Accident and Serious Incident Reports: AW

Definition

A selection of reports relating to accidents and serious incidents which involved Airworthiness as a factor.

The reports are listed below in two groups, the first of which lists the event according to the system affected. The second group identifies events in which Airworthiness was a contributing factor and lists the events by category.

Group 1 - Systems

Airframe

On 1 April 2011, a Southwest Boeing 737-300 climbing through FL340 experienced a sudden loss of pressurisation as a section of fuselage crown skin ruptured. A successful emergency descent was made with a diversion to Yuma, where the aircraft landed half an hour later. Investigation found that the cause of the failure was an undetected manufacturing fault in the 15 year-old aircraft. One member of the cabin crew and an off duty staff member who tried to assist him became temporarily unconscious after disregarding training predicated on the time of useful consciousness after sudden depressurisation.

On 29 December 2010 an American Airlines Boeing 757-200 overran the landing runway at Jackson Hole WY after a bounced touchdown following which neither the speed brakes nor the thrust reversers functioned as expected. The subsequent investigation found that although the speed brakes had been armed and the deployed call had been made, this had not occurred and that the thrust reversers had locked on transit after premature selection during the bounce. It was noted that had the spoilers been manually selected, the thrust reverser problem would not have prevented the aircraft stopping on the runway.

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.

On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.

On 6 April 2016, a BAe ATP partly left the side of the runway soon after touchdown, regaining it after 155 metres before completing its landing roll. It sustained damage rendering it unfit to continue flying but this was not noticed until five further flights had been made. Investigation attributed the excursion to lack of pilot response to unexpected beta range power and the continued flying to the aircraft Captain's failure to ensure proper event recording, accurate operator notification or a post-excursion engineering inspection of the aircraft. Systemic inadequacy in safety management and culture at the operator was identified.

Air Conditioning and Pressurisation

On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an Airbus A319 taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.

On 19 October 2012, a Jet2-operated Boeing 737-800 departing Glasgow made a high speed rejected take off when a strange smell became apparent in the flight deck and the senior cabin crew reported what appeared to be smoke in the cabin. The subsequent emergency evacuation resulted in one serious passenger injury. The Investigation was unable to conclusively identify a cause of the smoke and the also- detected burning smells but excess moisture in the air conditioning system was considered likely to have been a factor and the Operator subsequently made changes to its maintenance procedures.

On 5 March 2011, a Finnair Airbus A320 was westbound in the cruise in southern Swedish airspace after despatch with Engine 1 bleed air system inoperative when the Engine 2 bleed air system failed and an emergency descent was necessary. The Investigation found that the Engine 2 system had shut down due to overheating and that access to proactive and reactive procedures related to operations with only a single bleed air system available were deficient. The crew failure to make use of APU air to help sustain cabin pressurisation during flight completion was noted.

On 12 July 2018, a Boeing 737-800 was climbing through FL135 soon after takeoff from Sydney with First Officer line training in progress when the cabin altitude warning horn sounded because both air conditioning packs had not been switched on. The Captain took control and descended the aircraft to FL100 until the situation had been normalised and the intended flight was completed. The Investigation noted that although both pilots were experienced in command on other aircraft types, both had limited time on the 737 and concluded that incorrect system configuration was consequent on procedures and checklists not being managed appropriately.

On 21 February 2017, an Airbus A320 despatched with the APU inoperative experienced successive failures of both air conditioning and pressurisation systems, the second of which occurred at FL300 and prompted the declaration of a MAYDAY and an emergency descent followed by an uneventful diversion to Alicante. The Investigation found that the cause of the dual failure was likely to have been the undetectable and undetected degradation of the aircraft bleed air regulation system and whilst noting a possibly contributory maintenance error recommended that a new scheduled maintenance task to check components in the aircraft type bleed system be established.

Autoflight

On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase. The Investigation found that a malfunction which probably prevented use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for inability to control the aircraft manually given that dispatch without either autopilot working is permitted.

On 20 July 2011, the flight crew of a Swiss European Avro RJ-100 on a positioning flight from Nuremburg to Zurich responded inappropriately to an unexpected ‘bank angle’ alert in IMC. Near loss of control followed during which a PAN was eventually declared. The situation was resolved by a belated actioning of the QRH checklist applicable to the failure symptoms experienced. The subsequent investigation attributed the event to inappropriate crew response to a failure of a single IRU and poor manual flying skill whilst the situation was resolved.

On 10 March 2019, the left angle of attack vane of a Boeing 737-MAX 8 began recording erroneous values shortly after takeoff from Addis Ababa which triggered left stick shaker activation which continued for the remainder of the flight. Immediately after flap retraction was complete, a series of automatic nose down stabiliser trim inputs began, which the pilots were eventually unable to counter after which a high speed dive led to terrain impact six minutes after takeoff. The Investigation is continuing.

On 3 July 2017, an Airbus A319 sustained significant landing gear damage during the First Officer’s manual landing at Munich which recorded a vertical acceleration exceeding the threshold for a mandatory airworthiness inspection. That inspection found damage to nose and one main landing gear legs and, following Airbus advice, all three were replaced before release to service. The Investigation was unable to explain why neither pilot detected the incorrect pitch attitude and excessive rate of descent in time to take corrective action and noted that a reversion to manual flight during intermediate approach had been due to a technical malfunction.

On 25 May 2016, an Embraer ERJ 190 experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.

Communications

On 6 February 2019, an Airbus A330-200 Captain’s Audio Control Panel (ACP) malfunctioned and began to emit smoke and electrical fumes after coffee was spilt on it. Subsequently, the right side ACP also failed, becoming hot enough to begin melting its plastic. Given the consequent significant communications difficulties, a turnback to Shannon was with both pilots taking turns to go on oxygen. The Investigation found that flight deck drinks were routinely served in unlidded cups with the cup size in use incompatible with the available cup holders. Pending provision of suitably-sized cups, the operator decided to begin providing cup lids.

On 29 February 2016, control of a 50 kg, 3.8 metre wingspan UAV was lost during a flight test being conducted in a Temporary Segregated Area in northern Belgium. The UAV then climbed to 4,000 feet and took up a south south-westerly track across Belgium and into northern France where it crash-landed after the engine stopped. The Investigation found that control communications had been interrupted because of an incorrectly manufactured co-axial cable assembly and a separate autopilot software design flaw not previously identified. This then prevented the default recovery process from working. A loss of prescribed traffic separation was recorded.

On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.

On 15 September 2006, an Easyjet Airbus A319, despatched under MEL provision with one engine generator inoperative and the corresponding electrical power supplied by the Auxiliary Power Unit generator, suffered a further en route electrical failure which included power loss to all COM radio equipment which could not then be re-instated. The flight was completed as flight planned using the remaining flight instruments with the one remaining transponder selected to the standard emergency code. The incident began near Nantes, France.

On 15 January 2009, an Embraer 195-200 being operated by UK Regional Airline Flybe was passing overhead Edinburgh UK at FL370 at night when communications problems between the flight deck and cabin crew occurred following the selection of emergency power as a precautionary measure after smoke, considered to possibly be of electrical origin, had been observed in the galley. An en route diversion with an uneventful outcome was accomplished.

Electrical Power

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.

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

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.

On 12 October 2018, the crew of a Boeing 737-400 already released to service under MEL conditions with an inoperative No 1 engine generator encountered a loss of services from the No 2 electrical system en-route to East Midlands which created a situation not addressed by QRH procedures. The flight was completed and both the new and existing defects were subsequently rectified relatively easily. The Investigation concluded that the operator involved appeared to be prioritising operational requirements over aircraft serviceability issues and made a range of Safety Recommendations aimed at improving company safety culture and the effectiveness of regulatory oversight.

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.

Equipment/Furnishings

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.

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.

