Accidents and Incidents
This directory contains articles about particular Accidents and Incidents that are considered illustrative of the contemporary safety issues and recommended potential solutions. The information contained in the article summarising an individual accident or incident is derived from the published official investigation report, which may in each case be found on the SKYbrary bookshelf wherever possible in English as provided by the publishing Investigation Agency. A direct link to each official report is provided at the end of each summary article. The complete list of events is provided on this and the following pages in the order of the ICAO aircraft type designator in alphabetical order.
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Time of Day
Phase of Flight
Air Ground Communication
Controlled Flight Into Terrain
Loss of Control
Loss of Separation
Wake Vortex Turbulence
AW Affected System(s)
AW Contributing Factor(s)
Causal Factor Group(s)
S76, Peasmarsh East Sussex UK, 2012 On 3 May 2012, a Sikorsky S76C operating a passenger flight to a private landing site at night discontinued an initial approach because of lack of visual reference in an unlit environment and began to position for another. The commander became spatially disorientated and despite a number of EGPWS Warnings, continued manoeuvring until ground impact was only narrowly avoided - the minimum recorded height was 2 feet +/- 2 feet. An uneventful diversion followed. The Investigation recommended a review of the regulations that allowed descent below MSA for landing when flying in IMC but not on a published approach procedure.
S76, vicinity Lagos Nigeria, 2015 On 12 August 2015, a Sikorsky S76C crew on a flight from an offshore platform to Lagos lost control of their aircraft after a sudden uncommanded pitch up, yaw and roll began and 12 seconds later it crashed into water in a suburb of Lagos killing both pilots and four of the 10 passengers. The Investigation concluded that the upset had been caused by a critical separation within the main rotor cyclic control system resulting from undetected wear at a point where there was no secondary mechanical locking system such as a locking pin or a wire lock to maintain system integrity.
S76, vicinity Moosonee ON Canada, 2013 On 31 May 2013 the crew of an S76A helicopter positioning for a HEMS detail took off VFR into a dark night environment and lost control as a low level turn was initiated and did not recover. The helicopter was destroyed and the four occupants killed. The Investigation found that the crew had little relevant experience and were not operationally ready to conduct a night VFR take off into an area of total darkness. Significant deficiencies at the Operator and in respect of the effectiveness of its Regulatory oversight were identified as having been a significant context for the accident.
S92, en-route, east of St John’s Newfoundland Canada, 2009 On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.
S92, manoeuvring, near Black Rock Western Ireland, 2017 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.
S92, manoeuvring, near Shipston-on-Stour UK, 2019 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.
S92, northeast of Aberdeen UK, 2018 On 23 August 2018, a low experience Sikorsky S92 First Officer undergoing line training made a visual transit between two North Sea offshore platforms but completed an approach to the wrong one. The platform radio operator alerted the crew to their error and the helicopter then flew to the correct platform. The Investigation attributed the error primarily to the inadequate performance of both pilots on what should have been a straightforward short visual flight but particularly highlighted the apparent failure of the Training Captain to fully recognise the challenges of the flight involved when training and acting as Pilot Monitoring.
S92, vicinity of Offshore Platform east southeast of Halifax Canada, 2019 On 24 July 2019, whilst a Sikorsky S92A was commencing a second missed approach at the intended destination platform, visual contact was acquired and it was decided that an immediate visual approach could be made. However control was then temporarily lost and the aircraft almost hit the sea surface before recovery involving engine overtorque and diversion back to Halifax. The Investigation concluded that the crew had failed to safely control the aircraft energy state in a degraded visual environment allowing it to enter a vortex ring condition. As context, operator procedures, Flight Manual content and regulatory requirements were all faulted.
S92, West Franklin Wellhead Platform North Sea, 2016 On 28 December 2016, yaw control was lost during touchdown of a Sikorsky S92A landing on a North Sea offshore platform and it almost fell into the sea. The Investigation found that the loss of control was attributable to the failure of the Tail Rotor Pitch Change Shaft bearing which precipitated damage to the associated control servo. It was also found that despite HUMS monitoring being in place, it had been ineffective in proactively alerting the operator to the earlier stages of progressive bearing deterioration which could have ensured the helicopter was grounded for rectification before the accident occurred.
SB20 / C510, vicinity Lugano Switzerland, 2011 On 16 December 2011, a Saab 2000 in the hold and an opposite direction Cessna VLJ joining it lost procedural separation in IMC near Lugano due to conflicting ATC clearances issued by the same controller who had used the wrong Transition Level. Any risk of collision was removed by a TCAS RA activated on the Saab 2000 but the Investigation found that the DFTI radar display available to the controller to help resolve unexpected emergency situations was configured to systematically convert SSR standard pressure altitudes to QNH for altitude display using a distant and inappropriate value of QNH.
