Accident and Serious Incident Reports: LOC

Accident and Serious Incident Reports: LOC

Definition

Reports relating to accidents or serious incidents which involved in flight Loss of Control as a significant causal factor.

The accident and serious incident reports are grouped together below according to causal factors which led to loss of control.

Airframe Structural Failure

On 5 January 2024, a Boeing 737-9 which had just departed Portland was climbing through 14,800 feet when there was a loud bang followed by a rapid decompression. The cause - the loss of a fuselage plug fitted at an unused door location - was immediately obvious. An emergency was declared and a landing back at Portland was made after a total of twenty minutes airborne. The Investigation is continuing but has found that the fuselage plug involved was installed without being properly secured and noted that the aircraft had only recently been delivered new to the operator.

On 1 August 2019, an Airbus A320 annunciated an abnormal gear status indication when retraction was attempted after takeoff. Soon afterwards, an aircraft part was observed by an aircraft following the same taxi route as the A320 and recovered. After completing relevant drills, the A320 returned and completed a landing with significant damage to the left main gear which was nevertheless locked down. The runway was vacated and passengers disembarked. The Investigation found that the cause of the problem was the cyclic fatigue of a pin linking the two parts of the left main gear torque link of manufacturing origin.

On 21 January 2019, a Piper PA46-310P en-route north northwest of Guernsey was reported missing and subsequently confirmed to have broken up in flight during an uncontrolled descent. The Investigation found that neither the pilot nor the aircraft involved were able to be used for commercial passenger flight operations but also found that although the direct cause of loss of control was unproven, it was most likely the consequence of carbon monoxide poisoning originating from an exhaust system leak. The safety implications arising from operation of private flights for commercial passenger transport purposes contrary to regulatory requirements were also highlighted.

On 25 March 2018, an ATR 42-500 main landing gear bay door weighing 15 kg detached shortly after a night descent had begun but this was unknown until the flight arrived at Aurillac. The Investigation found that the root cause of the detachment was a loose securing nut which had triggered a sequence of secondary failures within a single flight which culminated in the release of the door. It was concluded that the event highlighted specific and systemic weakness in relevant airworthiness documentation and practice in relation to the lost door and the use of fasteners on this aircraft type generally.

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”.

Significant Systems or Systems Control Failure

On 17 November 2021, shortly after a Boeing 737-800 commenced initial descent into Patna from FL350, a cautionary alert indicating automatic pressurisation system failure was annunciated. When the initial actions of the prescribed non-normal procedure did not resolve the problem, the system outflow valve was fully opened and a rapid depressurisation followed. After this incorrect action, the relevant crew emergency procedures were then comprehensively not properly followed and it was further concluded that the Captain had temporarily lost consciousness after a delay in donning his oxygen mask. The context for the mismanaged response was identified as outflow valve in-service failure.

On 29 September 2019, an Airbus A330-200 received simultaneous indications of low pressure in two hydraulic systems soon after takeoff. An emergency was declared and a return to land was followed by a stop on the runway due to a burst main wheel tyre. A manual valve for one of the hydraulic systems located in the left main gear wheel well had completely detached and impact-damaged a pipe in a nearby but separate hydraulic system. Both systems lost their fluid with valve detachment attributed to fatigue failure of the attachment screws, a risk addressed by an un-adopted non-mandatory Service Bulletin. 

On 14 September 2021 the crew of a Saab S340B being used for type conversion training purposes were unable to cross start the left engine after it had been temporarily shut down to demonstrate single engine handling performance because the right starter-generator failed. A MAYDAY was declared and after prompt electrical load shedding, sufficient battery power remained to complete a successful diversion. The starter-generator failure was suspected to be attributable to its use whilst in service with a previous operator to support multiple starts at intervals which were insufficient to allow the unit to cool.

On 7 June 2021 an Embraer ERJ170 had just commenced its descent towards destination when both primary and secondary pitch trim systems failed resulting in excessive nose-down pitch control forces and an inoperative autopilot. The flight was completed without further event with the Pilot Flying using both hands on the control yoke to control pitch attitude manually. During the landing roll the nosewhweel steering system also failed. The pitch trim failure was attributed to probable jamming of the trim actuator due to water, possibly condensation, freezing within it. The steering system fault was attributed to a completely unrelated sensor failure.

