Report: Inadvertent brake application leads to rejected takeoff at V2

December 8, 2011

Final position of D-CKDM, about 5 m from the end of the paved surface of Runway 25 (photo: AAIB)

The crew of a Gulfstream G150 corporate jet rejected the takoff from Northolt Airport, London just before V2 speed because the airplane failed to rotate. 

A report by the U.K. AAIB details the serious incident that happened on February 6, 2011. A takeoff was attempted from runway 25 at Northolt Airport, London. When the commander pulled the control column back to rotate at rotation speed, VR, and subsequently fully back, the aircraft only pitched up to 1º. The takeoff was rejected just before V2, full braking was applied and the aircraft came to a stop at the end of the paved surface. A fire broke out around the left main wheels which was suppressed quickly by the Rescue and Fire Fighting Service (RFFS).

The flight data showed that the aircraft’s acceleration during the takeoff roll was below normal but the investigation did not reveal any technical fault with the aircraft. The most likely explanation for the lack of acceleration and rotation was that the brakes were being applied during the takeoff, probably as a result of inadvertent braking application by the commander, which caused a reduction in acceleration and a nose-down pitching moment sufficient to prevent the aircraft from rotating. However, it could not be ruled out that another factor had caused partial brake operation.

A similar occurrence led to a fatal accident in Yaroslavl, Russia on September 7, 2011 when a Yak-42 passenger plane crashed on takeoff when the airplane stalled. Forty-four occupants died in the accident. Investigation revealed that one of the crew members probably activated the brakes during the takeoff roll.

In the case of the Gulfstream incident, the AAIB reiterated two safety recommendation issued to EASA in 2009 pertaining specifications for a takeoff performance monitoring system which provides a timely alert to flight crews when achieved takeoff performance is inadequate for given aircraft configurations and airfield conditions.

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Report: Canadair CRJ runway excursion at Longyearbyen, Norway

December 7, 2011

A CRJ-200PF cargo plane suffered a serious runway excursion incident upon landing at Svalbard-Longyearbyen Airport (LYR/ENSB), Norway on January 25, 2010.

En route to Longyearbyen the crew were told by ATC to expect a runway 28 approach and landing. Braking effect in the landing direction was 4-3-2 (medium/good – medium – medium/poor), with sandy ice. The wind was stated to be 190º at 09 kts with maximum winds of 17 kts. The crosswind limits for these braking conditions were 25-15-10 kts, per the company Operations Manual.
The last update of the wind was given about one minute before landing. It was reported to be 190º at 10 kts with maximum winds of 18 kts varying in direction between 150 and 260 degrees.
The aircraft was configured with full flaps. Approach Speed ​​(Vref) was estimated to be 142 kt. On short final the airplane dropped below the glide path but this was corrected. The airplane touched down 500m down the runway. Reverse thrust was applied and the airplane decelerated normally until a speed of about 60 knots. The airplane drifted to the right, which was countered by the pilot. The plane then drifted to the left and continued off the side of the runway at an approx. 35 kt ground speed. It contacted the PAPI light installation before coming to rest after rotating around 160 degrees.

It was determined that the airplane landed far down the runway, entering a runway area (the last third) with the lowest friction. The safety margins of this landing at Longyearbyen were too small. Under the current conditions with sandy ice, freezing and high humidity, the deviation between the measured friction and aircraft braking effect could be large. A crosswind component up to the maximum can thus actually be above the be permitted.

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Initial report details Polish Boeing 767 gear-up landing

December 1, 2011

The Polish State Commission for Investigation of Air Accidents released an initial investigation report detailing the gear-up landing of a LOT Polish Airlines Boeing 767 on November 1.

The airplane operated on a regular passenger flight from Newark (EWR), USA to Warsaw (WAW), Poland. After take off, while retracting the landing gear and flaps hydraulic fluid began to leak from the central hydraulic system (installation “C”), what consequently led to pressure drop in this installation.  After completing the QRH procedure and consultation with the operator’s operations centre, the  flight crew decided to continue the flight to Warsaw.

During approach for landing at Warsaw the flight crew performed the QRH procedure which was connected with using the alternate landing gear extension system. The landing gear did not come down. A holding pattern was entered while the crew tried to lower the gear  in the  gravitational way, which was also unsuccessful. A Polish Air Force F-16 fighter flew by and confirmed the gear was up. Because the airplane was getting low on fuel, a safe emergency gear-up landing was carried out.

