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)
A345, Melbourne Australia, 2009 On 20 March 2009 an Airbus A340-500, operated by Emirates, commenced a take-off roll for a normal reduced-thrust take-off on runway 16 at Melbourne Airport. The attempt to get the aircraft airborne resulted in a tail strike and an overrun because insufficient thrust had been set based upon an incorrect flight crew data entry.
A346, en route, eastern Indian Ocean, 2013 On 3 February 2013, an Airbus A340 crew in the cruise in equatorial latitudes at FL350 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL350 and reversion to Alternate Law. Excessive vibration on the left engine then began and a diversion was made. The engine remained in use and was subsequently found undamaged with the fault attributed to ice/water ingress due to seal failure.
A346, en-route, near Amsterdam Netherlands, 2005 On 8 February 2005 an Airbus A340-600 was 11 hours into its flight from Hong Kong to London Heathrow when the No 1 and No 4 engines ran down in quick succession. A fuel management problem rather than a fuel shortage was then diagnosed but a manual transfer was only partially successful and a diversion to Amsterdam was made on three engines. The Investigation found that the master Fuel Control and Monitoring Computer had failed, that timely warnings of automated fuel control system malfunctions were not provided and that alternate low fuel level warnings were inhibited by inappropriate system design.
A346, en-route, northern Turkey, 2019 On 21 August 2019, an Airbus A340-600 encountered sudden-onset moderate to severe clear air turbulence whilst in the cruise at FL 360 over northern Turkey which resulted in a serious passenger injury. The Investigation found that the flight was above and in the vicinity of convective clouds exhibiting considerable vertical development but noted that neither the en-route forecast nor current alerting had given any indication that significant turbulence was likely to be encountered. It was noted the operator s flight crew had not been permitted to upload weather data in flight but since this event, that restriction had been removed.
A346, London Heathrow UK, 2009 On 12 December 2009, an Airbus A340-600 being operated by Virgin Atlantic Airways on a scheduled passenger flight departing from London Heathrow in night VMC was slow to rotate and the aircraft settled at an initial climb speed below VLS - defined as the lowest selectable speed which provides an appropriate margin above the stall speed. This prompted the PF to reduce the aircraft pitch attitude in order to accelerate which resulted in a poor rate of climb of between 500 and 600 fpm. The flaps were retracted on schedule and the aircraft continued its climb. At no time was full takeoff thrust selected. Later in the climb, the crew looked again at the take off data calculation and realised that they had made the departure with insufficient thrust set and using Vr and V2 speeds which were too low for the actual aircraft weight. The flight to the planned destination was completed.
A346, Quito Ecuador, 2007 On 31 August 2007 an Airbus A340-600 made a hard landing with drift /side slip present after a making a circling approach in good visibility with a relatively high cloudbase and was disabled on the runway after sustaining significant damage to the landing gear. It was found that the visual circling segment had been flown too close to the runway and the subsequent final approach had been unstabilised with touchdown being made at an excessive rate of descent. The destination risk assessment carried out by the airline involved was found to inadequate as was pilot training for the approach flown.
A359, Barcelona Spain, 2020 On 24 October 2020, an Airbus A350-900 took off in daylight from runway 07R at Barcelona without a clearance to do so when an Airbus A320 was on approach to land on runway 02 which involves an approach path that crosses over runway 07R and lateral separation was reduced to 2.8nm. The Investigation attributed the inadvertent failure to await clearance to “some form of reduced alertness” on the part of the crew.
A359, vicinity Frankfurt Germany, 2020 On 1 January 2020, an Airbus A350-900 made an unstabilised night ILS approach to Frankfurt in good visual conditions, descending prematurely and coming within 668 feet of terrain when 6nm from the intended landing runway before climbing to position for another approach. A complete loss of situational awareness was attributed to a combination of waypoint input errors, inappropriate autoflight management and communication and cooperation deficiencies amongst the operating and augmenting flight crew on the flight deck who were all type-rated holders of Thai-issued ATPLs. Neither of the observing pilots detected anything abnormal with the way the approach was being flown.
A359, vicinity Paris Orly France, 2020 On 4 February 2020, an Airbus A350-900 initiated a go around from its destination approach at 1,400 feet aal following a predictive windshear alert unsupported by the prevailing environmental conditions but the First Officer mishandled it and the stop altitude was first exceeded and then flown though again in a descent before control as instructed was finally regained four minutes later. Conflict with another aircraft occurred during this period. The Investigation concluded the underlying cause of the upset was a lack of awareness of autopilot status by the First Officer followed by a significant delay before the Captain took over control.
A35K, London Heathrow UK, 2022 On 2 January 2022, an Airbus A350-1000 floated during the landing flare at London Heathrow and when a go-around was commenced, a tail strike accompanied main landing gear runway contact. A subsequent further approach during which the Captain took over as handling pilot was completed uneventfully. The Investigation attributed the tailstrike to a full pitch up input made simultaneously with the selection of maximum thrust when very close to the runway surface, noting that although the initial touchdown had been just beyond the touchdown zone, 2,760 metres of runway remained ahead when the go around decision was made.
A388, en-route Batam Island Indonesia, 2010 On 4 November 2010, a Qantas Airbus A380 climbing out of Singapore experienced a sudden and uncontained failure of one of its Rolls Royce Trent 900 engines which caused considerable collateral damage to the airframe and some of the aircraft systems. A PAN was declared and after appropriate crew responses including aircraft controllability checks, the aircraft returned to Singapore. The root cause of the failure was found to have been an undetected component manufacturing fault. The complex situation which resulted from the failure in flight was found to have exceeded the currently anticipated secondary damage from such an event.
