Lebanon releases progress report on fatal Ethiopian Boeing 737-800 accident investigation

March 28, 2011

Flight ET409 flight profile

The Lebanese Ministry of Public Works & Transport released their investigation progress report regarding the January 2010 fatal accident involving a Ethiopian Flight 409 off the coast of Beirut.

On January 25, 2010 a Boeing 737-8AS(WL) passenger jet, registered ET-ANB, was destroyed in an accident 6 km southwest off Beirut International Airport (BEY), Lebanon. All 82 passengers and eight crew members were killed. The airplane operated on Ethiopian Airlines flight ET409 from Beirut International Airport (BEY) to Addis Ababa-Bole Airport (ADD).

The progress report indicated that IMC prevailed for the flight, and the flight was on an instrument flight plan. It was night in dark lighting conditions with reported isolated cumulonimbus clouds and thunderstorms in the area.
Flight ET409 was initially cleared by ATC on a LATEB 1 D Standard Instrument Departure (SID) from runway 21. Just before take-off, ATC changed the clearance to an “immediate right turn direct Chekka”.
The Boeing 737 took off from runway 21 at 02:36. After take-off ATC instructed ET409 to turn right on a heading of 315° and change frequencies and contact Beirut Control. ET409 acknowledged the clearance and continued a right turn. ATC instructed ET409 to turn left heading 270°, which was acknowledged. The flight continued the climbing left turn to heading 270° but did not maintain that heading. The aircraft continued on a southerly track. Just prior to reaching  altitude of 7700 feet, the stick shaker activated, sounding for a period of 29 seconds. Meanwhile the airplane reached an angle of attack (AOA) of 32° and began a descent to 6000 feet. When the stick shaker ceased, the aircraft began to climb again. At 02:40:56, just prior to reaching 9000 feet, the stick shaker activated again, sounding for a period of 26 seconds.

After reaching 9000 feet the aircraft made a sharp left turn and descended rapidly. The maximum registered bank angle was 118° left and the airplane reached a maximum registered speed was 407.5 knots at a G load of  4.412. The airplane disappeared from the radar screen and crashed into the Mediterranean Sea at 02:41:30.

Additional preliminary facts established by the investigators:

  • The aircraft weight and balance record was reviewed and no deficiencies or anomalies were noted.
  • No defect or deferred maintenance item was reported on the technical log after the arrival and before departure of the plane from Beirut.
  • The examination of the maintenance documents on this aircraft did not reveal any significant anomalies.
  • Based on the elements recovered up to 24 Feb, 2011 and the visual observation, no evidence of fire has been brought up.
  • The Flight Crew and Cabin Crew were licensed in accordance with the ECAA regulations.
  • The documents received by the Flight Crew prior to departure, including weather information, were in accordance with the relevant requirements.
  • The Captain had a total flying experience of 10,233 hours of which 188 hours on B 737-700/800.
  • The First Officer  had a total flying experience of 673 hours of which 350 hours as F/O on B 737-700/800.

The investigation is on-going.

More information:


Report: UK CAA publishes task forces’ recommendations on 7 top safety risks

March 28, 2011

The U.K. CAA launched a task force initiative in June 2009 to address the seven top safety risks.

The Paper pubsihed by the CAA consolidates the findings and recommendations of the task forces into one document.

The ‘Significant Seven’ safety risks cover:

  • loss of control;
  • runway overrun or excursion;
  • controlled flight into terrain (CFIT);
  • runway incursion and ground collision;
  • airborne conflict;
  • ground handling operations;
  • airborne and post-crash fire.

More information:


Report: Irish AAIU issues preliminary report on fatal Metro III accident at Cork

March 16, 2011

The Irish Air Accident Investigation Unit (AAIU) released its preliminary report of the investigation into the fatal accident at Cork Airport, February 10, 2011.

