Ryanair B738 at Memmingen on Sep 23rd 2012, descended below minimum safe height

Last Update: December 10, 2012 / 22:46:24 GMT/Zulu time

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Incident Facts

Date of incident
Sep 23, 2012

Classification
Incident

Airline
Ryanair

Flight number
FR-3214

Departure
Manchester, United Kingdom

Destination
Memmingen, Germany

Aircraft Registration
EI-DAC

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Ryanair Boeing 737-800, registration EI-DAC performing flight FR-3214 from Manchester,EN (UK) to Memmingen (Germany) with 135 passengers and 6 crew, was on a visual approach to Memmingen's runway 24 with the autopilot engaged at a target altitude of 2096 feet MSL turning onto but overshooting the extended runway centerline at high vertical descent rate. While attempting to align on the extended runway centerline, the aircraft still descending at high rate of descent, the aircraft descended below required minimum height of 1000 feet AGL about 4nm ahead of the runway threshold. Following an EGPWS warning "CAUTION TERRAIN!" the crew levelled off reaching a minimum height of 450 feet AGL and began to climb the aircraft, climbing through 460 feet AGL the crew received a "TERRAIN! TERRAIN! PULL UP! PULL UP!" EGPWS alert and initiated a go-around. The aircraft landed safely on their second approach.

In their monthly bulletin Germany's BFU rated the occurrence a serious incident and opened an investigation reporting the minimum safety height was 1000 feet AGL however the aircraft descended to 450 feet AGL before beginning to climb again, in response to the "Terrain! Pull Up!" warning the crew initiated a go-around, all of the sequence happening within seconds. The BFU used information off the Quick Access Recorder, radar data by DFS (German Air Traffic Control provider) and crew testimony for their report.

The BFU stated that according to the commander's testimony the aircraft had been delayed by about 25-30 minutes before departure from Manchester, a landing on Memmingen's runway 06 would require to turn around at the end of the runway and backtrack to the terminal compared to much shorter taxi following a landing on runway 24. The crew therefore requested runway 24 in order to make up for some of the delay, although runway 06 was active at Memmingen. The crew briefed the ILS approach to runway 24 and was subsequently cleared for the procedure approach. Again according to crew testimony the crew wasn't prepared for the procedure approach expecting radar vectors as usual. Following establishing visual contact with the aerodrome the crew therefore requested and was cleared for the visual approach. The aircraft descended to 4000 feet at high rate of descent and 250 KIAS, in the right downwind the speed was reduced to 220 KIAS. During the very short base leg the aircraft experienced a tail wind of about 20-30 knots, the crew continued, and flew through the extended center line, at which point the crew recognized the approach was not normal. The crew attempted to re-align with the extended center line, however the high rate of descent still prevailed.

The BFU have released an English version of their interim report, too.

On Dec 5th 2012 the BFU investigator in charge told German aviation news service aero.de in response to Ryanair's claims quoted here on The Aviation Herald (see below), that even though a manual approach was being flown the basic rules of instrument flight still apply, hence a minimum height of 1000 feet was applicable. The BFU does not rate all events of descending below that minimum height as safety relevant, however in this particular case the remaining height of only 450 feet prompted the BFU to investigate the occurrence and rate it a serious incident.

Ryanair reported on Dec 4th 2012, that the crew did not receive a "Caution Terrain" message, never levelled off but initiated the go-around prior to the "Terrain! Pull up!" EGPWS warning. There is no minimum height applicable to this type of approach. The incident was reported to the relevant Authorities less than 12 hours after the event, all data have been provided. In a subsequent phone call on Dec 4th 2012 Ryanair's chief pilot stated that the crew initiated the go-around prior to the "Caution Terrain" (confirming the Caution Terrain message disputed by Ryanair's press officer in e-mail before) and "Terrain! Pull Up!" message, that followed the Caution Terrain message almost instantly, and voiced concern that the sequence of events as portrayed by the BFU report create the impression the crew ignored warnings, something which is not at all tolerated within the company, rather than the crew preemptying the warnings.

Later Dec 4th Ryanair issued an official press release reading: "Ryanair flight FR3214 (Manchester - Memmingen) on 23 Sept last was on its final approach to the runway in Memmingen when they encountered unexpectedly high tail-winds. The crew decided to initiate a go-around procedure in-line with Ryanair operating policy. After they had already commenced the go-around the aircraft warning systems sounded and the crew completed their go-around, landing normally a short time later. This incident was reported to the IAA on 24 Sept, and is the subject of an ongoing investigation."

On Dec 5th Ryanair's press office sent an e-mail and phoned The Aviation Herald to the effect that they never disputed the "CAUTION TERRAIN" message actually claiming the first e-mail sent to The Aviation Herald on Dec 4th had been drafted by Ryanair's Chief Pilot and signed off at the top ranks of the airline. This e-mail demanded apologies by The Aviation Herald as well as removal of the story altogether. At the end of that conversation on Dec 5th it was decided upon request by Stephen McNamara that the initial e-mail should be published in full:

Dear Simon

I refer to your summary analysis of the BFU bulletin published in Aviation Herald today . The AH analysis contains a number of inaccurate claims relating to the incident that occurred on 23rd Sept at FFM .

1. There was no required 'minimum height' of 1000' applicable to this approach

2. The crew did not receive a 'CAUTION TERRAIN' warning before the go around was commenced .

3. The crew did not level off at any stage during the approach.

4. The crew initiated the Go Around before the 'Terrain Terrain PULL UP' warning and not after the warning, as claimed in the bulletin.

Ryanair reported this incident to the Regulatory Authorities less than 12 hours after a report was filed by the crew . We have provided the BFU (via AAIU ) with all of the data for this flight . We ask that the article be removed from the Aviation Herald website and an apology be issued by the AH for implying that the crew did anything wrong when recovering from this unstable approach incident.

This article is being picked up internationally and is inaccurate.

Please give this your urgent attention and call me to discuss.

Regards
Stephen
Stephen McNamara
Head of Communications
Ryanair Head Office
Dublin Airport