Report cites avoidable errors and captain's indecision as factors in 2003 Brest crash
Mistakes by the pilots were the primary cause of the 22 June 2003 Brit Air Bombardier CRJ100 accident, in which the captain was killed and the aircraft totally burned out, says the final report by France's air accident investigation office, the BEA. The co-pilot, cabin attendant and all 21 passengers survived when the regional jet hit the ground in a field during a night instrument landing system (ILS) approach to Brest airport, France. The aircraft was brought to rest within 50m (165ft) as it ploughed into trees.
Failures of omission are the main errors highlighted by the report. The captain - the pilot flying - and co-pilot were faulted for an incomplete approach briefing, and, critically, for failure to select approach (APPR) mode on the autopilot during the category 1 ILS approach to runway 26L at Brest. The aircraft did not lock on to the ILS glideslope or localiser because of the selected heading and vertical speed (HDG/VS) autopilot mode selected. According to the report, the crew first concentrated on trying to control the aircraft's deviation above and then below the glidepath, through the autopilot then fixated on its gradual drift to the left of the ILS localiser centreline, caused by a crosswind from the right.
The pilots were also criticised for continuing their approach below decision altitude, despite receiving several "glideslope" and "sink rate" warnings from the ground proximity warning system, and even though they had clearly not stabilised the approach and had no visual contact with the approach lights. The captain was slow initiating a go-around procedure just below 100ft (30m), but the airspeed was slow at 115-120kt (213-222kt) and the attitude remained nose-low.
The aircraft touched down "without violence" near the edge of a field 2,150m short of the runway and 450m to the left of the extended centreline in visibility of less than 1,000m, and immediately ran into trees. The captain's slowness in carrying out the go-around led to early speculation that he had become medically incapacitated on the approach. The co-pilot, twice after the captain had said he was going around, urged him to do so. The report says that if incapacitation was a factor it will never be proven because the impact killed the captain and his body remained in the aircraft as fire destroyed it.
The report cites as contributory factors the crew's poor communication and co-ordination with each other, and the fact that air traffic control, having advised the crew to expect to hold before being cleared for an approach, finally cleared the crew direct into the approach at short notice. The crew had a serviceable head-up display available but did not use it, the report notes.
The BEA makes 14 recommendations, including urging all foreign authorities to require additional training for CRJ pilots in handling go-arounds from a low-energy flight condition.
DAVID LEARMOUNT / LONDON
Source: Flight International
