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.

Into water

On 9 July 2018, an ATR 72-600 continued a non-precision approach to Al Hoceima below the procedure MDA without obtaining visual reference and subsequently struck the sea surface twice, both times with a vertical acceleration exceeding structural limits before successfully climbing away and diverting to Nador having reported a bird strike. The Investigation attributed the accident to the Captain’s repeated violation of operating procedures which included another descent below MDA without visual reference the same day and the intentional deactivation of the EGPWS without valid cause. There was significant fuselage structure and landing gear damage but no occupant injuries.

On 18 February 2009, the crew of Eurocopter EC225 LP Super Puma attempting to make an approach to a North Sea offshore platform in poor visibility at night lost meaningful visual reference and a sea impact followed. All occupants escaped from the helicopter and were subsequently rescued. The investigation concluded that the accident probably occurred because of the effects of oculogravic and somatogravic illusions combined with both pilots being focused on the platform and not monitoring the flight instruments.

On 23 August 2013, the crew of a Eurocopter AS332 L2 Super Puma helicopter making a non-precision approach to runway 09 at Sumburgh with the AP engaged in 3-axes mode descended below MDA without visual reference and after exposing the helicopter to vortex ring conditions were unable to prevent a sudden onset high rate of descent followed by sea surface impact and rapid inversion of the floating helicopter. Four of the 18 occupants died and three were seriously injured. The Investigation found no evidence of contributory technical failure and attributed the accident to inappropriate flight path control by the crew.

On 13 April 2013, a Lion Air Boeing 737-800 flew a day non precision approach to runway 09 at Bali (Denpasar) and continued when the required visual reference was lost below MDA. Despite continued absence of visual reference, the approach was continued until the EGPWS annunciation 'TWENTY', when the aircraft commander called a go around. Almost immediately, the aircraft hit the sea surface to the right of the undershoot area and broke up. All 108 occupants were rescued with only four sustaining serious injury. The Investigation attributed the accident entirely to the actions and inactions of the two pilots.

On 18 November 2009, an IAI Westwind on a medevac mission failed to make a planned night landing at Norfolk Island in unanticipated adverse weather and was intentionally ditched offshore because of insufficient fuel to reach the nearest alternate. The fuselage broke in two on water contact but all six occupants escaped from the rapidly sinking wreckage and were eventually rescued. The Investigation initially completed in 2012 was reopened after concerns about its conduct and a new Final Report in 2017 confirmed that the direct cause was flawed crew decision-making but also highlighted ineffective regulatory oversight and inadequate Operator procedures.

On 28 September 2018, a Boeing 737-800 was flown into the sea short of the intended landing runway at Chuuk during a non-precision approach which was continued below MDA without having obtained the required visual reference. The Investigation found that the Captain s approach had become unstable soon after autopilot disconnection and an excessive rate of descent had taken the aircraft below the indicated glideslope and below MDA despite multiple EGPWS Sink Rate aural Alerts and a visual-only PULL UP Warning with impact following 22 seconds after passing MDA. The absence of an aural PULL UP Warning was considered significant.

On 3 March 2014, a Dassault Falcon 20 engaged in navigation aid calibration for the Regulator was flown into the sea near Kish Island in dark night conditions. The Investigation concluded that the available evidence indicated that the aircraft had been inadvertently flown into the sea as the consequence of the crew experiencing somatogravic illusion. It was also noted that the absence of a functioning radio altimeter and pilot fatigue attributable to the long duty period was likely to have exacerbated the pilots' vulnerability to this illusion.

On 29 October 2014, a Shorts SD 3-60 ceased its climb out soon after take-off and was subsequently found to have descended into the sea at increasing speed with the impact destroying the aircraft. The Investigation found that the aircraft had been airworthy prior to the crash and, noting a dark night departure and a significant authority gradient on the fight deck, concluded that the pilot flying had probably experienced a somatogravic illusion as the aircraft accelerated during flap retraction and made a required left turn. The extent of any intervention by the other pilot could not be determined.

On 29 June 2009, an Airbus A310-300 making a dark-night visual circling approach to Moroni crashed into the sea and was destroyed. The Investigation found that the final impact had occurred with the aircraft stalled and in the absence of appropriate prior recovery actions and that this had been immediately preceded by two separate GWPS 'PULL UP' events. It was concluded that the attempted circling procedure had been highly unstable with the crew's inappropriate actions and inactions probably attributable to their becoming progressively overwhelmed by successive warnings and alerts caused by their poor management of the aircraft's flight path.

On 6 February 2007, a Beech King Air 200 on a scheduled passenger flight crashed into water soon after making a dark night VMC take off and initial climb from North Caicos. The Investigation noted that the regulatory requirement for a crew of two pilots had been ignored and that the pilot had probably consumed alcohol within the permitted limits prior to the take off. It was concluded that he had probably lost spatial awareness and been in the process of attempting recovery to the originally intended flight path when impact occurred.

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