Accident and Serious Incident Reports: CFIT

Accident and Serious Incident Reports: CFIT

Definition

Reports relating to accidents which resulted in Controlled Flight Into Terrain (CFIT) and serious incidents which could have resulted in CFIT.

The accident and serious incident reports are grouped together below in subcategories according to phase of flight.

En-route

On 24 March 2015, after waiting for the Captain to leave the flight deck and preventing his return, a Germanwings A320 First Officer put his aircraft into a continuous descent from FL380 into terrain killing all 150 occupants. Investigation concluded the motive was suicide, noted a history of mental illness dating from before qualification as a pilot and found that prior to the crash he had been experiencing mental disorder with psychotic symptoms which had not been detected through the applicable process for medical certification of pilots. Conflict between the principles of medical confidentiality and wider public interest was identified.

On 23 January 2013, a Canadian-operated DHC6 on day VFR positioning flight in Antarctica was found to have impacted terrain under power and whilst climbing at around the maximum rate possible. The evidence assembled by the Investigation indicated that this probably occurred following entry into IMC at an altitude below that of terrain in the vicinity having earlier set course en route direct to the intended destination. The aircraft was destroyed and there were no survivors.

On 15 March 2012, a Royal Norwegian Air Force C130J-30 Hercules en route on a positioning transport flight from northern Norway to northern Sweden crossed the border, descended into uncontrolled airspace below MSA and entered IMC. Shortly after levelling at FL 070, it flew into the side of a 6608 foot high mountain. The Investigation concluded that although the direct cause was the actions of the crew, Air Force procedures supporting the operation were deficient. It also found that the ATC service provided had been contrary to regulations and attributed this to inadequate controller training.

On 9 May 2012, a Sukhoi RRJ-95 on a manufacturer-operated demonstration flight out of Jakarta Halim descended below the promulgated safe altitude and, after TAWS alerts and warnings had been ignored, impacted terrain in level flight which resulted in the destruction of the aeroplane and death of all 45 occupants. The Investigation concluded that that the operating crew were unaware that their descent would take them below some of the terrain in the area until the alerts started and then assumed they had been triggered by an incorrect database and switched the equipment off.

On 19 December 2002, a Piper PA-46 Malibu, after takeoff from Son Bonet Aerodrome, penetrated the control zone (CTR) of Palma de Mallorca tower. The pilot was instructed to leave the CTR and the aircraft headed towards mountainous terrain to the north of the island where the flight conditions were below the VFR minimum. In level flight the aircraft impacted terrain at an altitude of 2000 ft killing all three occupants.

On 26 August 2003, at night, a Eurocopter EC155, operated by Hong Kong Government Flight Service (GFS), performing a casualty evacuation mission (casevac), impacted the elevated terrain in Tung Chung Gap near Hong Kong International airport.

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

Approach and Landing

On 4 March 2019, an Embraer 145 attempting to land off an ILS approach at Presque Isle in procedure-minima weather conditions flew an unsuccessful first approach and a second in similar conditions which ended in a crash landing abeam the intended landing runway substantially damaging the aircraft. The accident was attributed to the crew decision to continue below the applicable minima without acquiring the required visual reference and noted that the ILS localiser had not been aligned with the runway extended centreline and that a recent crew report of this fault had not been promptly passed to the same Operator.

On 1 January 2020, an Airbus A350-900 made an unstabilised night ILS approach to Frankfurt in good visual conditions, descending prematurely and coming within 668 feet of terrain when 6nm from the intended landing runway before climbing to position for another approach. A complete loss of situational awareness was attributed to a combination of waypoint input errors, inappropriate autoflight management and communication and cooperation deficiencies amongst the operating and augmenting flight crew on the flight deck who were all type-rated holders of Thai-issued ATPLs. Neither of the observing pilots detected anything abnormal with the way the approach was being flown.

On 10 September 2017, the First Officer of a Gulfstream G550 making an offset non-precision approach to Paris Le Bourget failed to make a correct visual transition and after both crew were initially slow to recognise the error, an unsuccessful attempt at a low-level corrective realignment followed. This had not been completed when the auto throttle set the thrust to idle at 50 feet whilst a turn was being made over the runway ahead of the displaced threshold and one wing was in collision with runway edge lighting. The landing attempt was rejected and the Captain took over the go-around.