A388, en-route, Bay of Bengal India, 2019 On 10 July 2019 an Airbus A380 in the cruise at night at FL 400 encountered unexpectedly severe turbulence approximately 13 hours into the 17 hour flight and 27 occupants were injured as a result, one seriously. The detailed Investigation concluded that the turbulence had occurred in clear air in the vicinity of a significant area of convective turbulence and a jet stream. A series of findings were related to both better detection of turbulence risks and ways to minimise injuries if unexpectedly encountered with particular reference to the aircraft type and operator but with wider relevance.
A388, en-route, north east of Singapore, 2011 On 31 January 2011, a Singapore Airlines Airbus A380-800 was in the cruise when there was sudden loud noise and signs of associated electrical smoke and potential burning in a toilet compartment with a corresponding ECAM smoke alert. After a fire extinguisher had been discharged into the apparent source, there were no further signs of fire or smoke. Subsequent investigation found signs of burning below the toilet floor and it was concluded that excessive current caused by a short circuit which had resulted from a degraded cable had been the likely cause, with over current protection limiting the damage caused by overheating.
A388, en-route, north northeast of Beira Mozambique, 2020 On 16 January 2020 an Airbus A380 in the cruise at FL 400 in an area of correctly forecast convective turbulence encountered severe turbulence not anticipated by the crew who had not put on the seatbelt signs or alerted the cabin crew in time for the cabin to be secured. An unsecured passenger was seriously injured and several other passengers and an unsecured member of cabin crew were lifted off their feet but managed to avoid injury. The Investigation concluded that the flight crew had not made full use of the capabilities of the available on board weather radar equipment.
A388, en-route, northern Afghanistan, 2014 On 5 January 2014, an Airbus A380-800 en route to Singapore at night made an emergency descent and diversion to Baku after a loss of cabin pressure without further event. The Investigation attributed the pressure loss to a fatigue crack in a door skin which was initiated due to a design issue with door Cover Plates, which had not been detected when the Cover Plate was replaced with an improved one eighteen months earlier. Safety Issues related to cabin crew use of emergency oxygen and diversions to aerodromes with a fire category less than that normally required were also identified.
A388, en-route, southeast of Mumbai India, 2014 On 18 October 2014, an Airbus A380 descending at night over north east India unexpectedly encountered what was subsequently concluded as likely to have been Clear Air Turbulence after diverting around convective weather. Although seat belt signs were already on, a flight deck instruction to cabin crew to be seated because of the onset of intermittent light to moderate turbulence was completed only seconds before the sudden occurrence of a short period of severe turbulence. Two unrestrained passengers and two of the cabin crew sustained serious injuries. There were other minor injuries and also some cabin trim impact damage.
A388, en-route, southwest Greenland, 2017 On 30 September 2017, an Airbus A380-800 en-route over Greenland suffered a sudden explosive uncontained failure of the number 4 engine shortly after thrust was increased to adjust the cruise level to FL 370. Following recovery of a crucial piece of ejected debris, the Investigation was able to determine that the failure was attributable to a specific type of fatigue failure within a titanium alloy used in the manufacture of the engine fan hub. This risk had not been identifiable during manufacture or in-service and had not been recognised by the engine manufacturer or during the engine certification process.
A388, en-route, Wyoming USA, 2020 On 2 February 2020, an Airbus A380 in the cruise at night at FL 330 encountered unforecast clear air turbulence with the seatbelt signs off and one unsecured passenger in a standard toilet compartment sustained a serious injury as a result. The Investigation noted that relevant airline policies and crew training had been in place but also observed a marked difference in the availability of handholds in toilet compartments provided for passengers with disabilities or other special needs and those in all other such compartments and made a corresponding safety recommendation to standardise and placard handhold provision in all toilet compartments.
A388, vicinity Moscow Domodedovo Russia, 2017 On 10 September 2017, an Airbus A380-800 cleared for an ILS approach at Moscow Domodedovo in visual daylight conditions descended below its cleared altitude and reached 395 feet agl whilst still 7nm from the landing runway threshold with a resultant EGPWS ‘PULL UP’ warning. Recovery was followed by an inadequately prepared second approach which was discontinued and then a third approach to a landing. The Investigation attributed the crew’s difficulties primarily to failure to follow various routine operating procedures relating to use of automation but noted that there had been scope for better presentation of some of these procedures.
A388/A320, vicinity Frankfurt Germany, 2011 On 13 December 2011, an Airbus 320 was allowed to depart from runway 25C at Frankfurt on a left turning SID just prior to the touchdown of an A380 on runway 25L. The A380 had then initiated a low go around which put it above, ahead of and parallel to the A320 with a closest proximity of 1nm / 200 ft, in breach of the applicable wake vortex separation minima of 7nm / 1000ft. The Investigation found that there had been no actual encounter with the A380 wake vortices but that systemic ATC operational risk management was inadequate.
AN26, Kassel Germany, 2007 On 4 October 2007, an Antonov An-26B cargo aircraft being operated for an unidentified Hungarian-registered carrier by a Ukrainian crew on an empty positioning flight from Stuttgart to Kassel overran the destination runway during a daylight landing in normal ground visibility. None of the six crew on board were injured. There was no damage to the aircraft but some damage to ground installations.
AN26, vicinity Birmingham UK, 2020 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.
AN26, vicinity Cox’s Bazar Bangladesh, 2016 On 29 March 2016, an Antonov AN-26B which had just taken off from Cox s Bazar reported failure of the left engine and requested an immediate return. After twice attempting to position for a landing, first in the reciprocal runway direction then in the takeoff direction with both attempts being discontinued, control was subsequently lost during further manoeuvring and the aircraft crashed. The Investigation found that the engine malfunction occurred before the aircraft became airborne so that the takeoff could have been rejected and also that loss of control was attributable to insufficient airspeed during a low height left turn.
