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| Date: | Monday 23 May 2022 |
| Time: | 13:41 |
| Type: |  Airbus A320-233 |
| Owner/operator: | Norwegian Air Sweden, opb AirHub Airlines |
| Registration: | 9H-EMU |
| MSN: | 1087 |
| Year of manufacture: | 1999 |
| Engine model: | IAE V2527E-A5 |
| Fatalities: | Fatalities: 0 / Occupants: 178 |
| Other fatalities: | 0 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | 1 nm E of Paris-Charles de Gaulle Airport (CDG/LFPG) -
 France
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | Stockholm-Arlanda Airport (ARN/ESSA) |
| Paris-Charles de Gaulle Airport (CDG/LFPG) | |
| Investigating agency: | BEA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Norwegian Air Sweden flight D84311, an Airbus A320-233, nearly struck the ground on approach to Paris-Charles de Gaulle Airport in France when it descended to 6 feet above ground level during a go-around.
The flight was operated by AirHub Airlines on behalf of Norwegian Air Sweden and had departed Stockholm-Arlanda Airport (ARN), bound for Paris-CDG. Weather at Paris-Charles de Gaulle was poor due to Cumulonimbus (CB) clouds with rain showers, causing limited visibility.
The flight was cleared for an Required Navigation Performance (RNP) approach to runway 27R. The lateral guidance in this RNP approach relied on satellite (GNSS) positioning. Vertical guidance was based on the aircraft barometric altitude.
During descent, the Intermediate (ITM) controller at CDG twice reported the QNH altimeter pressure setting to be 1011 instead of 1001 mb.
The controller also reported this incorrect setting to an easyJet flight, but that crew read back the correct value (1001).
The ITM instructed later gave instructions to an Air France flight, in French, with the correct QNH 1001.
The flight crew was subsequently cleared to land by the Tower controller while descending around 280 ft below the descent profile.
The ground Minimum Safe Altitude Warning (MSAW) was then triggered and the controller radioed the crew. The crew stated they did not hear this radio-communication. However, the crew initiated a go-around. The minimum radio-altimeter height was recorded at 6 ft above the ground, at 0.8 NM from the runway threshold. The crew could not see PAPIs and runway lights since Tower had forgotten to switch on runway approach lights. Tower subsequently switched on approach lights after the plane go around
A second approach was flown based on the same erroneous QNH, again resulting in an MSAW warning with ATC. This time the flight crew were able to see the runway and PAPI's, corrected the flight path on final and then landed without further incident.
Contributing factors:
9H-EMU’s near collision with the ground was due to a barometric approach being carried out with an incorrect altimeter setting (QNH) of +10 hPa, in a rain shower and with no external visual references.
Barometric approaches are particularly affected by the altimeter setting as it has an impact on the altitude adopted by the aeroplane and consequently the descent profile and vertical position along the flight path, including at minima.
The approach was thus carried out on a vertical profile around 280 ft below the published vertical profile, up to a minimum recorded and corrected radio-altimeter height of 6 ft, i.e. approximately 2 m, when the aircraft was about 0.9 NM from the runway threshold, without the crew being aware of this.
The following factors contributed to two barometric approaches being flown with an incorrect altimeter setting:
- human error in the exchanges communicating the QNH, the probability of which can never be reduced to zero;
- operating procedures for crews and air traffic controllers that are not very robust, or even ineffective against this threat;
- on-board and ground systems that are not very robust, or even ineffective against this threat.
The following factors contributed to the aeroplane descending to a near collision with the ground (near-CFIT):
- the approach lights not being illuminated;
- the absence of an on-board ground proximity warning, even though the TAWS system was operating in accordance with its design;
- the late triggering of the Minimum Safe Altitude Warning (MSAW) system, even though the system was operating in accordance with its design;
- a late and inadequate reaction by the air traffic controller to the triggering of this MSAW alert. The insufficient training of controllers with respect to the actions to be taken in response to this alert contributed to this inappropriate reaction.
The CFIT risk linked to an incorrect altimeter setting during a barometric approach has been known about for decades. However, the widespread use of ILS approaches probably helped to mask this threat and its consequences for a long time. More recently, satellite approaches with barometric vertical guidance have been promoted to increase the level of safety where previously only non-precision approaches existed. However, the increased use of these satellite approaches with barometric vertical guidance, in particular as a replacement for ILS approaches, has not led the aviation community to question the impact on safety levels, even though overall safety requirements are increasingly stringent.
Weather reported about the time of the incident (1141Z):
LFPG 231100Z 25008KT 9999 SHRA SCT016 BKN028 19/14 Q1001 TEMPO 3500 SHRA SCT060CB
LFPG 231200Z 29010KT 5000 SHRA FEW010 BKN015 BKN028 FEW050CB 16/15 Q1001 TEMPO 3500 SHRA SCT060CB
Accident investigation:
 |
|
Sources:
https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-airbus-a320-registered-9h-emu-operated-by-airhub-on-23-05-2022-at-paris-charles-de-gaulle-ad/
https://uk.flightaware.com/live/flight/9HEMU/history/20220523/0932Z/ESSA/LFPG
https://bea.aero/fileadmin/user_upload/BEA2022-0219_9H-EMU_preliminary_report_for_publication_EN_finalise.pdf
Location
Images:
Figure: BEA
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 03-Jun-2022 07:41 | harro | Added |
| 03-Jun-2022 07:43 | harro | Updated [Time, Narrative, ] |
| 11-Jul-2022 14:48 | harro | Updated [Total occupants, Source, ] |
| 11-Jul-2022 15:53 | harro | Updated [Location, Narrative, ] |
| 13-Jul-2022 08:54 | harro | Updated [Narrative, Photo, ] |
| 13-Jul-2022 08:56 | harro | Updated [Category, ] |
| 30-Aug-2022 11:37 | ThierryM | Updated [Narrative, ] |
| 11-Jul-2024 08:17 | ASN | Updated [Embed code, Narrative, Accident report, ] |
| 11-Jul-2024 08:20 | ASN | Updated [Category, ] |
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