Mid East B772 at Paris on Jun 5th 2016, wing tip and horizontal tail strike on go around
Last Update: December 17, 2019 / 15:59:38 GMT/Zulu time
The French BEA released their final report in French only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a French only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).
The final report concluded the probable cause of the serious incident was:
The late go around following an unstablized approach
Contributing to the serious incident were:
- lack of criteria for stabilized approach, both by the flight crew and the operator
- little recent experience and little practise of the relevant approach procedure by the pilot flying
- lack of hierarchy non conducive to Cockpit Resource Management
- operator without a safety management system and poor practises non conducive to safety culture.
The BEA reported that following landing on runway 07 the aircraft remained powered up, the recordings of the cockpit voice recorder were thus lost.
An inspection of the aircraft revealed traces of friction on the right wing tip and the leading edge of the right wing as well as the tip of the right horizontal stabilizer. A right wing fairing also showed traces of friction, one of its fasteners was broken. No damage was found at the landing gear. A detailed runway inspection revealed friction marks about 161 meters past the displaced threshold, length about 28 meters, about 19 to 22.5 meters to the right of the runway center line. Those marks were close to the touch down area identified by the flight data recorder.
The BEA reported the cloud base at the time of the occurrence was at 627 feet AGL.
Mid East Jet is a company based in Jeddah (Saudi Arabia), however, operating under US AoC since 2012, it operates aircraft in VIP configuraton. It was not required to have a Safety Management System. N777AS is used exclusively for the benefit of a single sponsor.
The crew of the aircraft consisted of a "Flight Captain" (66, ATPL, more than 13,000 hours total) in the left hand seat, a "Reserver Captain" (60, ATPL, 20,000 hours total, 2,000 hours on type) in the right hand seat, a "Trip Captain" (69, ATPL, more than 30,000 hours total) in the observer's seat, in addition a flight engineer was present in the cockpit at the time of the occurrence. The crew was fired in the days after the occurrence.
The flight captain had retired from American Airlines in 2013 (13,000 hours total at that time, he no longer logged the hours afterwards), flew Boeing 777s for Biman Bangladesh, Ethiopian Airlines and again Biman Bangladesh before joining Mid East 18 months for the event. In 2015 he performed 25 landings, in 2016 4 landings as pilot flying. He performed only one landing in the three months prior to the occurrence.
The trip captain joined Mid East in 2011 after retiring from his former company with 30,000 flight hours total and no longer logged his hours.
The BEA analysed the aircraft came out of clouds just prior to MDA leaving a short segment only to align with the runway. The correction was insufficient, the aircraft overshot the runway center line, the inertia of the aircraft makes it difficult to return the aircraft onto the center line. The lack of CVR recordings make it impossible to assess the decision making processes with certainty: the flight captain decided to continue the landing although the aircraft was not stabilized after the turn and a safe landing was not ensured, the roles of the reserve captain as well as the trip captain could not be determined, in particular it could not be established whether a go around call and when was made.
Regulations require at least 3 landings in the last 90 days to carry out a flight. The working schedule of the company of six weeks of duty (sometimes without flying) and six weeks of rest are incompatible with maintaining adequate maneouvering capabilities. It is thus likely the pilot flying had not accumulated sufficient recent experience to carry out an approach like into Bourget with ease despite his general experience.
The operator did not include LOC approaches in their training programme, that was outsourced to the US. It is likely no monitoring programme existed for its crews that would have permitted specific training on the flight simulator or a flight with instructor. There was lack of consideration for and lack of experience with operational risk management. Pilot testimonies suggested that the operator frequently intervened and insistently during varying phases of flight including the approach indicating lack of knowledge and lack of respect for operational constraints. These elements combined with the dismissal of the crew following the occurrence show an insufficient safety culture within the operator and lack of "just culture".
The airport operator studied the implementation of PAPIs in response to this and other occurrences and without waiting for certification implemented the first set of PAPIs, the implementation of a second set of PAPIs is being discussed. In addition the airfield operator is in dicussion with the CAA about the conditions under which runway 25 can be operated with respect to visibility.
LFPB 051030 AUTO VRB02KT 4300 BR OVC005 16/14 Q1019 BECMG 6000 NSW BKN020
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This article is published under license from Avherald.com. © of text by Avherald.com.
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