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TSB: Misidentification of runway in rain caused B737-800 to descend to 40 feet over water, Sint Maarten
4 June 2018

TSB: Misidentification of runway in rain caused B737-800 to descend to 40 feet over water, Sint Maarten

Dutch Safety Board issues report on DHC-8-400 main gear leg collapse on landing at Schiphol Airport

Report: Unstabilized tailwind approach causes runway excursion of Boeing 737-400 at Tombouctou, Mali

GAF Nomad belly landing in Papua New Guinea due to fracture in landing gear up-lock switch wiring

Colombia cites poor flight planning in LaMia Avro RJ85 fuel exhaustion accident near Rionegro

Colombian investigators published their final report into the November 2016 accident of an Avro RJ.85 that ran out of fuel and crashed near Rionegro, Colombia.

On November 28, 2016, LaMia flight LMI2933 departed Santa Cruz, Bolivia on a flight to Rionegro/Medellín Airport, Colombia. The aircraft carried the Brazilian Chapecoense football team for a match to Medellin. On approach to Rionegro all four engines flamed out. The aircraft impacted a wooded hillside. Six of the 77 occupants survived the accident.

The Grupo de Investigación de Accidentes Aéreos Colombia (GRIAA) concluded the following:

Probable causes
– Inappropriate planning and execution of the flight, since the amount of fuel required to fly from the airport of destination to an alternate airport was not considered, nor was the amount of reserve fuel, nor the contingency fuel, nor the minimum landing fuel, quantities of fuel required by aeronautical regulations for the execution of the type of international flight that the aircraft CP-2339 was performing.
– Sequential shutdown of all four (4) engines while the aircraft was descending on the GEMLI standby circuit as a result of the exhaustion of fuel on board.
– Inadequate decision making by the management of the operating company of the aircraft, as a consequence of the lack of operational safety assurance in their processes.
– Loss of situational awareness and misguided crew decision making, which kept the fixation on continuing a flight with an extremely limited amount of fuel. The crew was aware of the low level of fuel remaining, however, they did not take the corrective actions required to land at an airfield and obtain refueling to allow them to continue the flight safely.

Contributing Factors
– Premature configuration of the aircraft for landing, during the descent in the GEMLI position support pattern, since, considering the absence of thrust, this configuration affected the plane’s glide distance to the runway of Rionegro airport.
– Latent deficiencies in the planning and execution of non-scheduled transport flights, by the aircraft operator, related to the insufficient supply of the amount of fuel required.
– Specific shortcomings in the planning of the accident flight, on the part of the operator of the aircraft.
– Lack of operational supervision and control of the flight by the Operator, which did not supervised the planning of the flight, its execution, and the follow-up of the flight that was would have allowed the crew to be supported in making decisions.
– Absence of timely “priority”, “emergency” or other calls from the crew of the aircraft, during the flight, and especially when the fuel depletion in the descent and holding phase, which would have alerted to air traffic services to provide the necessary support.
– Organizational and operational deviation on the part of the Operator in the application of the fuel management procedures, as it did not comply in practice with what had been approved by the the DGAC of Bolivia in the process of certification of the company.
– Delay in the approach of CP-2933 to the Rionegro track, due to its late application for priority, and late declaration of fuel emergency, in addition to the traffic density in the VOR RNG support pattern.

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Investigating agency: Aerocivil 
Status: Investigation completed
Duration: 1 year and 5 months
Accident number: COL-16-37-GIA
Download report:  Final report

Germany issues safety recommendations after two Boeing 747-400F cargo aircraft lost flap parts

BFU Germany issued three safety recommendations after two Boeing 747-400F cargo aircraft lost flap parts.

On May 8, 2009 an Asiana Airlines Boeing 747-400F was on approach to Frankfurt International Airport, Germany. When the landing flaps were moved to the 30° position,  the crew heard an impact sound and noticed vibrations. The aircraft landed normally. It appeared that part of the left wing flap (Inboard Fore Flap) with dimensions of about 4.5 x 1 m had broken away and impacted the fuselage.

On October 8, 2014 a Korean Air Cargo Boeing 747-400F was on approach to Frankfurt International Airport, Germany. When the landing flaps were moved to the 30° position,  the crew heard a noise and subsequently, the aircraft rolled 8° to the left. The captain switched off the autopilot and continued the approach manually. A safe landing was carried out. After landing it appeared that a 4,5×1 m part of the ‘Inboard Fore Flap’ of the left wing had broken away.

It was concluded that in both cases the flap fitting broke due to pronounced oscillation/vibration fractures,  originating in a corrosion cavity.

As a result the BFU recommended Boeing to improve the corrosion resistance of the landing flap attachment fittings. The airlines were recommended to check and, if necessary, replace the landing flap attachment fittings installed on Boeing 747-400 type aircraft in accordance with the revised Manufacturer Service Bulletin (SB) 747-27-2366R3 and Service Letter 747-SL-57-085-C.

Missing flap part on the Asiana B747-400F (BFU)

TSB recommends mandatory installation of flight recorders for commercial and private business aircraft

TSB Canada recommends mandatory installation of lightweight flight recording systems by all commercial and private business operators not currently required to carry them, in the wake of a fatal corporate jet accident.

