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Bureau d’Enquetes et d’Analyses (BEA) – Safety Investigation Report
Serious incident to the BOMBARDIER CL-600-2E25 (CRJ-1000) registered F-HMLD on 20 October 2021 on approach to Nantes-Atlantique (Loire-Atlantique
The BEA has issued its final report on a serious incident involving a Bombardier CL-600 (CRJ-1000) on approach to Nantes in Oct 2021.  The crew read-back and set an incorrect QNH (1021) instead of 1002, which was not detected by the controller.  The approach was approximately 600ft below profile, resulting in a Minimum Safe Altitude Warning and controller intervention.

The safety lessons/recommendations for the operator in this are:

  • To have a procedure that crews treat an ATC generated Minimum Safe Altitude Warning the same as an EGPWS ‘Pull up’ warning.
  • To consider adding the feature called Altimeter Monitor on the Honeywell Mark V EGPWS that derives geometric altitude and generates an ‘Altimeter Setting’ warning if it computes that an incorrect QNH is set
    Posted: April 2023


Transport Canada Civil Aviation Safety Alert (CASA) No. 2021-03
Inaccurate Airborne Status Transmitted by Transponders and its Effect on Runway Monitoring and Conflict Alert Systems
Dated: January 2022


ASRS – Braille Emergency Exit Card Issues
CAT operators are required to make safety information accessible to disabled persons per Reg (EC) 1107/2006; you should have Braille briefings available and these need to be of the correct standard.
Posted: January 2020


ASRS Report – Jeppesen FD Pro User Confusion
Posted: January 2020


ASRS Report – B737-800 Brakes Locked on Take-off
Posted: January 2020


ASRS Report – B737-700 loss of pitot-static data
Dated: November 2018


ASRS Report – B737 NG Throttle Sensitivity
Dated: May 2018


ASRS Report – B787 Nose Landing Gear Pin Installation Issue
Dated: January 2018


Federal Aviation Administration (FAA) Safety Alerts for Operators (SAFOs)
SAFO 17007 Manual Flight Operations Proficiency
This SAFO encourages the development of training and line-operations policies which will ensure that proficiency in manual flight operations is developed and maintained for air carrier pilots.
Dated: May 2017


ASRS Report – B737-900 Electrical System Anomaly
Posted: February 2017


ASRS Report – B737/700 Uncommanded Fuel Transfer
Posted: October 2016


ASRS Report – A321 ROW/ROP False Alert
Dated: September 2016


ASRS Report – 737 NG TOGA Anomaly
Posted: September 2016


B737-800 Control Column Free Play in Cruise
Posted: June 2015


B737-700 Autoflight, IRS, and Flight Instrument Anomalies
Posted: June 2015


CRJ-700 Uncommanded Rudder Movement
Posted: June 2015


Federal Aviation Administration (FAA) Safety Alerts for Operators (SAFOs)
SAFO 14007 Aircraft Wake Turbulence Re-Categorization (RECAT) Updates, is now published. This SAFO advises aircraft operators of revisions to RECAT aircraft wake turbulence separation minimums.

Link to FAA website and all other available SAFOs documents
Dated: February 2015


B737-700 Coffee Maker Incident
NASA Aviation Safety Reporting System
Posted: April 2014


CRJ-700 Localizer Capture Faults
NASA Aviation Safety Reporting System
Posted: April 2014


A300 Electrical Failure
NASA Air Safety Reporting System
Posted: April 2014


Intercepting ILS GP from above – Autopilot Pitch-Up
Posted: December 2013


Airworthiness Directives; Various Transport Category Airplanes Equipped With Chemical Oxygen Generators Installed in a Lavatory
Department of Transportation – Federal Aviation Administration
[Docket No. FAA-2011-0157; Directorate Identifier 2010-NM-261-AD; Amendment 39-16630; AD 2011-04-09] RIN 2120-AA64
Dated: April 2011


NATS – Mode S Interrogation Pattern – Operator’s Fact Sheet
Dated: March 2011


Latest HSE Guidance on Connection of Ground Power to Aircraft with Engines Running
Dated: February 2011


Latest FAA/DOD Advice on Laser Attacks against Aviation
Dated: February 2011


CPH Letter – New Operational Restrictions at Copenhagen Airports
Dated: January 2011


Connection of Ground Power with Engines Running – Latest HSE Thinking
Dated: December 2010


GCAA Prompt Safety Recommendations for the Transporation of Lithium Batteries
GCAA Regulations & Investigation Department – October 2010

SAFO – Risk in Transporting Lithium Batteries in Cargo by Aircraft
Safety Alert for Operators (SAFO) 10017 – October 2010
Posted: November 2010


EASA Safety Information Bulletin 2010-26
Potential Performance Degradation of Anti-icing Fluids – Reduced Holdover Times
Dated: September 2010


The FAA has issued its Final Rule regarding the Re-Registration and Renewal of Aircraft Registration.
The Final Rule will be effective on October 1, 2010. All U.S. registered aircraft will need to be re-registered. Failure to comply with the rule will result in the cancellation of the United States registration of the aircraft.
Dated: July 2010


Safety Alert for Operation (SAFO) June 2010 – FAA US Department for Transport
Possible Misinterpretation of the Practical Test Standards (PTS) Language “Minimal Loss of Altitude”
To clarify the meaning of the approaches to stall evaluation criteria as it relates to “minimal loss of altitude” in the Airline Transport Pilot PTS.
Posted: July 2010