On 24 February 2016 a DHC6 (9N-AHH) on a VFR flight to Jomsom which had continued towards destination after encountering adverse weather impacted remote rocky terrain at an altitude of almost 11,000 feet approximately 15 minutes after takeoff after intentionally and repeatedly entering cloud in order to reach the destination. The aircraft was destroyed and all on board were killed. The Investigation attributed this to the crew’s repeated decision to fly in cloud and their deviation from the intended route after losing situational awareness. Spatial disorientation followed and they then failed to respond to repeated EGPWS cautions and warnings.

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

On 23 May 2022, an Airbus A320 came extremely close to collision with terrain as the crew commenced a go around they did not obtain any visual reference during a RNP approach at Paris CDG for which they were using baro-VNAV reference to fly to VNAV/LNAV minima. The corresponding ILS was out of service. The Investigation has not yet completely established the context for the event but this has been confirmed to include the use of an incorrect QNH which resulted in the approach being continued significantly below the procedure MDA. Six Interim Safety Recommendations have been issued.

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

On 14 March 2017, control of a Sikorsky S92A positioning in very poor visibility at 200 feet over the sea in accordance with an obstacle-marked FMS ground track in order to refuel at a coastally-located helipad was lost after it collided with late-sighted terrain ahead before crashing into the sea killing all on board. The Investigation attributed the accident to the lack of crew terrain awareness but found a context of inadequate safety management at the operator, the comprehensively ineffective regulatory oversight of the operation and confusion as to responsibility for State oversight of its contract with the operator.

On 14 October 2019, a Sikorsky S92A manoeuvring below low cloud in poor daylight visibility in an unsuccessful attempt to locate the intended private landing site flew north towards rising ground approximately ¾ mile east of it, coming within a recorded 28 feet above terrain near to occupied houses before making an emergency climb and over-torqing the engines followed by an unstable but successful second approach. The Investigation found relevant operator procedures absent or ineffective, an intention by the management pilot in command to reach the landing site despite conditions and uncertainty about the applicable regulatory context for the flight. 

On 16 July 2020, an Antonov AN26 on which a new Captain’s final line check was being performed made two consecutive non-precision approaches to Runway 33 at Birmingham both of which resulted in ATC instructing the aircraft to go around because of failure to follow the prescribed vertical profile. A third approach using the ILS procedure for runway 15 was successful. On the limited evidence available, the Investigation was unable to explain the inability to safely perform the attempted two non precision approaches to runway 33 or the continuation of them until instructed to go around by ATC.

On 29 January 2015, a Boeing 737-800 crew attempting to fly an NDB approach to Bergerac, with prior awareness that it would be necessary because of pre-notified ILS and DME unavailability, descended below 800 feet agl in IMC until an almost 1000 feet per minute descent when still over 8 nm from the runway threshold triggered an EGPWS ‘TERRAIN PULL UP’ warning and the simultaneous initiation of a go-around. The Investigation found that the PF First Officer was unfamiliar with NDB approaches but had not advised the Captain which resulted in confusion and loss of situational awareness by both pilots.

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 5 August 2019, a Cessa 560XLS touched down in runway undershot at Aarhus whilst making a night ILS approach there and damage sustained when it collided with parts of the ILS LOC antenna caused a fuel leak which after injury-free evacuation of the occupants then ignited destroying most of the aircraft. The Investigation attributed the accident to the Captain’s decision to intentionally fly below the ILS glideslope in order to touch down at the threshold and to the disabling of the EGWPS alerting function in the presence of a steep authority gradient, procedural non-compliance and poor CRM.

On 2 September 2016, an ATR72-600 cleared to join the ILS for runway 28 at Dublin continued 800 feet below cleared altitude triggering an ATC safe altitude alert which then led to a go around from around 1000 feet when still over 5nm from the landing runway threshold. The Investigation attributed the event broadly to the Captain’s inadequate familiarity with this EFIS-equipped variant of the type after considerable experience on other older analogue-instrumented variants, noting that although the operator had provided simulator differences training, the -600 was not classified by the certification authority as a type variant.

On 25 March 2019, a Boeing 737-800 making a non-precision daylight approach to Lanzarote with line training in progress began descending below the correct approach profile shortly after visual acquisition of the runway at 10nm when a much lower altitude than specified was maintained, EGPWS ‘CAUTION TERRAIN’ and ‘TERRAIN PULL UP’ activations eventually followed. With the terrain below clearly visible, the autopilot and autothrottle were disconnected and the aircraft flown level until the correct profile was regained after which the flight was then completed without further event. The Investigation made no findings which would fully explain the procedural non-compliance involved.

 

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