AN72, Sao Tome, Sao Tome & Principe, 2017 On 29 July 2017, an Antonov AN-74 crew sighted several previously unseen large eagles rising from the long grass next to the runway as they accelerated for takeoff at Sao Tome and, concerned about the risk of ingestion, made a high speed rejected takeoff but were unable to stop on the runway and entered a deep ravine just beyond it which destroyed the aircraft. The Investigation found that the reject had been unnecessarily delayed until above V1, that the crew forgot to deploy the spoilers which would have significantly increased the stopping distance and that relevant crew training was inadequate.
AS32 / B734, Aberdeen UK, 2000 For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.
AS32, en-route, near Peterhead Scotland UK, 2009 On 1 April 2009, the flight crew of a Bond Helicopters Eurocopter AS332 L2 Super Puma en route from the Miller Offshore Platform to Aberdeen at an altitude of 2000 feet lost control of their helicopter when a sudden and catastrophic failure of the main rotor gearbox occurred and, within less than 20 seconds, the hub with the main rotor blades attached separated from the helicopter causing it to fall into the sea at a high vertical speed The impact destroyed the helicopter and all 16 occupants were killed. Seventeen Safety Recommendations were made as a result of the investigation.
AS32, en-route, North Sea Norway, 1998 On 20 October 1998, in the North Sea, an Eurocopter AS332L Super Puma operated by Norsk HeliKopter AS, experienced engine failure with autorotation and subsequent lost of height. The crew misidentified the malfunctioning engine and reduced the power of the remaining serviceable engine. However, the mistake was realised quickly enough for the crew to recover control of the helicopter.
AS32, en-route, North Sea UK, 2002 On 28th February 2002, an Aerospatiale AS332L Super Puma helicopter en route approximately 70 nm northeast of Scatsa, Shetland Islands was in the vicinity of a storm cell when a waterspout was observed about a mile abeam. Soon afterwards, violent pitch, roll and yaw with significant negative and positive g occurred. Recovery to normal flight was achieved after 15 seconds and after a control check, the flight was completed. After flight, all five tail rotor blades and tail pylon damage were discovered. It was established that this serious damage was the result of contact between the blades and the pylon.
AS3B, en-route, northern North Sea UK, 2008 On 22 February 2008, a Eurocopter AS332 L2 Super Puma flying from an offshore oil platform to Aberdeen was struck by lightning. There was no apparent consequence and so, although this event required a landing as soon as possible, the commander decided to continue the remaining 165nm to the planned destination which was achieved uneventfully. Main rotor blade damage including some beyond repairable limits was subsequently discovered. The Investigation noted evidence indicating that this helicopter type had a relatively high propensity to sustain lightning strikes but noted that, despite the risk of damage, there was currently no adverse safety trend.
AS3B, vicinity Den Helder Netherlands, 2006 On 21 November 2006, the crew of a Bristow Eurocopter AS332 L2 making an unscheduled passenger flight from an offshore platform to Den Helder in night VMC decided to ditch their aircraft after apparent malfunction of an engine and the flight controls were perceived as rendering it unable to safely complete the flight. All 17 occupants survived but the evacuation was disorganised and both oversight of the operation by and the actions of the crew were considered to have been inappropriate in various respects. Despite extensive investigation, no technical fault which would have rendered it unflyable could be confirmed.
AS3B, vicinity Sumburgh Airport Shetland Islands UK, 2013 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.
AS50 / PA32, en-route, Hudson River NJ USA, 2009 On August 8, 2009 a privately operated PA32 and a Eurocopter AS350BA helicopter being operated by Liberty Helicopters on a public transport sightseeing flight collided in VMC over the Hudson River near Hoboken, New Jersey whilst both operating under VFR. The three occupants of the PA32, which was en route from Wings Field PA to Ocean City NJ, and the six occupants of the helicopter, which had just left the West 30th Street Heliport, were killed and both aircraft received substantially damaged.
AS50, Dalamot Norway, 2011 On 4 July 2011, a Eurocopter AS 350 making a passenger charter flight to a mountain cabin in day VMC appeared to suddenly depart controlled flight whilst making a tight right turn during positioning to land at the destination landing site and impacted terrain soon afterwards. The helicopter was destroyed by the impact and ensuing fire and all five occupants were fatally injured. The subsequent investigation came to the conclusion that the apparently abrupt manoeuvring may have led to an encounter with servo transparency at a height from which the pilot was unable to recover before impact occurred.
AS50, manoeuvring, East River New York USA, 2018 On 11 March 2018, an Airbus AS350 engine failed during a commercial sightseeing flight and autorotation was initiated. The pilot then noticed that the floor-mounted fuel cut-off had been operated by part of the tether system of one of the five passengers but there was insufficient time to restore power. On water contact, the automatic floatation system operated asymmetrically and the helicopter submerged before the occupants could evacuate. Only the pilot was able to release his harness and escape because the unapproved adapted passenger harnesses had no quick release mechanism. The Investigation found systemic inadequacy of the operator s safety management system.
AS50, manoeuvring, Kauai Hawaii USA, 2019 On 26 December 2019, an Airbus Helicopters AS350 on a commercial sightseeing flight over the Hawaiian island of Kauai impacted terrain and was destroyed killing all seven occupants. The Investigation concluded that the experienced pilot had decided to continue the flight into unexpectedly encountered cloud contrary to Company Policy. Contributory factors were identified as the delayed implementation of a Hawaiian aviation weather camera programme, an absence of regulatory leadership in the development of a weather training program for Hawaiian air tour pilots and an overall lack of effective regulatory monitoring and oversight of Hawaiian air tour operators’ weather-related operating practices.
