REPORT F-Es010324a MINISTERE DE L'equipement, DES TRANSPORTS
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RITE DE L'AVIATION CIVILE Accident BUREAU D'ENQUETES ET D'ANALYSES POUR LA SECU on 24 March 2001 at Saint-Barthélemy (971) to the DHC-6-300 registered F-OGES operated by Caraïbes Air Transport DU LOGEMENT, TOURISME ET DE LA MER - REPORT f-es010324a MINISTERE DE L'EQUIPEMENT, DES TRANSPORTS, F O R E W O R D This report presents the conclusions reached by the BEA on the circumstances and causes of this accident. In accordance with Annex 13 to the Convention on International Civil Aviation, with Directive 94/56/EC and with Civil Aviation Code (Book VII), the investigation is intended neither to apportion blame, nor to assess individual or collective liability. Its sole objective is to draw lessons from the occurrence which may help to prevent future accidents. Consequently, the use of this report for any purpose other than for the prevention of future accidents could lead to erroneous interpretations. SPECIAL FOREWORD TO ENGLISH EDITION This report has been translated and published by the BEA to make its reading easier for English-speaking people. As accurate as the translation may be, please refer to the original text in French. F-OGES – 24 March 2001 - 2 - Table of contents F O R E W O R D _______________________________________________________ 2 SPECIAL FOREWORD TO ENGLISH EDITION _______________________________ 2 GLOSSARY____________________________________________________________ 6 SYNOPSIS ____________________________________________________________ 7 ORGANISATION OF THE INVESTIGATION __________________________________ 8 1 - FACTUAL INFORMATION _____________________________________________ 9 1.1 History of the flight __________________________________________________ 9 1.2 Injuries to persons__________________________________________________ 10 1.3 Damage to aircraft __________________________________________________ 10 1.4 Other damage______________________________________________________ 10 1.5 Personnel information_______________________________________________ 10 1.5.1 Flight crew______________________________________________________ 10 1.5.1.1 Captain _____________________________________________________ 10 1.5.1.2 Co-pilot _____________________________________________________ 11 1.5.2 Ground personnel ________________________________________________ 12 1.5.2.1 AFIS agent __________________________________________________ 12 1.6 Aircraft information _________________________________________________ 12 1.6.1 Airframe________________________________________________________ 12 1.6.2 Powerplant _____________________________________________________ 14 1.6.3 Propellers ______________________________________________________ 14 1.6.4 Weight and balance ______________________________________________ 14 1.6.5 Maintenance ____________________________________________________ 15 1.7 Meteorological information___________________________________________ 15 1.7.1 General situation_________________________________________________ 15 1.7.2 Situation at the aerodrome _________________________________________ 15 1.8 Aids to navigation __________________________________________________ 16 1.9 Communications ___________________________________________________ 16 1.9.1 Radio communications with Saint-Martin Juliana aerodrome _______________ 16 1.9.2 Radio communications with Saint-Barthélemy aerodrome _________________ 17 F-OGES – 24 March 2001 - 3 - 1.10 Aerodrome information_____________________________________________ 17 1.10.1 Statistics ______________________________________________________ 18 1.10.2 Landing procedure on runway 10 ___________________________________ 19 1.11 Flight recorders ___________________________________________________ 19 1.12 Wreckage and impact information ____________________________________ 19 1.12.1 Impact ________________________________________________________ 19 1.12.2 Wreckage _____________________________________________________ 20 1.13 Medical and pathological information _________________________________ 21 1.14 Fire _____________________________________________________________ 21 1.15 Survival aspects __________________________________________________ 21 1.16 Tests and research ________________________________________________ 21 1.16.1 Examination of powerplant ________________________________________ 21 1.16.1.1 Engines____________________________________________________ 22 1.16.1.2 Propellers __________________________________________________ 22 1.16.1.3 Power levers________________________________________________ 22 1.16.1.4 Engine parameter indicators____________________________________ 22 1.16.1.5 Summary of examinations _____________________________________ 22 1.16.2 Playback of a film found in the wreckage _____________________________ 