reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2002 B735 CFIT Tunis Tunisia

Brief account : 

Following a step-down VOR/DME approach in poor weather by day, the B737-500 was destroyed when it struck a hill 3.6 miles from the runway.   

Crew-related factors : 

The only full report so far found is in French. The CVR transcript of conversation between the crew is in Arabic. The following comments are based on unofficial translations from the French only. 

The 34 year old Captain had a total of 4500 hours but was newly promoted with only 138 hours in command. He had also flown the B767 and B777. The 28 year old F/O had taken several years to complete his training and had a total of 880 hours. At the time of the accident the operator did not have any CRM training for its crews.

The flight encountered moderate turbulence due to CB and thunderstorm activity. The crew were cleared for the VOR/DME approach with an MDA of 580 ft aal. This was intended to be flown as a "dive and drive" step-down with autopilot and autothrust engaged. However, "the CVR analysis shows that the intermediate altitude and fix (970 ft / 3DME) was not mentioned either by the captain or the first officer during the 30 minutes of recording before impact.
The captain announced that 6 NM, they come down to minima. The first officer answered 600 ft. The captain again asked the question "6 NM, it will come down to how high?", to which the co-pilot again responded 600 ft."

The CVR indicates that the Captain was very anxious to get clear of the cloud and establish visual contact ( some 20 comments during the last half hour of flight). This led the Captain to start the descent almost a mile before reaching the final approach fix. As the airline used "step-down" "dive and drive" procedures, the 1000 fpm descent rate was greater than that to achieve a constant descent to the runway, and made steeper by a head wind.

While descending to the MDA and not the final (3 mile) fix altitude the aircraft was then much lower than it should be; the hill which it hit was covered in low cloud.  Although the report concluded that the weather was in accordance with forecasts and actual reports, these did not lead the crew to expect cloud cover at an altitude as low as 600 ft - the lowest stated was of the order of 2000 ft at the airfield with temporary degradations.  

The report concluded that although the Captain had conducted a briefing it was not clear how comprehensive it was. He also subjected the F/O to a significant amount of distracting technical questioning during the last part of the flight. Although perhaps "educational" rather than aggressive, his manner was such that the F/O became almost entirely passive and unquestioning of the Captain's actions and decisions.  

The report noted the relative rarity of non-precision approaches in both pilots training and experience and the effect that they have on workload on the PF, as well as the dangers of "step-down" procedures

The report also described (2.7.3) recommendations of the NTSB and FSF regarding the benefits of adopting "monitored approach" (PicMA) procedures to improve crew coordination and monitoring, but noted that EgyptAIr had not done implemented them. It made multiple recommendations about deficiencies in other aspects of the operation.  

If PicMA had been in use, it is likely that

1) the 970 ft final fix altitude would have been discussed. 

2) the F/O would have attempted to adhere to the profile more closely, and any deviation would have been quickly noted by the Captain, who appeared keen to show off his technical expertise.  As it was, the F/O as PM was reduced to the role of a passive observer of most of the Captain's flying.   

Type: 
B737-500
Where: 
Tunis Tunisia
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
Unknown
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
2002
Time: 
Day
Deterioration: 
Unknown
Vert Guidance: 
None
Both Head Up: 
No
Operator: 
Egyptair
Fully prepared: 
Yes
Actual Weather: 
Low Cloud
Autopilot : 
Y
CCAG: 
High