AS50, manoeuvring, southwest of Alta Norway, 2019 On 31 August 2019, all six occupants of an Airbus AS350 B3 being used for a sightseeing flight in northern Norway were killed after control was suddenly lost and the helicopter impacted the terrain below where the wreckage was immediately consumed by an intense fire. The Investigation found no airworthiness issues which could have led to the accident and concluded that the loss of control had probably been due to servo transparency, a known limitation of the helicopter type. However, it was concluded that it was the absence of a crash-resistant fuel system which had led to the fatalities.
AS55, vicinity Fairview Alberta Canada, 1999 On 28th April 1999, an AS-355 helicopter suffered an in-flight fire attributed to an electrical fault which had originated from a prior maintenance error undetected during incomplete pre-flight inspections. The aircraft carried out an immediate landing allowing evacuation before the aircraft was destroyed by an intense fire.
AS65, vicinity North Morecambe Platform Irish Sea UK, 2006 On 27 December 2006, an AS365 Dauphin 2, operated by CHC Scotia, crashed into the sea adjacent to a gas platform in Morecambe Bay, UK, at night, following loss of control.
AT43, Bergen Norway, 2005 On 31 January 2005, an ATR 42-300 being operated by Danish Air Transport on a scheduled passenger flight from Bergen to Florø in day VMC encountered pitch control difficulties during rotation and subsequent climb and after declaring an emergency made a successful return to land on the departure runway seven minutes later. None of the 25 occupants were injured and the only damage found was to the elevator and its leading edge fairings.
AT43, en-route, Folgefonna Norway, 2005 On 14 September 2005, an ATR 42-320 operated by Coast Air AS experienced a continuous build up of ice in the climb, despite the activation of de-icing systems aircraft entered an uncontrolled roll and lost 1500ft in altitude. The crew initiated recovery actions, the aircraft was stabilised, and the flight continued without further event.
AT43, Jersey Channel Islands, 2012 On 16 July 2012, the left main landing gear of a Blue Islands ATR 42-300 collapsed during landing at Jersey. The aircraft stopped quickly on the runway as the left wing and propeller made ground contact. Although the crew saw no imminent danger once the aircraft had stopped, the passengers thought otherwise and perceived the need for an emergency evacuation which the sole cabin crew facilitated. The Investigation found that the fatigue failure of a side brace had initiated the gear collapse and that the origin of this was a casting discontinuity in a billet of aluminium produced to specification.
AT43, Lubbock TX USA, 2009 On 27 January 2009, an ATR 42-300 being operated by Empire Airlines on a scheduled cargo flight from Fort Worth Alliance to Lubbock was making a night ILS approach in IMC to runway 17R at destination when it stalled and crashed short of the runway. The aircraft caught fire and was in any case effectively already destroyed by the impact. Both crew members were injured, one seriously.
AT43, Madang Papua New Guinea, 2013 On 19 October 2013, an ATR42 freighter departing Madang had to reject its takeoff when it was impossible to rotate and it ended up semi-submerged in a shallow creek beyond the airfield perimeter. The Investigation found that loading had been contrary to instructions and the aircraft had a centre of gravity outside the permitted range and was overweight. This was attributed to the aircraft operator s lack of adequate procedures for acceptance and loading of cargo. A lack of appreciation by all parties of the need to effectively mitigate runway overrun risk in the absence of a RESA was also highlighted.
AT43, vicinity Fond-du-Lac SK Canada, 2017 On 13 December 2017, control of an ATR 42-300 was lost just after it became airborne at night from Fond-du-Lac and it was destroyed by the subsequent terrain impact. Ten occupants sustained serious injuries from which one later died and all others sustained minor injuries. The Investigation found that the accident was primarily attributable to pre-takeoff ice contamination of the airframe with an inappropriate pilot response then preventing an achievable recovery. It was found that significant airframe ice accretion had gone undetected during an inadequate pre-flight inspection and that there was a more widespread failure to recognise airframe icing risk.
AT43, vicinity Geneva Switzerland, 2006 On 29 March 2006 at about 1 mile from touchdown when in VMC on a night approach to destination Geneva, an ATR 42-300 being operated by Farnair on a cargo flight experienced a sudden electrical fire in the flight deck and an emergency was declared to ATC. Despite this situation the aircraft was able to land normally and vacate the runway via an RET after which it was forced to stop.
AT43, vicinity Glasgow, UK 2012 On 22 February 2012, the crew of an ATR 42 making a radar-vectored ILS approach to runway 23 at Glasgow at night allowed the airspeed of the aircraft to reduce and a stall warning followed. Corrective action then led to an overspeed and further corrective action almost led to a second stall warning. The Investigation concluded that SOPs were not followed, monitoring was ineffective and crew cooperation during recovery was poor. It was considered that crew performance may have been affected by inadequate rest prior to a night flying duty period.
AT43, vicinity Oksibil Papua Indonesia, 2015 On 26 August 2015, contact was lost with an ATR 42-300 making a descent to Oksibil supposedly using detailed Company-provided visual approach guidance over mountainous terrain. Its burnt out wreckage was subsequently located 10 nm from the airport at 4,300 feet aal. The Investigation found that the prescribed guidance had not been followed and that the Captain had been in the habit of disabling the EGPWS to prelude nuisance activations. It was concluded that a number of safety issues identified collectively indicated that the organisational oversight of the aircraft operator by the regulator was ineffective.
AT43, vicinity Pristina Kosovo, 1999 On 12 November 1999, a French-registered ATR 42-300 being operated by Italian airline Si Fly on a passenger charter flight from Rome to Pristina was positioning for approach at destination in day IMC when it hit terrain and was destroyed, killing all 24 occupants. A post crash fire broke out near the fuel tanks after the impact.
AT43, vicinity Stansted UK, 2007 On 18 January 2007 an ATR 42-300 freighter developed a control difficulty just after a night take off from Stansted UK, which led the flight crew to declare an emergency and undertake an immediate return to land. The landing was uneventful but the approach flown was unstable, with EGPWS warnings, and the origin of the handling difficulty was considered to be, in part, due to inappropriate control inputs by one of the pilots.
