Airbus Within 6ft of the Ground nearly 1 mile Short of Runway
 

An Airbus 320 with 172 passengers and 6 crew came within 6ft of the ground when nearly a mile short of Paris CDG airport. In the report, released yesterday by the French Investigation Organisation BEA, it was confirmed French ATC repeatedly gave the wrong pressure setting (QNH) to the flight crew, but the correct setting to an Air France aircraft, in French. The first hole in a cheese riddled with holes.

https://pullingwingsfrombutterflies....uage-part-duex

Link to the preliminary BEA report [PDF]

Notwithstanding the references to "Air Sweden", the flight was operated by Maltese/Lithuanian carrier Airhub Airlines on an ACMI lease.

9 seconds between minima and TOGA.

Learning point #1.

Thank goodness they somehow escaped a horrible CFIT.

I didn't see in the BEA report whether the crew had listened to the ATIS and written it down on a 'bug card'. Nor if they had set the ATIS QNH on the PIC altimeter, and then returned PIC altimeter to standard pressure. Both were SOP in airlines I flew with.

When instructed by ATC to change to QNH, a cross-check is made that this agrees with the ATIS figure obtained previously. It would appear that the easyJet nearby had cross-checked the ATIS, because they read back the correct QNH.

Odd that the RAD ALT did not make any call outs, and strange that both crew apparently did not notice what must have been low RAD ALT readings, turning to amber on their PFDs at DH + 100'. Or maybe they did and the amber readout is what saved them?

And presumably GPWS did not call out because their rate of descent was not excessive, on a 3° approach, (mode 1), they were in landing configuration, (mode 4), and there was no glide-slope, (mode 5)?

I am wondering how 1001 and 1011 are spoken in French by French ATC; 'mille une' and 'mille onze' perhaps? instead of 'une zero zero une' or 'une zero une une'. This could have led to confusion in the ATCs mind; not realising the mistake when translating to English.
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Airhub Airlines… a subsidiary of Getjet Airlines. So a cheaper subsidiary of the cheapest… what could go wrong?
Operating for Norwegian… is that still going on?

From the initial report:- “Particular attention will be given, but not limited, to the analysis of the following points: - non-activation of TAWS alert, …”

Which ‘TAWS’ system (generic term) is fitted to this version (age) of aircraft, EGPWS or TAWS ?

A clear demonstration of the inherent danger of NPAs, whether conventional or RNP, compared to an ILS, you are reliant on a pressure setting to define your vertical profile. The aviation world is making, in my opinion, an unwise rush backwards in safety with the proliferation of new RNP approaches that may look all shiny and new but have the same flaws as older NPA's. In some ways it is worse as we have inconsistent terminology and procedures between various organisations, states, manufactures and airlines, they have all combined to make it a bit of a mess.

From experience ATC are usually hot on picking you up for minor altitude deviations. How did no one query why these guys were flying 300ft below their assigned altitude before beginning their approach?

If it helps, at no point after leaving FL360 were they in level flight.

I've done it only once in French (non-native French speaker) a long time ago with a small ATC unit, and then it was 'by the (french) book': 1001 unité zéro zéro unité / 1011 unité zéro unité unité. But wouldn't be surprised that at busy CDG the faster and less tongue breaking 'mille et un' / 'mille et onze' are used

As a former (Mil) ATCO, I find that simply atrocious. Wrong QNH passed? QNH read backs missed? Approach Lights not ON in foul weather? And the 'traditional' dual-language scenario?

God was clearly on the side of 178 people on this occasion, albeit by the smallest of margins.

That report makes rather startling reading with so many, some arguably minor, errors which very nearly led to the loss of the aircraft. My background is ATC and I am many years out of operational work, but the description of the ground-based aspects of this event are quite frightening to me. I may be living in a rose-tinted world when I think back to my operational days but I can't help thinking that almost every aspect of the event would have rung alarm bells - particularly the MSAW alert which I am sure would have had everyone running around double-checking the QNH in my day. And the idea that at 6ft RA there was no visual reference from the aircraft suggests that the weather (even the localised conditions included in the METAR) was less good than reported.

They used LNAV/VNAV minima and obviously had no GP?

On the first approach, why did the PF not engage TOGA and thereby initiate to go-around as soon as the aircraft reached the indicated MDA? (It appears not from the diagrams above).

And why did the PF disengage the autopilot when finally initiating the go-around? That is not a standard procedure.

And it is hard to imagine that no "minimums" call was not made by PM as well as called by the relevant audio system on the A320.

Nor any EGPWS warning? All sounds a little bit fabricated.

they would likely have been after the go around manoeuvring for approach #2.

You have a brick telling you whether you are good or not from the rwy threshold so yeah, you do have a "glide path", that "obviously" was not so obvious after all ;)

Well, yes - for avoidance of doubt, I was referring to the absence of level segments in the descent between cruise and the GA, in response to the point raised in the post preceding mine.

Hmmm,

On peut dire que le fromage a failli toucher le ventilateur!

Les passagers ont droit à une visite panoramique de Roissy-en-france, sans supplément, vous êtes les bienvenus.
Vous revenez maintenant, vous entendez !

... et prendre un taxi peut être si pénible à CDG, les pilotes de l'avion étaient serviables.

au revoir

It is remarkable that in the 21st century, my ipad and iphone have greater system safety than the airspace design and procedures we follow. Down in the weeds, a C145 GPS system will give reliably geometric height above the real world, without the issues of metric, french, or JFK's rapid fire info, and in the end the only information that we want is the absolute height at that point, the reason that we consider cold temperature corrections going into Nome, Bismark, or Ulan Bator...

The RALT should certainly have been giving the auto callouts, unless it is another Air Inter type deal where the "GPWS was not needed, as we don't make mistakes", until chopping off the tops of trees and the bottom of the plane and pax in the hills.

Not pretty. Any 5-G nearby?