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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Showing below 1385 results in range #801 to #900.

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B772, Cairo Egypt, 2011 On 29 July 2011 an oxygen-fed fire started in the flight deck of an Egypt Air Boeing 777-200 about to depart from Cairo with most passengers boarded. The fire rapidly took hold despite attempts at extinguishing it but all passengers were safely evacuated via the still-attached air bridge access to doors 1L and 2L. The flight deck and adjacent structure was severely damaged. The Investigation could not conclusively determine the cause of the fire but suspected that wiring damage attributable to inadequately secured cabling may have provided a source of ignition for an oxygen leak from the crew emergency supply

B772, Denver CO USA, 2001 On 5 September 2001, a British Airways Boeing 777-200 on the ground at Denver USA, was substantially damaged, and a refuelling operative killed, when a fire broke out following the failure of a refuelling coupling under pressure because of improper attachment.

B772, Dhaka Bangladesh, 2018 On 24 July 2018, a Boeing 777-200 making its second attempt to land at Dhaka in moderate to heavy rain partly left the runway during its landing roll and its right main landing gear sustained serious impact damage before the whole aircraft returned to the runway with its damaged gear assembly then causing runway damage. The Investigation attributed the excursion to the flight crew s inadequate coordination during manual handling of the aircraft and noted both the immediate further approach in unchanged weather conditions and the decision to continue to a landing despite poor visibility instead of going around again.

B772, en-route Bozeman MT USA, 2008 On 26 November 2008, a Boeing 777-200 powered by RR RB211 Trent 800 series engines and being operated by Delta AL on a scheduled passenger flight from Shanghai Pudong to Atlanta was in the cruise at FL390 in day VMC in the vicinity of Bozeman MT when there was an uncommanded thrust reduction or  rollback of the right engine.

B772, en-route, near Hrabove Eastern Ukraine, 2014 On 17 July 2014, ATC lost contact with a Malaysian Airlines Boeing 777-200 en route at FL330 and wreckage of the aircraft was subsequently found. An Investigation by the Dutch Transport Safety Board concluded that the aircraft had been brought down by an anti-aircraft missile fired from an area where an armed insurgency was in progress. It was also concluded that Ukraine already had sufficient reason to close the airspace involved as a precaution before the investigated event occurred and that none of the parties involved had recognised the risk posed to overflying civil aircraft by the armed conflict.

B772, en-route, near Mount Cameroon Cameroon, 2015 On 2 May 2015, a Boeing 777-200 deviating very significantly north of its normal route from Malabo to Douala at night because of convective weather had just turned towards Douala very close to 13,202 feet high Mount Cameroon whilst descending through 5000 feet, when an EGPWS TERRAIN AHEAD alert and ‘PULL UP’ warning prompted an 8,000 foot climb which passed within 2,100 feet of terrain when close to and still below the summit. The Investigation attributed the dangerous event primarily to a gross absence of the augmented crew’s situational awareness and the operator’s failure to risk-assess the route involved.

B772, en-route, north of Bahrain, 2017 On 27 September 2017, a Boeing 777-200LRF Captain left the flight deck to retrieve their crew meal about 40 minutes after departing Abu Dhabi but whilst doing so he collapsed unconscious in the galley and despite assistance subsequently died. A MAYDAY was declared and a diversion to Kuwait successfully completed by the remaining pilot. The Investigation determined that the cause of death was cardiopulmonary system collapse due to a stenosis in the coronary artery. It was noted that the Captain’s medical condition had been partially concealed from detection because of his unapproved use of potentially significant self-medication.

B772, en-route, northern Indian Ocean, 2014 On 16 April 2014, a pre-flight concern about whether a Boeing 777-200ER about to depart Singapore had been overfuelled was resolved by a manual check but an en-route fuel system alert led to close monitoring of the fuel system. When a divergent discrepancy between the two independent fuel remaining sources became apparent, an uneventful precautionary air turnback was made and overfuelling subsequently confirmed. The Investigation found that a system fault had caused overfuelling and that the manual check carried out to confirm the actual fuel load had failed to detect it because it had been not been performed correctly.

B772, en-route, Northern Kanto Japan, 2014 On 16 December 2014, a US-operated Boeing 777-200 encountered a significant period of severe clear air turbulence (CAT) which was unexpected by the flight crew when travelling eastbound over northern Japan at night between FL 270 and FL290. The decision to turn back to Tokyo to allow the nine seriously injured passengers and crew to be treated was made 90 minutes later. The Investigation concluded that the CAT encountered had been correctly forecasted but the Operator's dispatcher-based system for ensuring crew weather awareness was flawed in respect of international operations out of 'non hub' airports.

B772, en-route, Osaka Japan, 2017 On 23 September 2017, a large wing-to-body fairing panel confirmed to have dropped from a Boeing 777-200 passing over the centre of Osaka after takeoff off from Kansai hit and significantly damaged a moving vehicle. The Investigation found that the panel involved had a sufficient history of attachment bracket failures for Boeing to have developed an improved thicker bracket for new-build aircraft which had then been advised as available as a replacement for in-service 777-200 aircraft in a Service Letter which KLM had decided not to follow. Although some incorrect bracket attachment bolts were found, this was not considered contributory.

B772, en-route, southwest of Belfast UK, 2017 On 13 November 2017, fumes on a GE90-powered Boeing 777-200 sufficient to require flight crew oxygen mask use occurred as it descended towards London Heathrow. The flight was completed without further event. Subsequent engineering assessments twice led to release to service followed by recurrence and after the fourth such release, a left engine overheat was annunciated. After flight, a hole in the engine combustor case was found and the engine was removed for repair. The Investigation attributed the delayed identification of the causal fault to inappropriate guidance in the aircraft manufacturer s Fault Isolation Manual which was has since been amended.

B772, Las Vegas NV USA, 2015 On 8 September 2015, a catastrophic uncontained failure of a GE90-85B engine on a Boeing 777-200 taking off from Las Vegas was immediately followed by a rejected takeoff. A fuel-fed fire took hold and a successful emergency evacuation was completed. The Investigation traced the failure to a fatigue crack in the high pressure compressor well within the manufacturer s estimated crack initiation life and appropriate revisions to risk management have followed. The main operational risk concern of the Investigation was the absence of any procedural distinction in crew emergency responses for engine fires beginning in the air or on the ground.