The TSB is also concerned with Transport Canada’s reactive approach to oversight of private business aircraft operations. The details are in the investigation report (A16P0186) released today into the 2016 fatal loss of control and collision with terrain of a Cessna Citation 500 near Kelowna, British Columbia.

On 13 October 2016, a Cessna Citation 500 that was privately operated by Norjet Inc. departed Kelowna Airport, British Columbia, on a night instrument flight rules flight to Calgary/Springbank Airport, Alberta. The pilot and three passengers were on board. Shortly after departure, the aircraft departed controlled flight, entering a steep descending turn to the right until it struck the ground. No emergency call was made. All of the occupants were fatally injured. Impact forces and a post-impact fire destroyed the aircraft.

Because there were no flight recording systems on board the aircraft, the TSB could not determine the cause of the accident. The most plausible scenario is that the pilot, who was likely dealing with a high workload associated with flying the aircraft alone, experienced spatial disorientation and departed from controlled flight shortly after takeoff. The investigation also determined that the pilot did not have the recent night flying experience required by Transport Canada for carrying passengers at night. Pilots without sufficient recent experience flying at night or by instruments are at a greater risk of loss of control accidents.

The Board also raised a concern with the way Transport Canada (TC) had conducted oversight of private business aviation in Canada. During the course of its investigation, the TSB found no record that the operator of this aircraft had ever been inspected by TC. As such, TC was unaware of safety deficiencies in its flight operations, such as the failure to obtain approval for single-pilot operation of the aircraft and the pilot’s lack of recent night flying experience required to carry passengers at night. Since this occurrence, TC has said that it will conduct targeted inspections of private business operators starting in April 2018. The Board will continue to monitor this safety issue.

Side view of C-GTNG’s climb profile (Source: Google Earth, with TSB annotations)

Rain and lack of runway centreline lighting factors in Airbus A320 runway excursion incident at Toronto

The Transportation Safety Board of Canada (TSB) released its investigation report (A17O0025) into the runway excursion of Air Canada flight 623 at Toronto International Airport, Canada.

The investigation determined that weather conditions and lack of runway centreline lighting reduced the cues available to recognize the aircraft’s drift in time to correct the trajectory or to execute a safe go-around.

On 25 February 2017, the Airbus A320 was completing an evening flight to Toronto from Halifax/Stanfield International Airport, Nova Scotia, with six crew members and 119 passengers on board. Just before touchdown, the aircraft began to deviate to the right of the runway centreline. It deviated further to the right after touchdown and entered the grassy area to the west of the runway. It then travelled approximately 2390 feet through the grass parallel to the runway before returning to the pavement. During the excursion, the aircraft struck five runway edge lights, causing minor damage to the left outboard wheel and the left engine cowling. There were no reported injuries.

The investigation found that during the final approach phase, while the aircraft was less than 30 feet above ground and on the runway centreline, a right roll command input caused the aircraft to enter a shallow right bank and start drifting to the right. The crew had limited visual cues to accurately judge the aircraft’s lateral position because of rain, reduced windshield wiper capability and lack of runway centreline lighting. The severity of the drift was not recognized until the aircraft was less than 10 feet above ground and rapidly approaching the runway edge, which left limited time to correct the aircraft’s trajectory before contacting the surface. Given the risks involved in executing a go-around from a low level in response to significant drift, the pilot continued the landing sequence while attempting to minimize the extent of the excursion.

Following the accident, Air Canada instituted a program for inspections of windshield wiper tension, developed a drift training scenario for the simulator, and issued further flight crew guidance on lateral drifts and lateral runway excursions.

The aircraft’s track from 20 feet AGL until it came to a stop on the runway (TSB)

 

TSB Canada factual update on Fond-du-Lac ATR 42 accident: aircraft had ice contamination on takeoff

The Transportation Safety Board of Canada (TSB) released a factual update on its investigation (A17C0146) into the fatal ATR 42 aircraft accident that occurred in Fond-du-Lac, Canada, on 13 December 2017.

The updates details the following sequence of events:

  • On 13 December 2017, an ATR 42-320 aircraft operated by West Wind Aviation arrived at Fond-du-Lac Airport at 17:25 central standard time.
  • During the descent, the aircraft encountered icing conditions and the anti-icing and de-icing systems were activated. When the de-icing and anti-icing systems were turned off, residual ice remained on portions of the aircraft.
  • The aircraft stayed at the Fond-du-Lac Airport to board new passengers and cargo.
  • The operator, West Wind Aviation, had some de-icing equipment in the terminal building at the airport. The de-icing equipment that was available to WestWind Aviation in Fond-du-Lac consisted of two ladders, a hand-held spray bottle with electric blanket and wand, and a container of de-icing fluid. However, the aircraft was not de-iced before takeoff, and the takeoff was commenced with ice contamination on the aircraft.
  • The aircraft departed Fond-du-Lac Airport at 18:11 for Stony Rapids.
  • At 18:12, shortly after takeoff, the aircraft collided with trees and terrain less than a mile west of the end of Runway 28.

More info:

Final report: misunderstanding of conditional clearance causes runway collision at Medan, Indonesia