Volcanic Ash Documents

EASA Volcanic Ash Action Plan Update – July 2010
Posted: September 2010


Potential Operations in Future Ash Contaminated Areas
Since the height of the volcanic ash crisis in April and May the CAA has instituted a comprehensive Work Programme to look at all the aspects of establishing what ash is in the atmosphere, its potential affect on aircraft and how to manage the resultant risks. As an integral part of this Work Programme, CAA colleagues have participated in the ICAO Paris VA Task Force (TF), the ICAO HQ International VA TF, held regular teleconferences with OEMs and operators and held bilaterals/workshops with airlines and the Met Office. From the national perspective, one of the outcomes of this activity is a matrix looking at what types of operation might be possible in various types of airspace in any future ash event. A copy of the proposed matrix is attached.
The purpose of this matrix is to:
Help facilitate as much flight as possible in the vicinity or even within clouds of ash, especially where those flights (and machines typically used for those flights) are used to provide essential services to communities.
Identify clearly who has the responsibility for the decision to conduct operations in certain volumes of airspace and it puts the burden of responsibility and risk management firmly on the operators of the aircraft.
Recognise that the ash cloud is a source for a common failure mode (e.g. it would affect all engines on one aircraft) – that is why, for example, twin engine helicopters must be flown as if they were a single engine-machine.
We welcome your views on the ideas set out in the matrix and how it might affect your type of operation. The material has been sent to the following CAA consultative bodies and to NATS and other ANSPs: GACC (FOD), AOA (ASD), HIAL (ASD), FOLG (FOD), NATMAC (DAP)

As a consequence, you may be asked to comment on the matrix as an organisation more than once if you have representatives on more than one of these groups. It would be helpful if you could co-ordinate your response accordingly and, as this is largely an airworthiness issue, in the case of NATMAC representatives please forward your response to Ray Elgy in the Safety Regulation Group at Gatwick. His contact details are as follows: Ray Elgy, Head of Licensing and Training Standards, 2W, Aviation House, Gatwick Road, Gatwick Airport South, West Sussex, RH6 0YR [email protected] 01293 573250

In order to finalise and publish the document on the CAA website it would be helpful to have any comments no later than Friday 24 September 2010.
Dated: August 2010


Latest CAA Considerations on Volcanic Ash – April 2010
CAA Board Minutes April 2010 CAA Extraordinary Board Minutes April 2010

FCM-P35-2007 National Volcanic Ash Operations Plan for Aviation
U.S. Dept of Commerce / National Oceanic and Atmospheric Administration
OFCM Office of the Federal Coordinator For Meteorological Services and Supporting Research
August 2007


Alaska Interagency Operating Plan for Volcanic Ash Episodes
May 2008


Volcanic Ash NOTAMs
May 2010


Volcanic Ash Intl Teleconferencce Information Note – Report of Proceedings
17-23 April 2010 – UKCAA


Engine Damage to a NASA DC-8-72 Airplane from High Altitude Encounter with a Diffuse Volcanic Ash Cloud Document
NASA August 2003


European Space Agency SAVAA Project (SAVAA – Support to Aviation for Volcanic Ash Avoidance)

Effects of Volcanic Ash Cloud on the ATM Network
Conclusion of Effects of Volcanic Ash Cloud on the ATM Network

Post Flight Report
Cranfield University, Facility at Airbourne Atmospheric Measurement (FAAM)

ICAO Volcanic Ash Contingency Plan Eur Region September 2009


Health & Safety Executive – Inspection of Baggage Handling Activities


Open Letter from HSE to airports, airlines and ground handlers at GB airports re connection of ground power units to aircraft with engines running
Posted: January 2010


CAA and HSE roles in relation to EC Regulation 1107/2006 on the rights of disabled persons and persons with reduced mobility
Posted: January 2010


Ofcom Update: Date Correction – Forthcoming GPS jamming exercises
The MoD has informed Ofcom of the following GPS jamming exercise:
Dates: 14th and 15th October 2009.
Times: Maximum of two hours between the times of 08:00-12:00 and 13:30–15:30 each day.
Location: Within 1km of N50° 53.0’ and E000° 27.0’ (Bexhill, East Sussex).
Contact: Trial Manager (during the trial) on 07776 484226.
Dated: July 2009


At NATMAC 65, the Directorate undertook to distribute statistics covering controlled airspace infringement in the vicinity of Stansted Airport.
Stansted Infringement January 2004 – March 2009 Report
Stansted Infringements 2008 Report
Dated: April 2009


CAA SRG
Latest situation with SID Amended Climb
Detailed CAA e-mail ICAO State Letter
Dated: 17th April 2009


CAA
The CAA are seeking comment on AT Services in Class D/E Airspace
Dated: March 2009


NATS
NOTAM Ref: B0379/09
“On the 12th March there will be changes made to Central and Southern airspace in order to address congestion at CPT/WOD……….
Dated: March 2009


BBGA
Flight Safety Notice – De-Icing
Dated: February 2009


BAA
Safety Alert from the BAA H&S Department regarding electric wheelchairs/fire risk stored in the hold.
Dated: October 2008


Free Flight Safety Posters Available from FDS Consulting
News Release
Posters
Dated: 20th August 2008


Coventry ATS Supplementary instruction 02 of 2008
This details the changes to CVT VHF frequencies as published in the AIP at the next amendment.
In essence the changes are as follows.
124.80 is replaced by 118.175
122.0 is replaced by 123.825
119.250 is to be changed at a future date


Taxiway Layout Dublin Airport – AIC 3-03
Dated: January 2003


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