SB20, en-route, Muzzano Switzerland, 2013 On 28 November 2013, a Saab 2000 departing Lugano suffered an engine failure for no apparent reason and the crew determined that diversion to Milan was preferable to return to Lugano or continued climb over high terrain to reach intended destination Zurich. The Investigation found that the loss of engine power experienced was due to a double FADEC failure with a transient malfunction of one channel resulting in an automated transfer to the other channel which already had an undetected permanent fault attributable to maintenance error. It was noted that the airline involved had contracted out all continuing airworthiness responsibilities.
SB20, Stockholm Arlanda, 2001 On 18 December 2001, a Saab 2000 being operated by Air Botnia on scheduled passenger flight from Stockholm to Oulu was taxiing out at night in normal visibility in accordance with its ATC clearance when a car appeared from the left on a roadway and drove at speed on a collision course with the aircraft. In order to avoid a collision, the aircraft had to brake sharply and the aircraft commander saw the car pass under the nose of the aircraft and judged the vehicle’s closest distance to the aircraft to be four to five metres. The car did not stop, could not subsequently be identified and no report was made by the driver or other witnesses. The diagram below taken from the official report shows the site of the conflict - the aircraft was emerging from Ramp ‘G’ to turn left on taxiway ‘Z’ and the broken line shows the roadway which is crossed just before the left turn is commenced.
SB20, Unalaska AK USA, 2019 On 17 October 2019, a Saab 2000 overran the Unalaska runway after touchdown following difficulty braking and exited the airport perimeter before finally coming to rest on shoreline rocks. The Investigation attributed the poor braking to incorrect brake system wiring originating during maintenance some 2½ years earlier but noted the touchdown occurred with crew awareness that the prevailing tailwind component was well in excess of the permitted limits with no reason not to use the into-wind runway and attributed this to plan continuation bias. The aircraft operator’s failure to apply their specifically-applicable airport qualification requirements to the Captain was noted.
SB20, vicinity Billund Denmark, 2015 On 10 December 2015, a Saab 2000 descended below the prescribed vertical profile in IMC during a LLZ-only approach to Billund. An EGPWS ‘PULL UP’ warning was followed by a go around instead of the prescribed response to such a warning. A minor level bust and configuration exceedance followed after which the aircraft returned to its departure airport. Prior to the LLZ-only approach, an attempt to continue with an ILS approach to the same runway with only a LLZ signal available had also ended in a go around. In both cases, there was a complete failure to maintain vertical situational awareness.
SB20, vicinity Sumburgh, UK 2014 On 15 December 2014, the Captain of a Saab 2000 lost control of his serviceable aircraft after a lightning strike when he attempted to control the aircraft manually without first disconnecting the autopilot and despite the annunciation of a series of related alerts. The aircraft descended from 4,000 feet to 1,100 feet at up to 9,500 fpm and 80 knots above Vmo. A fortuitous transient data transmission fault caused autopilot disconnection making it possible to respond to EGPWS 'SINK RATE' and 'PULL UP' Warnings. The Investigation concluded that limitations on autopilot disconnection by pilot override were contrary to the type certification of most other transport aircraft.
SB20, Werneuchen Germany, 2002 On 10 July 2002, a Saab 2000 being operated by Swiss Air Lines on a scheduled public transport service from Basel to Hamburg encountered extensive thunderstorms affecting both the intended destination and the standard alternates and due to a shortage of fuel completed the flight with a landing in day VMC at an unmanned general aviation airstrip where the aircraft collided with an unseen obstruction. After the aircraft came to a stop with the landing gear torn off, the two cabin crew conducted the passenger evacuation on their own initiative. There was no fire and only one of the 20 occupants was injured. The aircraft was declared a hull loss due to the damage sustained relative to the location.
SF34 / B190, Auckland NZ, 2007 On 29 May 2007, a Saab 340 aircraft that was holding on an angled taxiway at Auckland International Airport was inadvertently cleared to line up in front of a landing Raytheon 1900D. The aerodrome controller transmitted an amended clearance, but the transmission crossed with that of the Saab crew reading back the line-up clearance. The pilots of both aircraft took action to avoid a collision and stopped on the runway without any damage or injury.
SF34 / E145, Stockholm Sweden, 2002 On 16 December 2002, a Saab 340 being operated by Swedish airline Skyways and arriving at Stockholm on a scheduled domestic passenger flight and an Embraer 145 being operated by Swiss on a scheduled passenger flight from Stockholm to Basel almost collided at the intersection between taxiways ‘Z’ and ‘A’ in normal night visibility. Upon seeing the Saab approaching on a conflicting track, the Embraer 145 was stopped very suddenly and the other aircraft passed within an estimated 3 metres. No persons were injured and neither aircraft was damaged. The diagram below taken from the official report shows the intersection involved.
SF34 / PA27, Nassau Bahamas, 2018 On 22 September 2018, a Saab 340B taking off in accordance with its clearance at Nassau came close to a midair collision over the main runway after a light aircraft began an almost simultaneous takeoff in the opposite direction of the same runway contrary to its received and correctly acknowledged non-conflicting takeoff clearance for a different runway without the TWR controller noticing. The light aircraft passed over the Saab 340 without either aircraft crew seeing the other aircraft. The Investigation noted that the light aircraft pilot had “forgotten” his clearance and unconsciously substituted an alternative.
