Descripción del Accidente ASN 15 AUG 2003 Boeing 737-33V HB-III - Oyonnax
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Estado:Accident investigation report completed and information captured
Fecha:viernes 15 agosto 2003
Tipo:Silhouette image of generic B733 model; specific model in this crash may look slightly different
Boeing 737-33V
Operador:easyJet Switzerland
Registración: HB-III
Numéro de série: 29338/3114
Año de Construcción: 1999-06-15 (4 years 2 months)
Horas Totales de la Célula:12814
Ciclos:11165
Motores: 2 CFMI CFM56-3C1
Tripulación:Fatalidades: 0 / Ocupantes: 5
Pasajeros:Fatalidades: 0 / Ocupantes: 126
Total:Fatalidades: 0 / Ocupantes: 131
Daños en la Aeronave: Considerable
Consecuencias: Repaired
Ubicación:sobre Oyonnax (   Francia)
Fase: En ruta (ENR)
Naturaleza:Vuelo Internacional Programado
Aeropuerto de Salida:Genève-Cointrin Airport (GVA/LSGG), Suiza
Aeropuerto de Llegada:London-Luton Airport (LTN/EGGW), Reino Unido
Número de Vuelo: 903
Descripción:
After a return flight to Nice (NCE), Boeing 737 HB-III approached Geneva (GVA). The crew had to avoid various thunderstorm cells between FL150 and an altitude of 7000 ft during the Geneva approach phase. Once the passengers had disembarked, the five crew members began the preparation for the next flight, destination Luton. An EasyJet company employee handed over to the pilots an envelope containing various items of information, including in particular the latest weather forecasts (TAF) and meteorological observations (METAR) for the subsequent flight. The flight crew already had the meteorological charts in their possession. According to the captain, the aircraft was parked too far away from the Geneva meteorological service office for them to go there during the stopover.
For the next scheduled flight, the commander was pilot not flying (PNF). Flight EZS 903 to Luton took off at 07:54 UTC from runway 23 and initially followed the standard instrument departure (SID) "DIPIR 1A". After passing 7000 ft in a climb, the aircraft began a right turn, following the assigned departure route. At the beginning of this manoeuvre, the copilot set the range of his electronic horizontal situation indicator (EHSI) from 10 to 20 NM; he then remarked to the captain that it would be preferable to continue straight on. A little later, the latter changed the range of his EHSI from 10 to 40 NM.. The automatic pilot was switched on.
Six seconds after the copilot’s remark, the captain requested clearance from Departure control to "maintain" heading 310: "Topswiss... nine O three, may we maintain flight level three- one zero to avoid, please." He received the reply: "Er- you mean... the heading? - Sorry? - You mean heading three one zero? - Yes, I would like to maintain heading three one zero for a while, for about... fifteen nautical miles." This deviation from the standard instrument departure was granted and the flight was handed over to the INI NORTH radar control sector frequency. At 07:58:37 UTC, the crew of flight EZS 903 was cleared to climb to flight level FL180, on heading 310. A few seconds later, ATC suggested him flying directly towards Dijon (DJL VOR), when convenient. The captain replied that he was expecting to proceed accordingly in approximately 10 NM. At 07:58:54 UTC the captain was busy using the flight management system (FMS) to determine the next heading which would allow him to turn towards DJL and increased the range of his EHSI to a value of 80 NM.
At 08:00:20 UTC, the airplane entered a serious hailstorm as it passed FL154 in a climb. A little later, the ground proximity warning system (GPWS) issued a voice alert "TOO LOW TERRAIN TERRAIN". At 08:00:27 UTC, the captain said "I’ve control... I take control". The copilot replied: "Your controls". At 08:00:31 UTC, the audible autopilot disengage warning sounded and remained audible for 38 seconds, until its autopilot disengage switch was pressed a second time to confirm the warning. The DFDR parameters reveal that at this instant the autothrottles were disengaged.
The captain noticed that the copilot’s windscreen was badly damaged and declared a distress situation to INI NORTH control sector at 08:00:33 UTC, with the message: "MAYDAY MAYDAY MAYDAY"; he also asked for permission to return to Geneva and announced that he was maintaining flight level FL160 and turning onto heading 270. The aircraft’s speed was approaching maximum operating speed (Vmo) and the copilot drew attention to this trend by interjecting: "Speed".
At 08:01:23 UTC, the captain asked the copilot to don his oxygen mask and put on protective goggles. The captain informed ATC that he was having problems with the windscreens and asked for clearance to descend to the minimum safe flight level; he was immediately cleared to flight level FL100 and then to an altitude of 7000 ft. The controller informed him that he could not see any conflicting traffic in the vicinity. At 08:02:56 UTC, the captain asked the copilot to carry out the window damage checklist (non-normal check-list 030 – window damage). The flight crew was then instructed to fly heading 090 and was then transferred to the Approach sector. They did not collate this message and did not answer back the consecutive calls of the INI NORTH sector controller. The flight crew called the Departure sector DEP, which is another frequency than the one who was attributed to them. The DEP sector controller asked the flight crew to contact the Final sector FIN on the frequency 120.3 MHz.
Taking into account the geographical position of the aircraft in distress at this time, the Approach radar controller proposed a direct approach on runway 05. The flight crew accepted this option and was then guided for interception of instrument landing system (ILS) 05. During the interception phase, the controller reported that the localizer 05 (LLZ) seemed to be out of order; the flight crew replied that he had the runway in sight and was subsequently cleared to land.
At 08:14 UTC, the aircraft touched down safely.

Probable Cause:

CAUSE: "The accident was caused by the aircraft flying into a shower of hail embedded in a thunderstorm cell, following inadequate utilisation of the information provided by the onboard weather radar.
The following factors played a part in the accident:
- shortcomings in crew resource management (CRM);
- no specific meteorological information concerning this hazard was transmitted."

Accident investigation:

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Investigating agency: BFU Switzerland
Status: Investigation completed
Duration: 4 years
Accident number: No. 1950
Download report: Final report


Subsiguiente / acciones de seguridad

BFU Switz. issued 2 Safety Recommendations

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Fotos

photo of Boeing-737-33V-HB-III
accident date: 15-08-2003
type: Boeing 737-33V
registration: HB-III
photo of Boeing-737-33V-HB-III
accident date: 15-08-2003
type: Boeing 737-33V
registration: HB-III
photo of Boeing-737-33V-HB-III
accident date: 15-08-2003
type: Boeing 737-33V
registration: HB-III
photo of Boeing-737-33V-HB-III
accident date: 15-08-2003
type: Boeing 737-33V
registration: HB-III
photo of Boeing-737-33V-HB-III
accident date: 15-08-2003
type: Boeing 737-33V
registration: HB-III
 

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Genève-Cointrin Airport to London-Luton Airport as the crow flies is 778 km (486 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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