic flight taking three ticketed business passengers from Toussus-le-Noble to Courchevel failed to stop before reaching the end of the destination landing runway after a day VMC approach was followed by a late touchdown. It then collided with a snow bank resulting in damage to aircraft but the five occupants were uninjured.  

Investigation

An Investigation into the Accident was carried out by the French Civil Aviation Accident Investigation Agency, the BEA. Relevant flight data was recovered from the aircraft’s avionics suite memory card and information concerning the conduct of the flight was available in statements by the two pilots on board and from videos taken by the passengers. The wider and somewhat complex circumstances under which the flight had been performed were established by widening the scope of the Investigation. 

The Context for the Accident

The 23 year-old Captain was a self-employed pilot who held a CPL/IR obtained 2½ years earlier and had a total of 398 hours single pilot flying experience on single piston-engined aircraft which had been acquired mainly by undertaking glider towing or parachute drop flights. He had flown a total of 10½ hours in the three months preceding the accident under investigation. The specific training which he had required to obtain an authorisation to operate into the Courchevel mountain airport had been completed two months earlier in a Jodel D140 and had been paid for by the company for which he was to be contracted when required as a freelance pilot. It had consisted of 6 landings at Courchevel with a suitably qualified Instructor. He had taken his skill test on the Piper PA-46, which consisted of two visual circuits with an Instructor at Orléans Saint-Denis-de-l’Hôtel the day before the accident after being provided with a PA-46 AFM by the same company who had contracted him to operate the flight to Courchevel. This meant that he had only ever operated into Courchevel once before with an Instructor and not in a PA-46 or similar aircraft and had only previously flown a PA-46 for 25 minutes with an Instructor who was unfamiliar with flight into any mountain airport in any aircraft type. This latter instructor, aware that the Captain would be making a commercial flight to Courchevel the following day, had advised him to increase his approach speed there by 5 to 7 knots when operating the PA-46.    

The company for whom the pilot was working on the accident flight was paid per flight by the passengers and invoiced them for their flights on behalf of the separately contracted pilots and aircraft owners to whom they then paid some of the money received from the passengers. This company was called ‘Big Blank’ and was visibly presented as an Air France-KLM Group subsidiary (which it was) - its Chief Executive Officer was a pilot employed by Air France. This company received passengers’ flight payments via a bank account with the name “Big Blank c/o Air France/KLM”. For the purpose of advertising flight availability, it operated a website called ‘Bluewings’ which described this website (www.bluewings.aero) (in very small print) as “a platform for private flights, connecting aeroplane owners, pilots and passengers”. Courchevel mountain airport was the first destination to be offered on the Bluewings website. 

No tickets were issued to passengers, just invoices from Big Blank for the flights provided. The accident aircraft had been dry leased from its owner by Big Blank for a period of one month subject to a maximum use of 15 hours. The recruitment of contracted pilots by the company was achieved by advertising on “specialised websites” and specifying that pilots had to have at least a CPL (Commercial Pilot License). Selected applicants were interviewed only to check their licences, ratings and site authorisations and no theoretical or practical selection process was followed. Although the Company “wanted the flights to be performed by two pilots”, there was no specified division of tasks for such flights and in the case of a two pilot flight, the pilots involved were expected to agree with each other on how to share the remuneration received for a flight. The accident flight Captain was aware that a ‘Safety Pilot’ would accompany him on the flight and had been informed that they would be a CPL holder.

In fact, the 22 year-old “Safety Pilot” travelling on the accident flight was only a PPL (Private Pilot License) holder who had recently completed the requirements for the grant of a CPL in 2018 but had not yet been issued with such a licence. This pilot stated to the Investigation that he had been called by a friend who worked for Bluewings to offer the opportunity to act s ‘Safety Pilot’ on the planned flight. He added that he had “explained to the caller that he did not hold a site authorisation for Courchevel, a mountain rating or a PA-46 rating” and specified that he had accepted the offer for the pleasure of flying and had not been paid. He was told by Bluewings that his presence on the flight “was just to reassure the passengers”. Having been contacted by the Captain contracted to operate the flight the day before and informed how the flight was going to be conducted, he had taken no part in the pre-flight preparations and had boarded the aircraft at the same time as the passengers. Once in the right hand cockpit seat, he had carried out the takeoff checklists with the Captain and conducted radio communications on request, although as the destination neared, the Captain had “managed radio communications on his own”. He added that during the approach, he had read out the landing checklist for the Captain.  

It was noted that the passenger who organised the flight, who was aware of a recent PA-46 fatal accident which had no direct connection to either Big Blank or its contractors, had been explicitly re-assured by a Big Blank employee that the “two qualified pilots” who would be operating the flight “knew the Courchevel mountain airport procedures well”. When the passengers arrived at the departure airport for their flight already confident that “Bluewings was linked to Air France”, their observation that “the same clothes (white shirt and navy pullover) were worn by the pilots had further reinforced their belief that they were travelling with an airline”.