B772, London Heathrow UK, 2007 On 26 February 2007, a Boeing 777-222 operated by United Airlines, after pushback from the stand at London Heathrow Airport, experienced internal failure of an electrical component which subsequently led to under-floor fire. The aircraft returned to a stand where was attended by the Airfield Fire Service and the passengers were evacuated.

B772, London Heathrow UK, 2008 On 17 January 2008, a British Airways Boeing 777 200ER crash-landed 330 metres short of the intended landing runway, 27L, at London Heathrow after a loss of engine thrust on short final. This un-commanded reduction of thrust was found to have been the result of ice causing a restriction in the fuel feed system. Prompt crew response minimized the extent of the inevitable undershoot so that it occurred within the airport perimeter.

B772, Manchester UK, 2005 On 1 March 2005, a Boeing 777-200 being operated by Pakistan International Airlines on a scheduled passenger flight from Lahore to Manchester experienced a landing gear fire during taxi in at destination after an apparently routine landing in normal day visibility. There were no flight deck indications of a significant fire but an emergency evacuation was recommended by attending Fire Crew and carried out. Thirty one of the 344 occupants sustained minor injuries during this evacuation and the rest were uninjured. Five firefighters also sustained minor injuries as they assisted passengers from the slides. Damage to the aircraft was minor.

B772, San Francisco CA USA, 2013 On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.

B772, Singapore, 2010 On 14 June 2010, a Boeing 777-200 being operated by British Airways on a scheduled passenger service from Singapore to London Heathrow with a relief crew present on the flight received indications of abnormal functioning of the right engine during a night take off in VMC. Subsequent and directly related developments en route, including greater than planned fuel consumption which put the intended destination out of reach, led to the declaration of a PAN to ATC and diversion to Amsterdam. Inspection after flight found that parts of the right engine were damaged or missing and the latter were matched to previously unidentified debris recovered from the runway at Singapore. None of the 214 occupants were injured.

B772, Singapore, 2013 On 19 December 2013, the left engine of a Boeing 777-200 taxiing onto its assigned parking gate after arrival at Singapore ingested an empty cargo container resulting in damage to the engine which was serious enough to require its subsequent removal and replacement. The Investigation found that the aircraft docking guidance system had been in use despite the presence of the ingested container and other obstructions within the clearly marked 'equipment restraint area' of the gate involved. The corresponding ground handling procedures were found to be deficient as were those for ensuring general ramp awareness of a 'live' gate.

B772, St Kitts West Indies, 2009 On 26 September 2009, the crew of a British Airways Boeing 777-200 unintentionally began and completed their take off in good daylight visibility from the wrong intermediate runway position with less than the required take off distance available. Due to the abnormally low weight of the aircraft compared to almost all other departures by this fleet, the aircraft nevertheless became airborne just before the end if the runway. The investigation attributed the error to a poorly marked taxiway and the failure of the crew to include the expected taxi routing in their pre flight briefing.

B772, Tokyo Narita Japan, 2008 On July 30 2008, a Boeing 777-200 being operated by Vietnam Airlines on a scheduled passenger flight landed at Narita in daylight and normal visibility and shortly afterwards experienced a right engine fire warning with the appropriate crew response following. Subsequently, after the aircraft had arrived at the parking stand and all passengers and crewmembers had left the aircraft, the right engine caught fire again and this fire was extinguished by the Airport RFFS who were already in attendance. There were no injuries and the aircraft sustained only minor damage.

B772, vicinity Denver USA, 2021 On 20 February 2021, a PW4077-powered Boeing 777-200 was climbing through 12,500 feet after takeoff from Denver when there was a sudden uncontained failure of the right engine. The associated fire did not fully extinguish in response to the prescribed non-normal procedure and on completion of a return to land, it was fully extinguished before the aircraft could be towed in for passenger disembarkation. The Investigation has already established that the failure originated in a single fan blade within which internal fatigue cracking had been initiated. All operators of 777s powered by PW4000 series engines have grounded their fleets indefinitely.

B773 / B738 / B738, Melbourne Australia, 2015 On 5 July 2015, as a Boeing 777-300ER was departing Melbourne, two Boeing 737-800s which were initially on short final for intersecting runways with their ground separation dependent on one receiving a LAHSO clearance, went around. When both approaching aircraft did so, there was a loss of safe terrain clearance, safe separation and wake vortex separation between the three aircraft. The Investigation attributed the event to the actions of an inadequately supervised trainee controller and inappropriate intervention by a supervisory controller. It also identified a systemic safety issue generated by permitting LAHSO at night and a further flaw affecting the risk of all LAHSO at Melbourne.

B773 / E190, Toronto Canada, 2020 On 7 March 2020, an Embraer ERJ190 was taking off at Toronto when it struck a bird and commenced and reported a high speed rejected takeoff. This call was not heard by ATC who then cleared a Boeing 777-300 to line up and takeoff on the same runway. As the 777 accelerated, its crew saw the ERJ190 ahead and also commenced a high speed rejected takeoff, successfully avoiding a collision. The Investigation found that the air/ground status of both aircraft was configured in accordance with current design standards in a way which prevented activation of the ground collision prevention system.

B773, Abu Dhabi UAE, 2016 On 27 September 2016, the left engine of a Boeing 777-300 failed on takeoff from Abu Dhabi after it ingested debris resulting from tread separation from one of the nose landing gear tyres and a successful overweight return to land then followed. The Investigation found that FOD damage rather than any fault with the manufacture or re-treading of the tyre had initiated tread separation and also noted the absence of any assessment of the risk of engine damage and failure from such debris ingestion which it was noted had the potential to have affected both engines rather than just one.

