What happened
On the night of September 23–24, 2022, a Swiftair Boeing 737-400, registered EC-NLS, was performing a commercial mail flight from Paris Charles de Gaulle to Montpellier - Méditerranée. While the crew had initially prepared for an ILS approach to runway 30R, a change in the active runway required them to switch to a VOR-DME approach for runway 12L. This change in approach was conducted without a new briefing.
During the approach, a storm cell was moving toward the airport from the southwest. As the aircraft reached short final, the crew decided to swap flying and monitoring roles. The captain moved to the pilot monitoring (PM) position, while the co-pilot took over as the pilot flying (PF). During the descent, the aircraft encountered windshear characterized by a sudden reduction in tailwind. The crew failed to detect this change or realize that the aircraft had passed the touchdown zone without making contact with the runway.
The aircraft touched down approximately 1,500 meters from the threshold of runway 12L. Due to the high energy level and the windshear event, the aircraft overran the runway and came to rest in an adjacent lake.
The investigation
The BEA examined the crew's situational awareness regarding approaching weather and their management of the approach stabilization. The investigation focused on the impact of the role swap on the co-pilot's ability to monitor flight parameters and the effectiveness of the standard callouts used during the transfer of controls. Additionally, the investigation reviewed the implementation of the Global Reporting Format (GRF) and how runway condition updates were communicated during rapid meteorological changes.
Findings
- The crew had low situational awareness regarding the approaching storm cell despite available meteorological information.
- The sudden swap of PF and PM roles created a surprise effect for the co-pilot, which hindered his ability to effectively perform monitoring tasks.
- The aircraft entered the final approach with a high energy level, and the crew lacked the cognitive resources to identify the windshear threat once it occurred.
- The standard callout for transferring controls did not sufficiently prompt the new PM to resume active monitoring of the aircraft's flight path.