1/5 www.bea.aero INVESTIGATION REPORT The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities. BEA2017-0598.en/April 2021 @BEA_Aero Incident to the Piper PA-34-220T registered N101FM and to the Airbus A320-200 registered D-ABHJ on 22 October 2017 on approach to Strasbourg airport (Bas-Rhin) Time 14:51 (1) Operator N101FM: Private D-ABHJ: Air Berlin Type of flight N101FM: Cross-country D-ABHJ: Commercial air transport (passengers) Persons on board N101FM: Pilot D-ABHJ : Captain, first officer, cabin crew and passengers Consequences and damage No damage This is a courtesy translation by the BEA of the Final Report on the Safety Investigation published in September 2020. As accurate as the translation may be, the original text in French is the work of reference. (1) Except where otherwise indicated, the times in this report are in Coordinated Universal Time (UTC). Two hours should be added to obtain the legal time applicable in Metropolitan France on the day of the event. 1 - HISTORY OF THE FLIGHT Note: the following information is principally based on statements, radio communication recordings and radar data. The pilot of the PA-34, the only person on board, was carrying out an IFR flight between Heubach airport (Germany) and Strasbourg-Entzheim airport (Bas-Rhin). He was in descent and in a layer of cloud, in IMC (2) conditions. The crew of the A320 took off from Baden-Baden airport (Germany), bound for Hamburg (Germany). The crews of both aeroplanes were in contact with Strasbourg approach. At 14:44, on first contact with the approach, the pilot of the PA-34 received clearance to descend to FL80 on heading 275, in order to be vectored for an ILS for runway 23. The pilot read back the clearance. At 14:49, the crew of the A320, in initial climb, received a clearance to climb to FL70 initially and then turn onto heading 045. At 14:50:14, the controller asked the crew of the A320 to reduce the rate of climb, informing them of the position of IFR traffic (the PA-34) “5 NM east of your position, 1000 ft above your clearance.” (2) Instrument Meteorological Conditions. Loss of separation between two IFR flights, activation of TCAS RA warning
Transcript
1/5
www.bea.aero
INVESTIGATION REPORT
The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities.
BEA2017-0598.en/April 2021
@BEA_Aero
Incident to the Piper PA-34-220T registered N101FMand to the Airbus A320-200 registered D-ABHJon 22 October 2017on approach to Strasbourg airport (Bas-Rhin)
Time 14:51(1)
Operator N101FM: PrivateD-ABHJ: Air Berlin
Type of flight N101FM: Cross-country D-ABHJ: Commercial air transport (passengers)
Persons on boardN101FM: Pilot D-ABHJ : Captain, first officer, cabin crew and passengers
Consequences and damage No damageThis is a courtesy translation by the BEA of the Final Report on the Safety Investigation published in September 2020. As accurate as the translation may be, the original text in French is the work of reference.
(1)Except where otherwise indicated,
the times in this report are in
Coordinated Universal Time (UTC). Two hours should be
added to obtain the legal time applicable
in Metropolitan France on the day
of the event.
1 - HISTORY OF THE FLIGHT
Note: the following information is principally based on statements, radio communication recordings and radar data.
The pilot of the PA-34, the only person on board, was carrying out an IFR flight between Heubach airport (Germany) and Strasbourg-Entzheim airport (Bas-Rhin). He was in descent and in a layer of cloud, in IMC(2) conditions.
The crew of the A320 took off from Baden-Baden airport (Germany), bound for Hamburg (Germany).
The crews of both aeroplanes were in contact with Strasbourg approach. At 14:44, on first contact with the approach, the pilot of the PA-34 received clearance to descend to FL80 on heading 275, in order to be vectored for an ILS for runway 23. The pilot read back the clearance.
At 14:49, the crew of the A320, in initial climb, received a clearance to climb to FL70 initially and then turn onto heading 045.
At 14:50:14, the controller asked the crew of the A320 to reduce the rate of climb, informing them of the position of IFR traffic (the PA-34) “5 NM east of your position, 1000 ft above your clearance.”
(2)Instrument Meteorological
Conditions.
Loss of separation between two IFR flights, activation of TCAS RA warning
At 14:50:26, observing that the PA-34 had flown through FL80 in descent, the controller asked the pilot to confirm his flight level and then to climb immediately to FL80: the pilot read back but did not climb.
