ASN Wikibase Occurrence # 314712
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Narrative:The crew conducted a ferry flight departing from Paris-Orly to Olbia (Sardinia, Italy). This flight was performed with the landing gear extended following a hydraulic failure that occurred during the previous flight.
|Date:||Wednesday 12 January 2011|
McDonnell Douglas MD-83
|Fatalities:||Fatalities: 0 / Occupants: |
|Aircraft damage:|| None|
|Location:||near Paris Orly Airport -
|Departure airport:||Paris-Orly Airport (ORY/LFPO)|
|Destination airport:||Olbia-Costa Smeralda Airport (OLB/LIEO)|
|Investigating agency: ||BEA|
|Confidence Rating:|| Accident investigation report completed and information captured|
During the flight preparation, the crew did not have the documentation required to calculate the fuel needed for a flight with extended landing gear and carried an inadequate amount of fuel. After approximately 23 minutes of flight, they observed that the fuel consumption was higher than expected and decided to return and land at Paris-Orly.
During the ILS approach, the crew performed a go-around due to a malfunction of the captain's VOR/ILS system and a descent that posed a risk of collision with terrain. They then executed a VOR/DME approach. The cloud base was 300 ft/AGL, equivalent to 600 ft/QNH, while the meteorological minima for the VOR/DME approach were 900 ft. The crew estimated that the remaining fuel necessitated landing after this approach. At the minimum descent altitude (MDA), they continued the descent until visual contact with the ground. Upon exiting the cloud layer at around 300 ft/AGL, they saw the runway to the left. They performed significant lateral maneuvers and landed halfway down the runway. The aircraft stopped a few meters from the runway end.
The incident resulted, in particular, from inadequate flight preparation and degraded crew resource management (CRM), which failed to correctly identify the status of the available navigation means on board and the various deviations from the planned trajectory.
This serious incident resulted from the combination of the following factors:
- Inadequate flight preparation, leading to the decision to conduct a ferry flight with extended landing gear without having the essential documentation to calculate the required fuel quantity to be loaded.
- Disruption of the refueling contracts, which prompted the crew to return to Paris-Orly instead of diverting for refueling.
- Degraded CRM that failed to identify:
-- The malfunction of the captain's VOR/ILS system during the first approach.
-- The operation of the ILS on the first officer's VOR/ILS system.
-- The various deviations from the planned trajectory.
| || |
|Investigating agency: ||BEA |
|Report number: || |
|Status: ||Investigation completed|
|Download report: || Final report|
Other occurrences involving this aircraft
|24 October 2017
||Mashhad International Airport (MHD/OIMM)
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