Loss of control and poor CRM cited in fatal Ethiopian Boeing 737 accident near Lebanon

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 flight departed at night on an instrument flight plan. Low clouds, isolated cumulonimbus (CB) and thunderstorms were reported in the area. After take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315°. ET 409 acknowledged and heading 315° was selected on the Mode Control Panel (MCP). As the aircraft was on a right turn, Control suggested to ET 409 to follow heading 270° “due to weather”. However, ET 409 continued right turn beyond the selected heading of 315° and Control immediately instructed them to “turn left now heading 270°”. ET 409 acknowledged, the crew selected 270° on the MCP and initiated a left turn.
ET 409 continued the left turn beyond the instructed/selected heading of 270° despite several calls from ATC to turn right heading 270° and acknowledgment from the crew. ET 409 reached a southerly track before sharply turning left until it disappeared from the radar screen and crashed into the sea about five minutes after the initiation of the take-off roll. The flight recorder data revealed that ET 409 encountered during flight two stick shakers for a period of 27 and 26 seconds. They also recorded 11 “Bank Angle” aural warnings at different times during the flight and an over-speed clacker towards the end of the flight. The maximum recorded AOA was 32°, maximum recorded bank angle was 118° left, maximum recorded speed was 407.5 knots, maximum recorded G load was 4.76 and maximum recorded nose down pitch value 63.1°.

Probable causes:

1. The flight crew’s mismanagement of the aircraft’s speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.
2. The flight crew failure to abide by CRM principles of mutual support and calling deviations hindered any timely intervention and correction.

Contributing factors:

1.  The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.
2.  The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.
3.  The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and lead to loss of situational awareness.
4.  The relative inexperience of the Flight Crew on type combined with their unfamiliarity with the airport contributed, most likely, to increase the Flight Crew workload and stress.
5.  The consecutive flying (188 hours in 51 days) on a new type with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the captain’s performance.
6.  The heavy meal discussed by the crew prior to take-off has affected their quality of sleep prior to that flight.
7.  The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed in the increase of the crew workload and stress level.
8.  Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.
9.  The F/O reluctance to intervene did not help in confirming a case of captain’s subtle incapacitation and/or to take over control of the aircraft as stipulated in the operator’s SOP.

More information:

• Investigation Report Ethiopian 409 Accident – Boeing 737-800 25th January 2010 Beirut – Lebanon
• ASN Accident Description

NTSB issues safety recommendations following B737 tailwind landing accident

The NTSB has issued four safety recommendations and reiterated one older recommendation to prevent runway excursion accidents following tailwind landings.

On December 22, 2009, American Airlines flight 331, a  Boeing 737-800, N977AN, ran off the departure end of runway 12 after landing at Kingston-Norman Manley International Airport (KIN), Jamaica. The aircraft landed approximately 4,000 feet down the 8,911-foot-long, wet runway with a 14-knot tailwind component and was unable to stop on the remaining runway length. After running off the runway end, it went through a fence, across a road, and came to a stop on the sand dunes and rocks above the waterline of the Caribbean Sea adjacent to the road. No fatalities or postcrash fire occurred.

The investigation, being conducted by the Jamaica CAA, is still ongoing. The NTSB, being part of the investigation, decided to issue the following recommendations to the Federal Aviation Administration (FAA):

 

Require principal operations inspectors to review flight crew training programs and manuals to ensure training in tailwind landings is (1) provided during initial and recurrent simulator training; (2) to the extent possible, conducted at the maximum tailwind component certified for the aircraft on which pilots are being trained; and (3) conducted with an emphasis on the importance of landing within the touchdown zone, being prepared to execute a go-around, with either pilot calling for it if at any point landing within the touchdown zone becomes unfeasible, and the related benefits of using maximum flap extension in tailwind conditions. (A-11-92)

Revise Advisory Circular 91-79, “Runway Overrun Prevention,” to include a discussion of the risks associated with tailwind landings, including tailwind landings on wet or contaminated runways as related to runway overrun prevention. (A-11-93)

Once Advisory Circular 91-79, “Runway Overrun Prevention,” has been revised, require principal operations inspectors to review airline training programs and manuals to ensure they incorporate the revised guidelines concerning tailwind landings. (A-11-94)

Require principal operations inspectors to ensure that the information contained in Safety Alert for Operators 06012 is disseminated to 14 Code of Federal Regulations Part 121, 135, and 91 subpart K instructors, check airmen, and aircrew program designees and they make pilots aware of this guidance during recurrent training. (A-11-95)

The National Transportation Safety Board also reiterates the following recommendation to the Federal Aviation Administration and reclassifies it “Open—Unacceptable Response”:
Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. (A-07-61)

This recommendation, A-07-61, was issued following the December 2005 runway excursion accident involving a Boeing 737-700 at Chicago-Midaway Airport.

