Overview
• Operator: Jump Air (on behalf of Aurigny Air Services)
• Aircraft Model: ATR-72-212A
• Registration: LY-JUP
• Flight Number: GR-651
• Route: Southampton (SOU) to Guernsey (GCI)
• Date: 12 August 2024
• Occupants: Not specified
• Casualties: None reported
• Nature of Incident: Descent below approach minima in fog, go-around initiated at dangerously low altitude
Incident Summary
A Jump Air ATR-72-212A, operating as flight GR-651 from Southampton (SOU) to Guernsey (GCI), entered a holding pattern over Guernsey before attempting an approach to runway 27 in dense fog and below published approach minima.
The aircraft descended to 56 feet AGL—well below the decision altitude—before initiating a go-around. For 15 seconds, the aircraft remained dangerously low, flying at altitudes between 61 and 78 feet AGL, before the crew managed to establish a climb.
Following the unstable approach and miscommunication between pilots, the flight diverted back to Southampton, where it landed safely.
On February 27, 2025, the UK Air Accidents Investigation Branch (AAIB) released its final report, identifying crew miscommunication, lack of adherence to approach bans, and deficiencies in non-technical skills training as contributing factors to the serious incident.
Sequence of Events
Pre-incident Conditions:
• Guernsey was experiencing dense fog, with reported Runway Visual Range (RVR) as low as 150 meters.
• The approach minima required an RVR above the regulatory threshold, meaning the aircraft was legally required to abandon the approach before reaching decision altitude.
• The crew failed to brief the approach ban requirement, indicating a misunderstanding of when they were required to discontinue the approach.
Approach & Descent Below Minima:
• The aircraft initiated the approach despite RVR being below the required minimum.
• As the aircraft descended past decision altitude, the commander believed he had the required visual references, while the co-pilot did not hear a response to his “Minimums” call.
• The co-pilot initiated a go-around call, but the commander was surprised and had not planned to abort the landing.
• Confusion in the cockpit led to delayed and improper execution of the go-around procedure.
Low-Level Flight & Recovery:
• After initiating the go-around, the aircraft remained between 61-78 feet AGL for 15 seconds, dangerously close to terrain and obstacles.
• The Flight Director (FD) commanded a pitch-up of 7.1°, but the aircraft remained at an almost level attitude, indicating a delayed response from both pilots.
• Neither pilot took immediate corrective action, suggesting a breakdown in situational awareness and crew coordination.
• Eventually, both pilots intervened, and the aircraft climbed to safety.
• The flight diverted to Southampton, landing without further incident.
Investigation & Findings
Final AAIB Report (February 27, 2025):
The probable causes of the incident were:
1. Continuing the approach below the approach ban altitude despite insufficient RVR—the commander may have misunderstood the regulations.
2. Breakdown in cockpit communication, leading to confusion and delayed decision-making during the critical phase of flight.
3. Failure to establish a proper go-around pitch attitude, resulting in a dangerously low-level flight over the airfield before climbing.
4. Lack of a shared mental model between the pilots, meaning neither was fully aware of the other’s actions or intentions.
Crew Performance Issues:
• The approach ban was not discussed in the approach briefing, suggesting a lack of situational planning.
• The co-pilot did not challenge the commander’s decision to continue the approach past the minimums.
• During the go-around, neither pilot had full situational awareness, leading to an extended period of low-level flight.
• The commander did not increase pitch sufficiently after selecting go-around mode.
• The co-pilot failed to take control or assertively direct the climb, even when realizing the aircraft was not climbing.
Operator Training Deficiencies:
• The airline’s non-technical skills training lacked a dedicated category for communication, despite the multinational nature of their flight crews.
• Ineffective communication training resulted in the failure of the pilots to establish a shared understanding of the situation.
• No structured training was in place to prevent misinterpretations of approach ban regulations.
Analysis & Safety Recommendations
For Airlines & Flight Crew Training:
• Emphasize clear briefings on approach bans and minimum RVR requirements during pre-landing checks.
• Enhance crew resource management (CRM) training, particularly in:
• Cockpit communication
• Decision-making under high-stress conditions
• Handling conflicting perceptions between pilots
• Ensure go-around procedures are fully understood and consistently executed, with:
• Immediate pitch-up upon selecting go-around
• Decisive and assertive actions by both pilots
• Implement stricter monitoring of pilot adherence to approach minima and RVR restrictions.
For Regulatory Authorities & Airport Operations:
• Improve ATC intervention protocols when aircraft continue below approach minima in unsuitable conditions.
• Consider reviewing approach procedures at Guernsey to reduce the likelihood of crews misjudging visibility requirements.
• Encourage stricter enforcement of approach bans, including mandatory go-arounds when RVR is below limits.
Weather Conditions at the Time (METAR Reports for EGJB – Guernsey)
• Wind: 280° at 11 knots
• Visibility: 50 to 550 meters in fog
• Sky Conditions: Overcast at ground level (BKN000, OVC000)
• Temperature: 18°C
• Altimeter: 1010 hPa
Conclusion
This incident highlights the dangers of continued descent below minimums, poor cockpit communication, and the need for strict adherence to regulatory approach bans. The lack of immediate corrective action after the go-around call demonstrates a breakdown in crew coordination and situational awareness, nearly leading to a serious accident.
The AAIB’s findings emphasize the importance of proper CRM training, particularly in multi-national flight crews where language barriers or different regulatory understandings may cause misinterpretation. Airlines must ensure all pilots are well-versed in approach ban regulations and proper go-around execution to prevent similar incidents in the future.
Disclaimer
“This report is based on available information as of 27 February 2025. While every effort has been made to ensure accuracy, the completeness of the details cannot be guaranteed. If you are the rightful owner of any referenced materials and wish them removed, please email takedown@cockpitking.com.”