A Swearingen SA-227BC Metro III passenger plane, registered EC-ITP, was damaged beyond repair in a landing accident at Cork Airport (ORK), Ireland. There were 10 passengers and two crew members on board. Both crew members and four passengers were killed.

The AAIU report documents the circumstances in which the flight crew attempted three approaches in low visibility conditions. The AOC of the operator contained approval for the aircraft to operate CAT I approaches only. At Cork Airport this meant a decision height of 200 feet at an RVR (touchdown) minimum of 550 m for runway 17 and 750 m for runway 35.

The aircraft first established on the ILS approach to runway 17 at 08:58.  RVRs passed by Cork Tower were 300/400/375.   A missed approach was carried out at 09:03 hrs, the lowest height recorded on this approach was 101 ft radio altitude.

A second ILS approach was then flown, to the reciprocal direction runway 35.  At 09:10 the flight crew reported established on the ILS runway 35.  The RVRs passed by the Tower at this time were 350/350/350.  A missed approach was carried out at 09:14, the lowest height recorded on this approach was 91 ft radio altitude.

The crew then decided to enter a holding pattern to see if the weather would improve. Meanwhile the crew inquired about weather conditions at other airports. Waterford, their alternate, as well as Shannon and Dublin were at or below minima. Weather at Kerry was favourable.

At 09:45 the aircraft reported established on the runway 17 ILS . The RVR (touchdown) improved to 550 m, which was passed to the flight crew by Cork Approach. The final RVRs passed to EC-ITP at 09.46 were 500/400/400 when the aircraft was 9.6 nm from the threshold of runway 17.  At approximately 400 ft radio altitude, recorded data shows the aircraft deviated to the right of the runway centreline, paralleling the centreline track.
The descent was continued below Decision Height (DH).  Power was reduced momentarily before being re-applied. Just below 100 ft radio altitude, a go-around was called by the PNF and was acknowledged by the PF. Recorded data shows that the aircraft rolled significantly to the left as the aircraft tracked towards the runway centreline.  This was immediately followed by a rapid roll to the right which brought the right wingtip into contact with the runway surface. Runway surface contact was made with a roll angle of 97 degrees to the right.  The initial impact mark was located 86 m from the runway threshold, and 2 m left of the centreline.  The aircraft continued to roll rapidly to the right and struck the runway in the fully inverted position 25 m beyond the initial impact point.

The investigation is on-going.

More information:

 


Report: Fatal EMB-120 loss of control accident during a simulated engine failure

May 20, 2010

Aerial view of the accident site at Darwin Airport. Photo: ATSB

A preliminary report released today by the Australian Transport Safety Bureau (ATSB) indicates that the fatal crash of an EMB-120 Brasilia at Darwin occurred during a simulated engine failure.

On 22 March 2010 an Embraer 120ER Brasilia turboprop plane, registered VH-ANB, was destroyed in a takeoff accident at Darwin Airport, NT (DRW), Australia. Both pilots were killed.
The ATSB report states that flight was a training flight to revalidate the captain’s command instrument rating. The supervisory pilot/training captain advised the aerodrome controller that the departure would incorporate asymmetric flight (a simulated engine failure), and was approved by the controller to perform the manoeuvre.
Witnesses reported that the takeoff appeared ‘normal’ until a few moments after becoming airborne, when the aircraft rolled and diverged left from its take-off path. They watched as the aircraft continued rolling left, and entered a steep nose-down attitude. The airplane impacted the ground in a right wing-low, nose-down attitude of about 65 degrees. A high intensity, fuel-fed fire that followed the collision with the ground destroyed most of the fuselage and cabin and right wing.


Report: flutter caused tailplane failure and crash of Grob SPn prototype

May 10, 2010

The Grob SPn first prototype, D-CSPN Photo by: Juergen Lehle (http://albspotter.eu/)

The fatal accident involving a prototype of the Grob SPn business jet in November 2006 was caused by tailplane flutter, according to the German BFU investigation report.
The airplane suffered a taiplane separation and crashed during a demonstration flight at the factory airfield of the manufacturer, Mindelheim-Mattsies Airport. Chief test pilot Gerard Guillaumaud was killed in the accident.

