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 18 October 2019, a Boeing 787-9 descending to 4,500 feet to join the ILS for runway 25R at Hong Kong at 15 nm from touchdown failed to establish on the localiser. The autopilot was disconnected and the aircraft manually positioned onto the localiser from the north establishing at 12 nm with terrain proximity not sufficient to activate the EGPWS. It was found that the deviation was attributable to an anomaly in the aircraft type Autopilot Flight Director System and a corresponding Alert Service Bulletin was issued by Boeing to replace the faulty system component.

On 22 November 2021, a Fokker F100 crew discovered as they neared their intended destination, Paraburdo, that the pre-departure forecast weather was so inaccurate that instead of the anticipated benign conditions, a much lower actual cloud base prevailed on a sector where additional fuel reserves were carried in place of the usual designated alternate(s). A delay in recognising the potential implications of initially unsuccessful approaches and difficulty in obtaining updated present and forecast weather for potential diversion options resulted in a fourth approach being intentionally continued very significantly below minima, albeit successfully. Relevant aircraft operator procedures were identified as inadequate.

On 22 April 2019, a Eurocopter-Kawasaki BK-117C-1 helicopter was being positioned for an aeromedical evacuation the following day when it was unintentionally flown into the sea at night. The three crew members were able to evacuate from the partially submerged aircraft before it sank. The accident was attributed to the single pilot’s loss of situational awareness due to loss of visual depth perception when using night vision goggles. The relevant aircraft operator procedures and the applicable regulatory requirements were both found be inadequate relative to the operational risk which the flight involved.

On 20 October 2021, the flight crew of a Bombardier CRJ1000 making a LNAV/VNAV approach at Nantes using Baro-VNAV minima read back an incorrect QNH which was not noticed by the controller. The crew then flew the approach approximately 530 feet below the procedure vertical profile which led to the MSAW system being activated and advised to the flight. The crew response was delayed until the controller had twice repeated the correct QNH after which the error was recognised and the vertical profile corrected. The investigation noted that neither the operator’s procedures nor aircraft instruments allowed straightforward crew detection of their error.

On 23 January 2020, a Bombardier CRJ700 making a HUD-supported manual Cat 3a ILS approach to Lyon Saint-Exupéry in freezing fog conditions deviated from the required flight path localiser and reached a minimum of 265 feet agl before a go around was initiated without initially being flown in accordance with standard procedures. The Captain involved was relatively new to type and had not previously flown such an approach in actual low visibility conditions. The Investigation was not able to determine exactly what contributed to the approach and initial go around being misflown but identified a number of possible contributors.

On 1 November 2021, a deHavilland DHC6-300 crew en-route to Fort Simpson realised that they had insufficient fuel on board to reach their intended destination and therefore decided to attempt a diversion to the nearest available airport at Fort Providence. As fuel available dwindled, one engine was shut down but after an inadvertent fuel tank selection, the initially intended diversion was no longer possible and a forced landing in a bog was successfully accomplished. The Training Captain involved had developed a habit of performing checklists silently and from memory after gaining all his professional pilot experience at the same operator.

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 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.

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 the augmented crew’s absence of 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. 

 

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