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Last updated: 24 September 2018
Status:Definitief
Datum:donderdag 26 september 2013
Tijd:10:18
Type:Silhouette image of generic A321 model; specific model in this crash may look slightly different
Airbus A321-231
Luchtvaartmaatschappij:Onur Air
Registratie: TC-OBZ
Constructienummer: 811
Bouwjaar: 1998-04-06 (15 years 6 months)
Aantal vlieguren:38700
Aantal vluchten:25500
Motoren: 2 IAE V2533-A5
Bemanning:slachtoffers: 0 / inzittenden: 7
Passagiers:slachtoffers: 0 / inzittenden: 220
Totaal:slachtoffers: 0 / inzittenden: 227
Schade: Geen
Plaats:5,6 km (3.5 mijl) WNW of Deauville-Saint Gatien Airport (DOL) (   Frankrijk)
Fase: Nadering (APR)
Soort vlucht:Internationale charter
Vliegveld van vertrek:Izmir-Adnan Menderes Airport (ADB/LTBJ), Turkije
Vliegveld van aankomst:Deauville-Saint Gatien Airport (DOL/LFRG), Frankrijk
Vluchtnummer:8Q1985
Beschrijving:
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 serious incident
The crew announced a visual approach on the radio but prepared for an MVL procedure. When the controller requested the crew to call back at the beginning of the downwind leg, the PF interpreted this message as an order to turn right. From this point on, the crew no longer followed a standard procedure but mixed up the MVL procedure with the visual approach procedure. They descended to the MDA (1,100 ft AAL) in the downwind leg and then continued the descent in the final turn under the final approach slope. The minimum recorded altitude was 528 ft (i.e. 49 ft above the aerodrome) at a distance of 3 NM from the runway threshold.
The serious incident was caused by:
- an incomplete transition from the MVL procedure to the visual approach procedure. The crew kept the MDA as their target altitude in the downwind leg;
- a loss of awareness of the aircraft's situation in the vertical plane. The crew commenced and continued the descent under the final approach slope. However, when flying over the sea, crews may have a tendency to fly too low because the external visual references are insufficient to accurately estimate height;
- the crew and the ATC represented the flight path which the aircraft was to follow to reach the downwind leg differently. The controller expected a flight path corresponding to a visual approach while the crew initiated an MVL procedure.
The controllers did not watch the aircraft's flight path on the final approach. The crew's response to the occurrence of TAWS alerts probably prevented a collision with the coast.

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


Veiligheidsmaatregelen

BEA issued 1 Safety Recommendation

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photo of Airbus A321-231 TC-OBZ
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Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Izmir-Adnan Menderes Airport en Deauville-Saint Gatien Airport bedraagt 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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