On the day of the accident, Novembe 29, 2006, the airplane had conducted a 60-minute test flight from the factory airfield of manufacturer, Mindelheim-Mattsies Airport. Various flight maneuvers and system tests were completed and the airplane landed at 11:40. The aircraft was parked on the apron and prepared for the next flight.
This flight would be a demonstration flight for a group of visitors with several fly-bys. The jet took off from runway 33 at 13:12 and the pilot flew a right hand circuit in and out of clouds. As it was lining up for a fly-by parts from the stabilizer separated. The pilot lost control and the airplane impacted a field.
Given the weather circumstances, the flight should have been conducted using Reduced Flight Display specifications. These included a maximum speed of 200 knots. The probable speed of the accident airplane was between 240 and 270 knots. This speed was below the maximum allowed speed for flutter tests, 297 kts.

The circumstances that led to the flutter could not be determined clearly due to lack of flight data and limited investigation.


Crew distraction causes gear-up landing of CRJ200 in Spain, 2007

March 24, 2010

The Spanish Civil Aviation Accident and Incident Investigation Commission (CIAIAC) published its final report regarding the gear-up landing of a  Canadair CRJ200 at Barcelona Airport, Spain in January 2007.
The airplane was on a scheduled passenger flight operated by Air Nostrum, from Valladolid Airport (VLL) to Barcelona Airport (BCN).
On the two previous flights, there had been problems with extending the flaps before landing. During the ground tests performed by the crew in Valladolid, the flaps extended and retracted normally, and so the captain decided to continue with the flights as scheduled.
During the flight, the crew went over the abnormal procedures to be followed in case of a repeat failure of the flaps system.
After taking off from Valladolid, the flaps were retracted normally and remained retracted during the cruise and descent phases until the initial approach to Barcelona, at which time they failed to extend to the 8-degree position when commanded, resulting in a “flap fail” warning on the EICAS. The copilot noted the discrepancy between the commanded 8° position on the flaps lever and the 0° indicated position. At that time they were below the clouds and under ATC radar control.
In the zero-flaps configuration, the ILS approach speed, in accordance with the relevant procedure, had to be maintained above 180 kt. ATC cleared them for the runway 25R approach and informed of a moderate intensity crosswind of 14 kt from 320°.
The aircraft descended until it touched down at an IAS of 172 kt, at which time the crew realized they had not lowered the landing gear. After a long slide on the runway, the aircraft stopped 240 m before the end of the runway.
There was no fire, though high temperatures and kerosene leaks were detected.


AAIB: Flight director mode confusion cited in serious DHC-8 incident

March 12, 2010
FDR data G-JECI

FDR parameters of the approach of G-JECI (AAIB)

An investigation into a serious incident involving a DHC-8-400 on approach to Edinburgh Airport, UK revealed that Flight Director mode confusion led to a descent to within 800 ft of local terrain approximately 5 nm from the runway threshold.

On December 23, 2008 a de Havilland Canada DHC-8-402Q Dash 8, registered G-JECI, was being operated on a scheduled passenger service from Southampton to Edinburgh as BEE247S. As it commenced its final approach to runway 24 at Edinburgh the approach controller (APC) instructed the aircraft to turn onto a heading of 280° to intercept the ILS localiser, descend from 3,000 ft to 2,100 ft and maintain a speed of at least 160 kt until 4 nm from touchdown. During the descent the aircraft accelerated to approximately 200 kt with flap and landing gear up.