AT43/A346, Zurich Switzerland, 2010 On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .
AT45 / B733, Munich Germany, 2004 During the hours of darkness at Munich on 3 May 2004, an ATR42-500 was given a conditional line up clearance for Runway 08R but contrary to this clearance then taxied onto that runway as a Boeing 737-300 was landing on it. The landing aircraft missed the right wingtip of the ATR-42, which continued taxing onto the runway as it approached, by a few metres .
AT45, en-route, north northwest of Tanegashima Japan, 2019 On 12 October 2019, an ATR 42-500 on which Captain upgrade line training was being conducted encountered mild clear air turbulence soon after descent began and despite setting flight idle power, a concurrent speed increase led to concern at a possible VMO exceedence. An abrupt and ultimately simultaneous manual increase in pitch attitude followed leading to serious injury to the unsecured cabin crew which rendered them unfit to work. The Investigation found that the upset - a change in pitch from -2.3° to +6.3°in one second - was almost entirely due to pitch input from both pilots rather than turbulence.
AT45, en-route, north of Aurillac France, 2018 On 25 March 2018, an ATR 42-500 main landing gear bay door weighing 15 kg detached shortly after a night descent had begun but this was unknown until the flight arrived at Aurillac. The Investigation found that the root cause of the detachment was a loose securing nut which had triggered a sequence of secondary failures within a single flight which culminated in the release of the door. It was concluded that the event highlighted specific and systemic weakness in relevant airworthiness documentation and practice in relation to the lost door and the use of fasteners on this aircraft type generally.
AT45, en-route, north of Islamabad Pakistan, 2016 On 7 December 2016, the crew of an ATR 42-500 lost control after airworthiness-related complications followed shutdown of the left engine whilst in the cruise and high speed terrain impact followed. The Investigation concluded that three pre-existing faults with the left engine and its propeller control mechanism had led to a loss of power which had necessitated its shutdown but that these faults had then caused much higher left side drag than would normally result from an engine shutdown and made it progressively more difficult to maintain control. Recovery from a first loss of control was followed by another without recovery.
AT45, vicinity Esbjerg Denmark, 2016 On 27 March 2016 an ATR 42-500 had just departed Esbjerg when the right engine flamed out. It was decided to complete the planned short flight to Billund but on the night IMC approach there, the remaining engine malfunctioned and lost power. The approach was completed and the aircraft evacuated after landing. The Investigation found the left engine failed due to fuel starvation resulting from a faulty fuel quantity indication probably present since recent heavy maintenance and that the right engine had emitted flames during multiple compressor stalls to which it was vulnerable due to in-service deterioration and hot section damage.
AT45, vicinity Prague Czech Republic, 2012 On 31 October 2012, the crew of an ATR42 on a handover airworthiness function flight out of Prague briefly lost control in a full stall with significant wing drop after continuing a prescribed Stall Protection System (SPS) test below the appropriate speed and then failing to follow the correct stall recovery procedure. Failure of the attempted SPS test was subsequently attributed to both AOA vanes having become contaminated with water during earlier aircraft repainting at a specialist contractor and consequently being constrained in a constant position whilst the SPS test was being conducted at well above the prevailing freezing level.
AT45, vicinity Sienajoki Finland, 2007 On 1 January 2007, the crew of a ATR 42-500 carried out successive night approaches into Seinajoki Finland including three with EGPWS warnings, one near stall, and one near loss of control, all attributed to poor flight crew performance including use of the wrong barometric sub scale setting.
AT72 / B732, vicinity Queenstown New Zealand, 1999 On 26 July 1999, an ATR 72-200 being operated by Mount Cook Airlines on a scheduled passenger flight from Christchurch to Queenstown entered the destination CTR without the required ATC clearance after earlier cancelling IFR and in marginal day VMC due to snow showers, separation was then lost against a Boeing 737-200 being operated IFR by Air New Zealand on a scheduled passenger flight from Auckland to Queenstown which was manoeuvring visually (circling) after making an offset VOR/DME approach in accordance with a valid ATC clearance.
AT72 / JS32, en-route, north east of Jonkoping Sweden, 2012 On 20 June 2012, an ATR72-200 level at FL140 and a climbing opposite direction Jetstream 32 received and correctly responded to co-ordinated TCAS RAs after ATC error. The controller had not noticed visual MTCD and STCA alerts and had attempted to continue active controlling after a TCAS RA declaration. The Investigation observed that the ineffectiveness of visual conflict alerts had previously featured in a similar event at the same ACC and that the ANSP had advised then that its addition was planned. TCAS RA response controller training was considered to be in need of improvement to make it more effective.
AT72, Cologne-Bonn Germany, 2020 On 27 April 2020, an ATR 72-200 freighter crew attempted a night takeoff in good visibility aligned with the edge of runway 06 and did not begin rejecting it until within 20 knots of the applicable V1 despite hearing persistent regular noises which they did not recognise as edge light impacts and so completed the rejection on the same alignment. The Investigation noted both pilots’ familiarity with the airport and their regular work together and attributed their error to their low attention level and a minor distraction during the turnround after backtracking.
AT72, Copenhagen Denmark, 2013 On 14 January 2013, selection of the power levers to ground idle after an ATR 72-200 touchdown at Copenhagen produced only one of the two expected low pitch indications. As the First Officer called 'one low pitch' in accordance with SOP, the Captain selected both engines into reverse. He was unable to prevent the resultant veer off the runway. After travelling approximately 350 metres on grass alongside the runway as groundspeed reduced, the runway was regained. A propeller control fault which would have prevented low pitch transition on the right engine was recorded but could not subsequently be replicated.