On 2 November 2017, the flight crew of an Airbus A320 climbing out of Cork detected a “strong and persistent” burning smell and after declaring a MAYDAY returned to Cork where confusing instructions from the crew resulted in a combination of the intended precautionary rapid disembarkation and an emergency evacuation using escape slides. The Investigation highlighted the necessity of clear and unambiguous communications with passengers which distinguish these two options and in particular noted the limitations in currently mandated pre flight briefings for passengers seated at over wing emergency exits.

On 29 March 2015, an Airbus A320 crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.

On 28 August 2006, a Hawker 800 collided with a glider at 16,000 feet in Class 'E' airspace. The glider became uncontrollable and its pilot evacuated by parachute. The Hawker was structurally damaged and one engine stopped but it was recovered to a nearby airport. The Investigation noted that the collision had occurred in an area well known for glider activity in which transport aircraft frequently avoided glider collisions using ATC traffic information or by following TCAS RAs. The glider was being flown by a visitor to the area with its transponder intentionally switched off to conserve battery power.

Fire Protection

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.

On 28 July 2011, 50 minutes after take off from Incheon, the crew of an Asiana Boeing 747-400F declared an emergency advising a main deck fire and an intention to divert to Jeju. The effects of the rapidly escalating fire eventually made it impossible to retain control and the aircraft crashed into the sea. The Investigation concluded that the origin of the fire was two adjacent pallets towards the rear of the main deck which contained Dangerous Goods shipments including Lithium ion batteries and flammable substances and that the aircraft had broken apart in mid-air following the loss of control.

On 25 May 2016, an Embraer ERJ 190 experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.

On 9 May 2010, Boeing 737-800 being operated by Swedish operator Viking Airlines on a public transport charter flight from Sharm el Sheikh, Egypt to Manchester UK and which had earlier suffered a malfunction which affected the level of redundancy in the aircraft pressurisation system, experienced a failure of the single air conditioning pack in use when over southern Austria and an emergency descent and en route diversion to Vienna were made. There were no injuries to any of the 196 occupants.

On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.

Flight Controls

On 8 October 2019, a BAe Jetstream 32 departing Münster/Osnabrück couldn’t be rotated and after beginning rejected takeoff from well above V1, the aircraft departed the side of the runway passing close to another aircraft at high speed before regaining the runway for the remainder of its deceleration. The Investigation noted that the flight was the first supervised line training sector for the very inexperienced First Officer but attributed the whole event to the Training Captain’s poor performance which had, apart many from other matters, led indirectly to the inability to rotate and to the subsequent directional control problem.

On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase. The Investigation found that a malfunction which probably prevented use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for inability to control the aircraft manually given that dispatch without either autopilot working is permitted.

On 19 April 2018, a Boeing 737-900 made a high speed rejected takeoff at Kathmandu in response to a configuration warning and overran the runway without serious consequences. The Investigation found that when a false Takeoff Configuration Warning caused by an out of adjustment switch had been annunciated just after V1, the Captain had decided to reject the takeoff because of concerns about the local terrain and locally adverse weather. It was noted that the aircraft operator did not provide criteria for rejecting takeoff up to or above the 80 knot crosscheck but that the Boeing reference QRH did so.

On 27 November 2017, an Embraer EMB 550 crew ignored a pre-takeoff indication of an inoperative airframe ice protection system despite taxiing out and taking off in icing conditions. The flight proceeded normally until approach to Paris Le Bourget when the Captain was unable to flare for touchdown at the normal speed and a 4g runway impact which caused a main gear leg to pierce the wing followed. The Investigation found that the crew had failed to follow relevant normal and abnormal operating procedures and did not understand how flight envelope protection worked or why it had activated on approach.

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.

Fuel

On 9 May 2019, a Cessna 550 level at FL 350 experienced an unexplained left engine rundown to idle and the crew began descent and a diversion to Savannah. When the right engine also began to run down passing 8000 feet, an emergency was declared and the already-planned straight-in approach was successfully accomplished without any engine thrust. The ongoing Investigation has already established that the likely cause was fuel contamination resulting from the inadvertent mixing of a required fuel additive with an unapproved substance known to form deposits which impede fuel flow when they accumulate on critical fuel system components.

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.

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.

On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.

On 28 August 2006, a Hawker 800 collided with a glider at 16,000 feet in Class 'E' airspace. The glider became uncontrollable and its pilot evacuated by parachute. The Hawker was structurally damaged and one engine stopped but it was recovered to a nearby airport. The Investigation noted that the collision had occurred in an area well known for glider activity in which transport aircraft frequently avoided glider collisions using ATC traffic information or by following TCAS RAs. The glider was being flown by a visitor to the area with its transponder intentionally switched off to conserve battery power.

Hydraulic Power

On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were injured.

On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.

On 1 November 2011, a Boeing 767-300 landed at Warsaw with its landing gear retracted after declaring an emergency in anticipation of the possible consequences which in this event included an engine fire and a full but successful emergency evacuation. The Investigation attributed inability to achieve successful gear extension using either alternate system or free fall to crew failure to notice that the Battery Busbar CB which controlled power to the uplock release mechanism was tripped. Gear extension using the normal system had been precluded in advance by a partial hydraulic system failure soon after takeoff from New York.

On 4 October 2014, the fracture of a hydraulic hose during an A330-200 pushback at night at Karachi was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. After some delay, during which a delay in isolating the APU air bleed exacerbated the ingress of fumes, the aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it which prevented use of the exit adjacent to it for evacuation.

An announcement by the Captain of a fully-boarded Boeing 757-200 about to depart which was intended to initiate a Precautionary Rapid Disembarkation due to smoke from a hydraulic leak was confusing and a partial emergency evacuation followed. The Investigation found that Cabin Crew only knew of this via the announcement and noted subsequent replacement of the applicable procedures by an improved version, although this was still considered to lack resilience in one respect. The event was considered to have illustrated the importance of having cabin crew close to doors when passengers are on board aircraft on the ground.

Ice and Rain Protection

On 27 November 2017, an Embraer EMB 550 crew ignored a pre-takeoff indication of an inoperative airframe ice protection system despite taxiing out and taking off in icing conditions. The flight proceeded normally until approach to Paris Le Bourget when the Captain was unable to flare for touchdown at the normal speed and a 4g runway impact which caused a main gear leg to pierce the wing followed. The Investigation found that the crew had failed to follow relevant normal and abnormal operating procedures and did not understand how flight envelope protection worked or why it had activated on approach.

On 25 February 2017, an Airbus A320 left the side of the landing runway at Toronto when, for undetermined reasons, the Captain, as Pilot Flying, set up a drift to the right just before touchdown. This was then followed by a lateral runway excursion into wet grass in rain-reduced visibility which continued for 1,650 metres before the aircraft regained the runway and stopped. The Investigation noted that both the absence of runway centreline lighting and the aircraft operator’s policy of not activating the aircraft rain repellent system or applying the alternative hydrophobic windshield coating may have increased the excursion risk.

On 13 June 2013, a rushed and unstable visual approach to Marsh Harbour by a Saab 340B was followed by a mishandled landing and a runway excursion. The Investigation concluded that the way the aircraft had been operated had been contrary to expectations in almost every respect. This had set the scene for the continuation of a visual approach to an attempted landing in circumstances where there had been multiple indications that there was no option but to break off the approach, including a total loss of forward visibility in very heavy rain as the runway neared.

On 5 November 2014, the crew of an Airbus A321 temporarily lost control of their aircraft in the cruise and were unable to regain it until 4000 feet of altitude had been lost. An investigation into the causes is continuing but it is already known that blockage of more than one AOA probe resulted in unwanted activation of high AOA protection which could not be stopped by normal sidestick inputs until two of the three ADRs had been intentionally deactivated in order to put the flight control system into Alternate Law.

On 11 January 2010, a British Aerospace ATP crew attempting to take off from Helsinki after a two-step airframe de/anti icing treatment (Type 2 and Type 4 fluids) were unable to rotate and the take off was successfully rejected from above V1. The Investigation found that thickened de/anti ice fluid residues had frozen in the gap between the leading edge of the elevator and the horizontal stabiliser and that there had been many other similarly-caused occurrences to aircraft without powered flying controls. There was concern that use of such thickened de/anti ice fluids was not directly covered by safety regulation.

