Serious incident to the Airbus A320 registered 9H-EMU operated by AirHub on 23/05/2022 on approach to CDG

• Print
• Download
• Follow this page
• Share

• Summary
• Report
• SAFETY RECOMMENDATIONS
• Annexes
• "LESSONS LEARNED" VIDEO

Summary of the final report

Safety Promotion Leaflet

Synopsis:

The crew of the Airbus A320 registered 9H-EMU were carrying out scheduled flight NSZ4311 between Stockholm Arlanda airport (Sweden) and Paris-Charles de Gaulle airport (France). Work was being carried out on the ILS for runway 27R at CDG, so the crew carried out a satellite approach with barometric vertical guidance (RNP APCH down to LNAV/VNAV minima).

During the approach, in a rain shower which severely impaired visibility, the crew were given an incorrect altimeter setting (QNH) by the air traffic service with a difference of 10 hPa (1011 hPa instead of 1001).

An error in the altimeter setting will mean that the aeroplane's actual altitude does not correspond to the altitude displayed. For approaches with barometric vertical guidance, the vertical profile and the associated vertical guidance are thus affected. Using a QNH value 10 hPa higher than the actual value resulted in the approach being flown on a vertical profile that was parallel to but around 280 ft (85 m) below the published vertical profile.

The design of the IFR procedures is based on normal operations and thus does not take into account an incorrect altimeter setting. The crews' operating procedures and those of the air traffic controllers did not prevent the use of an incorrect altimeter setting. Furthermore, neither the aeroplane's instruments nor the air traffic controller's tools were designed to detect this type of error.

At low height, a ground proximity warning (MSAW) was triggered in the control tower. Several seconds later, the air traffic controller informed the crew of the situation using an incorrect and inappropriate phraseology. The crew did not hear this announcement and continued their descent.

After reaching the indicated altitude corresponding to the chosen minima, the crew carried out a go-around because they had not acquired the visual references needed to continue the landing. During the manoeuvre, the minimum recorded and corrected radio-altimeter height was 6 ft, i.e. about 2 m, when the aeroplane was about 0.9 NM from the runway threshold, outside the limits of Paris-Charles de Gaulle airport. As per design, there was no on-board ground proximity alert (TAWS) during the event. In their statements, the crew indicated that they had not been aware of this proximity with the ground.

The second approach was also carried out with the same incorrect QNH. This time, the crew acquired visual contact with the ground, at a height of more than 600 ft. The PF corrected the flight path and landed without further incident.

The BEA has issued twelve safety recommendations, six safety recommendations were issued when the preliminary report was published on 11 July 2022, and six additional safety recommendations accompany the publication of the final report. These latter recommendations concern:

• the overall reassessment of the Controlled Flight Into Terrain (CFIT) risk and the associated mitigation measures in relation to the threat of an incorrect altimeter setting for baro-VNAV approach operations;
  
• maintaining the safety level of approach operations in Europe in 2030, in connection with the Commission Implementing Regulation (EU) 2018/1048 of 18 July 2018 laying down airspace usage requirements and operating procedures concerning performance-based navigation known as the "IR-PBN" regulation;
  
• ground systems for detecting an incorrect altimeter setting;
  
• onboard Terrain Awareness Warning Systems (TAWS);
  
• air traffic controller training in response to a MSAW alert;
  
• the DSNA safety management system.

Final report: The BEA issues 6 safety recommendations:

Preliminary report: The BEA has issued 6 safety recommendations

The recommendations are being processed

The status of the recommendations is available at SRIS2: click here

Note: in accordance with the provisions of Article 17.3 of Regulation No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation, a safety recommendation in no case creates a presumption of fault or liability in an accident, serious incident or incident. The recipients of safety recommendations report to the issuing authority in charge of safety investigations, on the measures taken or being studied for their implementation, as provided for in Article 18 of the aforementioned regulation.

Annex 1: "SOP Approach Using FINAL APP guidance"

Annex 2: "Meteo-France QNH study"

Annex 3: "SOP Airbus post SINCID"

General information

Local date	23/05/2022
Responsible entity	France - BEA
State or area of occurrence	Europe and North Atlantic - France - 95 Val-d'Oise
Location	On approach to Paris-Charles de Gaulle AD
Human consequences	None
Aircraft consequences	None
Occurrence class	Serious incident
Occurence category	CFIT: Controlled flight into or toward terrain
File number	BEA2022-0219

Flight Information

Aircraft category	Fixed Wing - Aeroplane - Large Aeroplane - Large Aeroplane
Operator	Malta (AirHub Airlines)
Manufacturer / Model	AIRBUS - A320
Aircraft Registration	9H-EMU
State of registry	Malta
Last departure point	Sweden - ESSA (ARN): Stockholm/Arlanda
Planned destination	France - LFPG (CDG): Paris Charles-De-Gaulle
Flight phase	Approach
Serial number	1087
Operator Type AG
Operation Type	Commercial Air Transport - Passenger - Airline

BEA is the French air safety investigation authority for civil aviation. The sole objective of the investigation is to improve air safety. It is intended neither to apportion blame nor to assess responsiblity.

Public link

Please use the above public link if you want to share this noodl on another website.