The aircraft did not level off as intended at 2,100 ft but continued to descend at a constant vertical speed such that it remained at all times below the ILS glideslope. At an altitude of approximately 1,800 ft, apparently without having noticed that the aircraft had descended below the cleared altitude before intercepting the ILS, the APC instructed the pilots to contact the aerodrome controller (ADC). At about this time Flap 5 was selected and the aircraft decelerated to approximately 180 kt.
The ground movement controller (GMC), who sat beside the ADC in the visual control room (VCR), saw the aircraft when it was approximately 5 nm from touchdown and noticed that it looked “substantially below the glidepath”. He mentioned this to the ADC. When shortly afterwards the co-pilot called, “tower jersey two four seven sierra is five and a half miles two four”, the ADC responded “jersey two four seven sierra roger and we’ve got you five miles out showing nine hundred feet is everything ok”.

The co-pilot replied “err affirm jersey two four seven sierra”. Not content with the response the ADC replied “jersey two four seven sierra how low are you planning on descending at the moment”. The co-pilot responded “err we’re gonna level now actually our glideslope capture obviously failed jersey two four seven sierra”. The controllers in the VCR saw the aircraft climb slightly and continue an apparently normal approach.

Attempting to regain the correct flight path manually, the commander initially experienced some difficulty disconnecting the autopilot and found that the aircraft tended to adopt a pitch attitude 8° below the horizon. When able to resume full control, at approximately 700 ft agl, he called for Flap 15 and landing gear down. The landing was completed without further incident.

A similar incident occurred on 8 May 2009 involving a DHC-8-400 on approach to Glasgow Airport.

Both incidents appear to have been initiated by Flight Guidance Control Panel (FGCP) selections which resulted in Flight Director modes other than those intended by the pilots. In the case of G-JECI, recorded data indicates that the altitude select mode was not armed after selection of a lower altitude. This problem would be alleviated if the altitude select mode was automatic upon selection of a new altitude and vertical mode, as is the case on several other aircraft types and as envisaged by the aircraft manufacturer in its discussions with operators.

The AAIB issued two safety recommendations:

Safety Recommendation 2009-005
It is recommended that Bombardier Aerospace enable automatic arming of the altitude select mode of the flight director fitted to Dash-8-400 series aircraft upon selection of a new altitude and vertical mode.

Safety Recommendation 2009-006
It is recommended that Flybe consider amending its standard operating procedures to require an altitude check whilst on final approach even when the pilots are in visual contact with the runway.


NTSB releases docket on DC-10 hard landing accident

March 11, 2010
DC-10 hard landing damage

Hard landing damage (photo: NTSB)

The NTSB released the accident docket on a DC-10 hard landing accident at Baltimore/Washington International Thurgood Marshall Airport (BWI/KBWI) on May 6, 2009.

The McDonnell Douglas DC-10-30, operated by World Airways as flight 8535, experienced a hard landing failing the left nose tire upon landing on runway 10 at BWI. The flight crew executed a go-around and landed on runway 33L. The flight was a contract Defense Department Air Mobility Command flight from Leipzig Airport (LEJ/EDDP), Germany. There were 168 passengers and 12 crew members on board, 4 occupants were taken to a local hospital, and the first officer experienced a serious injury. The airplane had substantial damage to the nose gear, electronics and equipment bay, and forward pressure bulkhead. Weather was reported as visual conditions with light winds.


AIB Norway: report released on A321 runway skid

March 11, 2010

The Accident Investigation Board of Norway published its final report of their investigation into a serious incident involving an Airbus A321 at Sandefjord Airport Torp (ENTO), Norway.