Indicating / Recording Systems

On 4 October 2013, a Boeing 747-200 touched down short of the intended landing runway at Sokoto after the Captain opted to reduce track miles by making a direct visual contact approach in dark night calm wind conditions rather than continuing as initially cleared towards an ILS approach in the reciprocal runway direction. The Investigation was hampered by an inoperative FDR and failure to preserve relevant CVR data on the grounded aircraft and concluded that the decision to make a visual approach rather than an ILS approach when the VASI was out of service for both runways was inappropriate.

On 7 February 2018, a Boeing 737-800 experienced an airspeed mismatch during takeoff on a post maintenance positioning flight but having identified the faulty system by reference to the standby instrumentation, the intended flight was completed without further event. After the recorded defect was then signed off as “no fault found” after a failure to follow the applicable fault-finding procedure, the same happened on the next (revenue) flight but with an air turnback made. The Investigation found that the faulty sensor had been fitted at build three earlier with a contaminated component which had slowly caused sensor malfunction to develop.

On 12 March 2014, an Airbus A319 left engine stopped without any apparent cause on approach to Paris CDG. The crew then started the APU which also stopped. The Investigation found that the cause was engine and APU fuel starvation caused by non-identification of a recurring intermittent malfunction in the fuel quantity indicating system because of a combination of factors including crew failure to record fuel status in line with clear instructions and an inadequate maintenance troubleshooting manual. An inadequately-written abnormal crew drill and the crew’s inadequate fuel system knowledge then resulted in the fuel crossfeed valve not being opened.

On 1 December 2017, an Airbus A320 made an unintentional - and unrecognised - hard landing at Pristina. As the automated system for alerting outside-limits hard landings was only partially configured and output from the sole available channel was not available, the aircraft continued in service for a further eight sectors before an exceedance was confirmed and the aircraft grounded. The Investigation noted that whilst the aircraft Captain is responsible for recording potential hard landings, the aircraft operator involved should ensure that at least one of the available automated alerting channels is always functional in support of crew subjective judgement.

On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase. The Investigation found that a malfunction which probably prevented use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for inability to control the aircraft manually given that dispatch without either autopilot working is permitted.

Landing Gear

On 15 November 2018, a Bombardier DHC8-300 made a main gear only touchdown at Stephenville with only minor damage after diverting there when the nose landing gear only partially extended when routinely selected on approach at the originally intended destination. The Investigation found that the cause was incorrect nose gear assembly which had allowed hydraulic fluid to leak and eventually led to it jamming. There was some concern at the way the flight was conducted following the problem which involved continuous smartphone communications with the operator and an overspeed which it was considered constituted an avoidable risk to safety.

On 11 December 2019, a Bombardier BD700 Global 6000 making a night landing at Liverpool suffered a nose wheel steering failure shortly after touchdown. The crew were unable to prevent the aircraft departing the side of the runway into a grassed area where it stopped, undamaged, in mud. The Investigation found that the crew response was contrary to that needed for continued directional control but also that no pilot training or QRH procedure covered such a failure occurring at high speed nor was adequate guidance available on mitigating the risk of inadvertent opposite brake application during significant rudder deflection.

On 16 November 2012, an Air Contractors Airbus A300 departed the left the side of the landing runway at Bratislava after an abnormal response to directional control inputs. Investigation found that incorrect and undetected re-assembly of the nose gear torque links had led to the excursion and that absence of clear instructions in maintenance manuals, since rectified, had facilitated this. It was also considered that the absence of any regulation requiring equipment in the vicinity of the runway to be designed to minimise potential damage to aircraft departing the paved surface had contributed to the damage caused by the accident.

On 13 April 2013, an Air France Airbus A330-200 was damaged during a hard (2.74 G) landing at Caracas after the aircraft commander continued despite the aircraft becoming unstabilised below 500 feet agl with an EGPWS ‘SINK RATE’ activation beginning in the flare. Following a superficial inspection, maintenance personnel determined that no action was required and released the aircraft to service. After take off, it was impossible to retract the landing gear and the aircraft returned. Considerable damage from the earlier landing was then found to both fuselage and landing gear which had rendered the aircraft unfit to fly.

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.

Navigation

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.

On 27 June 2016, an Airbus A319 narrowly avoided a mid-air collision with an AS532 Cougar helicopter whose single transponder had failed earlier whilst conducting a local pre-delivery test flight whilst both were positioning visually as cleared to land at Marseille and after the helicopter had also temporarily disappeared from primary radar. Neither aircraft crew had detected the other prior to their tracks crossing at a similar altitude. The Investigation attributed the conflict to an inappropriate ATC response to the temporary loss of radar contact with the helicopter aggravated by inaccurate position reports and non-compliance with the aerodrome circuit altitude by the helicopter crew.

On 25 May 2016, an Embraer ERJ 190 experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.

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

On 18 June 2016, a PC12 crew experienced a sudden corruption of the SVS image on their PFDs soon after a night take-off and the Pilot Flying initially reacted by increasing pitch in response to the false image which had obscured the primary flight path symbology on the PFD. Recovery was achieved before the resulting airspeed drop had activated the Stall Protection System by the pilots transferring their attention to the Standby Instrument Display. The Investigation noted that the SVS was not certified for primary flight path control but that the failure had created temporary spatial disorientation.

Oxygen

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

On 24 August 2001, an Air Transat Airbus A330-200 eastbound across the North Atlantic at night experienced a double-engine flameout after which Lajes on Terceira Island in the Azores was identified as the best diversion and a successful glide approach and landing there was subsequently achieved. The Investigation found that the flameouts had been the result of fuel exhaustion after a fuel leak from the right engine caused by a pre flight maintenance error. Fuel exhaustion was found to have occurred because the flight crew did not perform the QRH procedure applicable to an in-flight fuel leak.

On 22 March 2007, climbing out of Stockholm Sweden, the crew of a Malmö Aviation Avro RJ100 failed to notice that the aircraft was not pressurised until cabin crew advised them of automatic cabin oxygen mask deployment.

On 25 July 2008, a Boeing 747 suffered a rapid depressurisation of the cabin following the sudden failure of an oxygen cylinder, which had ruptured the aircraft's pressure hull. The incident occurred 475 km north-west of Manila, Philippines.

Airborne Auxiliary Power (APU)

On 20 January 2015, The APU of a Fokker 100 being routinely de-iced prior to departing Nuremburg oversped as a result of the ignition of ingested de-icing fluid in the APU. This led to its explosive uncontained failure as the result of which ejected debris entered the aft cabin and smoke occurred. No occupants were injured and all were promptly disembarked. The Investigation found that the de-icing contractor involved had not followed manufacturer-issued aircraft-specific de-icing procedures and in the continued absence of any applicable safety regulatory oversight of ground de-icing activity, corresponding Safety Recommendations were made.

On 26 June 2016, thick white smoke suddenly appeared in the cabin of a fully loaded Airbus A330-300 prior to engine start with the door used for boarding still connected to the air bridge. An emergency evacuation initiated by cabin crew was accomplished without injury although amidst some confusion due to a brief conflict between flight crew and cabin crew instructions. The Investigation found that the smoke had been caused when an APU seal failed and hot oil entered the bleed air supply and pyrolysed. Safety Recommendations in respect of both crew communication and procedures and APU auto-shutdown were made.

On 25 September 2001, an Embraer 145 in descent to Manchester sustained a low power lightning strike which was followed, within a few seconds, by the left engine stopping without failure annunciation. A successful single engine landing followed. The Investigation concluded that the cause of failure of the FADEC-controlled AE3007 engine (which has no surge recovery logic) was the aero-thermal effects of the strike to which all aircraft with relatively small diameter fuselages and close mounted engines are vulnerable. It was considered that there was a risk of simultaneous double engine flameout in such circumstances which was impossible to quantify.

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.