AT72, Dresden Germany, 2002 On 5 March 2002, an ATR72-202 departed from runway 22 at Dresden in good visibility at night aligned with the edge lights of the runway without the crew apparently being aware of their error. Damage to both the edge lights and the aircraft was subsequently discovered. The Investigation attributed the error to the crew, concluding that a contributing factor had been that the correctly promulgated and lit runway width represented a reduction from a previously greater width with the surface now outside the runway being of a similar appearance to the actual runway surface.
AT72, en-route, Mediterranean Sea near Palermo Italy, 2005 On 6 August 2005, a Tuninter ATR 72-210 was ditched near Palermo after fuel was unexpectedly exhausted en route. The aircraft broke into three sections on impact and 16 of the 39 occupants died. The Investigation found that insufficient fuel had been loaded prior to flight because the flight crew relied exclusively upon the fuel quantity gauges which had been fitted incorrectly by maintenance personnel. It was also found that the pilots had not fully followed appropriate procedures after the engine run down and that if they had, it was at least possible that a ditching could have been avoided.
AT72, en-route, southern Scotland UK, 2011 On 15 March 2011, an ATR 72-200 on a non revenue positioning flight from Edinburgh to Paris CDG in night VMC with just the two pilots on board began to experience roll and directional control difficulties as the aircraft accelerated upon reaching the planned cruise altitude of FL230. A PAN call was made to ATC and a return to Edinburgh was made with successful containment of the malfunctioning flying controls.
AT72, Helsinki Finland, 2012 On 19 August 2012, the crew of a Flybe Finland ATR 72-200 approaching Helsinki failed to respond appropriately to a fault which limited rudder travel and were then unable to maintain directional control after touchdown with a veer off the runway then following. It was concluded that as well as prioritising a continued approach over properly dealing with the annunciated caution, crew technical knowledge in respect of the fault encountered had been poor and related training inadequate. Deficiencies found in relevant aircraft manufacturer operating documentation were considered to have been a significant factor and Safety Recommendations were made accordingly.
AT72, Karup Denmark, 2016 On 25 January 2016, an ATR 72-200 crew departing from and very familiar with Karup aligned their aircraft with the runway edge lights instead of the lit runway centreline and began take-off, only realising their error when they collided with part of the arrester wire installation at the side of the runway after which the take-off was rejected. The Investigation attributed the error primarily to the failure of the pilots to give sufficient priority to ensuring adequate positional awareness and given the familiarity of both pilots with the aerodrome noted that complacency had probably been a contributor factor.
AT72, Mumbai India, 2009 On 10 November 2010, a Kingfisher Airlines ATR 72-200 made an excessively steep and unstabilised tailwind approach in light rain to runway 27 at Mumbai in visual daylight conditions. After touching down late, the aircraft was steered off the side of the runway when it became obvious that an overrun would otherwise occur. The Investigation found that ATC had failed to advise of water patches on the runway and aquaplaning had occurred. It also found that without aquaplaning, the available distance from the actual touchdown point would have been sufficient to stop the aircraft in.
AT72, Shannon Ireland, 2011 On 17 July 2011, an Aer Arann ATR 72-200 made a bounced daylight landing at Shannon in gusty crosswind conditions aggravated by the known effects of a nearby large building. The nose landing gear struck the runway at 2.3g and collapsed with subsequent loss of directional control and departure from the runway. The aircraft was rendered a hull loss but there was no injury to the 25 occupants. The accident was attributed to an excessive approach speed and inadequate control of aircraft pitch during landing. Crew inexperience and incorrect power handling technique whilst landing were also found to have contributed.
AT72, Shannon Ireland, 2014 On 26 February 2014, an ATR 72-202 which had been substituted for the ATR42 which usually operated a series of night cargo flights was being marshalled out of its parking position with a new flight crew on board when the left wing was in collision with the structure of an adjacent hangar. The Investigation found that the aircraft type had not been changed on the applicable flight plan and ATC were consequently unaware that the aircraft had previously been parked in a position only approved for the use by the usual smaller aircraft type.
AT72, Trollhättan Sweden, 2018 On 9 October 2018, an ATR 72-200 left the runway during a night landing at Trollhättan before regaining it undamaged and taxiing in normally. The excursion was not reported or observed except by the flight crew. The subsequent discovery of tyre mark evidence led to an Investigation which concluded that the cause of the excursion had been failure of the left seat pilot to adequately deflect the ailerons into wind on routinely taking over control from the other pilot after landing because there was no steering tiller on the right. The non-reporting was considered indicative of the operator’s dysfunctional SMS.
AT72, vicinity Budapest Hungary, 2016 On 16 March 2016, an engine fire occurred to an ATR 72-200 departing Budapest and after declaring a MAYDAY, it was landed in the reciprocal direction on the departure runway without further event. The Investigation found that the failure had been initiated by the fatigue-induced failure of a single blade in the power turbine assembly but with insufficient evidence to ascribe a cause for this. A number of almost identical instances of engine failure initiated by failure of a single turbine blade were noted. Opportunities for both ATC procedures and flight crew response to mandatory emergency procedures were also identified.
AT72, vicinity Pakse Laos, 2013 On 16 October 2013, the crew of an ATR72-600 unintentionally flew their aircraft into the ground in IMC during a go around from an unsuccessful non precision approach at destination Pakse. The Investigation concluded that although the aircraft had followed the prescribed track, the crew had been confused by misleading FD indications resulting from their failure to reset the selected altitude to the prescribed stop altitude so that the decision altitude they had used for the approach remained as the selected altitude. Thereafter, erratic control of aircraft altitude had eventually resulted in controlled flight into terrain killing all on board.
