ASN Wikibase Occurrence # 224513
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| Date: | Wednesday 17 April 2019 |
| Time: | 14:03 |
| Type: |  Beechcraft 200GT Super King Air |
| Owner/operator: | DGAC |
| Registration: | F-HNAV |
| MSN: | BY-175 |
| Year of manufacture: | 2013 |
| Fatalities: | Fatalities: 0 / Occupants: 3 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | near Paris-Le Bourget Airport -
 France
|
| Phase: | Manoeuvring (airshow, firefighting, ag.ops.) |
| Nature: | Calibration/Inspection |
| Departure airport: | Paris-Le Bourget Airport (LBG/LFPB) |
| Investigating agency: | BEA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Beech 200 registered F-HCEV performed a calibration flight departing from Paris-Le Bourget aerodrome, the main objective of which was to put into service the new DME associated with the Aigle VOR (LGL) located at 75 NM to the west. On their trip, the crew also had to check a radial used in the standard departure procedure (SID) for runway 21 at this aerodrome.
The Beech 200 registered F-HNAV carried out a calibration flight on the the same day aimed at calibrating the two new ILS on runway 08R / 26L at Paris-Charles de Gaulle aerodrome.
The crews of these two flights consisted of a captain and a co-pilot from ENAC, which is the operator performing these calibration flights. The monitoring of the calibration measurements was carried out by a DSNA in-flight controller located at the rear, in the cabin.
The F-HCEV flight program called for a calibration of the 086 radial of the LGL VOR following the standard departure procedure (SID 21), followed by a continuation to the LGL VOR. This calibration was therefore not considered by the air traffic controllers as an activity that could interfere with the calibration program for the F-HNAV crew, in progress at the time of the event.
During flight preparation, the flight controller traced this radial on an aeronautical map. The manual route made radial 086 pass north of the prohibited zone P23 corresponding to the city of Paris and seemed consistent with the route of SID 21. The two pilots therefore did not check the controller's route in flight. The investigation showed that there was an error in the published procedure and that the 086 radial crossed the forbidden zone P23 and was therefore not consistent with the published procedure.
Before takeoff, the crew of F-HCEV inserted SID 21 and radial 086 into the aircraft's FMS and displayed the airspaces. The MFD's zoom level did not allow the crew to visualize where this radial passed and to identify the inconsistency. As such a check was not made, it did not allow the crew to detect that the measurement was not possible.
The crew of F-HCEV took off from runway 21, climbed in the center line following SID 21, then turned right to take heading 270 given by the air traffic controller. During the initial climb, the F-HCEV captain zoomed out of the MFD display and noted that the radial inserted into the FMS was further south than expected and passed into prohibited zone P23.
The flight controller did not have the ability to display airspaces or SID 21 on the screens of the calibration system. He therefore did not have the same representation of the situation as the F-HCEV pilots and for him, the radial could not pass through Paris.
After discussions between the pilots and the F-HCEV flight controller, the crew asked the air traffic controller to head south to try to reach radial 086. In response, the air traffic controller gave the instruction to walk along the ring road on sight and take the best course to start the measurement, thinking that the crew would continue on their way west. Indeed, for the controller it was a standard departure with a calibration measurement during the passage on the SID, he therefore expected above all to respect the SID.
The control instruction was interpreted differently by the captain of the F-HCEV who made a U-turn to the left to reach the start of the measurement, then finding himself facing east, on a convergent trajectory with the F-HNAV located behind him. A TCAS resolution advisory was triggered despite the avoidance instructions given to the two crews by the air traffic controller.
The crew of the F-HCEV thus gave priority to carrying out the measurement, even if it meant deviating from the SID. It is also possible that the change from a navigation mode consisting of following a standard procedure using the on-board instruments to a navigation mode requiring the acquisition and following of landmarks on the ground could have disturbed the crew.
After this first approach, the air traffic controller guided the crew of F-HCEV to face west with the trajectory of SID 21 in front of them and again instructed the crew to follow. the peripheral in sight to reach the start of measurement. The crew of the F-HCEV then confused the ring road with another fast lane in front of them. This confusion may have been fostered by the existence of a similar visual cue in front of the aircraft when the controller gave this instruction.
Following this visual cue led the crew to take a northwest route, bringing them closer to F-HNAV again. The crew did not identify that a route to the northwest was incompatible with tracking the device. For the co-pilot, the main thing was not to approach the prohibited zone P23.
During this visual flight phase, which lasted about 1 min 30, the crew of the F-HCEV doubted the reference point to follow but did not make themselves known to the air traffic controllers who, for their part, did not have understood why the crew was leaving northwest and did not contact the crew to dispel doubt.
At the end of the second approach, the behavior of the F-HCEV appeared sufficiently erratic to the air traffic controller for him to ask the crew to interrupt the calibration and come back to land at Le Bourget aerodrome. After several discussions with the air traffic controllers, the crew of the F-HCEV finally continued their measurement program towards the LGL VOR.
Accident investigation:
 |
|
Sources:
https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-grave-du-beech-200-immatricule-f-hnav-et-du-beech-200-immatricule-f-hcev-survenu-le-17042/
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 30-Apr-2019 14:16 | harro | Added |
| 15-May-2021 08:31 | harro | Updated [Time, Total occupants, Location, Narrative] |
| 29-Sep-2023 16:47 | harro | Updated [[Time, Total occupants, Location, Narrative]] |
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