Serious incident to the CESSNA 510 Citation Mustang registered F-GMTJ on 22 January 2019 at Paris – Le Bourget (Seine Saint Denis)

Paris-Charles de Gaulle and an arrival on runway 25 at Paris-Le Bourget. It also specifies that take-offs from the south parallel runways of Paris-Charles de Gaulle can be made independently of the 27 and VPT 25 finals to Paris-Le Bourget. However, when an aeroplane is on a LOC 25, VOR 25 or RNAV RNP 25 approach to Paris-Le Bourget and finds itself less than 4 Nm abeam the final for 26R, then take-offs are no longer permitted from the south parallel runways of Paris-Charles de Gaulle. To facilitate visual approach, runway 25 is equipped with a lead-in line comprising a succession of sequentially-illuminated lights. Runway 25 is also equipped with a precision approach path indicator (PAPI). Runway 25 had been cleared of snow less than one hour before the incident. Indeed, the ATIS message recorded at 16:20 UT (17:20 local time) stated that snow was still being cleared from runway 25. The next ATIS message, recorded at 17:00 UT (18:00 local time), stated that runway 27 was closed due to snow clearing operations and that the approaches were made according to the ILS 27 procedure followed by a VPT 25, all other procedures needing prior clearance from the approach controller. It specified that runway 25 was wet and that the cloud ceiling was at 700 ft. (5) https://www. ecologie.gouv.fr/sites/ default/files/Recueil_ criteres_procedures_ vol_instruments.pdf 4/7 BEA2019-0022/March 2021 Successive ATIS messages indicated to the pilots to check their operating minima. At the time of the incident, the vicinity of the runway was covered with a thin layer of snow. Figure 3: Photo taken shortly after the incident, in the direction of landing, approximately 600 m before the threshold of runway 25 and showing the condition of the runway surface before the displaced threshold as well as the marks left by the aeroplane’s wheels during the runway veer-off. 2.4 Pilot information On the date of the incident, the 71-year-old pilot held a French private pilot licence for aeroplanes issued in 1975. He held a type rating for the Cessna 510 and a valid Multi Engine Instrument Rating (IR-ME) issued in 2009. His medical licence imposes the use of prescription lenses. On the date of the incident, he had logged 2,313 flight hours, of which 936 were on multi-engine aeroplanes and 728 on the Cessna 510. He had flown approximately 90 hours each year. In November 2014, he experienced a serious incident(6) during which he landed with the same aeroplane on the disused runway located between runways 25 and 27 at Paris-Le Bourget (see Figure 1) during a VOR 25 approach. 2.5 Pilot’s statement The pilot explained that following the serious incident in 2014, he had decided to sign a contract with the company, FlightSafety which has a Cessna 510 flight simulator in the UK. This company is approved by Cessna to provide initial and refresher training for pilots. (6) https://bea.aero/ fileadmin/uploads/ tx_elydbrapports/f- tj141103.pdf 5/7 BEA2019-0022/March 2021 The pilot explained that he had opted for a formula that would enable him to take refresher sessions in a simulator at his request and without restrictions. Under this contract, he travelled to the simulator approximately every six months. In particular, he had logged 12 flight hours in a simulator a few weeks prior to the incident, in November 2018. The pilot added that the simulator sessions usually involved instrument flight and the application of failure or emergency procedures; practising visual approaches was not the primary purpose of this training and this type of approach was scarcely covered. He specified that a significant number of the approaches that he was used to performing outside of Paris-Le Bourget concerned airports with specific rules in place such as La Mole (Var), Cannes (Alpes Maritimes) and Nice (Alpes Maritimes) airports in France, and Blackbushe airport in the UK. These approaches often involve visual manoeuvring in restricted environments. He added that in the presence of a displaced threshold, he was used to sighting the start of the runway and maintaining a slight throttle to fly over the unusable section of the runway. Before departing from Düsseldorf, he had consulted the ATIS message for Paris-Le Bourget, which stated that runway 27 was active. The braking coefficients given were compatible with the landing and he had prepared to perform the ILS 27 approach that he was very familiar with. He had identified that, at night, he might have difficulties in visually gauging the condition of the runway. When he was in contact with the INI controller at Paris-Charles de Gaulle, he was surprised by the clearance given for an approach to runway 27 followed by a VPT 25 manoeuvre. This approach was preprogrammed in his aeroplane’s navigation system and he was able to prepare it, but he had never performed it. He added that he had only ever made an approach to runway 25 according to the VOR 25 procedure once before, prior to the incident in 2014 and in daylight flying conditions. He added that he would have preferred to make the ILS 27 approach and that if he had been informed prior to his departure of the necessity to land on runway 25, he would have chosen to postpone his flight until the next day and waited for the possibility to land on runway 27. The pilot did not tell the controller of his preference for the ILS 27 procedure and his discomfort about a runway 25 approach. Equally, the marginal weather conditions and the possibility of not being able to acquire the visual references passing through the MDA were not evoked. He explained that when he was aligned on the ILS centreline of runway 27, he had slightly overshot the right turn point for the VPT 25; he did not yet have the runway in sight. When he emerged from the cloud layer, he had been surprised and dazzled by the brightness of the many lights on the ground: he explained that he had not seen either the lead-in line light aids or the PAPI(7). Knowing that the runway was slippery, he had decided to land early without having identified the presence of the displaced threshold. When the wheels (in the centreline, according to him) touched down, the pilot quickly felt the aeroplane veer to the left. He attempted to control the path using the brakes and the pedal but did not succeed in avoiding the runway veer-off, despite the antiskid system equipping the aeroplane. (7) Precision Approach Path Indicator. 