On 11 December 2008 an EMB 145 being operated by Finnish Commuter Airlines on a scheduled passenger flight caught fire during the taxi in after a night landing after the APU failed to start and a major electrical power failure occurred simultaneously. The fire was not detected until after the aircraft arrived on stand when, with the passengers still on board, a member of the ground crew saw signs of fire at the back of the aircraft. The aircraft s own fire suppression system was successfully used to extinguish the fire, the passengers left the aircraft and there were no injuries and only minor damage to the aircraft.

Propellers

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.

On 17 March 2017, uncommanded engine indications on a Saab 340B en route to Sydney were followed by vibration of the right engine after which, as the crew commenced right engine shutdown, its propeller assembly separated from the engine. A PAN was declared and the flight subsequently reached Sydney without further event. The Investigation found that the propeller gearbox shaft had fractured because of undetected internal fatigue cracking in the shaft. Applicable in-service shaft inspection procedures were found to be inadequate and mandatory enhancements to these procedures have since been introduced.

On 28 November 2013, a Saab 2000 departing Lugano suffered an engine failure for no apparent reason and the crew determined that diversion to Milan was preferable to return to Lugano or continued climb over high terrain to reach intended destination Zurich. The Investigation found that the loss of engine power experienced was due to a double FADEC failure with a transient malfunction of one channel resulting in an automated transfer to the other channel which already had an undetected permanent fault attributable to maintenance error. It was noted that the airline involved had contracted out all continuing airworthiness responsibilities.

On 9 January 2015, a Saab 340B encountered a flock of medium-sized birds soon after decelerating through 80 knots during its landing roll at Moruya. A subsequent flight crew inspection in accordance with the prevailing operator procedures concluded that the aircraft could continue in service but after completion of the next flight, a propeller blade tip was found to be missing. The Investigation concluded that the blade failure was a result of the earlier bird impact and found that airline procedures allowing pilots to determine continued airworthiness after a significant birdstrike had unknowingly been invalid.

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.

Rotors

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.

On 22 October 2012, the crew of a Eurocopter EC225 LP on a flight from Aberdeen to an offshore platform received an indication that the main gearbox (MGB) lubrication system had failed. Shortly after selecting the emergency lubrication system, that system also indicated failure and the crew responded in accordance with the QRH drill to “land immediately” by carrying out a successful controlled ditching. The ongoing investigation has found that there had been a mechanical failure within the MGB but that the emergency lubrication system had, contrary to indications, been functioning normally.

On 12 August 2015, a Sikorsky S76C crew on a flight from an offshore platform to Lagos lost control of their aircraft after a sudden uncommanded pitch up, yaw and roll began and 12 seconds later it crashed into water in a suburb of Lagos killing both pilots and four of the 10 passengers. The Investigation concluded that the upset had been caused by a critical separation within the main rotor cyclic control system resulting from undetected wear at a point where there was no secondary mechanical locking system such as a locking pin or a wire lock to maintain system integrity.

On 27 October 2018, a single pilot Augusta Westland AW169 lifted off from within the Leicester City Football Club Stadium, but after a failure of the tail rotor control system, a loss of yaw control occurred a few hundred feet above ground. The helicopter began to descend with a high rotation rate and soon afterward impacted the ground and almost immediately caught fire, which prevented those onboard surviving. An Investigation is being conducted by the UK AAIB.

On 28 December 2016, yaw control was lost during touchdown of a Sikorsky S92A landing on a North Sea offshore platform and it almost fell into the sea. The Investigation found that the loss of control was attributable to the failure of the Tail Rotor Pitch Change Shaft bearing which precipitated damage to the associated control servo. It was also found that despite HUMS monitoring being in place, it had been ineffective in proactively alerting the operator to the earlier stages of progressive bearing deterioration which could have ensured the helicopter was grounded for rectification before the accident occurred.

Engine - General

On 31 December 2017, a de Havilland DHC2 floatplane being manoeuvred at low level over Jerusalem Bay shortly after takeoff was observed to enter a steeply banked turn from which it appeared to depart controlled flight and impact the water surface below almost vertically. The Investigation concluded that the aircraft had stalled despite the exemplary proficiency record of the pilot and that in the absence of any other plausible explanation found that the loss of control was likely to have been the effect of an elevated exposure to carbon monoxide found during post mortem toxicology testing.

On 11 November 2019, one of the two PW100 series engines of a Bombardier DHC8-300 failed catastrophically when takeoff power was set prior to brake release. The Investigation found that the power turbine shaft had fractured in two places and all first and second stage power turbine blades had separated from their disks. The shaft failure was found to have been caused by fatigue cracking initiated by corrosion pitting which was assessed as probably the result of prolonged marine low-altitude operations by the aircraft. It was found that this fatigue cracking could increase undetected during service between scheduled inspections.

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.

On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.

On 28 February 2019, an Airbus A320 abandoned takeoff from Exeter when fight deck fumes/smoke accompanied thrust applied against the brakes. When informed of similar conditions in the cabin, the Captain ordered an emergency evacuation. Some passengers using the overwing exits re-entered the cabin after becoming confused as to how to leave the wing. The Investigation attributed the fumes to an incorrectly-performed engine compressor wash arising in a context of poorly-managed maintenance and concluded that guidance on overwing exit use had been inadequate and that the 1.8 metre certification height limit for exits without evacuation slides should be reduced.

Engine Fuel and Control

On 22 August 2019, the left engine of a Boeing 737-800 failed for unknown reasons soon after reaching planned cruise level of FL360 twenty minutes after departing Samos, Greece and two attempted relights during and after descent to FL240 were unsuccessful. Instead of diverting to the nearest suitable airport as required by applicable procedures, the management pilot in command did not declare single engine operation and completed the planned flight to Prague, declaring a PAN to ATC only on entering Czech airspace. The Investigation noted that engine failure was due to fuel starvation after failure of the engine fuel pump.

On 26 February 2020, after difficulty starting an Airbus A321 left engine for the first flight of the day, the same difficulty recurred on the third flight followed by subsequent en-route abnormalities affecting both engines. After no fault was found during post flight maintenance investigation, similar problems occurred starting the left engine and after takeoff from Gatwick, both engines malfunctioned and a MAYDAY return followed. The continuing Investigation has already found that the engine problems were attributable to fuel system contamination following the addition of 37 times the maximum permitted dosage of Kathon biocide during prior scheduled maintenance work.

On 8 February 2019, a Convair C131 climbing out of Nassau experienced a right engine propeller control malfunction. The Captain was able to stabilise power and continued the flight to Miami. As descent began, the same engine malfunctioned and was shut down but the left engine then also malfunctioned and, after an emergency declaration, a mishandled ditching followed. This wrecked the aircraft and only the First Officer survived, seriously injured. The Investigation noted that related engine malfunction on the outbound flight had not been recorded or investigated. No wreckage recovery was attempted so engine failure causes were not determined.

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.

On 25 March 2008, an Air Atlanta Icelandic Boeing 747-300 was decelerating after landing at Dhaka when a fuel leak in the vicinity of the No 3 engine led to a fire which could not be extinguished. An emergency evacuation was accomplished with only a few minor injuries. The cause of the fuel leak was traced to mis-assembly of a fuel feed line coupling during a C Check some six months previously. The failure to follow clear AMM instructions for this task in two specific respects was of concern to the Investigating Agency.

Bleed Air

On 23 September 2019, the flight crew of an Airbus A320 on approach to London Heathrow detected strong acrid fumes on the flight deck and after donning oxygen masks completed the approach and landing, exited the runway and shut down on a taxiway. After removing their masks, one pilot became incapacitated and the other unwell and both were taken to hospital. The other occupants, all unaffected, were disembarked to buses. The very comprehensive investigation was unable to establish the origin of the fumes but did identify a number of circumstantial factors which corresponded to those identified in previous similar events.