B773, Amsterdam Netherlands, 2017 On 21 April 2017, a Boeing 777-300 which had just departed Amsterdam was advised by ATC of a suspected tail strike and by cabin crew of a scraping noise during takeoff. Fuel dumping was followed by a return to land and evidence of a minor tail strike was identified. The Investigation found that the tail strike had resulted from a gross error in data input to the takeoff performance calculation which resulted in inadequate thrust, slow acceleration and rotation at a speed so low that had an engine malfunction occurred, safe continuation or rejection of takeoff would have been problematic.

B773, Auckland Airport New Zealand, 2007 On 22 March 2007, an Emirates Boeing 777-300ER, started its take-off on runway 05 Right at Auckland International Airport bound for Sydney. The pilots misunderstood that the runway length had been reduced during a period of runway works and started their take-off with less engine thrust and flap than were required. During the take-off they saw work vehicles in the distance on the runway and, realising something was amiss, immediately applied full engine thrust and got airborne within the available runway length and cleared the work vehicles by about 28 metres.

B773, Dhaka Bangladesh, 2016 On 7 June 2016, a GE90-115B engined Boeing 777-300 made a high speed rejected takeoff on 3200 metre-long runway 14 at Dhaka after right engine failure was annunciated at 149KCAS - just below V1. Neither crew nor ATC requested a runway inspection and 12 further aircraft movements occurred before it was closed for inspection and recovery of 14 kg of debris. The Investigation found that engine failure had followed Super Absorbent Polymer (SAP) contamination of some of the fuel nozzle valves which caused them to malfunction leading to Low Pressure Turbine (LPT) mechanical damage. The contaminant origin was not identified.

B773, Dubai UAE, 2016 On 3 August 2016 a Boeing 777-300 rejected a landing at Dubai from the runway following a late touchdown after floating in the flare. It then became airborne without either pilot noticing that the A/T had not responded to TO/GA switch selection and without thrust, control was soon lost and the aircraft hit the runway and slid to a stop. The Investigation found that the crew were unfamiliar with the initiation of a go around after touchdown and had failed to follow several required procedures which could have supported early recovery of control and completion of the intended go around.

B773, en route, northern Turkey, 2014 On 8 August 2014, the First Officer of a Boeing 777 in the cruise at night at FL340 inadvertently input a change of desired track into the MCP selected altitude window whilst acting as both PF and PM during controlled rest by the aircraft commander. The aircraft then descended for nearly 2 minutes without her awareness until ATC queried the descent and it was arrested at FL317.

B773, en-route, Bay of Bengal, 2011 On 18 October 2011, an Etihad Boeing 777-300 encountered severe turbulence westbound over the Bay of Bengal because of a late track deviation whilst the aircraft commander was briefly absent from the flight deck. Two occupants, one a member of the cabin crew and the other a passenger, sustained severe injuries and 12 other occupants sustained minor injuries. The subsequent Investigation noted that the severe weather encountered was evident well in advance and could have been avoided. The low level of experience in role and on aircraft type of the operating crew was noted.

B773, en-route, Bering Sea, 2013 On 2 July 2013, a Korean Air Lines Boeing 777-300 experienced an uncommanded in-flight shutdown of one of its GE90-115B engines while crossing the Bering Sea. The crew made an uneventful diversion to Anadyr Russia. The Korean Aviation and Railway Accident Investigation Board (ARAIB) delegated investigative duties of this event to the National Transportation Safety Board (NTSB) which identified the cause of the failure as a manufacturing process deficiency which could affect nearly 200 similar engines.

B773, en-route, east northeast of Anchorage AK USA, 2015 On 30 December 2015, a Boeing 777-300 making an eastbound Pacific crossing en-route to Toronto encountered forecast moderate to severe clear air turbulence associated with a jet stream over mountainous terrain. Some passengers remained unsecured and were injured, one seriously and the flight diverted to Calgary. The Investigation found that crew action had mitigated the injury risk but that more could have been achieved. It was also found that the pilots had not been in possession of all relevant information and that failure of part of the air conditioning system during the turbulence was due to an improperly installed clamp.

B773, en-route, near Kurihara Japan, 2018 On 24 June 2018, a Boeing 777-300 was briefly subjected to unexpected and severe Clear Air Turbulence (CAT) whilst level at FL300 which resulted in a serious injury to one of the cabin crew as they cleared up after in-flight service. The Investigation concluded that the turbulence had occurred because of the proximity of the aircraft to a strong jet stream and that the forecast available at pre-flight briefing had underestimated the strength of the associated vertical wind shear.

B773, en-route, north northwest of Adelaide Australia, 2017 On 14 October 2017, a Boeing 777-300ER en route to Sydney declared a MAYDAY and diverted to Adelaide after the annunciation of a lower deck hold fire warning and the concurrent detection of a burning smell in the flight deck. The remainder of the flight was completed without further event and after landing a precautionary rapid disembarkation was performed. The Investigation found that the fire risk had been removed by the prescribed crew response to the warning and that the burning which had occurred had been caused by chafing of a wiring loom misrouted at build.

B773, en-route, South China Sea Vietnam 2011 On 17 October 2011, a Singapore Airlines Boeing 777-300 in the cruise at night with a Training Captain in command made what turned out to be an insufficient deviation around a potential source of turbulence and, with the seat belt signs remaining off, a number of cabin crew and passenger injuries were sustained during sudden brief but severe turbulence encounter. The Operator subsequently introduced enhanced pilot training to support more effective weather avoidance and better use of the various types of weather radar fitted to aircraft in their 777 fleet.

B773, en-route, west of Haifa Israel, 2021 On 17 January 2021, a Boeing 777-300 which had just begun descent into Beirut encountered unexpected moderate to severe clear air turbulence which resulted in one major and several minor injuries to unsecured occupants including cabin crew. The Investigation found that the flight crew had acted in accordance with all applicable procedures on the basis of information available to them but noted that the operator’s flight watch system had failed to generate and communicate a message about a relevant SIGMET until after the severe turbulence episode due to a data processing issue not identified as representing an operational safety risk.