SF34, en-route, near Caltrauna Argentina, 2011 On 18 May 2011, a Saab 340 crew attempted to continue a climb to their intended cruising level in significant airframe icing conditions at night before belatedly abandoning the attempt and descending to a lower level but one where their aircraft was nevertheless still rapidly accumulating ice. They were unable to recover control after it stalled and a crash into terrain below followed. The Investigation attributed the accident to lack of crew understanding of the importance of both the detection of and timely and appropriate response to both significant rates of airframe ice accumulation and indications of an impending aerodynamic stall.
SF34, en-route, north of Edinburgh UK, 2017 On 5 June 2017, a Saab 340B encountered an unexpected short period of severe in-cloud turbulence and icing soon after climbing through FL 100 on departure from Edinburgh and a temporary but constrained loss of pitch control occurred during which three successive Angle of Attack-triggered stick shaker activations occurred before the severity of the turbulence reduced and the intended climb could be resumed. The Investigation found that the crew had not responded to the problem in accordance with prescribed procedures and that at no time during the episode had they set Maximum Continuous Power to aid prompt and effective recovery.
SF34, en-route, northern North Sea UK, 2014 On 3 October 2014, the crew of a Saab 340 in the cruise at FL150 in day IMC did not recognise that severe icing conditions had been encountered early enough to make a fully-controlled exit from them and although recovery from the subsequent stall was successful, it was achieved in a non-standard manner. The Investigation concluded that although both mountain wave effects and severe icing had contributed to the incident, the latter had been the main cause. Both crew understanding of airframe icing risk and supporting Operator and Manufacturer documentation on the subject were considered deficient.
SF34, en-route, Santa Maria CA USA, 2006 On 2 January 2006, an American Eagle Saab 340 crew failed to notice a progressive loss of climb performance in icing conditions and control of the aircraft was lost when it stalled at 11,700 feet and was only recovered after a 5200 feet height loss. The Investigation noted that the aircraft had stalled prior to the activation of the Stall Protection System and that the climb had been conducted with the AP engaged and, contrary to SOP, with VS mode selected. It was concluded that SLD icing conditions had prevailed. Four Safety Recommendations were made and two previous ones reiterated.
SF34, Izumo Japan, 2007 On 10 December, 2007 a SAAB 340B being operated by Japan Air Commuter on a scheduled passenger flight left the runway at Izumo Airport during the daylight landing roll in normal visibility and continued further while veering to the right before coming to a stop on the airport apron.
SF34, Kirkwall Orkney UK, 2003 On 12 September 2003, a Saab 340B being operated by UK regional airline Loganair on a scheduled passenger flight from Aberdeen to Kirkwall experienced a loss of pitch control during landing at destination and the rear fuselage contacted the runway causing damage to the airframe. Once the aircraft had cleared the runway, some passengers and some of the hold baggage was removed before the aircraft was taxied to its parking position because of a suspicion that the aircraft might have been loaded contrary to the accepted load and trim sheet.
SF34, Lappeenranta Finland, 2008 On 31 January 2008 a Saab 340B being operated by Czech airline Job Air on a scheduled passenger service from Helsinki to Lappeenranta under a wet lease contract for a Company called ‘Fly Lappeenranta’ which was not an aircraft operator. During the night landing at Lappeenranta, it departed the left side of the runway after touch down in normal visibility with snow falling. Propeller damage was caused when an attempt was then made to return the aircraft to the runway after the excursion. None of the 16 occupants was injured.
SF34, Marsh Harbour Bahamas, 2013 On 13 June 2013, a rushed and unstable visual approach to Marsh Harbour by a Saab 340B was followed by a mishandled landing and a runway excursion. The Investigation concluded that the way the aircraft had been operated had been contrary to expectations in almost every respect. This had set the scene for the continuation of a visual approach to an attempted landing in circumstances where there had been multiple indications that there was no option but to break off the approach, including a total loss of forward visibility in very heavy rain as the runway neared.
SF34, Moruya NSW Australia, 2015 On 9 January 2015, a Saab 340B encountered a flock of medium-sized birds soon after decelerating through 80 knots during its landing roll at Moruya. A subsequent flight crew inspection in accordance with the prevailing operator procedures concluded that the aircraft could continue in service but after completion of the next flight, a propeller blade tip was found to be missing. The Investigation concluded that the blade failure was a result of the earlier bird impact and found that airline procedures allowing pilots to determine continued airworthiness after a significant birdstrike had unknowingly been invalid.
SF34, Savonlinna Finland, 2019 On 7 January 2019, a Saab 340B made a late touchdown during light snowfall at night close to the edge of the runway at Savonlinna before veering off and eventually stopping. The Investigation attributed the excursion to flight crew misjudgements when landing but also noted the aircraft operator had a long history of similar investigated events in Scandinavia and had failed to follow its own documented Safety Management System. The Investigation also concluded that there was a significant risk that EU competition rules could indirectly compromise publicly-funded air service contract tendering by discounting the operational safety assessment of tendering organisations.
