What happened
On March 17, 1995, an AIRJET BAe 146-200 Quick Change, registration F-GOMA, was performing a positioning flight from Innsbruck, Austria, to Epinal-Mirecourt, France. The flight was operating under IFR conditions in IMC with light icing and significant turbulence.
During the intermediate approach to runway 27, the aircraft descended through 2,420 feet when the Ground Proximity Warning System (GPWS) issued a "Terrain, Terrain" and "Whoop Whoop, Pull Up" alert. In response to the alarm, the pilot attempted an immediate climb. While the aircraft initially gained altitude, the pilot then applied significant back pressure on the control column. This caused the aircraft to pitch up excessively to an attitude of +12.2 degrees, causing the airspeed to drop to 122 knots.
Following this, the aircraft entered a severe loss of control. The pitch attitude transitioned rapidly to a nose-down position of -46 degrees, with the aircraft reaching a minimum altitude of only 500 feet. During the subsequent recovery maneuver, the aircraft experienced a load factor of +2.8g and a maximum airspeed of 247 knots. The crew eventually stabilized the aircraft, climbed to 5,000 feet, and completed a normal landing at 12:00 UTC.
The investigation
The investigation focused on the sequence of events following the GPWS alert and the subsequent flight path deviations. Investigators examined the aircraft's flight parameters, including pitch, airspeed, and vertical acceleration. The investigation also reviewed the aircraft's configuration, noting that the engines were at 61% N1, the flaps were at 18 degrees, and the trim tab was at +4.1 degrees nose-up. Flight simulator sessions were conducted to replicate the incident, which successfully reproduced the flight path and the loss of control observed during the actual event.
Findings
- The primary cause of the loss of control was spatial disorientation of the pilot in command during the climb following the GPWS alert.
- The crew's attention was distracted during the approach, which led to the aircraft inadvertently descending below the protected altitude of the hippodrome and triggering the GPWS.
- Contributing factors included the unusual aircraft configuration (light weight and near the aft CG limit), a 30-degree bank angle during the power application, and adverse meteorological conditions involving heavy turbulence and IMC.