AT72, vicinity Stockholm Bromma Sweden, 2010 On 21 August 2010 a Golden Air Flyg ATR 72 under ATC control in Class C airspace was vectored close to three parachutists who had been dropped from a helicopter as part of an air show because of confusion between the ATC unit with responsibility for the incident airspace and the adjacent unit to which that responsibility had been delegated because it was nearest to the air show site. Additional confusion was caused by poor R/T practice by both ATC units and by different portrayal of a holding pattern on charts held by ATC and he flight crew.
AT72, vicinity Tyumen Russian Federation, 2012 On 2 April 2012, the crew of an ATR72-200 which had just taken off from Tyumen lost control of their aircraft when it stalled after the flaps were retracted and did not recover before it crashed and caught fire killing or seriously injuring all occupants. The Investigation found that the Captain knew that frozen deposits had accumulated on the airframe but appeared to have been unaware of the danger of not having the airframe de-iced. It was also found that the crew had not recognised the stall when it occurred and had overpowered the stick pusher and pitched up.
AT72, Zurich Switzerland, 2014 On 4 December 2014, directional control of an ATR 72-200 was compromised shortly after touchdown at Zurich after slightly misaligned nose wheels caused both tyres to be forced off their wheels leaving the wheel rims in direct contact with the runway surface. The Investigation found that the cause of the misalignment was the incorrect installation of a component several months earlier and the subsequent failure to identify the error. Previous examples of the same error were found and a Safety Recommendation was made that action to make the component involved less vulnerable to incorrect installation should be taken.
AT73, en-route, Roselawn IN USA, 1994 On 31 October 1994, an ATR 72 exited controlled flight after a flap retraction when descending through 9000 feet was followed by autopilot disconnect and rapid and very large un-commanded roll inputs from which recovery, not within the scope of received crew training, was not achieved. The investigation found this roll upset had been due to a sudden and unexpected aileron hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-icing boots during earlier holding in icing conditions which had been - unknown to the crew - outside the icing certification envelope.
AT75 / B739, Medan Indonesia, 2017 On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.
AT75, en-route, near Almansa Spain, 2017 On 9 September 2017, an ATR 72-500 crew temporarily lost control of their aircraft when it stalled whilst climbing in forecast moderate icing conditions after violation of applicable guidance. Recovery was then delayed because the correct stall recovery procedure was not followed. A MAYDAY declaration due to a perception of continuing control problems was followed by a comprehensively unstabilised ILS approach to Madrid. The Investigation concluded that the stall and its sequel were attributable to deficient flight management and inappropriate use of automation. The operator involved was recommended to implement corrective actions to improve the competence of its crews.
AT75, en-route, north of Visby Sweden, 2014 On 30 November 2014, an ATR 72-500 suddenly experienced severe propeller vibrations whilst descending through approximately 7,000 feet with the power levers at flight idle. The vibrations subsided after the crew feathered the right engine propeller and then shut the right engine down. The flight was completed without further event. Severe damage to the right propeller mechanism was found with significant consequential damage to the engine. Several other similar events were found to have occurred to other ATR72 aircraft and, since the Investigation could not determine the cause, the EASA was recommended to impose temporary operating limitations pending OEM resolution.
AT75, Port Vila Vanuatu, 2018 On 28 July 2018, a right engine compressor stall on an ATR72-500 bound for Port Vila followed by smoke in the passenger cabin led to a MAYDAY declaration and shutdown of the malfunctioning engine. The subsequent single engine landing at destination ended in a veer-off and collision with two unoccupied parked aircraft. The Investigation noted the disorganised manner in which abnormal/emergency and normal checklists had been actioned and found that the Before Landing Checklist had not been run which resulted in the rudder limiter being left in high speed mode making single engine directional control on the ground effectively impossible.
AT75, Rome Fiumicino Italy, 2013 On 2 February 2013, an ATR 72-500 bounced repeatedly when making a night landing at Rome Fiumicino which, in the presence of dual control inputs causing a pitch disconnect, resulted in complete detachment of the landing gear and a veer off before stopping. The accident was attributed to uncharacteristic mishandling by the type experienced Captain in the presence of ineffective crew resource management because of an extremely steep authority gradient resulting from a very significant difference in flight time on the aircraft type (9607 hours / 14 hours). The Investigation attributed an unacceptable delay in the rescue services’ response to managerial incompetence.
AT75, vicinity Cork Ireland, 2014 On 2 January 2014, the crew of an ATR 72-212A lost forward visibility due to the accumulation of a thick layer of salt deposits on the windshield whilst the aircraft was being radar positioned to an approach at Cork on a track which took it close to and at times over the sea in the presence of strong onshore winds. The Investigation concluded that the prevailing strong winds over and near to the sea in relatively dry air with little visible moisture present had been conducive to high concentrations of salt particles at low levels.
AT75, vicinity Magong Taiwan, 2014 On 23 July 2014, a TransAsia Airways ATR 72-500 crashed into terrain shortly after commencing a go around from a VOR approach at its destination in day IMC in which the aircraft had been flown significantly below the MDA without visual reference. The aircraft was destroyed and48 of the 58 occupants were killed. The Investigation found that the accident was entirely attributable to the actions of the crew and that it had occurred in a context of a systemic absence of effective risk management at the Operator which had not been adequately addressed by the Safety Regulator.
AT75, vicinity Manchester UK, 2016 On 4 March 2016, the flight crew of an ATR72-500 decided to depart from Manchester without prior ground de/anti icing treatment judging it unnecessary despite the presence of frozen deposits on the airframe and from rotation onwards found that manual forward control column input beyond trim capability was necessary to maintain controlled flight. The aircraft was subsequently diverted. The Investigation found that the problem had been attributable to ice contamination on the upper surface of the horizontal tailplane. It was considered that the awareness of both pilots of the risk of airframe icing had been inadequate.