More information:

• NTSB Safety Recommendations A-11-92 through -95 (PDF)

Indian incident report highlights aircraft evacuation procedures and decision making

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.

More info:

• ASN Accident description

Report: B737-800 rejected takeoff after V1

The Dutch Safety Board published the findings of their investigtion into a serious incident at Eindhoven Airport when the takeoff was rejected after the takeoff decision speed (V1).The Boeing 737-800 operated by Ryanair was taking off from runway 04 on the 4th of June 2010 at Eindhoven Airport, the Netherlands. At the time of rotating the aircraft to takeoff, the pilot flying decided to reject the takeoff because he believed the aircraft was unsafe to fly. The decision to reject was made after the takeoff decision speed (V1). The pilot performed a so-called high speed rejected takeoff.

The aircraft was halted before the end of the runway and the aircraft was subsequently taxied back to the terminal. The aircraft sustained no damage and no passengers or crew were injured.

The Safety Board concluded:
During the takeoff at Eindhoven airport the pilot flying perceived two control issues and one speed trend vector anomaly.

• The explanation for the control issues and speed trend vector anomaly was likely related to an outside atmospheric phenomenon. The origin of this atmospheric phenomenon could not be determined or explained with the information available.

The takeoff was rejected after the decision speed V1 and while the nose wheel was off the ground for approximately two seconds.

• The First Officer who was the pilot flying considered the control and speed trend vector problems to be serious enough and decided to reject the takeoff.
• According to company procedures only the Captain is authorized to make a rejected takeoff decision.
• To reject a takeoff above V1, especially when the nose wheel is off the ground, is in principle considered to be improper and unsafe.

There is no specific guidance from the operator or manufacturer on dealing with control issues at the time of rotating the aircraft.

• Specific guidance on rejecting a takeoff exist in case of an engine failure.
• Review of past statistics and studies show that pilot training and requirements focus on rejected takeoffs due to an engine failure. Studies and statistical information show that this accountsbfor less than 25% of the reasons for rejected takeoffs. Thus 75% of the reasons the reject a takeoff is not trained for.

More information:

• Safety Board report

Report: misaligned VOR track factor in Indonesian taxiway landing

Touch down marks on the parallel taxiway at Palembang

A Garuda Boeing 737-400 landed on a taxiway at Palembang in October 2008. NTSC investigators from Indonesia  concluded that the captain under training and instructor captain were focussed on instrument scanning when they were following the misaligned track, leading them to the parallel taxiway.

On 2 October 2008, a Boeing 737-4K5 aircraft, registered PK-GWT was being operated on an Instrument Flight Rules (IFR) scheduled passenger service from Jakarta Soekarno-Hatta Airport to Sultan Mahmud Badarudin II Airport, Palembang. There were two pilots, 4 flight attendants, and 49 passengers on board.

The co-pilot who occupied the left seat was a candidate captain under training and the Pilot in Command (PIC) occupying the right seat was a training captain (instructor). The co-pilot acted as the Pilot Flying (PF) during the flight, and the PIC acted as Pilot Monitoring (PM).

Prior to the departure from Jakarta, the pilots received a departure briefing consisting of weather, flight plan, and notams. The notams contained significant information for Palembang Airport that the parallel taxiway from intersection Alpha to taxiway Bravo was closed due to work in progress. The runway 29 Instrument Landing System (ILS) was not in service due to replacement of its localizer antenna.

The aircraft departed from Jakarta at 23:51 UTC. When it entered Palembang’s Controlled Airspace at 00:13, the crew was instructed by the Palembang Approach controller to track direct to the initial approaches point BANJAR and descends to 2,500 feet for the VOR/DME approach to runway 29. During the approach, the PIC reported that they were conducting the VOR/DME instrument approach procedure for runway 29.

