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ASN Wikibase Occurrence # 232176
Last updated: 24 November 2021
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Date:06-DEC-2019
Time:11:15 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8D6 (WL)
Owner/operator:Air Algérie
Registration: 7T-VJM
MSN: 30205/691
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:near Paris-Orly Airport (ORY/LFPO) -   France
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Tlemcen-Zenata Airport (TLM/DAON)
Destination airport:Paris-Orly Airport (ORY/LFPO)
Investigating agency: BEA
Narrative:
Flight AH1086 from Tlemcen to Paris-Orly was established on the localizer of runway 25. A bird control vehicle was traveling along taxiway W33 and came to a halt behind the holding point. While the Boeing 737 was on short final, there was a Runway Incursion Monitoring and Collision Avoidance System (RIMCAS) alert.
However, the bird‑control vehicle was behind the holding point and outside the runway safety area. The erroneous activation of the RIMCAS warning was due to the relocation of the holding point, after work, not being taken into account in the system parameters.
The controller reacted by ordering AH1086 to perform a go-around. The crew increased power, climbed on the centreline to 2,000 ft, and then started making a left turn. During the turn, the aircraft lost altitude and descended down to 1,250 ft, before climbing again to 3,000 ft. The crew carried out a new approach and landed at Orly.

Weather about the incident time (1115Z) included low visibility in rain:
LFPO 061100Z 20011KT 4500 -RA BR BKN005 02/01 Q1018
LFPO 061200Z 20013KT 3200 -RA BR BKN005 03/02 Q1016


Contributing factors
In the absence of a CVR recording and precise statements, it was not possible to precisely analyse the crew’s actions. The following factors may, nevertheless, have contributed to the observed deviations from the procedure and tracking of the path during the go-around:
- The startle effect linked to a go-around ordered by the controller when at low height.
- The missed approach path with a low published altitude and a left turn in initial climb which creates a high workload in a short time.
- The crew’s application of an initial high thrust given the stabilization altitude of the missed approach.
- Piloting based on a hybrid use of automatic systems (A/P, A/T and F/D) which was not conducive to acquiring the published altitude of the missed approach procedure.
- A breakdown in crew cooperation which may be explained by the startle effect linked to the go-around instruction and to the workload mentioned above.
- The display of the vertical speed target value on the PFD which may require a verification on the MCP. This may have contributed to the crew not detecting that the target value was not consistent with the desired path.
- The absence of a system check for consistency between the action carried out (selection of a higher altitude) and its result (mode reversion leading to a descent) along with the absence of a crew alert.
The controller’s messages to warn the crew of the plane’s descent, along with the GPWS warnings, probably contributed to the crew realising that they were on an erroneous path and to them levelling off the plane.

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-grave-du-boeing-737-immatricule-7t-vjm-exploite-par-air-algerie-survenu-le-06122019-a-orl/

Accident investigation:
cover
  
Investigating agency: BEA
Status: Investigation completed
Duration: 1 year and 10 months
Download report: Final report

Media:


Images:

Photo of 7T-VJM courtesy AirHistory.net


Palma de Mallorca (LEPA / LESJ / PMI)
4 August 2019; (c) Toni Marimón


Revision history:

Date/timeContributorUpdates
17-Jan-2020 15:32 harro Added
17-Jan-2020 15:32 harro Updated [Location, Narrative, Photo]
13-Oct-2021 09:20 harro Updated [Embed code, Narrative, Accident report]

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