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Biocide fuel contamination cause of A321 emergency at London-Gatwick
5 May 2021

Biocide fuel contamination cause of A321 emergency at London-Gatwick

Unstable approach led to DHC-8-300 hard landing and tailstrike, Canada

In its newly released investigation report the Transportation Safety Board of Canada (TSB) found that the January 2020 hard landing and tailstrike of a DHC-8-300 in Schefferville, Canada, was the result of an unstable approach.

On 20 January 2020, a DHC-8-314 operated by Air Inuit was conducting a flight from Québec-Jean Lesage Airport, to Schefferville Airport, with three crew members and 42 passengers on board. During the landing, the rear fuselage struck the runway as the wheels touched down. After landing, the aircraft taxied to the terminal to disembark the passengers. There were no injuries; however, the aircraft sustained substantial damage.

The investigation found that the flight crew forgot to perform the descent checklist and realized this at an inopportune time, while the captain (pilot monitoring) was providing a position report. Given ambiguities and contradictions in the company’s stabilized approach guidelines, the captain interpreted that he was allowed to continue the approach below 500 feet above aerodrome elevation, even though the aircraft had not been fully configured for the landing. When the aircraft passed this altitude, the pilots, who were dealing with a heavy workload, didn’t notice and continued the approach, which was unstable. At the time of the landing, the aircraft no longer had enough energy to arrest the descent rate solely by increasing pitch attitude. The pilot’s instinctive reaction to increase the pitch attitude during the flare, combined with the hard landing, resulted in the rear fuselage striking the runway, causing substantial damage to the aircraft’s structure.

The investigation also made findings as to risk related to Air Inuit’s standard operating procedures (SOPs) and training, and to Transport Canada’s (TC) oversight. Transport Canada assessed Air Inuit’s SOPs, but did not identify any specific issues with the operator’s stabilized approach guidelines. If TC does not assess the quality, consistency, accuracy conciseness, clarity, relevance, and content of SOPs, the procedures may be ineffective, increasing risks to flight operations.

Additionally, the captain had not received many of the required training elements during his recurrent training. If required training elements are not included in recurrent training, and if TC’s surveillance plan does not verify the content of crew training, there may be procedural deficiencies or deviations, increasing risks to flight operations.  

Following the occurrence, Air Inuit took a number of safety actions, including the revision of its SOPs to improve guidelines on several subjects, including stabilized approaches, and the revision of its training program to ensure that all training elements are covered within the two-year recurrent training cycle.

Estimated flight path of AIE820 (altitude above sea level, in feet, and remaining distance of the approach path, in statute miles) (Source: Google Earth, with TSB annotations)

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Limitations of see-and-avoid, lack of warning alerts, led to Alaska midair collision

A midair collision of two air tour airplanes was caused by “the inherent limitations of the see-and-avoid concept” along with the absence of alerts from both airplanes’ traffic display systems, the NTSB concluded.

The two airplanes, a float-equipped DHC-2 Beaver operated by Mountain Air Service and a float-equipped DHC-3 Otter operated by Taquan Air, collided at an altitude of 3,350 feet about eight miles northeast of Ketchikan, Alaska, May 13, 2019. The DHC-2 pilot and four passengers died; the DHC-3 pilot suffered minor injuries, nine passengers were seriously injured, and one passenger died.

Ketchikan graphic 14APR21.jpg

Investigators determined that the pilot of the DHC-2 would not have had the opportunity to see and avoid the DHC-3 because his view was obscured by the cockpit structure, right wing and a passenger in the copilot’s seat. The lack of apparent motion of the DHC-2 when viewed from the DHC-3, and the obscuration of the DHC-2 by the window post for 11 seconds before the collision, made it difficult for the DHC-3 pilot to see the DHC-2 airplane.

Both airplanes’ traffic display systems were equipped with ADS-B Out and In.
Although the traffic display system installed on the DHC-3 depicted aircraft in the area, it could not provide aural or visual alerts to warn of a potential collision. The pilot of the DHC-3 last recalled looking at his traffic display about four minutes before the accident and did not identify any collision threats. A traffic alerting feature previously available in the DHC-3 was disabled by a 2015 equipment upgrade.

Unlike the DHC-3, the pilot of the DHC-2 airplane had access to a traffic display system that could provide aural and visual alerts, but the DHC-2 pilot would not have received any such alerts because the DHC-3 airplane was not broadcasting required altitude information.

Requiring all Part 135 operators, as well as all air tour operators in high-traffic areas, to be equipped with collision avoidance technology that provides visual and aural alerts, were two of the five new recommendations made to the FAA. The NTSB also reiterated a safety recommendation to the FAA for the sixth time in five years. That recommendation asked the agency to require all Part 135 operators to establish safety management systems. 

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Pilot’s actions, maintenance issues contributed to fatal crash of historic B-17 airplane

The National Transportation Safety Board detailed in an accident report issued April 13 the circumstances that led to the crash of a Boeing B-17G airplane that killed seven people and injured seven others.

The NTSB determined the probable cause of the accident was the pilot’s failure to properly manage the airplane’s configuration and airspeed following a loss of engine power.

The Word War II-era Boeing B-17G airplane had just departed Bradley International Airport in Windsor Locks, Connecticut, Oct. 2, 2019, on a “living history flight experience” flight with 10 passengers when the pilot radioed controllers that the airplane was returning to the field because of an engine problem.  The airplane struck approach lights, contacted the ground before reaching the runway and collided with unoccupied airport vehicles; the majority of the fuselage was consumed by a post-crash fire.

Windsor Locks.jpg

Flightpath data indicated that during the return to the airport the landing gear was extended prematurely, adding drag to an airplane that had lost some engine power. An NTSB airplane performance study showed the B-17 could likely have overflown the approach lights and landed on the runway had the pilot kept the landing gear retracted and accelerated to 120 mph until it was evident the airplane would reach the runway.

The pilot also served as the director of maintenance for the Collings Foundation, which operated the airplane, and was responsible for the airplane’s maintenance while it was on tour in the United States. Investigators said the partial loss of power in two of the four engines was due to the pilot’s inadequate maintenance, which contributed to the cause of the accident.

The NTSB also determined that although the Collings Foundation had a voluntary safety management system in place, it was ineffective and failed to identify and mitigate numerous hazards, including the safety issues related to the pilot’s inadequate maintenance of the airplane.

The Federal Aviation Administration’s oversight of the Collings Foundation safety management system was also ineffective, the NTSB said, and cited both as contributing to the accident.

The NTSB recommended the FAA require safety management systems for the certain revenue passenger-carrying operations which included living history flight experience flights such as the B-17 flight.

The NTSB also issued recommendations to the FAA that would enhance the safety of revenue passenger-carrying operations conducted under Part 91, including those conducted with a living history flight experience exemption, which currently allows sightseeing tours aboard former military aircraft to be operated under less stringent safety standards than other commercial operations.

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