Description

On 11 September 2010, a DHC8-400 being operated by Flybe on a scheduled passenger flight from Bergerac France to Exeter failed to level as cleared during the approach at destination in day Visual Meteorological Conditions (VMC) and continued a premature descent without the awareness of either pilot due to distraction following a minor system malfunction until an Terrain Avoidance and Warning System (TAWS) ‘PULL UP’ Hard Warning occurred following which a recovery climb was initiated. There were no abrupt manoeuvres and no injuries to any of the 53 occupants.

Investigation

A Field Investigation was carried out by the UK AAIB. Despite Operator procedures intended to ensure that Serious Incidents were promptly reported to the AAIB and the occurrence taking place inbound to the Operator’s Head Office and main engineering base, such notification did not occur until five days after the event.

Despite no initial action to isolate the Flight Data Recorder (FDR) after the Incident, FDR data was subsequently preserved. The CVR had not been isolated after the event either and so in that case, the relevant record was overwritten. The failure to isolate both recorders after the incident was noted to have been contrary to Company Policy. Non volatile memory (NVM) data recovered from a failed Input Output Processor (IOP) was also found useful during the Investigation.