Serious incident to the Boeing 737-800 registered 7T-VJM operated by Air Algérie on 06/12/2019 at Paris-Orly (Val-de-Marne)

Cat. 2 investigation report: simplified-format report, adapted to the circumstances of the occurrence and the investigation stakes.

This is a courtesy translation by the BEA of the Final Report on the Safety Investigation published in October 2021. As accurate as the translation may be, the original text in French is the work of reference.

When the plane was on final for runway 25 at Orly, a Runway Incursion Monitoring and Collision Avoidance System (RIMCAS) warning was activated due to the presence of a bird-control vehicle in the vicinity of the runway safety area. However, the bird‑control vehicle was behind the holding point and outside the runway safety area. The erroneous activation of the RIMCAS warning was due to the relocation of the holding point, after work, not being taken into account in the system parameters.
Due to the RIMCAS warning and the absence of a reply from the driver of the vehicle, the controller ordered the crew to perform a go-around when they had passed through the decision altitude (DA).
The crew carried out the go-around by initially displaying a thrust and a pitch attitude which resulted in a high vertical speed. They then engaged the auto-throttle (A/T) although the autopilot (A/P) was disengaged. The left turn was started late and the high bank angle triggered the “Bank Angle” warning. The missed approach altitude was exceeded during the turn. Under the combined effect of a nose-down input from the PF and the A/T reducing the thrust, the plane next re-descended below 2,000 ft. The controller then cleared the crew to climb to 3,000 ft. The crew’s selection of this altitude caused a V/S mode reversion with the instantaneous vertical speed taken as the target speed (-1 100 ft/min).
The crew then followed the flight director (F/D) cues for around 20 s. During the descent, the controller contacted the crew three times, the “DON’T SINK” alert was activated and remained active for 45 s.
The crew stopped the descent at around 1,300 ft and levelled off for 30 s while accelerating up to 292 kt. They then resumed the climb to 3,000 ft. After stabilizing the plane at 3,000 ft, the crew carried out a second, uneventful approach.