Armavia CRJ2 at Nice on Dec 30th 2011, descended below minimum safe height on approach

Last Update: September 9, 2013 / 14:26:46 GMT/Zulu time

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Incident Facts

Date of incident
Dec 30, 2011

Classification
Report

Airline
Armavia

Departure
Yerevan, Armenia

Destination
Nice, France

Aircraft Registration
EK-20018

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

An Armavia Canadair CRJ-200, registration EK-20018 performing a flight from Yerevan (Armenia) to Nice (France), was on a VOR/DME approach to Nice's runway 04L and had been cleared to intercept radial 175 of the CGS VOR and for the VOR/DME approach to runway 04L, the crew however went through the radial without intercepting the radial. The controller instructed the aircraft to turn right onto a heading of 090 degrees and changed to runway 22R. The crew reported ready for the approach to runway 22R and was vectored onto radial 089 of AGZ VOR. Once the aircraft had established on the radial the controller cleared the aircraft to descend to 1500 feet to cross the final approach fix at 1500 feet. At 10 DME AGZ the aircraft however descended below 1500 feet and veered right off the radial, the minimum safe altitude warning (MSAW) activated at the controller's console for 41 seconds. The aircraft continues to turn and descend, no reaction from the controller. An area proximity alert activated at the controller's desk 11 seconds after the MSAW lasting for 78 seconds. The controller instructed the aircraft to turn to a heading of 270 degrees in an attempt to turn the aircraft clear of terrain, the rate of descent increased to 1700 feet per minute. When the aircraft descended through 550 feet MSL the controller shouts "you are mistaking the bay", the crew initates a go-around, stops the descent, the aircraft begins to climb and the minimum safe altitude alert at the control room stops. The controller subsequently, always using emergency phraseology, instructs the aircraft to climb to 3000 feet and vectors the aircraft for another intercept to radial 089, however, the aircraft again flies through the radial without intercept. The controller instructs heading 240, continuing to use emergency phraseology. When the aircraft was approximately close to the radial the crew announced they had the airfield in sight, the controller checked back whether they had the aerodrome in sight, and subsequently cleared the aircraft for a visual approach to runway 22R. The controller's area proximity warning again sounded for 3 seconds when the aircraft overflew Cap Ferrat at 1200 feet, but the aircraft accomplished a safe landing on runway 22R.

The French BEA released their final report in French concluding:

The incident was due to inadequate implementation of the approach procedure by the crew, the capacity of whose was saturated by the tasks of changing the approach procedure and complexity of the approach procedure.

The controller's response to the area proximity warning prevented a more serious outcome, the controller's miss of the descent minimum safe altitude warning however contributed to the delayed detection of the deviation from the approach trajectory.

The BEA reported the captain had accumulated 20,500 hours of total flying time, 913 hours on type, the first officer had accumulated 14,130 hours of total flying with 434 hours on type. The captain had, other than the first officer, attended an aerodrome familiarization ground training programme in March 2011, the first officer was not required to visit such a course.

The BEA stated that according to controller manuals the controller should issue following instructions in case of a MSAW activating and the crew not complying with vectoring: " ... Ground Alert, check your altitude IMMEDIATELY, QNH ... " and follow up " ... IMMEDIATELY climb 3000 feet and IMMEDIATELY turn left heading ... due to terrain IMMEDIATELY".

The BEA reported that out of 57 MSAW activations at the control room in January 2012 55 warnings were nuisance activations, only 2 warnings were accurate.

The crew reported in their testimony that they had not received a GPWS alert. The controller provided testimony that he turned attention to other aircraft when the MSAW activated and did not see the visual warning, he then detected the lateral deviation of the aircraft from the approach procedure but did not notice the aircraft had descended to a dangerous altitude.

Armavia declared bankrupt and ceased operation in March 2013.

The BEA issued a safety recommendation to France's DGAC to review the MSAW system to eliminate all nuisance warnings.
Incident Facts

Date of incident
Dec 30, 2011

Classification
Report

Airline
Armavia

Departure
Yerevan, Armenia

Destination
Nice, France

Aircraft Registration
EK-20018

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

This article is published under license from Avherald.com. © of text by Avherald.com.
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