On 28 February 2019, an Airbus A320 abandoned takeoff from Exeter when fight deck fumes/smoke accompanied thrust applied against the brakes. When informed of similar conditions in the cabin, the Captain ordered an emergency evacuation. Some passengers using the overwing exits re-entered the cabin after becoming confused as to how to leave the wing. The Investigation attributed the fumes to an incorrectly-performed engine compressor wash arising in a context of poorly-managed maintenance and concluded that guidance on overwing exit use had been inadequate and that the 1.8 metre certification height limit for exits without evacuation slides should be reduced.

On 19 October 2012, a Jet2-operated Boeing 737-800 departing Glasgow made a high speed rejected take off when a strange smell became apparent in the flight deck and the senior cabin crew reported what appeared to be smoke in the cabin. The subsequent emergency evacuation resulted in one serious passenger injury. The Investigation was unable to conclusively identify a cause of the smoke and the also- detected burning smells but excess moisture in the air conditioning system was considered likely to have been a factor and the Operator subsequently made changes to its maintenance procedures.

On 5 March 2011, a Finnair Airbus A320 was westbound in the cruise in southern Swedish airspace after despatch with Engine 1 bleed air system inoperative when the Engine 2 bleed air system failed and an emergency descent was necessary. The Investigation found that the Engine 2 system had shut down due to overheating and that access to proactive and reactive procedures related to operations with only a single bleed air system available were deficient. The crew failure to make use of APU air to help sustain cabin pressurisation during flight completion was noted.

On 22 December 2010, a Finnair Airbus A330-300 inbound to Helsinki and cruising in very cold air at an altitude of 11,600 metres lost cabin pressurisation in cruise flight and completed an emergency descent before continuing the originally intended flight at a lower level. The subsequent Investigation was carried out together with that into a similar occurrence to another Finnair A330 which had occurred 11 days earlier. It was found that in both incidents, both engine bleed air systems had failed to function normally because of a design fault which had allowed water within their pressure transducers to freeze.

Other

On 13 April 2019, an experienced Cessna 525 pilot almost lost control shortly after takeoff from Bournemouth when a recently installed performance enhancement system malfunctioned. After a six minute flight involving a potentially hazardous upset and recovery of compromised control, the turn back was successful. The Investigation found that although the pilot was unaware of the supplementary procedures supporting the modification, these did not adequately address possible failure cases. Also, certification flight tests prior to modification approval did not identify the severity of some possible failure outcomes and corresponding Safety Recommendations were made to the system manufacturer and safety regulators.

On 11 December 2019, a Bombardier BD700 Global 6000 making a night landing at Liverpool suffered a nose wheel steering failure shortly after touchdown. The crew were unable to prevent the aircraft departing the side of the runway into a grassed area where it stopped, undamaged, in mud. The Investigation found that the crew response was contrary to that needed for continued directional control but also that no pilot training or QRH procedure covered such a failure occurring at high speed nor was adequate guidance available on mitigating the risk of inadvertent opposite brake application during significant rudder deflection.

On 12 October 2018, the crew of a Boeing 737-400 already released to service under MEL conditions with an inoperative No 1 engine generator encountered a loss of services from the No 2 electrical system en-route to East Midlands which created a situation not addressed by QRH procedures. The flight was completed and both the new and existing defects were subsequently rectified relatively easily. The Investigation concluded that the operator involved appeared to be prioritising operational requirements over aircraft serviceability issues and made a range of Safety Recommendations aimed at improving company safety culture and the effectiveness of regulatory oversight.

On 2 November 2017, the flight crew of an Airbus A320 climbing out of Cork detected a “strong and persistent” burning smell and after declaring a MAYDAY returned to Cork where confusing instructions from the crew resulted in a combination of the intended precautionary rapid disembarkation and an emergency evacuation using escape slides. The Investigation highlighted the necessity of clear and unambiguous communications with passengers which distinguish these two options and in particular noted the limitations in currently mandated pre flight briefings for passengers seated at over wing emergency exits.

On 19 June 2016, a BAe 146-300 landed long at Khark Island and overran the end of the runway at speed with the aircraft only stopping because the nose landing gear collapsed on encountering uneven ground. The Investigation attributed the accident - which caused enough structural damage for the aircraft to be declared a hull loss - entirely to the decisions and actions of the aircraft commander who failed to go around from an unstabilised approach, landed long and then did not ensure maximum deceleration was achieved. The monitoring role of the low experience First Officer was ineffective.

Emergency Evacuation

On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.

On 8 March 2017, a Boeing MD83 departing Ypsilanti could not be rotated and the takeoff had to be rejected from above V1. The high speed overrun which followed substantially damaged the aircraft but evacuation was successful. The Investigation found that the right elevator had been locked in a trailing-edge-down position as a result of damage caused to the aircraft by high winds whilst it was parked unoccupied for two days prior to the takeoff. It was noted that on an aircraft with control tab initiated elevator movement, this condition was undetectable during prevailing pre flight system inspection or checks.

On 4 October 2014, the fracture of a hydraulic hose during an A330-200 pushback at night at Karachi was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. After some delay, during which a delay in isolating the APU air bleed exacerbated the ingress of fumes, the aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it which prevented use of the exit adjacent to it for evacuation.

On 31 October 2014, indications of a malfunction of the right over wing emergency exit slide on take off were followed during the return to land by the complete detachment of the slide and un-commanded but controllable roll. The Investigation found that a series of technical issues with the slide panel and carrier locking devices caused the slide carrier to deploy and the slide to unravel. Although an SB existed to address some of these issues, it had not been actioned on the aircraft. Two operational matters encountered during the Investigation were the subject of Safety Recommendations.

On 22 August 2015 the pilot of a civil-operated Hawker Hunter carrying out a flying display sequence at Shoreham failed to complete a loop and partial roll manoeuvre and the aircraft crashed into road traffic unrelated to the airshow and exploded causing multiple third party fatalities and injuries. The Investigation found that the pilot had failed to enter the manoeuvre correctly and then failed to abandon it when it should have been evident that it could not be completed. It was concluded that the wider context for the accident was inadequate regulatory oversight of UK civil air display flying risk management.

Rotary Aircraft Transmission

On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.

On 29 April 2016, an Airbus EC225 Super Puma main rotor detached without warning en-route to Bergen. Control was lost and it crashed and was destroyed. Rotor detachment was attributed to undetected development of metal fatigue in the same gearbox component which caused an identical 2009 accident to a variant of the same helicopter type. Despite this previous accident, the failure mode involved had not been properly understood or anticipated. The investigation identifies significant lessons to be learned related to gearbox design, risk assessment, fatigue evaluation, gearbox condition monitoring, type certification and continued airworthiness, which may also be valid for other helicopter types.

Group 2 - Contributors

Maintenance Error (valid guidance available)

On 31 December 2017, a de Havilland DHC2 floatplane being manoeuvred at low level over Jerusalem Bay shortly after takeoff was observed to enter a steeply banked turn from which it appeared to depart controlled flight and impact the water surface below almost vertically. The Investigation concluded that the aircraft had stalled despite the exemplary proficiency record of the pilot and that in the absence of any other plausible explanation found that the loss of control was likely to have been the effect of an elevated exposure to carbon monoxide found during post mortem toxicology testing.

On 15 November 2018, a Bombardier DHC8-300 made a main gear only touchdown at Stephenville with only minor damage after diverting there when the nose landing gear only partially extended when routinely selected on approach at the originally intended destination. The Investigation found that the cause was incorrect nose gear assembly which had allowed hydraulic fluid to leak and eventually led to it jamming. There was some concern at the way the flight was conducted following the problem which involved continuous smartphone communications with the operator and an overspeed which it was considered constituted an avoidable risk to safety.

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.

On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.

On 26 February 2020, after difficulty starting an Airbus A321 left engine for the first flight of the day, the same difficulty recurred on the third flight followed by subsequent en-route abnormalities affecting both engines. After no fault was found during post flight maintenance investigation, similar problems occurred starting the left engine and after takeoff from Gatwick, both engines malfunctioned and a MAYDAY return followed. The continuing Investigation has already found that the engine problems were attributable to fuel system contamination following the addition of 37 times the maximum permitted dosage of Kathon biocide during prior scheduled maintenance work.