At 00:28 the PIC reported that the aircraft was on final approach for runway 29.
At 00:30 the PIC reported that he had the runway insight after assuring the co-pilot that they both had seen the runway. The Aerodrome Controller gave the crew the clearance to land.
The co-pilot was concentrating on instrument scanning during the approach by following the VOR radial. He wanted to improve his ability to fly manual (without auto pilot) during an instrument approach. The PIC then rechecked if there was any item missed prior to land.

The ATC saw that the aircraft was not on the approach path properly and came close to the parallel taxiway.
At 00:32 the aircraft landed on the parallel taxiway, touching down 500 meters from the eastern end. Both pilot then realized that they were on the taxiway and also saw the barrier on the taxiway indicated that some part of the taxiway was closed. The PIC immediately applied manual brake and the aircraft stopped at the intersection of taxiway Charlie. The landing roll distance was about 700 meters.

The aircraft was then instructed to taxi via runway and taxiway Echo to the apron. No one was injured in this serious incident.
The investigators concluded that the Pilot monitoring was not sufficiently looking outside to cross-check the flight path to the runway. Also, there was a misalignment of the VOR approach path. There had been 10 pilot reports of misalignment of the final track for the runway 29 VOR/DME approach since May 2008. The VOR/DME runway 29 approach track to the runway 29 VOR was 291 degrees while the runway direction was 293 degrees. The 2 degrees differences between VOR approach path and runway direction has an off track to the right of approximately 200 meters off the runway centreline at the threshold runway 29.
The parallel taxiway used to be a temporary runway in 2003 when a new terminal was built.  The runway markings on the parallel taxi way reappeared after some time. These markings were visible to the aircraft on final approach.

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

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:

• Investigation Progress Report Ethiopian 409 Accident – Boeing 737-800 25th January 2010 Beirut – Lebanon
• ASN Accident Description

JTSB investigates serious runway incursion incident at Fukuoka, Japan

The Japan Transport Safety Board (JTSB) is investigating a serious runway incursion incident at Fukuoka Airport (FUK/RJFF), Japan involving two Boeing 737 airliners.

On December 26, Busan Air Flight 141 was instructed to hold short of runway 34 at taxiway W8. The Boeing 737-400  was heading back to Busan-Gimhae (Pusan) International Airport (PUS/RKPK), South Korea with 153 on board. The pilot however, taxied onto the runway.

At the same time, JAL Express Flight JL3530 from Sendai was on finals to runway 34. The flight had been given clearance to land and was 5,6 km from the airport when the Air Busan plane taxied onto the runway. The air traffic controller instructed JL3530 to go around.

The aircraft involved in the incident were Air Busan’s Boeing 737-48E, registered HL7517 and JAL Express’  Boeing 737-446, registered JA8998.

More information:

• Fukuoka (RJFF) aerodrome chart (PDF)
• JTSB inital report (in Japanese)

Lack of rules requiring dissemination of wind condition data and pilot’s insufficient rudder control cited as probable cause of 2008 Denver runway accident

Continental Flight 1404

The National Transportation Safety Board (NTSB) determined that the probable cause of the 2008 Continental Airlines flight 1404 runway excursion accident was the captain’s cessation of rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the aircraft departed the runway, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience.

Contributing to the accident was the air traffic control system that did not require or facilitate the dissemination of key available wind information to air traffic controllers and pilots, and inadequate cross wind training in the airline industry due to deficient simulator wind gust modeling.

On December 20, 2008, Continental Airlines flight 1404, a Boeing 737-500, veered off the left side of runway 34R during a takeoff from Denver International Airport. As a result, the captain initiated a rejected takeoff and the airplane came to rest between runways 34R and 34L. There was a post-crash fire. All 110 passengers and 5 crewmembers evacuated the airplane immediately after it came to rest. The captain and five passengers were seriously injured.

At the time of the accident, mountain wave and downsloping wind conditions existed in the Denver area and the strong localized winds associated with these conditions resulted in pulses of strong wind gusts at the surface that posed a threat to operations at Denver International Airport.

