What happened
On November 23, 1997, an AOM Minerve MD83, registration F-GRMC, was performing a scheduled domestic flight from Marseille to Paris-Orly. The flight crew, which included an instructor captain and two line training officers, was conducting a precision ILS approach to runway 07 under Instrument Meteorological Conditions (IMC).
As the aircraft passed the outer marker, the captain initiated a go-around. During this maneuver, the aircraft's altitude reached a minimum of only 67 feet above the ground. There were no injuries to the 131 passengers or the 7 crew members on board, and no damage was reported to the aircraft or third-party property.
The investigation
The BEA investigation examined flight data, cockpit voice recordings, radar data, and meteorological conditions. The investigators also conducted flight simulator sessions with instructor pilots to replicate the cockpit environment and workload. The inquiry focused on the crew's performance, the impact of fatigue, the ergonomic design of the MD83 cockpit, and the training protocols for line training officers (AEL) within the airline.
Findings
Several critical factors contributed to the incident:
- The captain was experiencing significant fatigue due to flight schedules that exceeded regulatory limits and the high workload associated with his instructor duties.
- The crew's workload was excessively high during the final approach, exacerbated by simultaneous audible alarms that were difficult to process.
- There was a lack of effective Crew Resource Management (CRM), as the two training officers were not sufficiently involved in the flight's execution.
- Cockpit ergonomics played a role, specifically regarding erroneous information displayed on the Flight Mode Annunciator (FMA) and the difficulty of detecting heading selection errors.
- The airline's operational structure and training methods for line training officers did not sufficiently foster situational awareness or responsibility among the junior crew members.