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Serious Incident description
Last updated: 23 April 2018
Status:Final
Date:Thursday 26 September 2013
Time:10:18
Type:Silhouette image of generic A321 model; specific model in this crash may look slightly different
Airbus A321-231
Operator:Onur Air
Registration: TC-OBZ
C/n / msn: 811
First flight: 1998-04-06 (15 years 6 months)
Total airframe hrs:38700
Cycles:25500
Engines: 2 IAE V2533-A5
Crew:Fatalities: 0 / Occupants: 7
Passengers:Fatalities: 0 / Occupants: 220
Total:Fatalities: 0 / Occupants: 227
Airplane damage: None
Location:5,6 km (3.5 mls) WNW of Deauville-Saint Gatien Airport (DOL) (   France)
Phase: Approach (APR)
Nature:Int'l Non Scheduled Passenger
Departure airport:Izmir-Adnan Menderes Airport (ADB/LTBJ), Turkey
Destination airport:Deauville-Saint Gatien Airport (DOL/LFRG), France
Flightnumber:8Q1985
Narrative:
Onur Air flight OHY 1985 departed Izmir, Turkey, on a charter flight to Deauville, France. The captain was Pilot Flying (PF) and this was his first flight to Deauville.
The flight crew prepared for an ILS approach for landing on runway 30 as the ATIS information indicated that this was the runway in use. This subsequently changed to runway 12. On first contact with the Deauville Approach controller at 10:07, the crew was informed that the active runway had changed and that another aircraft was preparing to take off ahead of them.
The controller suggested a runway 12 GNSS approach. However, the flight crew was not qualified for GNSS approaches. The crew radioed that they were preparing for a visual approach, but they prepared for a circle-to-land procedure.
When the controller requested to report downwind, the PF interpreted this message as an instruction to turn right. From that point on, the crew no longer followed standard procedures but mixed the circle-to-land procedure and visual the approach.
The flight descended to the MDA of 1100 ft AAL during the downwind leg and then continued the descent into the last turn under the glidepath for the final.
At 10:18:44, the TAWS "terrain ahead" alarm sounded for about eight seconds. The PF reacted by initially applying a pitch-up command. The aircraft attitude changed from 0.5° to 12° nose-up. At 10:18:52, a second "Terrain ahead pull up"-alarm sounded for approximately seven seconds. At this time, the aircraft was at a minimum recorded altitude of 528 ft (49 ft above the aerodrome) and 3 NM from the runway threshold. The PF reacted by reapplying a further pitch-up command. The attitude of the aircraft increased towards 16°.
The aircraft climbed again and the crew regained visual contact with the runway and realized that they were to the left of the centreline. As the aircraft, still climbing, approached the coast, the PF began a turn to the right. The controller saw the aircraft in an unusual attitude and asked: "One nine eight five, you are going around ?".
The crew responded that they were landing. The Tower controller then radioed: "Cleared to land, zero seven zero degrees, five to eight knots." The aircraft passed over the glide path indicated by the PAPI lights.
At about 1.5 NM from the threshold and at an altitude of 1,144 ft, the PF resumed the descent, decreasing the attitude to -1° to nose-down, and began the last left turn by banking the aircraft to 33° to align with the runway centreline. A TAWS "sink rate" alarm was then triggered for approximately three seconds.
The PF then contacted the controller, stating: "Onurair one nine eight five, (*) request circle to land for runway three zero, we are not able to land in 12 now."
The captain then explained on the frequency that they lost visual contact with the runway because of the sun. He requested and obtained clearance for a visual approach to runway 30.
The read back of the controller's clearance was done by the PF and PNF simultaneously.
The aircraft passed over the runway at a height of 300 feet. The crew retracted the flaps to position 3 and the PF began a right turn after passing the Deauville Airport. The aircraft climbed to a height of 1100 feet on a heading of 150 degrees and then began a left turn to align on runway 30. At the end of the turn, the crew selected the flaps in the full extended position and the TAWS glideslope alarm activated for approximately two seconds. At 10:23:28, the aircraft landed on runway 30.

The controllers did not observe the aircraft's track on final. A TAWS warning caused the crew to climb to a safe altitude from which they continued the approach.

Probable Cause:

Causes of the serious incident (translated from French):
The crew announced a visual approach on the frequency but prepared for an MVL (circle-to-land) procedure. When the controller requested a call back at the start of the downwind leg, the PF interpreted this message as an order to turn right. From that point on, the crew no longer followed a standard procedure but mixed the MVL procedure and the visual approach. They descended to the MDA (1,100 ft AAL) during the downwind leg and then continued the descent into the last turn below the glidepath.
The minimum recorded altitude was 528 ft (49 ft above the aerodrome) at a distance of 3 NM from the runway threshold.
The serious incident resulted from:
- an incomplete transition from the MVL procedure to the visual approach. The crew kept the MDA as their downwind target altitude;
- loss of situational awareness in the vertical plane. The crew commenced and continued the descent below the final approach path. While over sea, crews may tend to fly too low because external visual references are insufficient to accurately estimate the height;
- the difference in representation between the crew and the control on the trajectory that the aircraft must follow to reach the downwind leg. Air Traffic Control expected a visual approach course while the crew initiated an MVL procedure.

Accident investigation:
cover
Investigating agency: BEA
Status: Investigation completed
Duration: 4 years and 7 months
Accident number: tc-z130926
Download report: Final report


Follow-up / safety actions

BEA issued 1 Safety Recommendation

Show all AD's and Safety Recommendations

Photos

photo of Airbus A321-231 TC-OBZ
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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 Izmir-Adnan Menderes Airport to Deauville-Saint Gatien Airport as the crow flies is 2455 km (1535 miles).
Accident location: Approximate; accuracy within a few kilometers.

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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