6/7 BEA2019-0022/March 2021 Subsequent to the event, the pilot asked to practice the Paris-Le Bourget VPT 25 approach in a simulator. According to him, this approach presents no notable difficulty when it is practised in daylight and with good visibility conditions. He added that this type of approach becomes much more complicated at night and in adverse weather conditions, in particular due to the presence of a very significantly displaced threshold. The difficulty was accentuated by the fact that he had never been asked to perform this approach before. 2.6 Statements from controllers at Paris-Le Bourget control tower The tower manager said that the organisation had been complicated by the snowfalls of the day, combined with the high level of traffic expected. Firstly, departures had been delayed to allow snow to be cleared from runway 25, whilst arrivals had all been diverted to runway 27. The snow clearing operation on runway 25 had taken longer than expected before slipperiness measurements were met to enable the runway to be reopened. When runway 25 was able to be reopened, runway 27 was then closed and the snow clearing operation started on it. He added that, subsequent to the incident, several pilots in approach had decided to go around, not having the minima for the VPT 25 approach. The tower controller stated that he had seen the F-GMTJ pilot turn right according to the VPT 25 procedure and had asked him to call back when in sight. He had noted nothing abnormal. From their position in the Paris-Le Bourget tower and by night, none of the controllers had seen that the aeroplane had landed before the threshold of runway 25 and had veered-off the runway. 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. 3.1 Scenario The pilot made an approach to an airport that he knew behind the controls of his own aeroplane. During west-facing approaches, he was used to landing on runway 27, according to the ILS procedure. Although he prepared the VPT 25 approach beforehand when the INI controller gave him the instruction, the pilot was uncomfortable, only having very rarely made approaches to runway 25, never at night and never according to this procedure. It is possible that the incident that the pilot experienced in 2014 during a VOR 25 approach added stress in preparing for the approach. Faced with this uncomfortable situation, the pilot did not express his concerns to the controllers with whom he was successively in contact. Had he expressed his concerns, the controllers might have been able to assist him or propose a different approach procedure. 7/7 BEA2019-0022/March 2021 The weather conditions recorded indicated a cloud ceiling at 700 ft from the ground, below the minima fixed at 790 ft by the VPT 25 procedure. When the pilot left the approach path to runway 27 to follow the VPT 25 procedure, he could not yet see the runway. It was not possible to determine if the acquisition of visual references occurred before or after passing through the minimum descent altitude (MDA). The pilot was aware that the weather conditions could render the runway slippery: when he identified runway 25, he decided to land at the start of the runway as he was used to doing, without identifying the displaced threshold of nearly 900 m. The concrete section of the runway before the displaced threshold was probably very slippery even if it had been cleared of snow not long before. This may have caused the deviation to the left during the landing and the runway veer-off despite the presence of an antiskid system. 3.2 Contributing factors The following factors may have encouraged the pilot to land in a hurry to the detriment of identifying the specificities of runway 25: ˆ His very little experience of approaches to runway 25 at Paris-Le Bourget. ˆ His concern about preventing the 2014 incident from recurring. ˆ The night conditions with a cloud ceiling close to the minima and the many lights on the ground that dazzled the pilot when he could see the ground. 3.3 Safety lessons 3.3.1 No reminder of the presence of a displaced threshold on the approach charts The displaced thresholds of the different runways at Paris-Le Bourget airport are clearly shown on the chart depicting the taxiways and parking areas (see Figure 1) but the approach charts, including that of the VPT 25 used by the pilot, do not show these. Nowhere in the criteria concerning the design of instrument flight procedures does it mention the obligation to show the points delimiting the runway (threshold, displaced threshold, end of runway, taxiway, etc.) on an IFR approach chart. The pilot is supposed to undertake the final descent below the minima only once he has visually identified the runway threshold. 3.3.2 Pilot’s discomfort Faced with an uncomfortable situation in a controlled air space, pilots often don’t dare to express this, leaving themselves in a situation in which the handling of the situation is mistakenly considered to be acquired: a pilot always has the option to express their difficulties to the control services in order to obtain their assistance.