On 23 February 2019, a Raytheon B200 King Air which had recently departed Saanen was passing FL155 for cleared altitude FL240 when a total electrical failure occurred. On subsequently making contact with ATC on a hand-held personal radio, the pilot advised his intention to exit controlled airspace and complete an already commenced visual diversion to Lausanne which was then done. It was found that failure to use the prescribed normal checklists had resulted in an undetected electrical system selection error which had led to the successive discharge of both main batteries when corresponding alerts and warnings also went unnoticed.

Degraded flight instrument display

On 23 February 2019, a Raytheon B200 King Air which had recently departed Saanen was passing FL155 for cleared altitude FL240 when a total electrical failure occurred. On subsequently making contact with ATC on a hand-held personal radio, the pilot advised his intention to exit controlled airspace and complete an already commenced visual diversion to Lausanne which was then done. It was found that failure to use the prescribed normal checklists had resulted in an undetected electrical system selection error which had led to the successive discharge of both main batteries when corresponding alerts and warnings also went unnoticed.

On 6 February 1996, a Boeing 757-200 took off from Puerto Plata at night despite awareness at the 80 knot check that the Captains altimeter was not working. Thereafter, the crew became confused as to their actual airspeed and lost control before the aircraft hit the sea surface less than five minutes after takeoff. The Investigation found that the Captain’s pitot probe was blocked and that the three pilots on the flight deck had become confused about which airspeed indications were reliable and had then not recovered from an aerodynamic stall which followed the wholly avoidable mismanagement of the aircraft flight path.

On 18 July 2018, an Airbus A330-300 failed to reject its night takeoff from Brisbane despite the absence of any airspeed indication for either pilot. A PAN call was made as a climb to FL110 continued. Once there, preparations for a somewhat challenging return were made and subsequently achieved. The Investigation noted multiple missed opportunities, including non-compliance with several procedural requirements, to detect that all pitot mast covers had remained in place and was extremely concerned that the takeoff had been continued rather than rejected. Flawed aircraft operator ground handling procedures and ineffective oversight of contractors were also deemed contributory.

On 9 June 2021, an Airbus A320 Captain performing a relatively light weight and therefore rapid-acceleration takeoff from London Heathrow recognised as the standard 100 knot call was imminent that he had no speed indication so announced and performed a high speed rejected takeoff. Subsequent maintenance inspection found that the left pitot mast was blocked by the nest of a seasonally active solitary flying insect, noting that the aircraft had previously been parked for 24 hours on a non-terminal stand. Similar events, including another rejected takeoff, then followed and a comprehensive combined Investigation found all were of similar origin.

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 years earlier with a contaminated component which had slowly caused sensor malfunction to develop.

Uncommanded AP disconnect

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 4 March 2016, the flight crew of an ATR72-500 decided to depart from Manchester without prior ground de/anti icing treatment judging it unnecessary despite the presence of frozen deposits on the airframe and from rotation onwards found that manual forward control column input beyond trim capability was necessary to maintain controlled flight. The aircraft was subsequently diverted. The Investigation found that the problem had been attributable to ice contamination on the upper surface of the horizontal tailplane. It was considered that the awareness of both pilots of the risk of airframe icing had been inadequate.

On 27 February 2012, the crew of an Airbus A330 en route at night and crossing the East African coast at FL360 encountered sudden violent turbulence as they flew into a convective cell not seen on their weather radar and briefly lost control as their aircraft climbed 2000 feet with resultant minor injuries to two occupants. The Investigation concluded that the isolated and rapidly developing cell had not been detected because of crew failure to make proper use of their weather radar, but noted that activation of flight envelope protection and subsequent crew action to recover control had been appropriate.

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 24 May 2013 the fan cowl doors on both engines of an Airbus A319 detached as it took off from London Heathrow. Their un-latched status after a routine maintenance input had gone undetected. Extensive structural and system damage resulted and a fire which could not be extinguished until the aircraft was back on the ground began in one engine. Many previously-recorded cases of fan cowl door loss were noted but none involving such significant collateral damage. Safety Recommendations were made on aircraft type certification in general, A320-family aircraft modification, maintenance fatigue risk management and aircrew procedures and training.

AP Status Awareness

On 23 February 2019, a Boeing 767-300 transitioned suddenly from a normal descent towards Houston into a steep dive and high speed terrain impact followed. The Investigation found that after neither pilot had noticed the First Officer’s inadvertent selection of go around mode during automated flight, the First Officer had then very quickly responded with an increasingly severe manual pitch-down, possibly influenced by a somatogravic illusion. He was found to have had a series of short air carrier employments terminating after failure to complete training, had deliberately and repeatedly sought to conceal this history and lacked sufficient aptitude and competency.

