Description

On 6 November 2002, a Fokker 50 operated by Luxair, crashed on approach to Luxembourg Airport following loss of control attributed to intentional operation of power levers in the ground range, contrary to SOPs.

Synopsis

The following are extracts from the Accident report published by the Luxembourg Ministry of Transport:

Conclusions

…7. RVR was below approved company minima during the initial and the intermediate approach,

8. During the approach, the crew did not comply with the operator’s procedures,

9. Despite the fact that the meteorological conditions for a CAT II approach prevailed, none of the required prerequisites, to perform a CAT II approach, were taken by the crew.

10. The captain resumed the final approach after having announced a go-around, without co-pilot’s reaction,

11. In order to achieve this goal, the crew performed several non-standard actions, amongst which the prohibited positioning of the power levers beyond flight idle. The AFM contained a limitation that prohibits the selection of ground idle in flight.

12. The selection of the landing gear down, triggered the deactivation of the second safety device (solenoid secondary stops) which was a possible malfunction identified by the manufacturer.…

Causes

The initial cause of the accident was the acceptance by the crew of the approach clearance although they were not prepared to it, namely the absence of preparation of a go-around. It led the crew to perform a series of improvised actions that ended in the prohibited override of the primary stop on the power levers.

Contributory factors can be listed as follows

1. A lack of preparation for the landing, initiated by unnecessary occupations resulting from an obtained RVR value, which was below their company approved minima, created a disorganisation in the cockpit, leading to uncoordinated actions by each crewmember.

2. All applicable procedures as laid down in the operations manual were violated at some stage of the approach. All this did not directly cause the accident, but created an environment whereby privately designed actions were initiated to make a landing possible.

3. Routine and the will to arrive at its destination may have put the crew in a psychological state of mind, which could be the origin of the deviations from standard procedures as noticed.

4. The low reliability of the installed secondary stop safety device that was favoured by the non-application of service bulletin ABSC SB F050-32-4. Also the mode of distribution of the safety information (Fokker Aircraft B.V. - Service letter137) to the operator as well as the operator’s internal distribution to the crews, that did not guarantee that the crews were aware of the potential loss of secondary stop on propeller pitch control.

5. The lack of harmony resulting from the use of various training centres and non-standardised programs that might have impaired the synergy of the crew."

Related Articles

LOC

• Loss of Control,
• Recovery from Unusual Aircraft Attitudes,
• Stall,

Further Reading

For further information see:

• The full Accident Report, published by the Luxembourg Ministry of Transport, and
• The Appendices to that report.