AT75, vicinity Nelson New Zealand, 2017 On 9 April 2017, an ATR 72-500 crew were unable to obtain a right main landing gear locked down indication during their approach to Nelson and diverted to Palmerston North where the gear did not collapse on landing. The Investigation found the indication had been consequent on failure of both right main gear locking springs due to corrosion and that existing preventative maintenance procedures would not have detected this. It was also noted that contrary to the applicable procedures, the crew had cycled the gear several times which might, but in the event did not, have had significant effects.
AT75, vicinity Yasouj Iran, 2018 On 18 February 2018, contact was lost with an ATR72-500 approaching Yasouj and two days later the wreckage of the aircraft was located in mountainous terrain with no sign of survivors. The flight recorders were eventually recovered and their data helped attribute the accident to descent below the designated minimum safe altitude followed by an encounter with severe mountain wave conditions which led to the crew losing control and a terrain impact which destroyed the aircraft and killed all its occupants. An apparently widespread failure to recognise the potential risk of severe mountain wave encounters was also found.
AT76, Canberra Australia, 2017 On 19 November 2017, an ATR 72-600 being operated by a flight crew who were simultaneously undertaking a routine Line Check during revenue flying made a hard landing at Canberra which caused significant damage to the aircraft. The Investigation noted that the low experience First Officer had mismanaged the final stages of the approach so that it was no longer stabilised and that although the opportunity was there, the Captain had failed to intervene promptly enough to prevent the resulting hard landing. The Check Captain had assessed the imminent landing as likely to be untidy rather than unsafe.
AT76, Canberra Australia, 2019 On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.
AT76, Dublin Ireland, 2015 On 23 July 2015, an ATR72-600 crew suspected their aircraft was unduly tail heavy in flight. After the flight they found that all passenger baggage had been loaded in the aft hold whereas the loadsheet indicated that it was all in the forward hold. The Investigation found that the person responsible for hold loading as specified had failed do so and that this failure had not been detected by the supervising Dispatcher who had certified the loadsheet presented to the aircraft Captain. Similar loading errors, albeit all corrected prior to flight, were found by the Operator to be not uncommon.
AT76, en route, west-southwest of Sydney Australia, 2014 On 20 February 2014, an ATR 72-600 crew mishandled their response to an intended airspeed adjustment whilst using VS mode during descent to Sydney and an upset involving opposite control inputs from the pilots caused an elevator disconnect. The senior cabin attendant sustained serious injury. After recovery of control, the flight was completed without further event. Post flight inspection did not discover damage to the aircraft which exceeded limit and ultimate loads on the stabilisers and the aircraft remained in service for a further five days until it was grounded for replacement of both horizontal and vertical stabilisers.
AT76, en-route, east of Cork Ireland, 2016 On 24 August 2016, an ATR 72-600 experienced a static inverter failure which resulted in smoke and fumes which were identifiably electrical. Oxygen masks were donned, a MAYDAY declared and after the appropriate procedures had been followed, the smoke / fumes ceased. The Investigation noted a long history of capacitor failures affecting this unit which continued to be addressed by successive non-mandatory upgrades including another after this event. However, it was also found that there was no guidance on the re-instatement of systems disabled during the initial response to such events, in particular the total loss of AC electrical power.
AT76, en-route, near Førde Airport Norway, 2016 On 14 November 2016, an ATR72-600 crew lost control at FL150 in severe icing conditions. Uncontrolled rolls and a 1,500 feet height loss followed during an apparent stall. After recovery, the Captain announced to the alarmed passengers that he had regained control and the flight was completed without further event. The Investigation found that the crew had been aware that they had encountered severe icing rather than the forecast moderate icing but had attempted to continue to climb which took the aircraft outside its performance limitations. The recovery from the stall was non-optimal and two key memory actions were overlooked.
AT76, Ende Indonesia, 2015 On 19 October 2015, an ATR 72-600 crew mishandled a landing at Ende, Indonesia, and a minor runway excursion occurred and pitch control authority was split due to simultaneous contrary inputs by both pilots. A go around and diversion direct to the next scheduled stop at Komodo was made without further event. The Investigation noted that the necessarily visual approach at Ende had been unstable with a nosewheel-first bounced touchdown followed by another bounced touchdown partially off-runway. The First Officer was found to have provided unannounced assistance to the Captain when a high rate of descent developed just prior to the flare.
AT76, Fez Morocco, 2018 On 6 July 2018, an ATR 72-600 followed an unstable approach at Fez with a multiple-bounce landing including a tail strike which caused rear fuselage deformation. The aircraft then continued in operation and the damage was not discovered until first flight preparations the following day. The Investigation found that the Captain supervising a trainee First Officer as handling pilot failed to intervene appropriately during the approach and thereafter had failed to act responsibly. The context for poor performance was assessed as systemic weakness in both the way the ATR fleet was being run and in regulatory oversight of the Operator.
AT76, Lisbon Portugal, 2016 On 22 October 2016, an ATR 72-600 Captain failed to complete a normal night landing in relatively benign weather conditions and after the aircraft had floated beyond the touchdown zone, it bounced three times before finally settling on the runway in a substantially damaged condition. The Investigation noted that touchdown followed an unstabilised approach and that there had been little intervention by the First Officer. However, it tentatively attributed the Captain s poor performance to a combination of fatigue at the end of a repetitive six-sector day and failure of the operator to provide adequate bounced landing recognition and recovery training.
AT76, Semarang Indonesia, 2016 On 25 December 2016, a type-experienced ATR72-600 Captain bounced the aircraft twice nose gear first whilst attempting a night landing at Semarang and during a third bounce on the right main gear only, it collapsed. The aircraft drifted right and after two further bounces began to decelerate and came to a stop. The Investigation found that after a normally-flown approach, the aircraft had not been flared and effective recovery action had not followed the bounce. It was concluded that the Captain had been subject to a visual illusion which had distorted his perception of height above the runway.