An Airbus A321, registration OY-VKA and flight number VKG866, flew from Tenerife Airport (GCTS) to Sandefjord Airport Torp (ENTO) on 26th of March 2006. The flight was operated by My Travel Airways Scandinavia.
The first officer was Pilot Flying (PF) and the commander was Pilot Not Flying (PNF). The crew reviewed updated weather and runway status before commencing the approach to ENTO. Air Traffic Information Services (ATIS) indicated dry runway and Braking Action (BA) GOOD.
When checking in on Tower frequency, the crew was informed that the runway was contaminated by 8 mm wet snow with a measured (Friction Coefficient, FC) of 32-33-31. These numbers indicated a MEDIUM BA.
The crew requested wind information in order to check for any crosswind or tailwind limitations. They made a mental consideration regarding the landing conditions and decided that it was acceptable to perform the landing. The airplane got high on the glide slope after passing 250 ft Radio Height. This resulted in a touch down approximately 780 metres from the threshold. After landing the crew experienced POOR braking action and suspected auto brake failure. The first officer performed maximum manual braking without noticing any BA. After landing the crew experienced POOR BA and suspected a brake failure. The commander took control, pulled the Park Brake (PB) and steered the aircraft with Nose Wheel Steering (NWS) towards the left side of the runway with guidance from the first officer.
The effect of the PB and NWS was that the aircraft skidded sideways towards the end of the runway 18. This resulted in increased deceleration and the aircraft stopped at the very end of the hard surfaced runway, with the nose wheel against a concrete antennae base.
The crew advised the TWR about the anticipated runway excursion while the aircraft skidded towards the end. This allowed the TWR to alert the fire and rescue crew even before the aircraft had stopped. The fire and rescue service functioned as expected.
No persons were injured and the aircraft got some skin and nose wheel damage. The commander shut down the engines and evacuated the passengers through the forward left cabin door. The passengers were transported to the terminal building by buses while the crew remained in the aircraft being towed to the terminal.

AIBN issued three safety recommendations to MyTravel Scandinavia (now Thomas Cook Airlines Scandinavia) and two recommendations to Sandefjord Airport Torp, related to operations on contaminated runways.


BFU: Final report on A320 crosswind landing mishap

March 4, 2010

The German Federal Bureau of Aircraft Accident Investigation (BFU) released the final report 5X003-0/08 of their investigation into a serious incident involving an Airbus A320 at Hamburg Airport in March 2008.  The left wing of the A320 had made contact with the ground during an attempted cross-wind landing.

Lufthansa Airbus A320-211 file photo - ASN

Because of the weather associated with hurricane Emma, on 1 March 2008  Lufthansa Airbus A320 registered D-AIQP left Munich Airport (MUC) on a scheduled flight to Hamburg (HAM) at 12:31 about two hours behind schedule, with a crew of five and 13

2 passengers. Given the ATIS weather report including wind of 280°/23 kt with gusts of up to 37 kt, during the cruise phase of the flight the crew decided on an approach to Runway 23, the runway then also in use by other traffic. During the approach to land, the aerodrome controller gave several updates on the wind. Immediately prior to touchdown, the wind was reported as 300°/33 kt, gusting up to 47 kt. At the time of the decrab-procedure there was no significant gust.
The initial descent was flown by autopilot and the co-pilot assumed manual control from 940 ft above ground.
After the aircraft left main landing gear had touched down, the aircraft lifted off again and immediately adopted a left wing down attitude, whereupon the left wingtip touched the ground. The crew initiated a go-around procedure. The aircraft continued to climb under radar guidance to the downwind leg of runway 33, where it landed at 1352 hrs. No aircraft occupants were injured. The aircraft left wingtip suffered damage from contact with the runway.

This serious landing incident took place in the presence of a significant crosswind and immediate causes are as follows:

  • The sudden left wing down attitude was not expected by the crew during the landing and resulted in contact between the wingtip and the ground.
  • During the final approach to land the tower reported the wind as gusting up to 47 knots, and the aircraft continued the approach. In view of the maximum crosswind demonstrated for landing, a go-around would have been reasonable.

The following systematic causes led to this serious incident:

  • The terminology maximum crosswind demonstrated for landing was not defined in the Operating Manual (OM/A) and in the Flight Crew Operating Manual (FCOM), Vol. 3, and the description given was misleading.
  • The recommended crosswind landing technique was not clearly described in the aircraft standard documentation.
  • The limited effect of lateral control was unknown.

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