B773, Hong Kong China, 2017 On 28 April 2017, a Boeing 777-300 made a 3.2g manual landing at Hong Kong, which was not assessed as such by the crew and only discovered during routine flight data analysis, during a Final Line Check flight for a trainee Captain. The Investigation noted that the landing technique used was one of the reasons the Check was failed. The trainee had been an experienced 737 Captain with the operator who had returned from 777 type conversion training with another airline and was required to undertake line training to validate his command status in accordance with local requirements.

B773, Lagos Nigeria, 2010 On 11 Jan 2010, an Air France Boeing 777-300ER successfully rejected a night take off from Lagos from significantly above V1 when control column pressure at rotation was perceived as abnormal. The root and secondary causes of the incident were found to be the failure of the Captain to arm the A/T during flight deck preparation and his inappropriate response to this on the take off roll. It was considered that his performance may have being an indirect consequence of his decision to take a 40 minute period of in-seat rest during the 90 minute transit stop at Lagos.

B773, Lisbon Portugal, 2016 On 13 January 2016 ice was found on the upper and lower wing surfaces of a Boeing 777-300ER about to depart in the late morning from Lisbon in CAVOK conditions and 10°C. As Lisbon had no de-ice facilities, it was towed to a location where the sun would melt the ice more quickly but during poorly-planned manoeuvring, one of the wingtips was damaged by contact with an obstruction. The Investigation attributed the ice which led to the problematic re-positioning to the operator’s policy of tankering most of the return fuel on the overnight inbound flight where it had become cold-soaked.

B773, London Heathrow UK, 2016 On 30 August 2016, a Boeing 777-300 crew began takeoff from London Heathrow at an intersection one third of the way along the runway using the reduced thrust calculated for a full-length take off instead of the rated thrust calculated for the intersection takeoff. As a result, the aircraft was only just airborne as it crossed the airport boundary and an adjacent public road. The Investigation attributed the data input error to crew failure to respond appropriately on finding that they had provisionally computed performance data based on different assumptions and concluded that the relevant Operator procedures were insufficiently robust.

B773, Mauritius, 2018 On 16 September 2018, a Boeing 777-300 was beginning its takeoff from Mauritius when an inadvertently unsecured cabin service cart left its stowage in the forward galley area and travelled at increasing speed towards the rear of the cabin injuring several passengers before it stopped after meeting an empty seat towards the rear of the cabin. The Investigation noted that cabin crew late awareness of an abnormal aircraft configuration and its consequences had led to them generally prioritising service delivery over safety procedures prior to takeoff with this then leading to an overlooked safety task not being detected.

B773, Munich Germany, 2011 On 3 November 2011, a Boeing 777-300ER crew lost directional control of their aircraft soon after touchdown and after veering off one side of runway 08R, it then crossed to the other side of it before stopping. The Investigation found that during the final stages of an intended autoland in CAT 1 conditions, an ILS LLZ signal disturbance caused by a departing aircraft had led a flight path deviation just before touchdown and, after delaying a pre-briefed automatic go-around until this was inhibited by main gear runway contact, the crew failed to either set thrust manually or disconnect the autopilot.

B773, Paris CDG France, 2013 On 28 July 2013, with passengers still boarding an Air France Boeing 777-300, an abnormal 'burnt' smell was detected by the crew and then thin smoke appeared in the cabin. A MAYDAY was declared and the Captain made a PA telling the cabin crew to evacuate the passengers via the doors, only via the doors. The resulting evacuation process was confused but eventually completed. The Investigation attributed the confused evacuation to the way it had been ordered and established that a fault in the APU had caused the smoke and fumes which had the potential to be toxic.

B773, Singapore, 2016 On 27 June 2016, a Boeing 777-300ER powered by GE90-115B engines returned to Singapore when what was initially identified as a suspected right engine oil quantity indication problem evidenced other abnormal symptoms relating to the same engine. The engine caught fire on landing. The substantial fire was quickly contained and an emergency evacuation was not performed. The cause of the low oil quantity indication and the fire was a failure of the right engine Main Fuel Oil Heat Exchanger which had resulted in lubrication of the whole of the affected engine by a mix of jet fuel and oil.

B773, Tokyo Japan, 2016 On 27 May 2016, a Boeing 777-300 crew made a high speed rejected take off when departing from Tokyo after a number one engine failure warning was quickly followed by a fire warning for the same engine and ATC advice of fire visible. As the fire warning continued with the aircraft stopped, an emergency evacuation was ordered. The Investigation found that the engine failure and fire had occurred when the 1st stage disc of the High Pressure Turbine had suddenly failed as result of undetected fatigue cracking which had propagated from an undetected disc manufacturing fault.

B773, vicinity Houston TX USA, 2014 On 3 July 2014, a Boeing 777-300 departing Houston came within 200 feet vertically and 0.61nm laterally of another aircraft after climbing significantly above the Standard Instrument Departure Procedure (SID) stop altitude of 4,000 feet believing clearance was to FL310. The crew responded to ATC avoiding action to descend and then disregarded TCAS 'CLIMB' and subsequently LEVEL OFF RAs which followed. The Investigation found that an inadequate departure brief, inadequate monitoring by the augmented crew and poor communication with ATC had preceded the SID non-compliance and that the crew should have followed the TCAS RAs issued.

B773, vicinity Melbourne Australia, 2011 On 24 July 2011, a Thai Airways International Boeing 777-300 descended below the safe altitude on a night non-precision approach being flown at Melbourne and then failed to commence the go around instructed by ATC because of this until the instruction had been repeated. The Investigation concluded that the aircraft commander monitoring the automatic approach flown by the First Officer had probably experienced  automation surprise in respect of the effects of an unexpected FMS mode change and had thereafter failed to monitor the descent of the aircraft with a selected FMS mode which was not normally used for approach.

B773, vicinity Shanghai Pudong China, 2019 On 2 September 2019, a Boeing 777-300 failed to continue climbing following a night takeoff from Shanghai when the autopilot was quickly engaged. When it began to descend, inaction after several EGPWS DON’T SINK Alerts was followed by an EGPWS ‘PULL UP’ Warning. Recovery then followed but only after autopilot re-engagement led to another descent did the crew recognise that a single character FMS data input error was the cause. The Investigation was concerned that both pilots simultaneously lost situational awareness of the low aircraft altitude during the event and noted both procedural non-compliance and sub-optimal crew interaction.

