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Accident
Last updated: 17 October 2017
Status:Schlussbericht
Datum:Dienstag 16 Oktober 2012
Zeit:21:22
Flugzeugtyp:Silhouette image of generic CRJ7 model; specific model in this crash may look slightly different
Bombardier CL-600-2C10 Regional Jet CRJ-701ER
Betrieben durch:Air France
Gemietet von :Brit Air
Kennzeichen: F-GRZE
Werknummer: 10032
Baujahr: 2001
Betriebsstunden:19841
Anzahl Zyklen der Zelle:19063
Triebwerk: 2 General Electric CF34-8C5B1
Besatzung:Todesopfer: 0 / Insassen: 4
Fluggäste:Todesopfer: 0 / Insassen: 53
Gesamt:Todesopfer: 0 / Insassen: 57
Sachschaden: schwer beschädigt
Konsequenzen: Repaired
Unfallort:Lorient-Lann Bihoué Airport (LRT) (   Frankreich)
Flugphase: Landung (LDG)
Betriebsart:Inländischer planmäßiger Passagierflug
Flug von:Paris-Orly Airport (ORY/LFPO), Frankreich
Flug nach:Lorient-Lann Bihoué Airport (LRT/LFRH), Frankreich
Flugnummer:937QL
Unfallbericht:
Brit Air Flight 937QL departed Paris-Orly, France at 20:30 on a domestic flight to Lorient. The captain was pilot flying. This was the fifth and last flight of the day for the crew.
At 21:00, just prior to descent, the crew listened to ATIS information Whisky, which indicated that runway 07 was in use with a PAR procedure. Four minutes later the controller at Lorient reported that winds were from 160° at 17 kt with gusts to 26 kt. The flight then requested an ILS approach to runway 25 (CAT I), which was approved.
At 21:10, the controller repeated the wind conditions and reported that "the runway is wet with puddles (mouillée avec flaques d’eau)" and that the preceding aircraft had difficulties during landing due to aquaplaning. Shortly thereafter, the controller reported showers at the airfield and the visibility had decreased to 2000 m.
At 21:12, the crew was cleared to descend to 3000 ft. The controller stated that a runway inspection found that the runway was "wet with puddles", repeating the information about the previous landing.
At 21:20, the aircraft was established on the ILS at an altitude of about 1900 ft and a speed of 180 kt. Planned approach speed Vapp was 140 kts. The autopilot was engaged.
The flight was cleared to land and at 1000 ft, with a 4 knot tail wind, the aircraft was established on the ILS with a speed of 144 kt. The crew concluded that the approach was stable and continued their descent through the rain. Wind screen wipers were set at maximum. Meanwhile the speed increased to 154 knots at the time the airplane passed 500 feet.
The autopilot was then disconnected. The airplane crossed the threshold of runway 25 at a height of 56 feet and at a speed of 153 knots. The copilot reported to the captain that visibility was poor and that they were slightly left of the runway centreline.
Nine seconds later, the main gear touched down about 1130 m from the threshold of runway 25, which is 2230 m long. The ground speed was 140 kts. The spoilers were then deployed and the crew deployed the thrust reversers, applying maximum reverse thrust. The airplane did not decelerate as expected and left the runway at a ground speed of 66 kts. It struck localizer antennas before coming to rest about 200 m from the threshold of runway 07.
The crew issued a distress call and ordered the evacuation of the aircraft.

Probable Cause:

The accident was caused by the crew deciding not to abort the landing although they were not aware either of the degree to which runway conditions were contaminated or of the remaining length of runway available.
Continuing the landing can be explained by:
- Insufficient situational awareness linked to:
* Crew performance degraded by fatigue and routine,
* Unfamiliarity with safety margins and inadequate TEM training;
- An approach to safety by the operator that did not encourage crews to question their plan of action.

The following factors contributed to the incident:
- The crew’s under-estimation of the meteorological conditions;
- Operational instructions that were sometimes unclear or contradictory, thereby undermining teamwork;
- The characteristics of runway 25, which were also not documented in the Brit Air Operations Manual;
- The organisation of aerodrome operations that contributed to the deviations identified concerning runway 25 not being corrected in a timely manner;
- A lack of common phraseology that would guarantee crews and controllers to \have a shared comprehension of the true condition of the runway;
- The organisation of training and checks that prevented the operator from recognising and improving its safety performance;
- Incomplete integration of the risks of fatigue by the airline.

Accident investigation:
cover
Investigating agency: BEA
Status: Investigation completed
Duration: 1 year
Accident number: f-ze121016
Download report: Final report

Informationsquelle:
» SKYbrary 


Sicherheitsempfehlungen

BEA issued 15 Safety Recommendations

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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 Paris-Orly Airport to Lorient-Lann Bihoué Airport as the crow flies is 439 km (275 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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