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Improper crosswind landing technique causes ATR 72-600 runway excursion at Indore Airport, India
8 July 2018

Improper crosswind landing technique causes ATR 72-600 runway excursion at Indore Airport, India

BEA France criticizes Egypt’s halting of the formal investigation into the crash of EgyptAir MS804

The French investigation bureau, BEA, criticized Egypt’s authorities for halting the formal accident investigation into the crash of EgyptAir flight MS804.

On May 19, 2016, EgyptAir flight MS804, an Airbus A320 impacted the Mediterranean Sea some 200 km north of the Egyptian coast line, killing all 66 on board. The flight was en route from Paris to Cairo at the time.

Following the accident, a formal investigation was launched by the Egyptian authorities per ICAO Annex 13. The BEA appointed an accredited representative to represent France as the state of design of the aircraft. During this investigation, the Egyptian authorities published the following elements about the accident:

  • The flight recorders stopped operating while the aircraft was in cruise at an altitude of 37,000 feet;
  • The aircraft systems sent ACARS messages indicating the presence of smoke in toilets and the avionics bay;
  • The data from the data recorder confirms these messages;
  • The playback of the cockpit voice recorder reveals, in particular, that the crew mentioned the existence of a fire on board;
  • Several pieces of debris were retrieved from the accident site. Some of these had signs of having been subject to high temperatures, and traces of soot.

Once the data from the flight recorders had been retrieved, the Egyptian authorities continued their work in Egypt. In addition, the BEA had collected the following elements:

  • A signal from an emergency locator transmitter was sent at 00:37 i.e. around eight minutes after the transmission of the last ACARS message;
  • Data from a Greek primary radar (sent by the Greek authorities to the BEA) shows that the aircraft had descended in a turn until collision with the surface of the water.

Based on these elements, the BEA considered that the most likely hypothesis was that a fire broke out in the cockpit while the aircraft was flying at its cruise altitude and that the fire spread rapidly resulting in the loss of control of the aircraft.
For its part, the BEA’s Egyptian counterpart announced in December 2016, the discovery of traces of explosive on human remains. It stated that, in accordance with Egyptian legislation, this finding led it to transfer the file to the Egyptian Attorney General who would from now on be responsible for carrying out the investigation.
The BEA’s proposals concerning further work on the debris and recorded data were not, as far as the BEA knows, followed up. The technical elements of the investigation already collected by Egypt, including those provided by the BEA, are protected by the Egyptian judicial investigation.

In an effort to continue the safety investigation mission, the BEA asked to meet the Egyptian Attorney General. This took place at the end of May 2018. In this meeting, the Egyptian authorities explained that as it had been determined that there had been a malicious act, the investigation now fell within the sole jurisdiction of the judicial authorities.
The BEA’s Egyptian counterpart did not publish the final report which would have allowed the BEA to set out its differences of opinion as authorized by the international provisions.
The BEA considers that it is necessary to have this final report in order to have the possibility of understanding the cause of the accident and to provide the aviation community with the safety lessons which could prevent future accidents.
BEA considers that the most likely hypothesis is the rapid spread of a fire and would like investigations into this hypothesis to be continued in the interests of aviation safety.

Inadequate flight planning led to Global Express collision with runway lights at Montreal/St-Hubert

Damage to left main landing gear and rear centre fuselage of the Global Express (TSB)

The Transportation Safety Board of Canada (TSB) found that inadequate flight planning led to a Global Express aircraft colliding with runway lights after landing at the Montreal/St-Hubert Airport.

On 15 May 2017, a U.S.-registered Bombardier Global Express corporate jet aircraft was flying from Teterboro, New Jersey, to Montreal/St-Hubert Airport, Quebec, with three crew members and one passenger on board. The aircraft was cleared to land on runway 06L at Montreal/St-Hubert Airport, which had been reduced in size to 75 feet wide and 5000 feet long due to construction work. At about 10:55 local time, the aircraft touched down partially outside of the confines of the reduced-width runway, striking seven temporary runway edge lights. The pilot flying brought the aircraft back to the reduced-width runway centreline before coming to a stop 300 feet from the shortened runway end. There were no injuries but the aircraft sustained substantial damage.

The investigation found that the crew’s flight planning did not adequately prepare them to ensure a safe landing. The flight crew believed that the entire width of the runway was available, despite notices to airmen (NOTAMs), communication with the air traffic controller and other information indicating the reduced runway size. Before landing, the flight crew misinterpreted the runway markings, and the pilot flying perceived the runway side stripe marking along the left edge of the runway as being the runway centreline. As a result, the aircraft touched down partly outside the limits of the available runway.

The approach briefing conducted by the flight crew did not include a review of the NOTAMs in effect at the airport, as required by the aircraft operator. This review could have made the crew aware of the reduced runway width prior to landing. If flight crews conduct incomplete approach briefings, there is a risk that information that is crucial for flight safety will be missed.

Following the occurrence, the operator of Montreal/St-Hubert Airport added a popup window to its website. It contained a message describing the construction work and specified that flight crews must read the notices to airmen in effect at the airport. Flight crews could also download a diagram of the construction work.

More information:

ATSB issues final report on airprox incident involving two Beech 200’s in Australia

NTSB issues final report on British Airways Boeing 777-200 uncontained engine failure at Las Vegas

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