SF34, Stornoway UK, 2015 On 2 January 2015, the commander of a Saab 340 suddenly lost directional control during a within-limits crosswind take off and the aircraft left the runway onto grass at approximately 80 knots. No call to reject the take off was made and no action was taken to shut down the engines until the aircraft had come to a stop in the soft ground with a collapsed nose gear and substantial damage to the propellers and lower forward fuselage. The Investigation concluded that the most likely explanation for the excursion was the absence of any rudder input as the aircraft accelerated.
SF34, vicinity Mariehamn Finland, 2012 On 14 February 2012 a Latvian-operated Saab 340 acknowledged an ATC clearance to make a procedural ILS approach to Mariehamn and then completely disregarded the clearance by setting course direct to the aerodrome. Subsequently, having lost situational awareness, repeated GPWS PULL UP warnings at night in VMC were ignored as control of the aircraft was lost with a recovery only achieved an estimated 2 seconds before ground impact would have occurred and then followed by more ignored PULL UP Warnings due to continued proximity to terrain before the runway was sighted and a landing achieved.
SF34, vicinity Newcastle New South Wales Australia, 2012 On 8 November 2012, the crew of a Saab 340 advised destination ATC at Newcastle in daylight hours that they were 'visual' and were so cleared. The aircraft was then observed to turn towards the lights of an industrial complex 6nm from the airport and descend and ATC intervened to provide guidance to final approach. Investigation found that the experienced Captain was guiding the First Officer, who had gained his professional licence 10 months earlier, towards what he had mistaken for the runway. Descent, perceived by the Captain as on 'finals', continued to 680 feet agl before a climb commenced.
SF34, vicinity Sydney Australia, 2008 On 3 November 2008, a Saab 340B being operated on a domestic passenger flight by Regional Express AL was tracking in daylight to join a 7nm final for Runway 34R at destination Sydney, when a passenger sustained minor injuries as the result of a transient encounter with turbulence that had led to a momentary loss of control of the aircraft and which was suspected as being of wake vortex origin.
SF34, vicinity Sydney Australia, 2017 On 17 March 2017, uncommanded engine indications on a Saab 340B en route to Sydney were followed by vibration of the right engine after which, as the crew commenced right engine shutdown, its propeller assembly separated from the engine. A PAN was declared and the flight subsequently reached Sydney without further event. The Investigation found that the propeller gearbox shaft had fractured because of undetected internal fatigue cracking in the shaft. Applicable in-service shaft inspection procedures were found to be inadequate and mandatory enhancements to these procedures have since been introduced.
SF34/AT72, Helsinki Finland, 2011 On 29 December 2011 a Golden Air ATR 72 making a daylight approach to runway 22R at Helsinki and cleared to land observed a Saab 340 entering the runway and initiated a low go around shortly before ATC, who had observed the incursion, issued a go around instruction. The Investigation attributed the breach of clearance by the Latvian-operated Saab 340 primarily to poor CRM, a poor standard of R/T and inadequate English Language proficiency despite valid certification of the latter.
SF34/SF34, vicinity Stornoway UK, 2011 On 15 October 2011, a Loganair Saab 340 in uncontrolled airspace and inbound and level at 2000 feet QNH on a procedural non precision approach in day IMC to runway 18 at Stornoway received a TCAS RA ‘DESCEND’ when a second Loganair Saab 340 outbound on the same procedure descended prematurely to the same altitude contrary to ATC clearance. The subsequent investigation concluded that the failure of the controller to re-iterate the requirement to remain at 3000 feet outbound until advised had contributed the crew error. Minimum separation after the TCAS RA was less than 0.1nm horizontally when 500 feet vertically.
SH33 / MD83, Paris CDG France, 2000 On the 25th of May, 2000 a UK-operated Shorts SD330 waiting for take-off at Paris CDG in normal visibility at night on a taxiway angled in the take-off direction due to its primary function as an exit for opposite direction landings was given a conditional line up clearance by a controller who had erroneously assumed without checking that it was at the runway threshold. After an aircraft which had just landed had passed, the SD330 began to line up unaware that an MD83 had just been cleared in French to take off from the full length and a collision occurred.
SH36 / SH36, manoeuvring, Watertown WI USA, 2006 On 5 February 2006, two Shorts SD-360-300 aircraft collided in mid air while in formation near Watertown, WI, USA; both aircraft suffered damage. One aircraft experienced loss of control and impacted terrain while the other made an emergency landing, overunning the runway, at a nearby airport.
SH36, vicinity East Midlands UK, 1986 On 31 January 1986, at night during an instrument approach, a Shorts SD3-60 operated by Aer Lingus Commuter experienced a loss of control attributed to airframe ice accretion. When fully established on the Instrument Landing System (ILS), the aircraft began a series of divergent rolling oscillations which were accompanied by a very high rate of descent. The crew was able to regain control of the aircraft just before contact with power cables and subsequent impact with terrain near East Midlands Airport.