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 20 October 2013, a Boeing 757-200 Co-Pilot believed his aircraft was at risk of stalling when he saw a sudden low airspeed indication on his display during a night descent and reacted by increasing thrust and making abrupt pitch-down inputs. Other airspeed indications remained unaffected. The Captain took control and recovery to normal flight followed. The excursion involved a significant Vmo exceedance, damage to and consequent failure of one of the hydraulic systems and passengers and cabin crew injuries. The false airspeed reading was attributed by the Investigation to transient Ice Crystal Icing affecting one of the pitot probes.

On 17 November 2013, the crew of a Boeing 737-500 failed to establish on the ILS at Kazan after not following the promulgated intermediate approach track due to late awareness of LNAV map shift. A go around was eventually initiated from the unstabilised approach but the crew appeared not to recognise that the autopilot used to fly the approach would automatically disconnect. Non-control followed by inappropriate control led to a high speed descent into terrain less than a minute after go around commencement. The Investigation found that the pilots had not received appropriate training for all-engine go arounds or upset recovery.

On 1 October 2014, an Embraer 190 made a very hard landing at Amsterdam after the flight crew failed to recognise that the aircraft had not been configured correctly for the intended automatic landing off the Cat 1 ILS approach being flown. They were slow to respond when no automatic flare occurred. The Investigation was unable to fully review why the configuration error had occurred or why it had not been subsequently detected but the recent type conversion of both the pilots involved was noted.

Non-normal FBW flight control status

On 6 November 2018, an Airbus A340-600 in the cruise northbound over the Swiss Alps received an overspeed warning after encountering an unexpected wind velocity change but the crew failed to follow the prescribed response procedure. This led initially to a climb above their cleared level and further inappropriate actions were then followed by PAN and MAYDAY declarations as control of the aircraft was briefly lost in a high speed descent to below their cleared level. The operator subsequently enhanced pilot training realism by providing it in a simulator configured for the aircraft variant operated and introduced ‘upset recovery training’.

On 14 September 2010, the crew of a Sichuan Airlines Airbus A319 continued an ILS approach into Wuxi despite awareness of adverse convective weather conditions at the airport. Their inattention to automation management then led to a low energy warning and the inappropriate response to this led to the activation of flight envelope protection quickly followed by a stall warning. Inappropriate response to this was followed by loss of control and a full stall and high rate of descent from which recovery was finally achieved less than 900 feet agl.

On 28 February 2018, an Airbus A320 would not rotate for a touch-and-go takeoff and flightpath control remained temporarily problematic and the aircraft briefly settled back onto the runway with the gear in transit damaging both engines. A very steep climb was then followed by an equally steep descent to 600 feet agl with an EGPWS ‘PULL UP’ activation before recovery. Pitch control was regained using manual stabiliser trim but after both engines stopped during a MAYDAY turnback, an undershoot touchdown followed. The root cause of loss of primary pitch control was determined as unapproved oil in the stabiliser actuator.

On 12 September 2015, an Airbus A320 autopilot and autothrust dropped out as it climbed out of Perth and multiple ECAM system messages were presented with intermittent differences in displayed airspeeds. During the subsequent turn back in Alternate Law, a stall warning was disregarded with no actual consequence. The Investigation attributed the problems to intermittently blocked pitot tubes but could not establish how this had occurred. It was also found that the priority for ECAM message display during the flight had been inappropriate and that the key procedure contained misleading information. These ECAM issues were subsequently addressed by the aircraft manufacturer.

On 5 May 2019, a Sukhoi RRJ-95B making a manually-flown return to Moscow Sheremetyevo after a lightning strike caused a major electrical systems failure soon after departure made a mismanaged landing which featured a sequence of three hard bounces of increasing severity. The third of these occurred with the landing gear already collapsed and structural damage and a consequential fuel-fed fire followed as the aircraft veered off the runway at speed. The subsequent evacuation was only partly successful and 41 of the 73 occupants died and 3 sustained serious injury. An Interim Report has been published.

Loss of Engine Power

On 12 September 2021, a Boeing 777-300 in the cruise at FL 380 and approaching Oman from the east at night experienced a sudden left engine failure. It was shut down, a PAN call was made and diversion to Muscat made in preference to completing the intended flight to Abu Dhabi. An off-wing examination of the GE90 engine which failed found that the hydro-mechanical unit of the accessory gearbox had malfunctioned in a way which allowed fuel to mix with the engine oil. This failure had not been anticipated in the applicable Fault Identification Manual which was amended accordingly.