Maintenance Error (invalid guidance available)

On 28 February 2019, an Airbus A320 abandoned takeoff from Exeter when fight deck fumes/smoke accompanied thrust applied against the brakes. When informed of similar conditions in the cabin, the Captain ordered an emergency evacuation. Some passengers using the overwing exits re-entered the cabin after becoming confused as to how to leave the wing. The Investigation attributed the fumes to an incorrectly-performed engine compressor wash arising in a context of poorly-managed maintenance and concluded that guidance on overwing exit use had been inadequate and that the 1.8 metre certification height limit for exits without evacuation slides should be reduced.

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.

On 19 October 2012, a Jet2-operated Boeing 737-800 departing Glasgow made a high speed rejected take off when a strange smell became apparent in the flight deck and the senior cabin crew reported what appeared to be smoke in the cabin. The subsequent emergency evacuation resulted in one serious passenger injury. The Investigation was unable to conclusively identify a cause of the smoke and the also- detected burning smells but excess moisture in the air conditioning system was considered likely to have been a factor and the Operator subsequently made changes to its maintenance procedures.

On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were injured.

On 10 January 2011, a Europe Airpost Boeing 737-300 taking off from Montpelier after repainting had just rotated for take off when the leading edge slats extended from the Intermediate position to the Fully Extended position and the left stick shaker was activated as a consequence of the reduced stalling angle of attack. Initial climb was sustained and soon afterwards, the slats returned to their previous position and the stick shaker activation stopped. The unexpected configuration change was attributed to paint contamination of the left angle of attack sensor, the context for which was inadequate task guidance.

Inadequate Maintenance Schedule

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.

On 31 December 2017, a de Havilland DHC2 floatplane being manoeuvred at low level over Jerusalem Bay shortly after takeoff was observed to enter a steeply banked turn from which it appeared to depart controlled flight and impact the water surface below almost vertically. The Investigation concluded that the aircraft had stalled despite the exemplary proficiency record of the pilot and that in the absence of any other plausible explanation found that the loss of control was likely to have been the effect of an elevated exposure to carbon monoxide found during post mortem toxicology testing.

On 11 November 2019, one of the two PW100 series engines of a Bombardier DHC8-300 failed catastrophically when takeoff power was set prior to brake release. The Investigation found that the power turbine shaft had fractured in two places and all first and second stage power turbine blades had separated from their disks. The shaft failure was found to have been caused by fatigue cracking initiated by corrosion pitting which was assessed as probably the result of prolonged marine low-altitude operations by the aircraft. It was found that this fatigue cracking could increase undetected during service between scheduled inspections.

On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.

On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were injured.

Inadequate Maintenance Inspection

On 7 February 2018, a Boeing 737-800 experienced an airspeed mismatch during takeoff on a post maintenance positioning flight but having identified the faulty system by reference to the standby instrumentation, the intended flight was completed without further event. After the recorded defect was then signed off as “no fault found” after a failure to follow the applicable fault-finding procedure, the same happened on the next (revenue) flight but with an air turnback made. The Investigation found that the faulty sensor had been fitted at build three earlier with a contaminated component which had slowly caused sensor malfunction to develop.

On 26 February 2020, after difficulty starting an Airbus A321 left engine for the first flight of the day, the same difficulty recurred on the third flight followed by subsequent en-route abnormalities affecting both engines. After no fault was found during post flight maintenance investigation, similar problems occurred starting the left engine and after takeoff from Gatwick, both engines malfunctioned and a MAYDAY return followed. The continuing Investigation has already found that the engine problems were attributable to fuel system contamination following the addition of 37 times the maximum permitted dosage of Kathon biocide during prior scheduled maintenance work.

On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.

On 13 April 2013, an Air France Airbus A330-200 was damaged during a hard (2.74 G) landing at Caracas after the aircraft commander continued despite the aircraft becoming unstabilised below 500 feet agl with an EGPWS ‘SINK RATE’ activation beginning in the flare. Following a superficial inspection, maintenance personnel determined that no action was required and released the aircraft to service. After take off, it was impossible to retract the landing gear and the aircraft returned. Considerable damage from the earlier landing was then found to both fuselage and landing gear which had rendered the aircraft unfit to fly.

On 1 April 2011, a Southwest Boeing 737-300 climbing through FL340 experienced a sudden loss of pressurisation as a section of fuselage crown skin ruptured. A successful emergency descent was made with a diversion to Yuma, where the aircraft landed half an hour later. Investigation found that the cause of the failure was an undetected manufacturing fault in the 15 year-old aircraft. One member of the cabin crew and an off duty staff member who tried to assist him became temporarily unconscious after disregarding training predicated on the time of useful consciousness after sudden depressurisation.

Inadequate QRH Drills

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.

On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.

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.

On 5 March 2011, a Finnair Airbus A320 was westbound in the cruise in southern Swedish airspace after despatch with Engine 1 bleed air system inoperative when the Engine 2 bleed air system failed and an emergency descent was necessary. The Investigation found that the Engine 2 system had shut down due to overheating and that access to proactive and reactive procedures related to operations with only a single bleed air system available were deficient. The crew failure to make use of APU air to help sustain cabin pressurisation during flight completion was noted.

On 6 November 2019, the crew of an Embraer E175LR which had just taken off from Atlanta experienced difficulty in maintaining pitch control after an apparent pitch trim runaway and an emergency was declared. Control was subsequently regained and a return to land was made without further problems. The Investigation is continuing but has identified the root cause as wiring damage arising from incorrect installation, noted that potentially related corrective action was not mandated and determined that the operator’s QRH drill for the situation encountered had significantly contained only one memory action rather the two in the aircraft manufacturer’s version.

OEM Design fault

On 8 October 2019, a BAe Jetstream 32 departing Münster/Osnabrück couldn’t be rotated and after beginning rejected takeoff from well above V1, the aircraft departed the side of the runway passing close to another aircraft at high speed before regaining the runway for the remainder of its deceleration. The Investigation noted that the flight was the first supervised line training sector for the very inexperienced First Officer but attributed the whole event to the Training Captain’s poor performance which had, apart many from other matters, led indirectly to the inability to rotate and to the subsequent directional control problem.

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.

On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.

On 17 July 2007, the commander of a TAM Airlines Airbus A320 being operated with one thrust reverser locked out was unable to stop the aircraft leaving the landing runway at Congonhas at speed and it hit buildings and was destroyed by the impact and fire which followed killing all on board and others on the ground. The investigation attributed the accident to pilot failure to realise that the thrust lever of the engine with the locked out reverser was above idle, which by design then prevented both the deployment of ground spoilers and the activation of the pre-selected autobrake.

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.

Damage Tolerance

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.

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.

On 26 September 2011, a Boeing 757-200 being operated by United Airlines on a scheduled passenger flight from Chicago to Denver experienced a left engine bird strike during deceleration after landing on runway 35R at destination in normal day visibility. The affected engine ran down as the aircraft cleared the runway and was shut down after a report of smoke being emitted from it. The aircraft was stopped and the remaining engine also shut down prior to a tow to the assigned terminal gate for passenger disembarkation. None of the 185 occupants were injured but the affected engine was severely damaged and there was visible evidence that some debris from it had impacted the aircraft fuselage.

On 10 November 2013 the left engine of a Fairchild SA227 on final approach suddenly ceased to produce any power at approximately 500 feet whilst continuing to operate. The crew did not identify what had happened in time to avoid losing control of the aircraft which then impacted terrain, caught fire and was destroyed. The Investigation found that premature failure of engine components had caused the engine malfunction and noted that some pilots may believe that the Negative Torque Sensing (NTS) System provided for the engines on this aircraft type will always detect high drag conditions arising from power loss.

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.