SH36, vicinity Edinburgh UK, 2001 On 27 February 2001, a Loganair SD3-60 lost all power on both engines soon after take off from Edinburgh. An attempt to ditch in the Firth or Forth in rough seas resulted in the break up and sinking of the aircraft and neither pilot survived. The loss of power was attributed to the release of previously accumulated frozen deposits into the engine core when the engine anti icing systems were selected on whilst climbing through 2200 feet. These frozen deposits were considered to have accumulated whilst the aircraft had been parked prior to flight without engine intake blanks fitted.
SH36, vicinity Marsa Brega Libya, 2000 On 13 January 2000, a Shorts SD3-60 suffered a double engine failure on approach to Marsa Brega, Libya, attributed to failure to use engine anti-icing during flight in icing conditions. The aircraft ditched into the sea and was destroyed by impact forces.
SH36, vicinity Oshawa ON Canada, 2004 On 16 December 2004, an Air Cargo Carriers Shorts SD3-60 attempted to land at Oshawa at night on a runway covered with 12.5mm of wet snow which did not offer the required landing distance. After unexpectedly poor deceleration despite selection of reverse propeller pitch, full power was applied and actions for a go around were taken. Although the aircraft then became airborne in ground effect, it subsequently failed to achieve sufficient airspeed to sustain a climb and an aerodynamic stall was followed by impact with terrain and trees beyond the end of the runway. The aircraft was substantially damaged and both pilots sustained serious injuries but there was no post-crash fire
SH36, vicinity Sint Maarten Eastern Caribbean, 2014 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.
SS2, Manoeuvring West Mojave Desert CA USA, 2014 On 31 October 2014, the crew of a SpaceShip Two suborbital rocket, being operated by Scaled Composites on a routine test flight, broke up in flight after the co-pilot prematurely operated a release mechanism for an aerodynamic braking system which then deployed without further crew intervention. The NTSB Investigation concluded that whilst the co-pilot's error was the immediate cause of the accident, the context for it was the operator's failure to adequately understand and mitigate risk, and weakness in the FAA oversight process which led to inappropriate waivers from the normal requirements for issue of an experimental permit to fly.
SU95, manoeuvring near Jakarta Indonesia, 2012 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.
SU95, Moscow Sheremetyevo Russia, 2019 On 5 May 2019, a Sukhoi RRJ-95B making a manually-flown return to Moscow Sheremetyevo after a lightning strike caused a major electrical systems failure soon after departure made a mismanaged landing which featured a sequence of three hard bounces of increasing severity. The third of these occurred with the landing gear already collapsed and structural damage and a consequential fuel-fed fire followed as the aircraft veered off the runway at speed. The subsequent evacuation was only partly successful and 41 of the 73 occupants died and 3 sustained serious injury. An Interim Report has been published.
SW4 / Vehicle, Dunedin New Zealand, 2010 On 25 May 2010 an Airwork SA227 Metroliner operating a cargo flight narrowly missed colliding with a vehicle on the runway during its night landing at Dunedin in normal visibility. The vehicle was subsequently found to have been on the runway without the appropriate authority in order to carry out a security inspection and the vehicle only co-incidentally at the side of the runway as its driver was unaware of the aircraft. It was noted such access had become a matter of custom and practice for which the context was inadequate procedures for control of airside vehicular access.
SW4, Cork Ireland, 2011 On 10 February 2011, control of a Spanish-operated Fairchild SA227 operating a scheduled passenger flight from Belfast UK to Cork, Ireland was lost during an attempt to commence a third go around due to fog from 100 feet below the approach minimum height. The Investigation identified contributory causes including serial non-compliance with many operational procedures and inadequate regulatory oversight of the Operator. Complex relationships were found to prevail between the Operator and other parties, including “Manx2”, an Isle of Man-based Ticket Seller under whose visible identity the aircraft operated. Most resultant Safety Recommendations concerned systemic improvement in regulatory oversight effectiveness.
SW4, Dryden ON Canada, 2020 On 24 February 2020, the crew of a Fairchild SA-227 departing Dryden lost directional control and the aircraft veered off the side of the runway soon after beginning its takeoff roll with the subsequent impact with a frozen snow bank causing significant damage to the aircraft. The Investigation found that takeoff had been commenced with the right propeller still on the start locks after failure to follow two separate normal procedures during what was the very inexperienced First Officer’s first day of line training after joining the operator and obtaining a type rating.
SW4, en-route, near La Alianza Puerto Rico, 2013 On 2 December 2013, an SA227 Freighter crew lost control of their aircraft after commencing descent from an 11,000 feet cruise in night VMC and it was destroyed by terrain impact which followed structural break-up at about 1,500 feet agl. The Investigation concluded that the break-up had followed an aggressive elevator input in a late attempt to recover from an earlier loss of control which the evidence suggested had been the consequence of unintended crew actions rather than mechanical anomalies. A number of previous SA227 loss of control events were identified, some of which had potentially similar features.