On 10 August 2019, the left Rolls Royce Trent 1000 engine of a Boeing 787-8 just airborne from Rome Fiumicino suddenly malfunctioned and was shut down. A MAYDAY was declared and the flight returned for an overweight landing during which both left main gear tyres deflated. The underlying cause of the engine failure was found to have been intermediate pressure turbine blade detachment attributable to previously-identified serviceability issues. Wider concerns were identified in relation to the key underlying engine certification standards and to the hazard created by the ejection of large quantities of engine debris into a densely populated area.

On 20 July 2021, a Boeing 747-8F experienced a series of problems with an overspeed and fire affecting the left outboard engine soon after takeoff from Hong Kong and although it was shut down, the fire continued until just before landing. About twenty minutes after landing trapped residual leaked fuel then auto-ignited and that fire was quickly extinguished. The origin of the engine malfunction and continuing airborne fire was identified as undetected improper installation of a component in the engine’s Fuel Metering Unit at build which caused a fuel leak that was the sole origin of the engine malfunction.

On 20 January 2020, a DHC8-300 encountered severe icing conditions and both engines successively failed during its approach to Bergen. The automatic ignition system restarted the engines but for a short time the aircraft was completely without power. It was concluded that ice had accreted on and then detached from the engine air inlets and either entered the combustion chamber partly melted and caused a flameout or disrupted the airflow into the engine sufficiently to stall it. Shortcomings were identified in the operator’s documentation for operation in icing conditions and further review of weather radar use by ATC is recommended.

On 25 November 2021, a Fokker F50 departing Helsinki experienced an engine malfunction which resulted in un-commanded propeller feathering following which the associated engine continued to run until shutdown during which time it began to overspeed. Recovery to a landing was subsequently achieved but the failure experienced was untrained and this led to both direct and indirect consequences which resulted in a sub optimal crew response to the emergency. The Investigation also highlighted opportunities to improve aspects of the air traffic control emergency response during such emergencies and identified language proficiency certification issues.

Crew Incapacitation

On 29 October 2019, an Airbus A321 was descending towards its destination, Kaohsiung, when the First Officer suddenly lost consciousness without warning. The Captain declared a MAYDAY and with cabin crew assistance, he was secured clear of the flight controls and given oxygen which appeared beneficial. He was then removed to the passenger cabin where a doctor recommended continuing oxygen treatment. On arrival, he had fully regained consciousness. Medical examination and tests both on arrival and subsequently were unable to identify a cause although a context of cumulative fatigue was considered likely after three consecutive nights of inadequate sleep.

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

On 21 January 2019, a Piper PA46-310P en-route north northwest of Guernsey was reported missing and subsequently confirmed to have broken up in flight during an uncontrolled descent. The Investigation found that neither the pilot nor the aircraft involved were able to be used for commercial passenger flight operations but also found that although the direct cause of loss of control was unproven, it was most likely the consequence of carbon monoxide poisoning originating from an exhaust system leak. The safety implications arising from operation of private flights for commercial passenger transport purposes contrary to regulatory requirements were also highlighted.

On 15 August 2016, the cognitive condition of an Airbus A320 Captain deteriorated en-route to Riga and he assigned all flight tasks to the First Officer. When his condition deteriorated further, an off duty company First Officer travelling as a passenger was invited to occupy the flight deck supernumerary crew seat to assist. Once descent had commenced, the Captain and assisting First Officer swapped seats and the flight was thereafter completed without any further significant event. The Investigation concluded that the Captain’s serious physical and mental exhaustion had been the result of the combined effect of chronic fatigue and stress.

On 15 August 2018, a Boeing 737-300SF crew concerned about a small residual pressure in a bleed air system isolated after a fault occurred en-route then sought and were given non-standard further troubleshooting guidance by company maintenance which, when followed, led directly and indirectly to additional problems including successive incapacitation of both pilots and a MAYDAY diversion. The Investigation found that the aircraft concerned was carrying a number of relevant individually minor undetected defects which meant the initial crew response was not completely effective and prompted a request for in-flight assistance which was unnecessary and led to the further outcomes.

Flight Management Error

On 17 November 2021, shortly after a Boeing 737-800 commenced initial descent into Patna from FL350, a cautionary alert indicating automatic pressurisation system failure was annunciated. When the initial actions of the prescribed non-normal procedure did not resolve the problem, the system outflow valve was fully opened and a rapid depressurisation followed. After this incorrect action, the relevant crew emergency procedures were then comprehensively not properly followed and it was further concluded that the Captain had temporarily lost consciousness after a delay in donning his oxygen mask. The context for the mismanaged response was identified as outflow valve in-service failure.