Contributing ADD

On 5 March 2011, a Finnair Airbus A320 was westbound in the cruise in southern Swedish airspace after despatch with Engine 1 bleed air system inoperative when the Engine 2 bleed air system failed and an emergency descent was necessary. The Investigation found that the Engine 2 system had shut down due to overheating and that access to proactive and reactive procedures related to operations with only a single bleed air system available were deficient. The crew failure to make use of APU air to help sustain cabin pressurisation during flight completion was noted.

On 12 October 2018, the crew of a Boeing 737-400 already released to service under MEL conditions with an inoperative No 1 engine generator encountered a loss of services from the No 2 electrical system en-route to East Midlands which created a situation not addressed by QRH procedures. The flight was completed and both the new and existing defects were subsequently rectified relatively easily. The Investigation concluded that the operator involved appeared to be prioritising operational requirements over aircraft serviceability issues and made a range of Safety Recommendations aimed at improving company safety culture and the effectiveness of regulatory oversight.

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.

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.

On 5 June 2015, a DHC8-200 descending towards Bradley experienced an in-flight fire which originated at a windshield terminal block. Attempts to extinguish the fire were unsuccessful with the electrical power still selected to the circuit. However, the fire eventually stopped and only smoke remained. An emergency evacuation was carried out after landing. The Investigation was unable to establish the way in which the malfunction that caused the fire arose but noted the continuing occurrence of similar events on the aircraft type and five Safety Recommendations were made to Bombardier to address the continuing risk.

Component Fault in Service

On 7 February 2018, a Boeing 737-800 experienced an airspeed mismatch during takeoff on a post maintenance positioning flight but having identified the faulty system by reference to the standby instrumentation, the intended flight was completed without further event. After the recorded defect was then signed off as “no fault found” after a failure to follow the applicable fault-finding procedure, the same happened on the next (revenue) flight but with an air turnback made. The Investigation found that the faulty sensor had been fitted at build three earlier with a contaminated component which had slowly caused sensor malfunction to develop.

On 13 April 2019, an experienced Cessna 525 pilot almost lost control shortly after takeoff from Bournemouth when a recently installed performance enhancement system malfunctioned. After a six minute flight involving a potentially hazardous upset and recovery of compromised control, the turn back was successful. The Investigation found that although the pilot was unaware of the supplementary procedures supporting the modification, these did not adequately address possible failure cases. Also, certification flight tests prior to modification approval did not identify the severity of some possible failure outcomes and corresponding Safety Recommendations were made to the system manufacturer and safety regulators.

On 11 November 2019, one of the two PW100 series engines of a Bombardier DHC8-300 failed catastrophically when takeoff power was set prior to brake release. The Investigation found that the power turbine shaft had fractured in two places and all first and second stage power turbine blades had separated from their disks. The shaft failure was found to have been caused by fatigue cracking initiated by corrosion pitting which was assessed as probably the result of prolonged marine low-altitude operations by the aircraft. It was found that this fatigue cracking could increase undetected during service between scheduled inspections.

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.

On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an Airbus A319 taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.

Component Fault After Installation

On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.

On 16 January 2010, an Iran Air Airbus A300-600 veered off the left side of the runway after a left engine failure at low speed whilst taking off at Stockholm. The directional control difficulty was attributed partly to the lack of differential braking but also disclosed wider issues about directional control following sudden asymmetry at low speeds. The Investigation concluded that deficiencies in the type certification process had contributed to the loss of directional control. It was concluded that the engine malfunction was due to the initiation of an engine stall by damage caused by debris from a deficient repair.

On 25 March 2008, an Air Atlanta Icelandic Boeing 747-300 was decelerating after landing at Dhaka when a fuel leak in the vicinity of the No 3 engine led to a fire which could not be extinguished. An emergency evacuation was accomplished with only a few minor injuries. The cause of the fuel leak was traced to mis-assembly of a fuel feed line coupling during a C Check some six months previously. The failure to follow clear AMM instructions for this task in two specific respects was of concern to the Investigating Agency.

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.

On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were injured.

Pilot Verbal-only Defect Communication

Shortly after take-off from Jersey Airport, Channel Islands, a F27 experienced an uncontained engine failure and a major fire external to the engine nacelle. The fire was extinguished and the aircraft landed uneventfully back at Jersey.

On 12 January 2009, the flight crew of an Easyjet Boeing 737-700 on an airworthiness function flight out of Southend lost control of the aircraft during a planned system test. Controlled flight was only regained after an altitude loss of over 9000 ft, during which various exceedences of the AFM Flight Envelope occurred. The subsequent investigation found that the Aircraft Operators procedures for such flights were systemically flawed.

On 28 November 2004, a KLM B737-400 departed laterally from the runway on landing at Barcelona due to the effects on the nosewheel steering of a bird strike which had occured as the aircraft took off from Amsterdam.

On September 13 2008, at night and in good visual conditions*, a Boeing 737-500 operated by Aeroflot-Nord executed an unstabilised approach to Runway 21 at Bolshoye Savino Airport (Perm) which subsequently resulted in loss of control and terrain impact.

On 22 December 1999, a KAL Boeing 747 freighter crashed shortly after take-off from Stansted UK, following an ADI malfunction.

Corrosion/Disbonding/Fatigue

On 31 December 2017, a de Havilland DHC2 floatplane being manoeuvred at low level over Jerusalem Bay shortly after takeoff was observed to enter a steeply banked turn from which it appeared to depart controlled flight and impact the water surface below almost vertically. The Investigation concluded that the aircraft had stalled despite the exemplary proficiency record of the pilot and that in the absence of any other plausible explanation found that the loss of control was likely to have been the effect of an elevated exposure to carbon monoxide found during post mortem toxicology testing.

On 11 November 2019, one of the two PW100 series engines of a Bombardier DHC8-300 failed catastrophically when takeoff power was set prior to brake release. The Investigation found that the power turbine shaft had fractured in two places and all first and second stage power turbine blades had separated from their disks. The shaft failure was found to have been caused by fatigue cracking initiated by corrosion pitting which was assessed as probably the result of prolonged marine low-altitude operations by the aircraft. It was found that this fatigue cracking could increase undetected during service between scheduled inspections.

On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.

On 27 August 2016, debris from sudden uncontained failure of the left CFM56-7B engine of a Boeing 737-700 climbing through approximately FL 310 west southwest of Pensacola in day VMC penetrated the fuselage barrel and caused a rapid depressurisation. An emergency descent and a diversion to Pensacola followed without further event. The Investigation found that collateral damage had followed low-cycle fatigue cracking of a single fan blade due to a previously unrecognised weakness in the design of this on-condition component which, because it had not been detected during the engine certification process, meant its consequences “could not have been predicted”.

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.

Cross Connection

On 11 November 2018, an Embraer 190-100LR just airborne on a post maintenance non revenue positioning flight became extremely difficult to control as it entered cloud despite the complete absence of any flight control warnings. After reversion to Direct Law, partial normal control was regained and, once visual, the flight was guided to an eventually successful landing. The Investigation found that the aircraft had been released from heavy maintenance with the aileron system incorrectly configured and attributed this primarily to the comprehensively dysfunctional working processes at the maintenance facility involved. Extensive airframe deformation meant the aircraft was a hull loss.

On 13 August 2012, an Ilyushin IL76 freighter overran landing runway 11 at St John's at 40 knots. The Investigation established that although a stabilised approach had been flown, the aircraft had been allowed to float in the presence of a significant tail wind component and had not finally touched down until half way along the 2590 metre long runway. It was also found that reverse thrust had then not been fully utilised and that cross connection of the brake lines had meant that the anti skid pressure release system worked in reverse sense, thus reducing braking effectiveness.

On 21 March 2001 an Airbus A320-200, operated by Lufthansa, experienced a flight controls malfunctions shortly after take-off which resulted in loss of control and subsequent near terrain impact. The uncontrolled roll, due to the malfunction of the pilot flying's sidestick, was recovered by the other pilot and the aircraft safely returned to land in Frankfurt without further incident.