SW4, en-route, North Vancouver BC Canada, 2015 On 13 April 2015, a Swearingen SA226 Metro II which had recently departed on a cargo flight was climbing normally when it suddenly entered an unexplained and steep descent a few minutes after takeoff. There were no communications from the pilots. It was later found to have impacted terrain after a rate of descent exceeding 30,000 fpm had created aerodynamic forces which caused structural disintegration to begin before impact. The Investigation could not determine why but concluded that “alcohol intoxication almost certainly played a role” and noted that indications that the Captain was a chronic alcoholic had not prompted any intervention.
SW4, en-route, Taranaki Province New Zealand, 2005 On 3 May 2005, Fairchild-Swearingen SA227 (Metro III), operated by Airwork (NZ) Limited, was on a night air transport freight flight when it suffered a loss of control which developed into a spiral dive. The crew did not recover the control and the aircraft became overstressed which resulted in an in-flight break up and terrain impact, killing both crewmembers.
SW4, Mirabel Montreal Canada, 1998 On 18 June 1998, the crew of a Swearingen SA226 did not associate directional control difficulty and an extended take off ground run at Montreal with a malfunctioning brake unit. Subsequent evidence of hydraulic problems prompted a decision to return but when evidence of control difficulties and fire in the left engine followed, a single engine diversion to Mirabel was flown where, just before touchdown, the left wing failed upwards. All occupants were killed when the aircraft crashed inverted. The Investigation found that overheated brakes had caused an engine nacelle fire which spread and eventually caused the wing failure.
SW4, New Plymouth New Zealand, 2009 A visual approach by a Swearingen SA227 at New Plymouth was rushed and unstable with the distraction of a minor propeller speed malfunction and with un-actioned GPWS warnings caused by excessive sink and terrain closure rates. After a hard touchdown close to the beginning of the runway, directional control was lost and the aircraft left the runway to the side before continuing parallel to it for the rest of the landing roll.
SW4, Sanikiluaq Nunavut Canada, 2012 On 22 December 2012, the crew of a Swearingen SA227 attempting a landing, following an unstabilised non-precision approach at Sanikiluaq at night with questionable alternate availability in marginal weather conditions, ignored GPWS PULL UP Warnings, then failed in their attempt to transition into a low go around and the aircraft crashed into terrain beyond the runway. One occupant – an unrestrained infant – was killed and the aircraft was destroyed. The Investigation faulted crew performance, the operator and the regulator and reiterated that lap-held infants were vulnerable in crash impacts.
SW4, Thompson MB Canada, 2017 On 2 November 2017, a Fairchild SA 227-AC Metro III landing at Thompson after a ferry-permit flight issued to facilitate a hydraulic fluid leak rectification left the runway when reverse pitch was selected and sustained substantial damage. The Investigation found that the flight had been continued without shutting down the left engine when its oil pressure dropped below the level requiring this in the QRH. The oil loss was found to be attributable to the same cause as a similar loss identified two days previously for which rectification had supposedly been achieved. The hydraulic leak did not affect the flight.
SW4, vicinity Aberdeen UK, 2002 On 24 December 2002, a SA 227 Metroliner III being operated by Danish freight and passenger charter operator Benair on a positioning flight from Aberdeen to Aalborg with just the two pilots on board crashed just after take off in marginal VMC at night following a loss of control. It collided with a car which caught fire and both aircraft and car were destroyed although only one person, one of the flight crew, sustained any injury, which was minor.
SW4, vicinity Lockhart River Queensland Australia, 2005 On 7 May 2005, a Fairchild Aircraft Inc. SA227-DC Metro 23 aircraft, was being operated by Transair on an IFR flight from Bamaga to Cairns, with an intermediate stop at Lockhart River, Queensland. The aircraft impacted terrain approximately 11 km north-west of the Lockhart River aerodrome and was destroyed by the impact forces and an intense, fuel-fed, post-impact fire.
SW4, vicinity Red Lake ON Canada, 2013 On 10 November 2013 the left engine of a Fairchild SA227 on final approach suddenly ceased to produce any power at approximately 500 feet whilst continuing to operate. The crew did not identify what had happened in time to avoid losing control of the aircraft which then impacted terrain, caught fire and was destroyed. The Investigation found that premature failure of engine components had caused the engine malfunction and noted that some pilots may believe that the Negative Torque Sensing (NTS) System provided for the engines on this aircraft type will always detect high drag conditions arising from power loss.
T154 / B752, en-route, Uberlingen Germany, 2002 On 1st July 2002, a Russian-operated Tu154 on a passenger flight collided at night with a cargo Boeing 757-200 over Überlingen, Germany with the consequent loss of control of both aircraft and the death of all occupants. The collision occurred after an ATC control lapse had led to a conflict which generated coordinated TCAS RAs which the B757 followed but the TU-154, in the presence of a conflicting ATC instruction, did not.
T154, vicinity Smolensk Russian Federation, 2010 On 10 April 2010, a Polish Air Force Tupolev Tu-154M on a pre-arranged VIP flight into Smolensk Severny failed to adhere to landing minima during a non precision approach with thick fog reported and after ignoring a TAWS ‘PULL UP’ Warning in IMC continued descent off track and into the ground. All of the Contributory Factors to the pilot error cause found by the Investigation related to the operation of the aircraft in a range of respects including a failure by the crew to obtain adequate weather information for the intended destination prior to and during the flight.
