N777as
Last Update: December 17, 2019 at 3:59:38 PM
A Mid East Jet Boeing 777-200, registration N777AS performing a flight from Riyadh (Saudi Arabia) to Paris Le Bourget (France) with 9 crew, performed a LOC A approach to Le Bourget's runway 25, which is offset to the runway center line by 26 degrees. The aircraft initially performed the approach on autopilot in LNAV/VNAV modes (Vapp 143 KIAS), the aircraft was configured for landing with flaps 30, gear extended, just prior to descending through minimum descent altitude (614 feet AGL) the crew disengaged the autopilot, autothrottle remained on. Descending through 300 feet AGL the aircraft descended at 900 fpm, the pitch angle reduced. Descending through 200 feet AGL, 1100 meters/3600 feet from the runway threshold at a heading of 275 degrees magnetic, the aircraft begins a left turn, the pitch reached 1.8 degrees nose down, an aural EGPWS alarm 'SINK RATE! SINK RATE!' sounds at 1200 fpm rate of descent at about 150 feet AGL, engine power (at this point at 38% N1) is being gradually increased, the pilot flying provides pitch up commands. The aircraft crosses through the runway center line at 19 degrees offset maintaining 100 feet AGL, airspeed reduced through 137 KIAS, the aircraft is now 50 meters/150 feet right of the runway centerline maintaining 100 feet AGL at 5-7 degrees nose up. The aircraft turns left and begins to descent again, a second EGPWS alarm 'SINK RATE! SINK RATE!' triggers. The thrust levers are pushed forward without TO/GA activation. The right main gear touches down on the runway at +1.96G, pitch 10 degrees nose up and right bank angle of 16 degrees. About 2 second later the right main gear becomes airborne again, the airspeed reaches a minimum of 117 KIAS, autothrottle engages in Thrust Reference, the autopilot switches to VNAV Speed mode. The aircraft climbs through 100 feet AGL at 133 KIAS, the flaps are reduced to 20 degrees, tower informs the crew that he saw the aircraft touch the runway abnormally. Tower initiated a runway inspection which did not find any anomaly. The aircraft positioned for another approach to runway 07 and landed without further incident.
The French BEA released their final report in French only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a French only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).
The final report concluded the probable cause of the serious incident was:
The late go around following an unstablized approach
Contributing to the serious incident were:
- lack of criteria for stabilized approach, both by the flight crew and the operator
- little recent experience and little practise of the relevant approach procedure by the pilot flying
- lack of hierarchy non conducive to Cockpit Resource Management
- operator without a safety management system and poor practises non conducive to safety culture.
The BEA reported that following landing on runway 07 the aircraft remained powered up, the recordings of the cockpit voice recorder were thus lost.
An inspection of the aircraft revealed traces of friction on the right wing tip and the leading edge of the right wing as well as the tip of the right horizontal stabilizer. A right wing fairing also showed traces of friction, one of its fasteners was broken. No damage was found at the landing gear. A detailed runway inspection revealed friction marks about 161 meters past the displaced threshold, length about 28 meters, about 19 to 22.5 meters to the right of the runway center line. Those marks were close to the touch down area identified by the flight data recorder.
The BEA reported the cloud base at the time of the occurrence was at 627 feet AGL.
Mid East Jet is a company based in Jeddah (Saudi Arabia), however, operating under US AoC since 2012, it operates aircraft in VIP configuraton. It was not required to have a Safety Management System. N777AS is used exclusively for the benefit of a single sponsor.
The crew of the aircraft consisted of a 'Flight Captain' (66, ATPL, more than 13,000 hours total) in the left hand seat, a 'Reserver Captain' (60, ATPL, 20,000 hours total, 2,000 hours on type) in the right hand seat, a 'Trip Captain' (69, ATPL, more than 30,000 hours total) in the observer's seat, in addition a flight engineer was present in the cockpit at the time of the occurrence. The crew was fired in the days after the occurrence.
The flight captain had retired from American Airlines in 2013 (13,000 hours total at that time, he no longer logged the hours afterwards), flew Boeing 777s for Biman Bangladesh, Ethiopian Airlines and again Biman Bangladesh before joining Mid East 18 months for the event. In 2015 he performed 25 landings, in 2016 4 landings as pilot flying. He performed only one landing in the three months prior to the occurrence.
The trip captain joined Mid East in 2011 after retiring from his former company with 30,000 flight hours total and no longer logged his hours.
The BEA analysed the aircraft came out of clouds just prior to MDA leaving a short segment only to align with the runway. The correction was insufficient, the aircraft overshot the runway center line, the inertia of the aircraft makes it difficult to return the aircraft onto the center line. The lack of CVR recordings make it impossible to assess the decision making processes with certainty: the flight captain decided to continue the landing although the aircraft was not stabilized after the turn and a safe landing was not ensured, the roles of the reserve captain as well as the trip captain could not be determined, in particular it could not be established whether a go around call and when was made.
Regulations require at least 3 landings in the last 90 days to carry out a flight. The working schedule of the company of six weeks of duty (sometimes without flying) and six weeks of rest are incompatible with maintaining adequate maneouvering capabilities. It is thus likely the pilot flying had not accumulated sufficient recent experience to carry out an approach like into Bourget with ease despite his general experience.
The operator did not include LOC approaches in their training programme, that was outsourced to the US. It is likely no monitoring programme existed for its crews that would have permitted specific training on the flight simulator or a flight with instructor. There was lack of consideration for and lack of experience with operational risk management. Pilot testimonies suggested that the operator frequently intervened and insistently during varying phases of flight including the approach indicating lack of knowledge and lack of respect for operational constraints. These elements combined with the dismissal of the crew following the occurrence show an insufficient safety culture within the operator and lack of 'just culture'.
The airport operator studied the implementation of PAPIs in response to this and other occurrences and without waiting for certification implemented the first set of PAPIs, the implementation of a second set of PAPIs is being discussed. In addition the airfield operator is in dicussion with the CAA about the conditions under which runway 25 can be operated with respect to visibility.
Metar:
LFPB 051030 AUTO VRB02KT 4300 BR OVC005 16/14 Q1019 BECMG 6000 NSW BKN020
The flight track of N777AS (Graphics: BEA):
N777as Inside
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
N777AS Boeing 777-24Q - 29271, operated by Mid East Jet Manufacture Date. Age: 22 years 2 months. Last seen on FlightRadar24. Flight History: N777AS. N777AS (2003 BOEING 777-24Q owned by BANK OF UTAH TRUSTEE) Aircraft Registration - FlightAware Want more information about this aircraft? You might be interested in our FBO ToolBox service. Registration: N777AS Airline Mid East Jet Country: Saudi Arabia Date: 1990 - Codes: XAH General information & flightlog Serial number: 29271 LN:174: Type: 777-24Q: First flight date:: Test registration: Plane age: 22.2 years: Seat configuration: Flights recorded. JetPhotos.com is the biggest database of aviation photographs with over 4 million screened photos online! Why not follow us on Facebook to be the first to find out about the latest developments. Let us know what you think of the site and tell us what features you want to see next.
Incident Facts
Date of incident
Jun 5, 2016
Classification
Report
Airline
Mid East Jet
Aircraft Type
Boeing 777-200
ICAO Type Designator
B772
Aircraft Registration
N777AS