As a result of this accident the NTSB issued 14 recommendations to the Federal Aviation Administration regarding mountain waves, wind dissemination to flightcrews, runway selection, pilot training for crosswind takeoffs, and crashworthiness.

More information: Report NTSB/AAR-10/04

Airport safety recommendations after Indonesian B737 runway excursion accident

Wreckage of the Boeing 737 after it came to rest in an area of shallow muddy water surrounded by mangrove vegetation. Photo: NTSC

The Indonesian National Transportation Safety Committee (NTSC) issued their preliminary report regarding the runway excursion accident involving a Boeing 737. Seven safety recommendations were issued addressing various aspects of airport safety.

On April 13, 2010 a Boeing 737-322 passenger plane, registered PK-MDE, sustained substantial damage in a runway excursion accident at Manokwari-Rendani Airport (MKW/WASR), Indonesia. All 103 passengers and seven crew members survived but ten sustained serious injuries.
Merpati Flight MNA836 operated on a scheduled flight from Sorong-Dominique Edward Osok Airport (SOQ/WAXX). Departure was delayed for almost three hours due to heavy rain over Manokwari.
On approach Rendani Radio informed the crew that the weather was continuous slight rain, visibility 3 kilometers, cloud overcast with cumulus-stratocumulus at 1,400 feet, temperature 24 degrees Celsius, QNH 1012 hectopascals.
At 10:54 the crew reported that they were on final for runway 35. The controller informed them that the wind was calm, runway condition was wet and clear.
The crew read back the wind condition and that the runway was clear, but did not mention the wet runway condition.
The aircraft was observed to make a normal touchdown on the runway, about 120 meters from the approach end of runway 35. Witnesses on the ground and on board reported that engine reverser sound was not heard during landing roll.
During the landing roll, the aircraft veered to the left about 140 meters from the end of runway 35, then overran the departure end of runway 35. It came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River.
The airport rescue and fire fighting unit was immediately deployed to assist the post-crash evacuation. Due to the steep terrain 155 meters from the end of runway 35, the rescuers had to turn back and use the airport’s main road to reach the aircraft. The accident site was in an area of shallow muddy water surrounded by mangrove vegetation.

Seven safety recommendations were issued:

1) The Directorate General Civil of Aviation (DGCA) should ensure that Merpati Nusantara Airlines Operational Specifications and other technical and operational safety requirements are met.

2) DGCA should urgently review the Rendani Airport, Manokwari runway complex, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

3) DGCA should urgently review all airports involving Part 121 and 135 operations, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

4) DGCA should urgently ensure that Indonesian airports equipped with visual approach slope guidance systems, maintain the equipment to a serviceable standard.

5) DGCA should review the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they a) meet the minimum requirements, including timeliness, specified in ICAO Annex 14; and b) meet the requirements to cover the area up to 5 NM (8 Km) from the airport perimeter.

6) Merpati should review its technical and operational safety requirements to ensure they are implemented.

7) Merpati should review equipment used by airport Rescue and Fire Fighting Services at airports in its network, to ensure that they meet the minimum requirements for Boeing 737 aircraft.

FAA proposes $325,000 civil penalty against Continental Airlines

The U.S. Federal Aviation Administration (FAA) has proposed to assess a civil penalty of $325,000 against Continental Airlines, Inc., for operating an aircraft on at least a dozen commercial flights without properly maintaining its right main landing gear.

The FAA alleges that on December 20, 2008, the crew of a Continental Boeing 737 saw a warning light on the right main landing gear indicator after the gear retracted on a flight from Houston to Los Angeles International Airport, CA (LAX/KLAX). After discussing the situation with Continental maintenance control, the crew elected to continue the flight.

However, the flight diverted to Phoenix-Sky Harbor International Airport, AZ (PHX/KPHX) after the crew noticed the aircraft was burning an excessive amount of fuel. On the ground, Continental maintenance workers inspected the landing gear but did not make a required entry in the aircraft’s maintenance log or any other maintenance record about the abnormal landing gear indication.

The FAA alleges the airline operated the aircraft on at least 12 additional passenger flights before the abnormal gear indication was addressed by mechanics, in violation of Federal Aviation Regulations.

Continental Airlines has 30 days from the receipt of the FAA’s civil penalty letter to respond to the agency.