At 14:50:40, the controller asked the crew of the A320 to immediately turn left onto heading 045 and then a few seconds later, the pilot of the PA-34 to immediately turn left onto heading 210. The two crews read back. The crew of the A320 followed the clearance and increased the left turn while the pilot of the PA-34 turned right towards the north, contrary to the clearance he had received.
At 14:51:25, the controller asked the pilot of the PA-34 what had happened. The latter replied that he had encountered difficulties with the autopilot and that he was trying to hold the aeroplane. The controller again asked him to climb to FL80 using the emergency phraseology but the pilot continued to descend.
At 14:51:51, the crew of the A320 reported a TCAS(3) resolution advisory (RA) and started to descend. The minimum separation between the two aeroplanes was reached with a vertical separation of around 750 ft. The PA-34 reached its lowest point, FL74, and then started climbing. A few seconds later, the crew of the A320 reported that the conflict was over, that they were returning to their heading and joined FL70.
(3)The type of TCAS resolution advisory
(RA) was not formally specified by the
crew of the A320. The manoeuvres
made indicated that it was probably an order to descend.
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At 14:52:21, the controller asked the pilot of the PA-34 to turn left onto heading 250, in descent to 3,500 ft in order to intercept the ILS for runway 23 and cleared the approach.
At 14:52:43, the controller repeated the clearance previously given. A few moments later, the pilot turned left onto heading 250. Subsequently, he turned right towards the northwest.
At 14:54:29, the controller told him that he was on a path perpendicular to the approach path and asked him to turn left back to heading 250. The pilot joined heading 250.
At 14:57:10, the pilot reported that he was established on the glide and the localizer. A few moments later, he reported that he had flown under the slope and that he was climbing again. He landed on runway 23 at 15:02.
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2 - ADDITIONAL INFORMATION
2.1 PA-34 N101FM pilot information
The 36-year-old pilot resides in Germany. He holds a French Private Pilot Licence (SEP) issued in 2008 and extended in September 2017. He also holds an American Commercial Pilot Licence with IFR and multi-engine ratings issued in June 2017.
At the time of the incident, he had logged 276 flight hours of which 24 hours on the PA-34 and 2 hours in actual IMC. He had logged a little under 18 h on this aeroplane since its acquisition a few days beforehand.
2.2 PA-34 N101FM pilot’s statement
The pilot indicated that he had bought this aeroplane for professional use. He had previously been used to aeroplanes equipped with a glass cockpit and he was still not familiar with the more traditional instruments in his new aeroplane. The day of the accident, he was flying to Strasbourg to carry out a few dual flights with an instructor in order to get used to the aeroplane.
He explained that during the flight, he had encountered difficulties with the autopilot which had not taken into account the descent input to FL80. At the same time, he noticed that the indications on the vertical speed indicator were fluctuating, with large variations, both up and down. He indicated that he took manual control of the aircraft during this flight phase.
He added that he had received numerous instructions from the controller in a very short period, which appeared to him to be sometimes contradictory.
Being in IMC conditions and still not familiar with the aeroplane, he concentrated on flying to the detriment of the communications with the controller.
He added that following the incident, he had flown again and encountered dysfunctions with the autopilot once more. After a few days, the GARMIN 430 GNSS(4) navigation equipment equipping the plane was sent to a maintenance workshop(5). It was then changed a few weeks later for a glass cockpit system.
3 - CONCLUSIONS
The conclusions are solely based on the information which came to the knowledge of the BEA during the investigation. They are not intended to apportion blame or liability.
Scenario
When the controller identified that the pilot of the PA-34 was descending below the clearance for FL80, he immediately identified a potential conflict with the Airbus A320 taking off. His instructions were given to the crews of both aeroplanes using the emergency phraseology. The controller was not aware of the difficulties encountered by the pilot of the PA-34 and had no means of understanding his manoeuvres.
(4)Global Navigation Satellite System.
(5)Detailed information about the
work carried out by the workshop was not
reported; it was not possible to establish
a possible failure.
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Contributing factors
The following factors may have contributed to the incident:
� The pilot’s small amount of experience on this aeroplane which he had recently acquired.
� The pilot’s small amount of experience with the aeroplane’s navigation system. � The pilot’s small amount of experience in flying in IMC conditions. � The unexpected behaviour of the navigation system(6) which surprised the pilot during
a dynamic flight phase, in IMC conditions.
Safety lessons
The instructions which the controller gave to the crew of the Airbus A320 and this crew’s compliance with the TACAS resolution advisory to descend meant that a dangerous situation between the two aeroplanes was avoided.