Initial investigation results indicate that on the P6 panel on the flight deck, the circuit breaker C829 BAT BUS DISTR (on A1 position) was in the position „Off”, while the circuit breaker C4248 LANDING GEAR – ALTN EXT MOTOR (on F6 position) was in the position „On”.

The circuit breaker C829 (BAT BUS DISTR) indicated on Photo 5 protects several airplane systems including the alternate landing gear extension system. The „Off” position of the circuit breaker was not recorded or indicated by the airplane systems (FDR – Flight Data Recorder and EICAS – Engine Indications and Crew Alerting System).

After connecting the ground power unit, setting C829 (A1) BAT BUS DISTR circuit  breaker in the position „On” and activation of the alternate landing gear extension system, the landing gear was extended and the airplane was recovered.

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AAIU Ireland publishes final report on serious runway incursion incident at Dublin

November 14, 2011

The Irish Air Accident Investigation Unit (AAIU) published the final investigation report into a serious runway incursion incident at Dublin in October 2010.

On 16 October 2010 a THY Turkish Airlines Boeing 737-800 aircraft (TC-JGG) taxied onto the active runway 28 at Dublin Airport (DUB), Ireland. At the same time a Germanwings Airbus A319 aircraft (D-AGWJ) was on short final approach to land on the same runway. Dublin ATC had cleared TC-JGG to taxi in preparation for subsequent departure from runway 28 and the aircraft was instructed to hold short of the runway. D-AGWJ had been cleared to land. The crew of the landing aircraft observed TC-JGG approaching the runway and initiated a go-around manoeuvre. Simultaneously ATC issued a go-around instruction. D-AGWJ descended to a height of less than 200 ft above the ground, less than 0.4 nautical miles (nm) from its touchdown point, before it climbed away.

The AAIU established the following Probable Cause:
The crew of TC-JGG did not comply with their taxi clearance limit as issued by ATC, and the aircraft entered an active runway without permission.

Contributory Factors:

  1. Distraction of the crew of TC-JGG during the taxi by head-down cockpit tasks. The Operator’s Operations Manual states that, while taxiing, “both pilots must be very careful about the environment”.
  2. Misinterpretation by the crew of TC-JGG of a statement concerning a further holding position in their Jeppesen Manual.
  3. The absence of a verbal cross-check procedure for runway entry in the Operations Manual of TC-JGG.

Six safety recommendations were issued:

  1. Turkish Airlines should consider an amendment to their Operations Manual Part-B Chapter 2 Normal Procedures to ensure that the handling pilot maintains an external look-out at all times during taxi. (IRLD2011018)
  2. Turkish Airlines should consider an amendment to their Operations Manual Part-B Chapter 2 Normal Procedures to include a verbal cross-check between crew members when an aircraft is about to enter or cross a runway, whether active or non-active. (IRLD2011019)
  3. The Dublin Airport Authority, in conjunction with the Irish Aviation Authority, should consider originating an amendment of AIP Ireland, Section EIDW AD 2.20, paragraph 8.4, to clarify the statement “A further holding position is established on RWY 16/34”. (IRLD2011020)
  4. The Dublin Airport Authority, in conjunction with the Irish Aviation Authority, should consider originating an amendment of AIP Ireland, Section EIDW AD 2.20, to include a statement that the holding position for RWY 34 on TWY E1 is combined or co-located with the Cat I holding position for RWY 28 on TWY E1.(IRLD2011021)
  5. The Dublin Airport Authority, in conjunction with the Irish Aviation Authority, should consider the provision of stopbar lights on TWY E1 at the combined holding position for RWY 34 and RWY 28 Cat I.(IRLD2011022)
  6. The Irish Aviation Authority should consider the inclusion of a reference to both RWYs 28 and 34 in ATC instructions to aircraft taxiing in the area of the combined runway holding position. (IRLD2011023

Brakes applied on takeoff led to fatal Yaroslavl Yak-42 accident

November 2, 2011

Investigators of the Russian Interstate Aviation Commission (MAK) presented the findings of their investigation into the fatal Yak-42 accident at Yaroslavl in September 2011.