What Happened

Prior to the accident flight, the Captain carried out the pre-flight inspection of the aircraft and uplifted fuel. He also called the Courchevel Aerodrome Flight Information Service (AFIS) agent to obtain the latest weather and was informed that the runway was clear of snow and “suitable for the PA-46” and filed an IFR Flight Plan. He was the last to board the aircraft (after the passengers) and on doing so carried out a passenger safety briefing covering de-pressurisation and the use of the oxygen masks and the procedure for an emergency evacuation. The flight proceeded uneventfully and as they passed abeam Geneva, he cancelled the IFR flight plan and initially continued towards the Courchevel overhead to inspect the airport visually and noted that the wind appeared calm and the runway was damp with “a few patches of snow” visible. He also called the AFIS agent who advised that the surface wind was 240° 3 knots, the visibility greater than 10 km, the QNH 1018 and the air temperature -1 °C.

He then joined final approach to runway 22, the only permitted landing direction because of the short upwardly inclined runway. Although the Captain subsequently stated that he “considered that the final approach was stabilised, with the indicated speed being “around 92 knots”, recorded flight data indicated otherwise with considerable variations in power setting, airspeed and rate of descent indicating that it had been unstabilised. Apart from earlier variations and an eventually fairly constant rate of descent of around 800 fpm, the final 20 seconds of the approach were made with the power at idle before power was progressively increased as the initially upward sloping part of the 537 metre-long runway (see the illustration below) neared. The aircraft floated just above the runway for around ten seconds before power was returned to idle. After two seconds, touchdown then followed about 270 metres past the threshold - approximately half way along the inclined part of the runway - with the speed still a recorded 79 knots. Despite maximum braking, albeit with the Captain’s detection of locked wheels leading him to briefly release brake pedal pressure, it was then not possible to stop the aircraft before it reached the top of the incline and, after travelling over the 123 metres of level surface which followed, it overran the end of the runway and collided with a mound of snow previously cleared from the runway.

The longitudinal profile of the Courchevel runway (altitudes are in feet amsl). [Reproduced from the Official Report]

A retrospective weight and balance calculation for the flight found that the aircraft had been overloaded for takeoff and at its maximum allowable landing weight at touchdown.

Discussion  

The fact that a mountain airport pilot authorisation, in this specific case for Courchevel, was generic and not linked to aircraft type was considered inappropriate and contributory to the accident.

The illegal activity of Big Blank, the company which facilitated and was paid for the flight but held neither an AOC nor an operating permit and had consequently not taken on the responsibilities of a provider of commercial air transport had not been detected by the State Civil Aviation Safety Directorate (DSAC) or the Air Transport Police unit (GTA) of the State Civil Aviation Authority (DGAC). It was concluded that this was because neither organisation proactively sought out relevant breaches of the clearly communicated applicable regulatory requirements. The consequence of this was a significantly increased risk to the safety of the flight involved of which the passengers were completely unaware.  

Six Contributory Factors which may have contributed to the accident outcome and its context were identified as follows:

(1) In respect of the long landing and the Captain’s generally low level of experience:

  • The absence of any experience at Courchevel mountain airport since obtaining his authorisation to operate there.
  • The absence of experience of landing at a mountain airport in an aircraft whose characteristics were very different to those of the Jodel D140.
  • Minimal experience of flying the Piper PA-46.

(2) In respect of both the pilot and the service provider company erroneously assessing the risks associated with this flight:

  • The absence of any operational support for the pilot.
  • The service provider’s desire to show that they were able to carry out a commercial service with passengers.

(3) In respect of a passenger transport flight being carried out which did not comply with the commercial air transport requirements:

  • The absence of oversight of this type of practice by the civil aviation authorities.

Two Safety Lessons were formally documented at the conclusion of the Investigation as follows:

Connecting aeroplane owners, pilots and passengers
This occurrence illustrates that for passengers, marketed flights where aeroplane owners, pilots and passengers are put into contact with each other, might look like a commercial air transport flight. However, they may be carried out in a private capacity and not offer the same safety and insurance guarantees as commercial air transport. The companies or web platforms may not be aware of the risks relating to this type of operation. Pilots with little experience may accept even more readily to perform these flights as it would allow them to increase their number of flight hours and to start working in the passenger transport sector. However, this type of flight leads to substantial operational pressure for the pilot.

Information for passengers
Passengers must ensure, for all passenger commercial air transport flights, that a ticket is issued for the flight to be carried out. Before taking any actions, passengers can obtain information from the DGAC via a page on the Ministère de la Transition écologique website. This page gives, in particular, the list of all the French operators which hold an Air Operator Certificate. This source of information does not seem to be widely known and is little used by passengers.

Two Safety Recommendations were issued as a result of the Investigation as follows:

  • that the French Civil Aviation Authority (DGAC) direct that supplementary training or experience criteria are required when using an aeroplane whose class, type or performance is significantly different from the class or type of aeroplane used for the site authorisation training. [FRAN 2021-005]
  • that the French Civil Aviation Authority (DGAC) formalise a coordinated action plan between its relevant services and the Air Transport Police (GTA) to actively search for and identify air operations proposed or organised by web platforms which resemble commercial air operations without meeting the regulatory requirements in force, then clearly rule on the legality of these operations and bring to an end the operations which do not guarantee the required safety level. [FRAN 2021-006]

The Final Report was published in the definitive French language version on 16 July 2021 and subsequently in an English translation on 2 December 2021.

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