B773, vicinity Toronto Canada, 2012 On 28 May 2012 a GE90-powered Air Canada Boeing 777-300ER experienced sudden failure of the right engine during the initial climb after take off. There were no indications of associated engine fire and the failed engine was secured, fuel jettisoned and a return to land made. The Investigation found that the failure was related to a known manufacturing defect which was being controlled by repetitive boroscope inspections, the most recent of which was suspected not to have identified deterioration in the affected part of the engine.

B77L, Copenhagen Denmark, 2011 On 17 April 2011, a Boeing 777F bounced three times during an attempted landing at Copenhagen during which the underside of the aircraft was damaged by two tailstrikes. The second occurred during over-rotation for a go around commenced after thrust reverser deployment, with 760 metres of the 3300 metre-long runway remaining. The Investigation observed that a go around initiated after thrust reverser deployment was contrary to an express prohibition in the aircraft type FCOM. It was noted that the aircraft commander was an instructor pilot and that both pilots had less than 200 hours experience on the aircraft type.

B77L, Paris CDG France, 2015 On 22 May 2015, a Boeing 777F augmented crew attempted a reduced thrust daylight takeoff from Paris CDG using a thrust setting based on a weight 100 tonnes below the actual weight after an undetected crew error. The tailstrike protection system prevented fuselage runway contact after rotation attempts but only after a call from an augmenting crew member was full thrust set with the aircraft becoming airborne near the runway end. The Investigation noted poor crew performance but concluded that operator management of the risk involved and the corresponding regulatory oversight had been inadequate in a number of ways.

B77W, en-route, northeast of Los Angeles USA, 2016 On 16 December 2016, a Boeing 777-300 which had just departed from runway 07R at Los Angeles was radar vectored in Class  B airspace at up to 1600 feet below the applicable minimum radar vectoring altitude. The Investigation found that the area controller s initial vectoring had been contrary to applicable procedures and their communication confusing and that they had failed to recover the situation before it became dangerous. As a result, as the crew were responding in night IMC to a resulting EGPWS  PULL UP Warning, the aircraft had passed within approximately 0.3 nm of obstructions at the same altitude.

B77W, London Heathrow UK, 2021 On 2 July 2021, during pre-departure loading of a Boeing 777-300 at Heathrow prior to passenger boarding with only the operating crew on board, a rear hold fire warning was annunciated and smoke and fumes subsequently entered the passenger cabin. The Investigation found that the source was a refrigerated container which had been subject to abnormal external impact prior to or during loading causing a short circuit in its battery pack. The refrigeration system involved was found by design to inhibit fire following a short circuit but it was noted that QRH response procedures did not apply to the circumstances.

B788, Boston MA USA, 2013 On 7 January 2013, a battery fire on a Japan Air Lines Boeing 787-8 began almost immediately after passengers and crew had left the aircraft after its arrival at Boston on a scheduled passenger flight from Tokyo Narita. The primary structure of the aircraft was undamaged. Investigation found that an internal short circuit within a cell of the APU lithium-ion battery had led to uncontained thermal runaway in the battery leading to the release of smoke and fire. The origin of the malfunction was attributed to system design deficiency and the failure of the type certification process to detect this.

B788, en-route Shikoku Island Japan, 2013 On 16 January 2013, a main battery failure alert message accompanied by a burning smell in the flight deck was annunciated as an ANA Boeing 787-8 climbed through FL320 on a domestic flight. A diversion was immediately initiated and an emergency declared. A landing at Takamatsu was made 20 minutes later and an emergency evacuation completed. The Investigation found that the battery had been destroyed when thermal runway followed a suspected internal short circuit in one of the battery cells and concluded that certification had underestimated the potential consequences of such a single cell failure.

B788, en-route, central Romania, 2017 On 10 March 2017, a Boeing 787-8 lost contact with ATC over central Romania whilst the Captain was taking his second in-seat controlled rest and flight continued through Romanian and then, in daylight and without clearance, into Hungarian airspace. After well over an hour out of contact, military fighter interception prompted the re-establishment of normal communication. It was found that whilst the Captain was asleep, both speakers had been off and the First Officer had not been wearing her headset although she claimed that normal ATC communications had occurred whilst admitting that they had not been written down as required.

B788, en-route, Chengde China, 2019 On 15 August 2019, a Boeing 787 descending towards destination Beijing received ATC approval for convective weather avoidance but this was then modified with both a new track requirement and a request to descend which diminished its effectiveness. A very brief encounter with violent turbulence followed but as the seat belt signs had not been proactively switched on, the cabin was not secured and two passengers sustained serious injuries and two cabin crew sustained minor injuries. The Investigation noted that weather deviation requests could usefully be accompanied by an indication of how long they were required for.

B788, en-route, near Huesca northeast Spain, 2019 On 3 November 2019, a Boeing 787-8 descending towards Barcelona experienced an unanticipated airspeed increase and the unduly abrupt manual pitch response which resulted in a large and rapid oscillation in vertical acceleration during an otherwise smooth descent resulted in two serious injuries, one to a passenger and the other to one of the cabin crew. It appeared that the cause of the airspeed increase was an unexplained vertical mode reversion from VNAV SPD to VNAV PTH about 20 seconds prior to the upset caused by the response to it. 

B788, en-route, north of Darwin NT Australia, 2015 On 21 December 2015, a Boeing 787-8 at FL400 in the vicinity of convective weather conducive to ice crystal icing penetrated an area which included maximum intensity weather radar returns. A very short period of erratic airspeed indications followed and the FCS reverted to Secondary Mode requiring manual flying. Since this Mode remained 'latched' and could therefore only be reset on the ground, it was decided that an en route diversion was appropriate and this was accomplished without further event. Boeing subsequently modified the FCS software to reduce the chances of reversion to Secondary Mode in short-duration unreliable airspeed events.