On September 7, 2011 a Yak Service Yak-42 passenger jet crashed on takeoff from Yaroslavl-Tunoshna Airport (IAR), Russia, killing 44. The airplane carried members of the Lokomotiv Yaroslavl ice hockey team for a match in Minsk.
It was determined that:

  • the crew calculated the V1 speed to be 190 km/h; however this was incorrect as it should have been 220 km/h;
  • the copilot had medical issues, he had leg coordination disturbances and the deep sensibility disorders of lower extremities. The medicine Phenobarbital, which has a negative impact on the nervous system, was found in his blood which degraded his performance;
  • while the captain had over 1300 hours of experience flying Yak-42 aircraft, he flew the smaller Yak-40 aircraft before that and had more experience in those aircraft. The same applied to the copilot. Both aircraft have a different method of braking and the captain or copilot (it could not be concluded who pushed the brakes) probably held his feet on the pedals during takeoff in a similar manner that he had used on the Yak-40. In the accident he inadvertently activated the brakes while pulling on the controls to lift the nose for takeoff.

The investigators established that there were at least four contributing factors, including a lack of pilot training, the absence of control over the crew’s preparation for flight, the pilots’ failure to follow standard takeoff procedures and poor coordination between the crew during the takeoff.

 


Preliminary report issued on Maldives DHC-6 training flight accident

October 16, 2011

The Maldives Accident Investigation Coordinating Committe published a preliminary investigation report regarding the July 11, 2011 accident involving a DHC-6 Twin Otter.

The float-equipped de Havilland Canada DHC-6 Twin Otter sustained substantial damage in a heavy landing in Biyaadhoo Training Lagoon, Maldives. The two pilots on board were not injured. The airplane was used for an annual re-current training flight. Departure time at Malé (MLE) was 08:20 and the flight had to be back before 09:30 because both crew members were scheduled to do a commercial flight at that time.
During the training five landings and take-offs were made simulating different conditions of flight. All these landings and take-offs were made inside the lagoon except the last landing where the crew decided to land on open water outside the lagoon. The crew were simulating a tail wind/single engine landing.
As per the crew, the aircraft initial touch down was smooth. However, they stroke a wave which made the aircraft bounce foe about 20 feet. With the low power aircraft hit the water again with great impact, resulting multiple float attachments to break. Both front and main spreader bars broke and floats rose up, twisted and hitting the bottom engine cowlings. Propeller cuts were found on front of both floats. Also, the flaps as well as the flap selectors were found on the zero position.

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Report: Wrong engine shut down following engine failure on Jetstream 41 caused Durban crash

October 7, 2011

Investigators of the South African CAA released the final report of their investigation into the cause of a September 2009 fatal accident involving a Jetstream 41 twin turboprop airplane at Durban.

The aircraft commenced its take off roll from runway 06 at Durban (DUR) and shortly before it became airborne a catastrophic failure occurred in the nr.2 (right hand) engine due to a fatigue failure of the second stage rotating air seal. It continued to climb to an altitude of about 500 feet AMSL. Immediately after raising the undercarriage, the nr.1 (left hand) engine spooled down from 100% to zero within seven seconds. The aircraft then descended and the stick shaker activated. The airplane force landed in a small field and skidded before coming  to rest with the fuselage broken in two and detached from the wings.

The Probable Cause was determined as follows:

Engine failure after takeoff followed by inappropriate crew response, resulting in the loss of both lateral and directional control, the misidentification of the failed engine, and subsequent shutdown of the remaining serviceable engine.
Contributing factors:

  • Separation of the second-stage turbine seal plate rim;
  • Failure of the captain and first officer to implement any crew resource management procedures as prescribed in the operator’s training manual;
  • The crew’s failure to follow the correct after take-off engine failure procedures as prescribed in the aircraft’s flight manual.
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Report: Unstabilized approach preceded Colombian ERJ-145 runway excursion

September 26, 2011

The Colombian aircraft accident investigation committee concluded that the an ERJ-145 runway excursion at Mitú, Colombia occurred because the flight crew continued to land following an unstabilzed approach.

On May 5, 2010. an Embraer ERJ145, registered HK-4536, sustained substantial damage in a runway excursion accident at Mitú-Fabio Alberto León Bentley Airport (MVP), Colombia. There were no fatalities and there was no fire.
SATENA flight NSE-9634 had departed Villavicencio-La Vanguardia Airport (VVC) on a domestic flight to Mitú. The airplane could not be stopped on the runway when it landed on runway 20. It overran into a down sloping field, causing the undercarriage to collapse. The airplane came to rest 167 metres past the runway threshold and 4 metres below runway elevation.