Engine Compressor Washing

On 28 February 2019, an Airbus A320 abandoned takeoff from Exeter when fight deck fumes/smoke accompanied thrust applied against the brakes. When informed of similar conditions in the cabin, the Captain ordered an emergency evacuation. Some passengers using the overwing exits re-entered the cabin after becoming confused as to how to leave the wing. The Investigation attributed the fumes to an incorrectly-performed engine compressor wash arising in a context of poorly-managed maintenance and concluded that guidance on overwing exit use had been inadequate and that the 1.8 metre certification height limit for exits without evacuation slides should be reduced.

On 3 October 2015, an Airbus A320 which had just taken off from Dublin experienced fumes from the air conditioning system in both flight deck and cabin. A 'PAN' was declared and the aircraft returned with both pilots making precautionary use of their oxygen masks. The Investigation found that routine engine pressure washes carried out prior to departure have been incorrectly performed and a contaminant was introduced into the bleed air supply to the air conditioning system as a result. The context for the error was found to be the absence of any engine wash procedure training for the Operator's engineers.

On 9 September 2012, the crew of a DHC8-300 climbing out of Abu Dhabi declared a PAN and returned after visual evidence of the right engine overheating were seen from the passenger cabin. The Investigation found that the observed signs of engine distress were due to hot gas exiting through the cavity left by non-replacement of one of the two sets of igniters on the engine after a pressure wash carried out overnight prior to the flight and that the left engine was similarly affected. The context for the error was identified as a dysfunctional maintenance organisation at the Operator.

On 5 July 2006, during daytime, a Boeing 737-500, operated by Air Nippon Co., Ltd. took off from Fukuoka Airport as All Nippon Airways scheduled flight 2142. At about 08:10, while flying at 37,000 ft approximately 60 nm southeast of Kushimoto VORTAC, a cabin depressurization warning was displayed and the oxygen masks in the cabin were automatically deployed. The aircraft made an emergency descent and, at 09:09, landed on Chubu International Airport.

Ejected Engine Failure Debris

On 11 November 2019, one of the two PW100 series engines of a Bombardier DHC8-300 failed catastrophically when takeoff power was set prior to brake release. The Investigation found that the power turbine shaft had fractured in two places and all first and second stage power turbine blades had separated from their disks. The shaft failure was found to have been caused by fatigue cracking initiated by corrosion pitting which was assessed as probably the result of prolonged marine low-altitude operations by the aircraft. It was found that this fatigue cracking could increase undetected during service between scheduled inspections.

On 27 August 2016, debris from sudden uncontained failure of the left CFM56-7B engine of a Boeing 737-700 climbing through approximately FL 310 west southwest of Pensacola in day VMC penetrated the fuselage barrel and caused a rapid depressurisation. An emergency descent and a diversion to Pensacola followed without further event. The Investigation found that collateral damage had followed low-cycle fatigue cracking of a single fan blade due to a previously unrecognised weakness in the design of this on-condition component which, because it had not been detected during the engine certification process, meant its consequences “could not have been predicted”.

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.

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.

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.

Dispatch of Unserviceable Aircraft

On 13 April 2013, an Air France Airbus A330-200 was damaged during a hard (2.74 G) landing at Caracas after the aircraft commander continued despite the aircraft becoming unstabilised below 500 feet agl with an EGPWS ‘SINK RATE’ activation beginning in the flare. Following a superficial inspection, maintenance personnel determined that no action was required and released the aircraft to service. After take off, it was impossible to retract the landing gear and the aircraft returned. Considerable damage from the earlier landing was then found to both fuselage and landing gear which had rendered the aircraft unfit to fly.

On 27 February 2001, a Loganair SD3-60 lost all power on both engines soon after take off from Edinburgh. An attempt to ditch in the Firth or Forth in rough seas resulted in the break up and sinking of the aircraft and neither pilot survived. The loss of power was attributed to the release of previously accumulated frozen deposits into the engine core when the engine anti icing systems were selected on whilst climbing through 2200 feet. These frozen deposits were considered to have accumulated whilst the aircraft had been parked prior to flight without engine intake blanks fitted.

On 12 October 2018, the crew of a Boeing 737-400 already released to service under MEL conditions with an inoperative No 1 engine generator encountered a loss of services from the No 2 electrical system en-route to East Midlands which created a situation not addressed by QRH procedures. The flight was completed and both the new and existing defects were subsequently rectified relatively easily. The Investigation concluded that the operator involved appeared to be prioritising operational requirements over aircraft serviceability issues and made a range of Safety Recommendations aimed at improving company safety culture and the effectiveness of regulatory oversight.

On 11 November 2018, an Embraer 190-100LR just airborne on a post maintenance non revenue positioning flight became extremely difficult to control as it entered cloud despite the complete absence of any flight control warnings. After reversion to Direct Law, partial normal control was regained and, once visual, the flight was guided to an eventually successful landing. The Investigation found that the aircraft had been released from heavy maintenance with the aileron system incorrectly configured and attributed this primarily to the comprehensively dysfunctional working processes at the maintenance facility involved. Extensive airframe deformation meant the aircraft was a hull loss.

On 16 July 2016, an Airbus A321’s unstabilised approach at Fuerteventura during pilot line training was not discontinued and takeover of control and commencement of a go-around had occurred just before a very hard runway contact. The subsequent landing was successful but serious damage to the main landing gear was not rectified before the next flight. The Investigation found that the hard touchdown had been recorded as in excess of 3.3g and that the return flight had been “risky and unsafe” after failure of the Captain and maintenance personnel at the Operator to recognise the seriousness of the hard landing.

Maintenance FOD

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.

On 27 October 2017, an Airbus A320 returned to Auckland after advice from ATC that the right engine may have been affected by ingestion of FOD during engine start - a clipboard and paper left just inside the right hand engine by an employee of the airline’s ground handling contractor acting as the aircraft loading supervisor. The subsequent inspection found paper throughout the engine and minor damage to an engine fan blade and the fan case attrition liner. The Dispatcher overseeing the departure said she had seen the clipboard inside the engine but assumed it would be retrieved before departure.

On 11 February 2017, a Cessna 402 failed to stop on the runway when landing at Virgin Gorda and was extensively damaged. The Investigation noted that the landing distance required was very close to that available with no safety margin so that although touchdown was normal, when the brakes failed to function properly, there was no possibility of safely rejecting the landing or stopping normally on the runway. Debris in the brake fluid was identified as causing brake system failure. The context was considered as the Operator s inadequate maintenance practices and a likely similar deficiency in operational procedures and processes.

In flight separation of failed component

On 14 August 2018, an Airbus A320 departed Perth without full removal of its main landing gear ground locks and the unsecured components fell unseen from the aircraft during taxi and takeoff, only being recovered after runway FOD reports. The Investigation identified multiple contributory factors including an inadequately-overseen recent transfer of despatch responsibilities, the absence of adequate ground lock use procedures, the absence of required metal lanyards linking the locking components not attached directly to each gear leg flag (as also found on other company aircraft) and pilot failure to confirm that all components were in the flight deck stowage.

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.

On 17 March 2017, uncommanded engine indications on a Saab 340B en route to Sydney were followed by vibration of the right engine after which, as the crew commenced right engine shutdown, its propeller assembly separated from the engine. A PAN was declared and the flight subsequently reached Sydney without further event. The Investigation found that the propeller gearbox shaft had fractured because of undetected internal fatigue cracking in the shaft. Applicable in-service shaft inspection procedures were found to be inadequate and mandatory enhancements to these procedures have since been introduced.

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.

On 16 October 2015, the unlatched fan cowl doors of the left engine on an A320 fell from the aircraft during and soon after takeoff. The one which remained on the runway was not recovered for nearly an hour afterwards despite ATC awareness of engine panel loss during takeoff and as the runway remained in use, by the time it was recovered it had been reduced to small pieces. The Investigation attributed the failure to latch the cowls shut to line maintenance and the failure to detect the condition to inadequate inspection by both maintenance personnel and flight crew.

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