B788, en-route, Northwest Pacific Ocean, 2019 On 1 June 2019, a Boeing 787-8 lost all cabin air conditioning after both packs failed less than an hour from its destination, Narita. When the Cabin Altitude reached 10,000 feet, the descent already commenced was completed as an emergency descent and the flight thereafter was without further event. The Investigation found that although an amended non normal procedure restricting pack resets to a maximum altitude of 35000 feet had been issued almost two months earlier, it was still “under review” at the operator which has since amended their procedures for assessing manufacturer communications which have operational safety implications.

B788, en-route, southwest of Kansai Japan, 2019 On 29 March 2019, both engines of a Boeing 787-8 on descent to Kansai malfunctioned in quick succession causing auto ignition to be triggered by sub-idle engine rpm but thereafter, sufficient thrust was available to safely complete the flight just under half an hour after the dual malfunction. The Investigation found that the cause of these malfunctions had been contamination of the fuel system with abnormally large concentrations of residue which could be reliably traced to a routinely applied biocide and which had solidified and intermittently impeded the transfer of fuel from the tanks to the engines.

B788, London Heathrow UK, 2013 On 12 July 2013 an unoccupied and unpowered Boeing 787-8, remotely parked at London Heathrow after an arrival earlier the same day caught fire. An investigation found that the source of the fire was an uncontained thermal runaway in the lithium-metal battery within an Emergency Locator Transmitter (ELT). Fifteen Safety Recommendations, all but one to the FAA, were made as a result of the Investigation.

B788, vicinity Amritsar India, 2018 On 19 April 2018, a Boeing 787-8 suddenly encountered a short period of severe turbulence as it climbed from FL160 towards clearance limit FL 190 during a weather avoidance manoeuvre which had taken it close to the Amritsar overhead and resulted in a level bust of 600 feet, passenger injuries and minor damage to cabin fittings. The Investigation found that the flight had departed during a period of adverse convective weather after the crew had failed to download a pre flight met briefing or obtain and review available weather updates.

B789 / A388, Singapore, 2017 On 30 March 2017, a Boeing 787 taxiing for departure at night at Singapore was involved in a minor collision with a stationary Airbus A380 which had just been pushed back from its gate and was also due to depart. The Investigation found that the conflict occurred because of poor GND controlling by a supervised trainee and had occurred because the 787 crew had exercised insufficient prudence when faced with a potential conflict with the A380. Safety Recommendations made were predominantly related to ATC procedures where it was considered that there was room for improvement in risk management.

B789 / B744, Amsterdam Netherlands, 2019 On 13 February 2019, a Boeing 787 departing Amsterdam was given a non-standard long pushback by ATC in order to facilitate the use of its stand by an incoming flight and when a Boeing 747 was subsequently given a normal pushback by a single tug driver working alone who was unaware of the abnormal position of the 787 and could not see it before or during his pushback, a collision followed. The Investigation concluded that the relevant airport safety management systems were systemically deficient and noted that this had only been partially rectified in the three years since the accident.

B789 / B773, Delhi India, 2017 On 7 October 2017, an arriving Boeing 787-9 and a departing Boeing 777-300 lost separation during intended use of runway 29 at Delhi when the 787-9 commenced a go around from overhead the runway because the departing 777-300 was still on the runway and came within 0.2 nm laterally and 200 feet vertically after ATC had failed to ensure that separation appropriate to mixed mode use was applied using speed control. The conflict was attributed to failure of the TWR controller to adhere to prevailing standard operating procedures.

B789 / C172, en-route, northwest of Madrid Spain, 2017 On 8 August 2017, a Boeing 787-9 climbing through FL109 after departing Madrid received and promptly followed a TCAS RA  DESCEND against crossing traffic at FL110 and this action quickly resolved the conflict. The Investigation found that both aircraft involved were following their IFR clearances and attributed the conflict to the controller involved who forgot to resolve a previously-identified potential conflict whilst resolving another potential conflict elsewhere in the sector. It was also found that the corresponding STCA activation had not been noticed and in any event had occurred too late to be of use.

B789, en-route, eastern Belgium, 2017 On 29 April 2017, a Boeing 787-9 which had just reached cruise altitude after despatch with only one main ECS available began to lose cabin pressure. A precautionary descent and PAN was upgraded to a rapid descent and MAYDAY as cabin altitude rose above 10,000 feet. The Investigation found that aircraft release to service had not been preceded by a thorough enough validation of the likely reliability of the remaining ECS system. The inaudibility of the automated announcement accompanying the cabin oxygen mask drop and ongoing issues with the quality of CVR readout from 787 crash-protected recorders was also highlighted.

B789, en-route, west of Swansea UK, 2020 On 1 October 2020, a Boeing 787-9 was approaching the top of descent when the cabin crew discovered a mobile phone crushed in a flat bed seat which had just been changed to the seated position for landing. A fire which had started was extinguished and the Captain declared a ‘PAN’ to ensure the fire service attended the arrival. The Investigation noted that there are currently no seat design requirements to prevent electronic devices from becoming trapped in seats and that it is proving challenging to find a workable solution. A Safety Recommendation to improve seat design regulations was made.

B789, London Gatwick UK, 2018 On 28 March 2018, a Boeing 787-9 crew inadvertently commenced takeoff from the displaced threshold of the departure runway at Gatwick instead of the full length which was required for the rated thrust used. The Investigation found that the runway involved was a secondary one which the crew were unfamiliar with and to which access was gained by continuing along a taxiway which followed its extended centreline. It was noted that at least four other similar incidents had occurred during the previous six months and that various risk reduction actions had since been taken by the airport operator / ANSP.

B789, London Heathrow UK, 2020 On 9 February 2020, the tail strike prevention system on a Boeing 787-9 was annunciated during takeoff from London Heathrow in gusting crosswind conditions. Permission to hold at 6000 feet to conduct the response procedure was given and since this procedure did not permit pressurisation, an overweight return to land followed. The Investigation found that although the tail strike protection system had returned the pitch rate to the correct one after an exceedence just before commencing rotation, lateral control inputs then resulted in a decrease in lift resulting in the tail contact angle being reached whilst still on the runway.

