GR651 - Incident: Jump AT72 at Guernsey on Aug 12th 2024

A Jump Air Avions de Transport Regional ATR-72-212A on behalf of Aurigny Air Services, registration LY-JUP performing flight GR-651 from Southampton,EN to Guernsey,CI (UK), was on approach to Guernsey when the aircraft entered a hold. About 45 minutes later the crew attempted an approach to Guernsey's runway 27 and continued in fog below published minima for the approach before eventually initiating a go around. The aircraft subsequently climbed to safety and returned to Southampton for a safe landing.

The aircraft is still in Southampton 9 days later.

The British AAIB reported the aircraft reached 56 feet AGL before the aircraft initiated a go around violating the approach minima in fog. The occurrence was rated a serious incident and is being investigated.

On Feb 27th 2025 the AAIB released their final bulletin concluding the probable causes of the serious incident were:

The flight continued the descent below the approach ban altitude whilst on an approach to Runway 27 at Guernsey Airport despite not having the required RVR. The commander may have been reverting to a previous understanding of the regulations, and this was not challenged by the co-pilot at any point. When the aircraft passed the approach minima, confusion and miscommunication between the crew resulted in a go-around being called and selected, but the pitch remained at around that required for level flight. The aircraft flew over the airfield between 61 – 78 ft agl for 15 seconds before interventions from both crew members resulted in a climb. The flight was diverted to Southampton Airport where it landed without further incident.

The AAIB analysed:

Approach ban

Both crew members were aware of the approach ban but it was neither mentioned nor included in the approach brief. The commander may have reverted to a previous understanding of the regulations which he understood to permit him to continue down to the minimums before making a decision to land or go-around based on what he saw. The co-pilot did not challenge this understanding either before the approach or as they passed the approach ban point.

Crew performance

Without a CVR it is not possible to know exactly what communication occurred between the crew before and during the approach or after the aircraft passed the decision altitude. Any discussion of the communications that took place therefore relies on the recollection of the commander and co-pilot.

During the flight to Guernsey, neither pilot discussed the approach ban or whether it might apply to their subsequent approach. They did discuss what they would do if the weather was below minimums, and what their subsequent actions for the diversion would be. Once the aircraft was established on the glideslope, neither pilot can recall there being any further discussion about the RVR although they were given the information on several occasions by ATC.

As the aircraft passed decision altitude the commander recalls seeing the required visual references and hearing the co-pilot call ‘minimums’ to which he called ‘Contact, Land’ as per the SOPs. The co-pilot does not recall hearing any response to his call of ‘Minimums’ and as a result assumed that the commander was not visual with the lights. The commander was surprised when the co-pilot called for a go-around. Ineffective communication meant that neither pilot was sure what the other was doing or planning. As a result, there was confusion about the go-around. Neither pilot was fully aware of the other pilot’s intentions or the situation. They did not share a common picture of where the aircraft was or what they were trying to achieve. Despite this when the co-pilot did call for a go-around, the commander immediately complied by pressing the go-around button on the power lever.

Once the go-around button was pressed and the flaps retracted as required at the commander’s request, the FD would have indicated a 7.1° pitch up as per the aircraft design. During the next 15 seconds although the aircraft pitch did vary, it did not increase to a steady positive pitch that would have resulted in the aircraft climbing away from the ground. Despite the lack of climb and the commander not responding to his prompts, the co-pilot made no attempt to take control to correct the flight path. The commander did not try and climb the aircraft despite the lack of landing gear retraction and the perceived lack of response from the co-pilot.

The lack of a shared mental model between the pilots had the result that neither was aware of how close to the ground and obstacles they were for an extended period of time.

Operator’s non-technical skills

The operator used the EASA framework for their non-technical skills assessment, but this did not include a specific category for communications. Communications are partially covered by different parts of the framework but there was no standalone assessment of those behaviours. This meant that there was no specific effort by the operator to assess, train and improve the communication skills of their crews, despite the diversity of their nationalities and native languages.

Related Flight: GR651, Aurigny Air Services News