Accident and Serious Incident Reports: CFIT

Definition

Reports relating to accidents which resulted in Controlled Flight Into Terrain (CFIT) and serious incidents which could have resulted in CFIT.

The accident and serious incident reports are grouped together below in subcategories according to phase of flight.

En-route

On 24 March 2015, after waiting for the Captain to leave the flight deck and preventing his return, a Germanwings A320 First Officer put his aircraft into a continuous descent from FL380 into terrain killing all 150 occupants. Investigation concluded the motive was suicide, noted a history of mental illness dating from before qualification as a pilot and found that prior to the crash he had been experiencing mental disorder with psychotic symptoms which had not been detected through the applicable process for medical certification of pilots. Conflict between the principles of medical confidentiality and wider public interest was identified.

On 23 January 2013, a Canadian-operated DHC6 on day VFR positioning flight in Antarctica was found to have impacted terrain under power and whilst climbing at around the maximum rate possible. The evidence assembled by the Investigation indicated that this probably occurred following entry into IMC at an altitude below that of terrain in the vicinity having earlier set course en route direct to the intended destination. The aircraft was destroyed and there were no survivors.

On 15 March 2012, a Royal Norwegian Air Force C130J-30 Hercules en route on a positioning transport flight from northern Norway to northern Sweden crossed the border, descended into uncontrolled airspace below MSA and entered IMC. Shortly after levelling at FL 070, it flew into the side of a 6608 foot high mountain. The Investigation concluded that although the direct cause was the actions of the crew, Air Force procedures supporting the operation were deficient. It also found that the ATC service provided had been contrary to regulations and attributed this to inadequate controller training.

On 9 May 2012, a Sukhoi RRJ-95 on a manufacturer-operated demonstration flight out of Jakarta Halim descended below the promulgated safe altitude and, after TAWS alerts and warnings had been ignored, impacted terrain in level flight which resulted in the destruction of the aeroplane and death of all 45 occupants. The Investigation concluded that that the operating crew were unaware that their descent would take them below some of the terrain in the area until the alerts started and then assumed they had been triggered by an incorrect database and switched the equipment off.

On 26 August 2003, at night, a Eurocopter EC155, operated by Hong Kong Government Flight Service (GFS), performing a casualty evacuation mission (casevac), impacted the elevated terrain in Tung Chung Gap near Hong Kong International airport.

Approach and Landing

On 6 June 2020, a Boeing 787-10 on approach at Abu Dhabi began a low go around from an RNAV(RNP) approach when it became obvious to the crew that the aircraft was far lower than it should have been but were unaware why this occurred until an ATC query led them to recognise that the wrong QNH had been set with recognition of the excessively low altitude delayed by haze limiting the PAPI range. The Investigation found that advice of MSAW activations which would have enabled the flight crew to recognise their error were not advised to them.

On 14 March 2017, control of a Sikorsky S92A positioning in very poor visibility at 200 feet over the sea in accordance with an obstacle-marked FMS ground track in order to refuel at a coastally-located helipad was lost after it collided with late-sighted terrain ahead before crashing into the sea killing all on board. The Investigation attributed the accident to the lack of crew terrain awareness but found a context of inadequate safety management at the operator, the comprehensively ineffective regulatory oversight of the operation and confusion as to responsibility for State oversight of its contract with the operator.

On 14 October 2019, a Sikorsky S92A manoeuvring below low cloud in poor daylight visibility in an unsuccessful attempt to locate the intended private landing site flew north towards rising ground approximately ¾ mile east of it, coming within a recorded 28 feet above terrain near to occupied houses before making an emergency climb and over-torqing the engines followed by an unstable but successful second approach. The Investigation found relevant operator procedures absent or ineffective, an intention by the management pilot in command to reach the landing site despite conditions and uncertainty about the applicable regulatory context for the flight. 

On 16 July 2020, an Antonov AN26 on which a new Captain’s final line check was being performed made two consecutive non-precision approaches to Runway 33 at Birmingham both of which resulted in ATC instructing the aircraft to go around because of failure to follow the prescribed vertical profile. A third approach using the ILS procedure for runway 15 was successful. On the limited evidence available, the Investigation was unable to explain the inability to safely perform the attempted two non precision approaches to runway 33 or the continuation of them until instructed to go around by ATC.

On 2 September 2016, an ATR72-600 cleared to join the ILS for runway 28 at Dublin continued 800 feet below cleared altitude triggering an ATC safe altitude alert which then led to a go around from around 1000 feet when still over 5nm from the landing runway threshold. The Investigation attributed the event broadly to the Captain’s inadequate familiarity with this EFIS-equipped variant of the type after considerable experience on other older analogue-instrumented variants, noting that although the operator had provided simulator differences training, the -600 was not classified by the certification authority as a type variant.

 

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