TBM8, Birmingham UK, 2011 On 12 January 2011, a privately operated Socata TBM850 light aircraft on a flight from Antwerp to Birmingham lost radio contact with ATC whilst in IMC on a non precision approach to runway 15 prior to the issue of a landing clearance and prior to checking in on the ATC TWR frequency. It continued the approach to obtain the required visual reference before landing over the top of a DHC8-400 aircraft which had lined up ready for take off in accordance with ATC instructions. No damage or personal injury resulted from the close proximity.
TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 On 21 January 1999, a UK Royal Air Force Tornado GR1 and a private Cessna 152 collided in mid air, at low level in day VMC with the resultant loss of both aircraft and the death of all occupants.
UAV, Barcarès near Perpignan France, 2019 On 14 July 2019, after control of a DJI-Inspire 2 UA was lost, it descended into people on the ground under power causing multiple minor injuries. The Investigation found that “professional drone pilots” were operating the UA in gross breach of the approval obtained, had deleted all recorded controller evidence of the accident flight and that their account of the loss of control was not compatible with the evidence recovered from the UA. It also noted that the risk of injury to third parties was increased by the absence of protection around the propellers which was not a regulatory requirement.
UAV, Darling Harbour Sydney Australia, 2021 On 15 January 2021, the pilot of a DJI Inspire 2 UAV being operated on a contracted aerial work task under a conditional permit lost control of it and, after exiting the approved operating area, it collided with the window of a hotel guest room causing consequential minor injuries to the occupant. The Investigation found that the loss of control was attributable to “strong magnetic interference” almost immediately after takeoff which caused the compass to feed unreliable data to the Internal Management Unit which destabilised its accelerometer and led to the loss of directional control which resulted in the collision.
UAV, manoeuvring, north of Reims France, 2006 On 29 February 2016, control of a 50 kg, 3.8 metre wingspan UAV was lost during a flight test being conducted in a Temporary Segregated Area in northern Belgium. The UAV then climbed to 4,000 feet and took up a south south-westerly track across Belgium and into northern France where it crash-landed after the engine stopped. The Investigation found that control communications had been interrupted because of an incorrectly manufactured co-axial cable assembly and a separate autopilot software design flaw not previously identified. This then prevented the default recovery process from working. A loss of prescribed traffic separation was recorded.
UAV, manoeuvring, Poole Dorset UK, 2020 On 19 November 2020, the police operator of a DJI Matrice M210 UA lost control of it over Poole when it drifted beyond Visual Line Of Sight (VLOS) and communication ceased. It was subsequently damaged when colliding with a house in autoland mode. The Investigation found that a partial power failure had followed battery disconnection with its consequences not adequately communicated to the pilot. It faulted both the applicable UA User Manual content and the absence of sufficient UA status and detected wind information to the pilot. A failure to properly define VLOS was identified but not considered directly causal.
UAV, vicinity Goodwood West Sussex UK, 2019 On 4 July 2019, the operator of an Alauda Airspeeder UAV lost control of it and it climbed to 8000 feet into controlled airspace at a designated holding pattern for London Gatwick before falling at 5000 fpm and impacting the ground close to housing. The Investigation was unable to establish the cause of the loss of control but noted that the system to immediately terminate a flight in such circumstances had also failed, thereby compromising public safety. The approval for operation of the UAV was found to been poorly performed and lacking any assessment of the airworthiness of the UAS.
ULAC / A319 vicinity Southend UK, 2013 On 18 July 2013, an Airbus A319 level at 2000 feet QNH in Class G airspace and being radar vectored towards an ILS approach at Southend in day VMC had a sudden but brief base leg encounter with a paramotor which was not visible on radar and was seen too late for avoiding action to be practicable, before passing within an estimated 50 metres of the A319. The paramotor pilot could not subsequently be traced. The Investigation made a safety recommendation to the UK CAA to review the regulation and licensing of paramotor pilots.
Vehicle / B712, Perth Western Australia, 2014 On 26 July 2014, the crew of a Boeing 717 which had just touched down on the destination landing runway at Perth in normal day visibility as a heavy shower cleared the airport area after previously receiving and acknowledging a landing clearance saw the rear of a stationary vehicle on the runway centreline approximately 1180 metres from the landing threshold. An immediate go around was called and made and the aircraft cleared the vehicle by about 150 feet. The same experienced controller who had issued the landing clearance was found to have earlier given runway occupancy clearance to the vehicle.
Vehicle / B738, Brisbane Australia, 2006 On 21 April 2006, a Boeing 737-800 cleared to take off from Brisbane began to do so whilst a vehicle was crossing the same runway in accordance with an ATC clearance issued on a different frequency. The aircraft crew saw the vehicle as they accelerated but decided that it would be clear by the time they reached its position. The vehicle driver reported that he was still within the runway strip when the aircraft passed. Since the occurrence, the adoption at Brisbane of the ICAO recommended procedure of using one frequency for all runway occupancy is being “actively considered”.