B789, Melbourne Australia, 2021 On 22 September 2021, a Boeing 787-9 was found on arrival at its destination, Los Angeles, to have completed the 14½ hour flight from Melbourne with all four fan cowl static ports taped over. The crew had not observed any adverse consequence. The Investigation attributed the oversight to inadequate pre-flight maintenance and operational procedures and found that failure to identify the taping had resulted in the aircraft departing with reduced redundancy to the engine electronic control systems of both engines.

B789, Oslo Norway, 2018 On 18 December 2018, a Boeing 787-9 was instructed to taxi to a specified remote de-icing platform for de-icing prior to takeoff from Oslo. The aircraft collided with a lighting mast on the de-icing platform causing significant damage to both aircraft and mast. The Investigation found that in the absence of any published information about restricted aircraft use of particular de-icing platforms and any markings, lights, signage or other technical barriers to indicate to the crew that they had been assigned an incorrect platform, they had visually assessed the clearance as adequate. Relevant Safety Recommendations were made.

B789, Tel Aviv Israel, 2018 On 29 March 2018, an augmented Boeing 787-9 crew completed an uneventful takeoff from Tel Aviv on a type conversion line check flight for one of the First Officers in the crew. After getting airborne, the crew found that all performance calculations including that for takeoff had been made on the basis of a Zero Fuel Weight which was 40 tonnes below the actual figure of 169 tonnes. The Investigation found that it was highly probable that automatic reduction in commanded pitch-up when rotation was attempted at too low a speed had prevented an accident during or soon after liftoff.

B78X, vicinity Abu Dhabi UAE, 2020 On 6 June 2020, a Boeing 787-10 on approach at Abu Dhabi began a low go around from an RNAV(RNP) approach when it became obvious to the crew that the aircraft was far lower than it should have been but were unaware why this occurred until an ATC query led them to recognise that the wrong QNH had been set with recognition of the excessively low altitude delayed by haze limiting the PAPI range. The Investigation found that advice of MSAW activations which would have enabled the flight crew to recognise their error were not advised to them.

BA11, en-route, Didcot Oxfordshire UK, 1990 On 10 June 1990, a BAC 1-11 operated by British Airways, during climb, experienced sudden explosive depressurisation which resulted in loss of the left hand windscreen. The commander was sucked in the windscreen aperture and was successfully secured by the cabin crew, while the first officer executed a safe landing.

BCS3, Porto Portugal, 2018 On 15 July 2018, an Airbus 220-300 crew were slow to recognise that the maximum de-rate thrust required for their takeoff from Porto had not been reached but after increasing it were able to get safely airborne prior to the end of the runway. The Investigation found that applicable SOPs had not been followed and that the function of both the spoiler and autothrottle systems was inadequately documented and understood and in the case of the former an arguably flawed design had been certified. Five similar events had been recorded by the aircraft operator involved in less than six months.

BE20, Nadi Fiji, 2010 On 25 April 2010, a Beech King Air touched down at Nadi with its landing gear in the transit position after flying a night approach during which a significant electrical system failure had occurred. The landing gear retracted and the aircraft left the runway to the side and came to a stop resting on its fuselage. The Investigation attributed the electrical failure, which directly affected the landing gear operating system and required two diodes to have both failed was likely to have meant that one would have failed on an earlier occasion with no apparent consequence.

BE20, vicinity Gallatin Field MT USA, 2007 On February 6, 2007, a Beech 200 King Air, being operated by Metro Aviation on an EMS positioning flight from Great Falls MT to Gallatin Field MT, collided at night in VMC with mountainous terrain approximately 13 nm north-northwest of the intended destination shortly after advising that the airport was in sight and requesting and obtaining permission for a visual approach.

BE20, vicinity Gillam Canada, 2019 On 24 April 2019, the engine of a Beech B200 en-route from Winnipeg to Churchill at FL 250 failed due to fuel exhaustion and the crew realised that they had forgotten to refuel before departure. An emergency was declared and a diversion to the nearest available airport was commenced but the right engine later failed for the same reason leaving them with no option but to land on a frozen lake surface. The Investigation concluded that confusion as to relative responsibility between the trainee Captain and the supervising pilot-in-command were central to the failure to refuel prior to departure as intended.

BE20, vicinity Glasgow UK, 2012 On 15 September 2012, the crew of a Beech Super King Air on a medevac flight making an ILS approach to runway 23 at Glasgow became temporarily distracted by the consequences of a mis-selection made in an unfamiliar variant of their aircraft type and a rapid descent of more than 1000 feet below the 3500 feet cleared altitude towards terrain in IMC at night followed. An EGPWS  PULL UP Warning and ATC MSAW activation resulted before the aircraft was recovered back to 3500 feet and the remainder of the flight was uneventful.

BE20, vicinity North Caicos British West Indies, 2007 On 6 February 2007, a Beech King Air 200 on a scheduled passenger flight crashed into water soon after making a dark night VMC take off and initial climb from North Caicos. The Investigation noted that the regulatory requirement for a crew of two pilots had been ignored and that the pilot had probably consumed alcohol within the permitted limits prior to the take off. It was concluded that he had probably lost spatial awareness and been in the process of attempting recovery to the originally intended flight path when impact occurred.

BE20, vicinity Stapleford UK, 2015 On 3 October 2015, the pilot of a Beech Super King Air on a business flight lost control in IMC shortly after take-off and the aircraft subsequently impacted terrain at high speed. The Investigation concluded on the balance of probabilities that pilot medical incapacitation was likely to have occurred. It was noted that the aircraft had not been fitted with TAWS nor was it required to be but it was found that alerting from such a system would have increased the chances of the only passenger, another professional pilot, successfully taking over and three corresponding Safety Recommendations were made.

BE20/SF34, vicinity Stornoway UK, 2011 On 31 December 2011 a USAF C12 Beech King Air descended 700 feet below the cleared outbound altitude on a procedural non precision approach to Stornoway in uncontrolled airspace in IMC and also failed to fly the procedure correctly. As a result it came into conflict with a Saab 340 inbound on the same procedure. The Investigation found that the C12 crew had interpreted the QNH given by ATC as 990 hPa as 29.90 inches, the subscale setting units used in the USA. The Saab 340 pilot saw the opposite direction traffic on TCAS and descended early to increase separation.