On 6 November 2018, an Airbus A340-600 in the cruise northbound over the Swiss Alps received an overspeed warning after encountering an unexpected wind velocity change but the crew failed to follow the prescribed response procedure. This led initially to a climb above their cleared level and further inappropriate actions were then followed by PAN and MAYDAY declarations as control of the aircraft was briefly lost in a high speed descent to below their cleared level. The operator subsequently enhanced pilot training realism by providing it in a simulator configured for the aircraft variant operated and introduced ‘upset recovery training’.

On 25 November 2021, a Fokker F50 departing Helsinki experienced an engine malfunction which resulted in un-commanded propeller feathering following which the associated engine continued to run until shutdown during which time it began to overspeed. Recovery to a landing was subsequently achieved but the failure experienced was untrained and this led to both direct and indirect consequences which resulted in a sub optimal crew response to the emergency. The Investigation also highlighted opportunities to improve aspects of the air traffic control emergency response during such emergencies and identified language proficiency certification issues.

On 3 August 2009, control of a rotary UAV being operated by an agricultural cooperative for routine crop spraying in the south western part of South Korea was lost and the remote pilot was fatally injured when it then collided with him. The Investigation found that an inappropriately set pitch trim switch went unnoticed and the consequentially unexpected trajectory was not recognised and corrected. The context was assessed as inadequacies in the operator’s safety management arrangements and the content of the applicable UAV Operations Manual as well as lack of recurrent training for the operators’ qualified UAV remote pilots.

On 8 February 2021, an Embraer 500 Phenom 100 (9H-FAM) crew lost control of their aircraft shortly before the intended touchdown when it stalled due to airframe ice contamination. The resulting runway impact collapsed the nose and main gear, the latter causing fuel leak and resultant fire as the aircraft slid along the runway before veering off it. The Investigation found that flight in icing conditions during the approach had not been accompanied by the prescribed use of the airframe de-icing system and that such non compliance appeared to be routine and its dangers unappreciated.

Flight Control Error

On 6 November 2018, an Airbus A340-600 in the cruise northbound over the Swiss Alps received an overspeed warning after encountering an unexpected wind velocity change but the crew failed to follow the prescribed response procedure. This led initially to a climb above their cleared level and further inappropriate actions were then followed by PAN and MAYDAY declarations as control of the aircraft was briefly lost in a high speed descent to below their cleared level. The operator subsequently enhanced pilot training realism by providing it in a simulator configured for the aircraft variant operated and introduced ‘upset recovery training’.

On 11 October 2019, an Embraer ERJ195LR abandoned an initial landing attempt at Warsaw after a hard bounce but the correct go-around procedure was not followed. The rate of climb rapidly increased to over 4000 feet per minute. Concurrently, the required engine thrust was not set and airspeed rapidly diminished to a point where the stick shaker was activated. Stall and Upset Recovery procedures were not correctly followed and the aircraft commander was slow to take control of the situation. Full control was regained at 1,200 feet above ground level and a subsequent approach and landing were without further event.

On 6 May 2022, a Boeing 737-800 sustained a tail strike during takeoff from Kathmandu during a flight being used to revalidate a Captain’s airport familiarisation training. Running the applicable non-normal procedure was delayed until above the unusually high minimum safe altitude but when actioned, some of its requirements were not initially or fully followed. A precautionary diversion to Kolkata was subsequently completed. The Investigation found that an excessive pitch rate during rotation had resulted in the pitch angle limit being exceeded. The absence of sufficient procedural guidance on tail strike response and some crew unfamiliarity with depressurisation procedures was noted.

On 3 August 2009, control of a rotary UAV being operated by an agricultural cooperative for routine crop spraying in the south western part of South Korea was lost and the remote pilot was fatally injured when it then collided with him. The Investigation found that an inappropriately set pitch trim switch went unnoticed and the consequentially unexpected trajectory was not recognised and corrected. The context was assessed as inadequacies in the operator’s safety management arrangements and the content of the applicable UAV Operations Manual as well as lack of recurrent training for the operators’ qualified UAV remote pilots.

On 27 January 2020, an MD83 made an unstabilised tailwind non-precision approach to Mahshahr with a consistently excessive rate of descent and corresponding EGPWS Warnings followed by a very late nose-gear-first touchdown. It then overran the runway end, continued through the airport perimeter fence and crossed over a ditch before coming to a stop partly blocking a busy main road. The aircraft sustained substantial damage and was subsequently declared a hull loss but all occupants completed an emergency evacuation uninjured. The accident was attributed to the actions of the Captain which included not following multiple standard operating procedures.