22 1.16.2.1 Position and attitude of the aircraft_______________________________ 23 1.16.2.1.1 Lateral position___________________________________________ 23 1.16.2.1.2 Aircraft attitude___________________________________________ 24 1.16.2.2 Operation of powerplant _______________________________________ 24 1.16.3 Measurements on DHC-6 _________________________________________ 27 1.16.3.1 Observations on the flights_____________________________________ 27 1.16.3.1.1 Aircraft track_____________________________________________ 28 1.16.3.1.2 Conduct of the flight_______________________________________ 28 1.16.3.1.3 Ergonomics of power levers_________________________________ 29 1.16.3.2 Comparison with the film found in the wreckage ____________________ 29 1.16.3.2.1 Positioning of F-OGES_____________________________________ 29 1.16.3.2.2 Engine speed____________________________________________ 30 1.16.4 Orographic study of the Saint-Barthélemy approach path ________________ 30 1.16.4.1 Effects of a wind from the 120° sector ____________________________ 30 1.16.4.2 Effects of a partial flattening of the rocky outcrop____________________ 30 1.16.5 Principles of propeller control ______________________________________ 31 1.16.6 Preventing setting of reverse beta range in flight _______________________ 32 1.17 Organisational and management information __________________________ 33 1.17.1 Caribéenne des Transports Aériens - Air Caraïbes _____________________ 33 1.17.2 Caraïbes Air Transport ___________________________________________ 33 1.18 Additional information _____________________________________________ 33 1.18.1 Training and checks undertaken by Air Caraïbes _______________________ 33 1.18.2 Witness statements______________________________________________ 33 1.18.2.1 AFIS agent _________________________________________________ 34 1.18.2.2 The Air Caraïbes supervisor____________________________________ 35 1.18.2.3 A flight instructor_____________________________________________ 35 1.18.2.4 The Manager of Caraïbes Air Transport___________________________ 35 1.18.2.5 A mechanic_________________________________________________ 36 1.18.2.6 The Air Caraïbes maintenance manager __________________________ 36 F-OGES – 24 March 2001 - 4 - 1.18.2.7 Inhabitants _________________________________________________ 36 1.18.2.8 A Captain __________________________________________________ 37 1.18.2.9 A retired pilot _______________________________________________ 37 1.18.2.10 Two passengers ____________________________________________ 37 1.18.2.11 A Winair mechanic __________________________________________ 37 1.18.3 Regulatory requirements relating to recent experience __________________ 38 1.18.4 Operational requirements relating to Saint-Barthélemy __________________ 38 1.18.5 Crew actions on approach and at landing_____________________________ 39 1.18.6 Measures taken since the accident__________________________________ 40 1.18.7 Selection of beta range in flight_____________________________________ 40 1.18.8 Accident in the United States to a CASA C-212 ________________________ 41 1.18.9 Validity of the Captain’s license ____________________________________ 41 2 - ANALYSIS _________________________________________________________ 42 Summary of findings___________________________________________________ 42 2.1 Elements from the operational context _________________________________ 42 2.1.1 The pilots’ experience _____________________________________________ 42 2.1.2 Context of the flight _______________________________________________ 43 2.1.3 Relations between crew members ___________________________________ 43 2.1.4 Short repetitive flights _____________________________________________ 44 2.1.5 Difficulty of the approach to runway 10 ________________________________ 44 2.1.6 Confusion between "beta range" and "reverse beta range" ________________ 44 2.2 Hypothesis tree ____________________________________________________ 45 2.2.1 The triggering event is external to the crew ____________________________ 45 2.2.2 The triggering event is linked to crew action ____________________________ 46 2.2.2.1 Involuntary action _____________________________________________ 46 2.2.2.2 Deliberate action______________________________________________ 47 2.2.2.2.1 Deliberate action corresponding to a normal maneuver ____________ 47 2.2.2.2.2 Deliberate action corresponding to an unexpected maneuver________ 48 3 - CONCLUSION ______________________________________________________ 50 3.1 Findings __________________________________________________________ 50 3.2 Probable Causes ___________________________________________________ 51 4 - SAFETY RECOMMENDATIONS________________________________________ 52 LIST OF APPENDICES__________________________________________________ 54 F-OGES – 24 March