The Board of Inquiry found that the probable cause of the accident was the execution of a landing on runway 20 at Mitu, following a destabilized approach especially with respect to deviations of height and speed when crossing the runway threshold, and the EGPWS alarm sound, which caused the aircraft to exceed the available runway. Additionally, the crew used  faulty techniques for landing on short and wet runways. Contributing to the accident was the lack of planning to carry out and complete the published instrument approach procedure for runway 20 and the deviation from standard operating procedures of the company.

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Indian incident report highlights aircraft evacuation procedures and decision making

September 19, 2011

The investigation into an evacuation of a Boeing 737-800 on a taxiway at Mumbai Airport, India revealed poor decision making and highlights the importance of aircraft evacuation procedures.

On August 27, 2010 Jet Airways Boeing 737-800 aircraft, VT-JGM, was operating flight 9W-2302 from Mumbai to Chennai. There were 139 passengers 3 flight crew members, 4 cabin crew members and 8 ACM (Additional Crew Member) cabin crew onboard.
While taxying to the runway an additional cabin crew (ACM) seated at row 35A apparently observed some fire from left engine and informed another ACM on seat 35B who also claimed to have confirmed the fire from the left engine. Immediately the ACM seated on 35B got up from his seat and went to the rear galley and informed the captain about the fire. In turn the captain asked the cabin crew in charge-CCIC (L1 Position) to confirm the fire. She also confirmed fire to the Captain. But all the indications in the cockpit were normal and there was no fire warning.

However based on the confirmation given by the CCIC he ordered for precautionary evacuation. A precautionary emergency was declared and Engines and APU were shut down. For the purpose of evacuation L2,R1 and R2 slide chutes were deployed and inflated. Also Left side aft over wing exit door and right side both over-wing exit door were opened.
During the evacuation time airport fire and rescue services were also deployed. However no foams were discharged as there was no fire/smoke. At the time of incident the taxi track was wet due drizzling of previous hours. Weather was fine. In the process of evacuation 25 passengers were injured and four of them were seriously injured with multiple fractures on the legs. There was neither smoke nor actual fire in the incident.

Investigators concluded that wrong decision of the captain to carry out evacuation for non-real emergency situation of imaginative fire from the left engine, leading to the serious injuries to passengers is the most probable cause for the incident.

Contributory factors were:

  1. Non-awareness of the effect of anti-collision light by the ACMs, cabin crew and CCIC
  2. Over reacted ACMs and absence of company policy on ACM role in the flight
  3. Failure of CCIC to play her role in evacuation
  4. Incorrect usage of non-required exit for evacuation
  5. Lack of training on over-wing exit evacuation
  6. Wrong door guarding procedure
  7. Lack of situational awareness and crew coordination of the cockpit crew.
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Russian Tu-134 accident caused by poor decision making in below-minima weather conditions

September 19, 2011

The Tu-134 broke up. (photo: Ministry of Emergency Situations)

The Russian Interstate Aviation Committee (IAC) published the final report of their investigation into the fatal accident involving a Tupolev 134 jetliner at Petrozavodsk, Russia, blaming poor decision making in below-minima weather conditions.

On June 20, 2011 a Tu-134 operated by RusAir on behalf of RusLine, crashed on final approach to Petrozavodsk Airport (PES). The Tupolev struck trees and crash-landed on a highway while on final approach to runway 01. Forty-seven occupants died in the accident; five survived.

The investigators concluded that the airplane flew an approach in conditions worse than weather minimums for the airfield and that the crew failed decide to go-around. Instead the airplane descended below the minimum safe altitude in the absence of visual contact with approaching lighting and landmarks, which led to contact with trees and the ground in controlled flight.
Contributing factors were:

  • Poor interaction of the crew and poor crew resource management (CRM) from the commander of the flight during the approach. The pilot subordinated himself to the navigator causing the co-pilot to be effectively excluded from decisions;
  • The use during the flight of a navigator in a light level of alcoholic intoxication;
  • Incorrect weather forecast with regards to height of the cloud base, visibility and severe weather – fog;
  • The use of navigation equipment that used satellite navigation to determine the aircrafts position, which was in violation of the Flight Manual Supplement for the Tu-134.

 

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