Serious incident Airbus A319-111 F-GRHU,
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ASN Wikibase Occurrence # 236339
 
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Date:Wednesday 23 September 2009
Time:
Type:Silhouette image of generic A319 model; specific model in this crash may look slightly different    
Airbus A319-111
Owner/operator:Air France
Registration: F-GRHU
MSN: 1471
Year of manufacture:2001
Engine model:CFMI CFM56-5B5/P
Fatalities:Fatalities: 0 / Occupants:
Aircraft damage: None
Category:Serious incident
Location:Paris-Charles de Gaulle Airport (CDG/LFPG) -   France
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Moskva-Sheremetyevo Airport (SVO/UUEE)
Destination airport:Paris-Charles de Gaulle Airport (CDG/LFPG)
Investigating agency: BEA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The crew of Air France flight AF 2545 performed an ILS CAT 1 approach to runway 27R at Paris-Charles de Gaulle Airport. The decision height was 200 feet. The captain, at the minima, performed a go-around due to the weather conditions that deteriorated during the approach.
During this manoeuvre, he engaged the autopilot. The descent continued and a GPWS alarm sounded. The lowest recorded height was 76 feet.


COnclusions:
This serious go-around altitude loss incident is due to:
- the engagement of the AP in an unsuitable mode;
- the failure to activate the go-around modes, as a result of the thrust levers being positioned in an unsuitable notch;
- a lack of attitude monitoring.
The following factors may have contributed to the incident:
- inaccuracies in the drafting of the procedure available to the crew;
- a deviation in the application of the procedure related to taking operational constraints into account. 

Accident investigation:
cover
  
Investigating agency: BEA
Report number: 
Status: Investigation completed
Duration: 11 months
Download report: Final report

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/perte-momentanee-du-controle-de-la-trajectoire-en-remise-de-gaz-alarme-gpws/

Revision history:

Date/timeContributorUpdates
23-May-2020 16:23 harro Added

Corrections or additions? ... Edit this accident description

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