ATION D'ANALYSES POUR LA SECURITE DE L'AVI Accident on 22 June 2003 at Guipavas (21) to the Bombardier Canadair LA MER – BUREAU D'ENQUETES ET CL-600 2B 19 registered F-GRJS operated by Brit Air REPORT TRANSLATION f-js030622a INISTERE DES TRANSPORTS, DE L’EQUIPEMENT, DU TOURISME ET FOREWORD This report presents the technical conclusions reached by the BEA on the circumstances and causes of this accident. In accordance with Annex 13 of the Convention on International Civil Aviation, European Directive 94/56/CE and French Law n° 99-243 of 29 March 1999, the conclusions contained in this report are intended neither to apportion blame, nor to assess individual or collective responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents or incidents. 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, the original text in French should be considered as the work of reference. F-GRJS - 22 June 2003 - 2 - Table of contents SYNOPSIS............................................................................................................. 8 ORGANIZATION OF THE INVESTIGATION......................................................... 9 1 - BASIC INFORMATION................................................................................... 10 1.1 History of Flight............................................................................................ 10 1.2 Killed and Injured ......................................................................................... 12 1.3 Damage to Aircraft ....................................................................................... 12 1.4 Other damage ............................................................................................... 12 1.5 Personnel information ................................................................................. 13 1.5.1 Flight crew ............................................................................................... 13 1.5.2 Brest Guipavas Approach Controller........................................................ 16 1.6 AEROPLANE INFORMATION....................................................................... 16 1.6.1 Airframe ................................................................................................... 16 1.6.2 Engines.................................................................................................... 17 1.6.3 Maintenance ............................................................................................ 17 1.6.4 Weight and Balance................................................................................. 17 1.6.5 Equipment................................................................................................ 18 1.7 METEOROLOGICAL INFORMATION........................................................... 27 1.7.1 General situation...................................................................................... 27 1.7.2 Situation at Brest Guipavas ..................................................................... 28 1.7.3 Flight Dossier........................................................................................... 28 1.7.4 Meteorological information received in flight ............................................ 29 1.7.5 Evolution in Brest Runway 26-L RVR’s during the approach ................... 30 1.8 Aids to Navigation........................................................................................ 30 1.9 Telecommunications.................................................................................... 31 1.9.1 Radio communications............................................................................. 31 1.9.2 Radar recordings ..................................................................................... 34 1.10 Aerodrome Information.............................................................................. 35 1.10.1 Infrastructure.......................................................................................... 35 1.10.2 Situation at the time of the accident....................................................... 35 1.10.3 ILS arrival procedure on Runway 26 Left............................................... 36 F-GRJS - 22 June 2003 - 3 - 1.11 Flight Recorders......................................................................................... 38 1.11.1 Types and Readout Operations ............................................................. 38 1.11.2 CVR readout .......................................................................................... 38 1.11.3 FDR Analysis ......................................................................................... 41 1.11.4 Approach track....................................................................................... 44 1.12 SITE AND WRECKAGE INFORMATION .................................................... 45 1.12.1 Description of site .................................................................................. 45 1.12.2 Description of Wreckage........................................................................ 49 1.13 Medical and Pathological Information...................................................... 51 1.14 Fire............................................................................................................... 51 1.15 Survival Aspects ........................................................................................ 52 1.15.1 Organisation of Rescue ......................................................................... 52 1.15.2 Occupant Survival.................................................................................. 52 1.16 Tests and Research.................................................................................... 55 1.16.1 Calculations of Wind Characteristics...................................................... 55 1.16.2 Inspection of Aeroplane Equipment ....................................................... 56 1.16.3 Flight Simulator Research...................................................................... 57 1.16.4 Behaviour of the CRJ-100 on Go-around............................................... 58 1.16.5 Bombardier Simulation of Aeroplane Behaviour prior to Accident.......... 60 1.16.6 Ground Proximity Warning System (GPWS).......................................... 61 1.16.7 MSAW Simulation (Minimum Safe Altitude Warning)............................. 62 1.16.8 Cockpit Ergonomics............................................................................... 63 1.17 Information on Organizations and Management ..................................... 65 1.17.1 The Operator ......................................................................................... 65 1.17.2 Training of Flight Personnel ................................................................... 67 1.17.3 Brest Guipavas ATC .............................................................................. 68 1.18 Additional Information ............................................................................... 74 1.18.1 Low Go-arounds .................................................................................... 74 1.18.2 Procedures in Place at Brit Air ............................................................... 75 1.18.3 Regulatory environment regarding approaches ..................................... 78 1.18.4 Testimony .............................................................................................. 79 2 - ANALYSIS ...................................................................................................... 85 2.1 Accident Scenario ........................................................................................ 85 2.1.1 Takeoff, Climb and Cruise ....................................................................... 85 2.1.2 Management of the Descent, Preparation of Holding and Approach ....... 85 2.1.3 Approach Clearance – Non-arming of Approach Mode ........................... 85 2.1.4 Passing through the Glide Slope - Correction of Flight Path in Vertical Plane..88 2.1.5 Flight Path Correction in Horizontal Plane ............................................... 91 2.1.6 Go-around................................................................................................ 92 2.1.7 Aeroplane's Ground Run.......................................................................... 93 F-GRJS - 22 June 2003 - 4 - 2.2 Decisions Relating to the Approach........................................................... 94 2.2.1 Context of the Decisions .......................................................................... 94 2.2.2 Decision to Begin the Approach............................................................... 94 2.2.3 Decision to Continue the Approach after Passing through the Glide Slope . 94 2.2.4 Decision to Continue the Approach under 1,000 feet AGL ...................... 95 2.3 Work Environment ....................................................................................... 95 2.3.1 Teamwork ................................................................................................ 95 2.3.2 Operator’s Procedures............................................................................. 96 2.3.3 Awareness of Low-speed Characteristics