BE9L, Zurich Switzerland, 2007 On 27 September 2007, a Beech 90 King Air being operated single pilot by a small UK air taxi operator on a day cargo flight from Southend UK to Zurich left the runway after unintentionally touching down at destination without the landing gear extended following an approach in day VMC. The pilot, the only occupant, was uninjured but the aircraft was declared a hull loss because of substantial damage.

BN2A, vicinity Bonaire Netherlands Antilles, 2009 On 22 October 2009, a BN2 Islander suspected to have been overloaded experienced an engine failure shortly after departure from Curaçao. Rather than return, the Pilot chose to continue the flight to the intended destination but had to carry out a ditching when it proved impossible to maintain height. All passengers survived but the Pilot died. The cause of the engine failure could not be established but the Investigation found a context for the accident which had constituted systemic failure by the Operator to deliver operational safety which had been ignored by an inadequate regulatory oversight regime.

BN2P / B763, vicinity Kagoshima Japan, 2015 On 10 October 2015, a Britten-Norman BN2 instructed to join final behind a Boeing 767 instead joined in front of it which obliged the 767 crew to make a go around. The Investigation was unable to establish why the BN2 pilot failed to follow their conditional clearance but noted that the 'follow' clearance given onto final approach had not been accompanied by a sequence number, and when giving the aircraft type to be followed so that its sighting could be reported, the controller had not challenged the incomplete readback or repeated the aircraft type when subsequently issuing the clearance.

BN2P, Antigua East Caribbean Sea, 2012 On 7 October 2012, a Britten-Norman BN2 Islander pilot lost control of their aircraft shortly after take off from Antigua when the right engine stopped due to the presence of water in the corresponding fuel tank. The Investigation found that heavy rain whilst the aircraft had been parked prior to flight had resulted in water entering the tank because of anomalies in the fuel tank filler neck and cap. The reason why the pilot had been unable to keep control of the aircraft was not explained but evidence of his performance under training and test suggested weakness in aircraft control.

BN2P, Montserrat (British Overseas Territory), 2011 On 22 May 2011 a Britten-Norman BN2A Islander being operated by Bermudian domiciled carrier Montserrat AW on a scheduled passenger flight from Antigua to Montserrat was considered at risk of an overrun after visual positioning to a day landing on runway 28 at destination in normal ground visibility. The pilot intentionally steered the aircraft off one side of the runway to decrease the degree of potential hazard and the aircraft came to a stop beside the runway and 46 metres from its end without injuries to any of the 8 occupants or damage to the aircraft.

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C130 / C27J, manoeuvring, near Mackall AAF NC USA, 2014 On 1 December 2014, a night mid-air collision occurred in uncontrolled airspace between a Lockheed C130H Hercules and an Alenia C27J Spartan conducting VFR training flights and on almost reciprocal tracks at the same indicated altitude after neither crew had detected the proximity risk. Substantial damage was caused but both aircraft were successfully recovered and there were no injuries. The Investigation attributed the collision to a lack of visual scan by both crews, over reliance on TCAS and complacency despite the inherent risk associated with night, low-level, VFR operations using the Night Vision Goggles worn by both crews.

C172, McKinney TX USA, 2003 On 8 July 2003, a Cessna 172S on an instructional flight hit a vulture which caused significant structural damage to the left wing. During the attempted forced landing which followed, control of the aircraft was lost and the aircraft crashed into terrain near McKinney TX USA.

C172, Toronto Canada, 2003 On 9th October 2003, a Cessna 172, suffered loss of power and made a forced landing after experiencing Carburettor Icing, over Toronto, Canada

C177, vicinity Calling Lake Alberta Canada, 2000 On 30th May 2000, a Cessna 177 lost control shortly after take-off from Calling Lake, Alberta, Canada, crashed and suffered a post crash fire.

C185, Smithers BC Canada, 2000 On 27 September 2000, a Cessna 185, struck a snow covered hillside, probably while in controlled flight, en-route from Smithers BC, Canada.

C185, Wellington New Zealand, 1997 On Monday 3 March 1997 at 1014 hours, privately owned and operated Cessna 185 encountered wake turbulence from previous departing aircraft, the pilot lost control of the aircraft at a height from which recovery was not possible and the aircraft descended to the ground.

C208, Helsinki Finland, 2005 On 31 January 2005, the pilot of a Cessna 208 which had just taken off from Helsinki lost control of their aircraft as the flaps were retracted and the aircraft stalled, rolled to the right and crashed within the airport perimeter. The Investigation found that the take off had been made without prior airframe de/anti icing and that accumulated ice and snow on the upper wing surfaces had led to airflow separation and the stall, a condition which the pilot had failed to recognise or respond appropriately to for undetermined reasons.

C208, vicinity Pelee Island Canada, 2004 On 17 January, 2004 a Cessna 208 Caravan operated by Georgian Express, took off from Pellee Island, Ontario, Canada, at a weight significantly greater than maximum permitted and with ice visible on the airframe. Shortly after take off, the pilot lost control of the aircraft and it crashed into a frozen lake.

C212, en-route, Bamiyan Afghanistan, 2004 On 27 November 2004, a CASA C212 operated by Presidential Airways, crashed in moutainous terrain near Bamiyan, Afghanistan. The aircraft stalled while trying to climb over a ridge.

C25A / Vehicle, Reykjavik Iceland, 2018 On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within  less than a metre of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.

C25A, Bern Switzerland, 2018 On 2 March 2018, a Cessna 525A touched down at Bern aligned with the left hand edge of the runway and then left it completely before re-entering it after a little over 300 metres and completing the landing roll without further event. Damage to the aircraft and six runway edge and taxi lights was subsequently found. The Investigation noted that the crew stated that they had retained full visual contact with the runway during final approach and that the recorded braking action was good. It was not possible to establish why neither pilot had been aware of the misalignment.

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