Vehicle / B752, Dublin Ireland, 2009 On 29 May 2009, a Boeing 757-200 being operated by UK Airline Thomson Airways on a passenger charter flight from Sharm-el-Sheikh, Egypt to Dublin and having just landed on runway 10 at destination at night in poor visibility overtook a small ride-on grass mower moving along the right hand side of the runway in approximate line with the aircraft’s right hand wing tip. The driver of the mower was unaware of the arriving aircraft until he heard it on the runway behind him. Prior to the landing, ATC had been informed that all grass-cutting equipment previously working on and around the runway had cleared it.
Vehicle / B773, Singapore, 2013 On 3 October 2013, a vehicle entered an active runway without clearance after partial readback of a potentially confusing clearance was not challenged by the controller. A different controller then cleared a Boeing 777-300 to land without taking all available action to ensure that the runway was clear. The aircraft crew saw the vehicle near the edge of the runway after touchdown and manoeuvred their aircraft away from it, although the aircraft wing still passed over it. At the time of the incident, vehicles with clearance were permitted to cross red stop bars, a policy which has since been changed.
Vehicle / E190 / E121, Jersey Channel Islands, 2010 On 1 June 2010, an Airport RFFS bird scaring vehicle entered the active runway at Jersey in LVP without clearance and remained there for approximately three minutes until ATC became aware. The subsequent Investigation found that the incursion had fortuitously occurred just after an ERJ 190 had landed and had been terminated just as another aircraft had commenced a go around after failure to acquire the prescribed visual reference required to continue to a landing. The context for the failure of the vehicle driver to follow existing procedures was found to be their inadequacy and appropriate changes were implemented.
Vehicle / E190, Toronto Canada, 2013 On 11 March 2013, at night, a Sunwing Airlines' mechanic left their vehicle on the ramp with the engine running and in 'drive' and, unseen, it began moving towards the adjacent runway threshold, at which point ATC noticed a ground radar target and instructed an Air Canada Embraer 190 which was close to landing in accordance with a valid clearance to go around. The pilots did not hear these instructions and landed directly over the vehicle with approximately 35 feet clearance without seeing it.
Vehicle / PA31, Mackay SE Australia, 2008 On 29 June 2012, a Piper PA31 taking off from runway 05 on a passenger charter flight just missed hitting an inspection vehicle which had entered the take off runway from an intersecting one contrary to ATC clearance. The overflying aircraft was estimated to have cleared the vehicle by approximately 20 feet and the pilot was unaware it had entered the active runway. The driver had been taking a mobile telephone call at the time and attributed the incursion to distraction. The breached clearance had been given and correctly read back approximately two minutes prior to the conflict occurring.
Vehicle / PAY4, Perth Western Australia, 2012 Whilst a light aircraft was lined up for departure, a vehicle made an incorrect assumption about the nature of an ambiguously-phrased ATC TWR instruction and proceeded to enter the same runway. There was no actual risk of conflict since, although LVP were still in force after earlier fog, the TWR controller was able to see the vehicle incursion and therefore withhold the imminent take off clearance. The subsequent Investigation noted that it was imperative that clearance read backs about which there is doubt are not made speculatively in the expectation that they will elicit confirmation or correction.
Vehicle / UNKN, Singapore Changi, 2013 On 4 April 2013, during a brief daytime runway closure for inspection purposes, a vehicle entered the runway without ATC awareness and was still there when the runway was re-opened and the first landing clearance was issued. TWR control subsequently observed the vehicle on the runway visually but, when they were unable to make contact with it, instructed the aircraft on final approach to go around when it was just under 1nm from touchdown. It was discovered that the vehicle involved had been in broken contact with another nearby aerodrome because the wrong radio frequency had been selected.
Vehicles / B722, Hamilton ON Canada, 2013 On 19 March 2013 a Boeing 727 freighter was cleared to take off on a runway occupied by two snow clearance vehicles. The subsequent cancellation of the take off clearance was not received but a successful high speed rejected take off was accomplished on sight of the vehicles before their position was reached. The Investigation attributed the occurrence to the controller's failure to 'notice' the runway blocked indicator on his display and to his non-standard use of R/T communications. The late sighting of the vehicles by the aircraft crew was due to the elevated runway mid section.
Vehicles / B737, Toronto Canada, 2008 On 29 July 2008, a Boeing 737-700 taking off from Toronto in accordance with its TWR clearance was about a third of the way down the runway when three vehicles, which had previously been cleared to enter the same runway by a GND controller were seen. The aircraft became airborne approximately 760 metres from the vehicles.
WW24, vicinity John Wayne Airport Santa Ana CA USA, 1993 On 15 December 1993, the crew of an IAI Westwind on a domestic passenger charter flight failed to leave sufficient separation between their aircraft and the Boeing 757 ahead on finals in night VMC and lost control or their aircraft which crashed killing all occupants and destroying the aircraft in the impact and post-crash fire.
WW24, vicinity Norfolk Island South Pacific, 2009 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.