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Serious Incident
Last updated: 24 April 2018
Statuts:Enquête Officielle
Date:jeudi 26 septembre 2013
Heure:10:18
Type/Sous-type:Silhouette image of generic A321 model; specific model in this crash may look slightly different
Airbus A321-231
Compagnie:Onur Air
Immatriculation: TC-OBZ
Numéro de série: 811
Année de Fabrication: 1998-04-06 (15 years 6 months)
Heures de vol:38700
Cycles:25500
Moteurs: 2 IAE V2533-A5
Equipage:victimes: 0 / à bord: 7
Passagers:victimes: 0 / à bord: 220
Total:victimes: 0 / à bord: 227
Dégats de l'appareil: Aucun
Lieu de l'accident:5,6 km (3.5 milles) WNW of Deauville-Saint Gatien Airport (DOL) (   France)
Phase de vol: En approche (APR)
Nature:Charter International
Aéroport de départ:Izmir-Adnan Menderes Airport (ADB/LTBJ), Turquie
Aéroport de destination:Deauville-Saint Gatien Airport (DOL/LFRG), France
Numéro de vol:8Q1985
Détails:
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 de l’incident grave:
L’équipage annonce à la fréquence une approche à vue mais se prépare à une procédure MVL. Au moment où le contrôleur demande de rappeler en début de vent arrière, le PF interprète ce message comme un ordre de virer à droite. À partir de cet instant, l’équipage ne suit plus de procédure standard mais mélange la procédure de MVL et l’approche à vue. Il descend jusqu’à la MDA (1 100 ft AAL) pendant la branche de vent arrière puis poursuit la descente en dernier virage sous le plan de la finale.
L’altitude minimale enregistrée est de 528 ft (soit 49 ft au-dessus de l’aérodrome) à une distance de 3 NM du seuil de piste.
L’incident grave résulte de :
- une transition incomplète de la procédure MVL vers l’approche à vue. L’équipage a gardé la MDA comme altitude cible en vent arrière ;
- une perte de conscience de la situation de l’avion dans le plan vertical. L’équipage a débuté et poursuivi la descente sous le plan d’approche finale. Lors d’un survol maritime, les équipages peuvent avoir tendance à voler trop bas car les références visuelles extérieures sont insuffisantes pour estimer précisément la hauteur ;
- la différence de représentation entre l’équipage et le contrôle sur la trajectoire que doit suivre l’aéronef pour atteindre la branche de vent arrière. Le contrôle s’attend à une trajectoire correspondant à une approche à vue alors que l’équipage initie une procédure MVL.

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


Opérations de secours

BEA issued 1 Safety Recommendation

Show all AD's and Safety Recommendations

Photos

photo of Airbus A321-231 TC-OBZ
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Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Izmir-Adnan Menderes Airport et Deauville-Saint Gatien Airport est de 2455 km (1535 miles).
Accident location: Approximate; accuracy within a few kilometers.

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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