Environmental Factors

On 5 December 2021 an Airbus A359-900 crew encountered a very brief episode of unexpected clear air turbulence associated with visible signs of convective weather in the vicinity and not having had prior warning, the senior cabin crew fell and was seriously injured. The Investigation concluded that the actual risk of turbulence prevailing and typical for the location and season as the end of daylight approached was greater than that perceived by the pilots despite their familiarity with the local area and its weather and that releasing the cabin crew from their previously secured positions had been inappropriate.

On 6 November 2018, an Airbus A340-600 in the cruise northbound over the Swiss Alps received an overspeed warning after encountering an unexpected wind velocity change but the crew failed to follow the prescribed response procedure. This led initially to a climb above their cleared level and further inappropriate actions were then followed by PAN and MAYDAY declarations as control of the aircraft was briefly lost in a high speed descent to below their cleared level. The operator subsequently enhanced pilot training realism by providing it in a simulator configured for the aircraft variant operated and introduced ‘upset recovery training’.

On 11 October 2019, an Embraer ERJ195LR abandoned an initial landing attempt at Warsaw after a hard bounce but the correct go-around procedure was not followed. The rate of climb rapidly increased to over 4000 feet per minute. Concurrently, the required engine thrust was not set and airspeed rapidly diminished to a point where the stick shaker was activated. Stall and Upset Recovery procedures were not correctly followed and the aircraft commander was slow to take control of the situation. Full control was regained at 1,200 feet above ground level and a subsequent approach and landing were without further event.

On 21 October 2020, an Embraer ERJ170 on short final at Paris CDG responded to a Windshear Warning by breaking off the approach and climbing. The Warning soon stopped but when the aircraft drifted sideways in the strong crosswind towards the adjacent parallel runway from which an Airbus A320 had just taken off, an STCA was quickly followed by a TCAS RA event. The Investigation was concerned at the implications of failure to climb straight ahead from parallel runways during unexpected go-arounds. Safety Recommendations were made on risk management of parallel runway operations by both pilots and safety regulators.

On 20 January 2020, a DHC8-300 encountered severe icing conditions and both engines successively failed during its approach to Bergen. The automatic ignition system restarted the engines but for a short time the aircraft was completely without power. It was concluded that ice had accreted on and then detached from the engine air inlets and either entered the combustion chamber partly melted and caused a flameout or disrupted the airflow into the engine sufficiently to stall it. Shortcomings were identified in the operator’s documentation for operation in icing conditions and further review of weather radar use by ATC is recommended.

Bird or Animal Strike

On 28 September 2012, control of a Sita Air Dornier 228 being flown by an experienced pilot was lost at approximately 100 feet aal after take off from Kathmandu in benign daylight weather conditions and the aircraft stalled without obvious attempt at recovery before impacting the ground where a fire broke out. All occupants were killed and the aircraft was destroyed. The comprehensive investigation found that insufficient engine thrust was being delivered to sustain flight but, having eliminated engine bird ingestion and aircraft loading issues, was unable to establish any environmental, airworthiness or loading issue which might have caused this.

On 19 January 2013, a Rolls Royce Trent 700-powered Virgin Atlantic Airbus A330-300 hit some medium sized birds shortly after take off from Orlando, sustaining airframe impact damage and ingesting one bird into each engine. Damage was subsequently found to both engines although only one indicated sufficient malfunction - a complete loss of oil pressure - for an in-flight shutdown to be required. After declaration of a MAYDAY, the return to land overweight was completed uneventfully. The investigation identified an issue with the response of the oil pressure detection and display system to high engine vibration events and recommended modification.

On 3 August 2006, a Qantas Boeing 767-300 encountered a large flock of birds during rotation and sustained multiple strikes on many parts of the aircraft. Left engine vibration immediately increased but as reducing thrust also reduced the vibration, it was decided following consultation with maintenance to continue to the planned destination, Sydney.

On 10 November 2008, a Boeing 737-800 about to land at Rome Ciampino Airport flew through a large and dense flock of starlings, which appeared from below the aircraft. After the crew had made an unsuccessful attempt to go around, they lost control due to malfunction of both engines when full thrust was applied and a very hard impact half way along the runway caused substantial damage to the aircraft. The Investigation concluded that the Captain s decision to attempt a go around after the encounter was inappropriate and that bird risk management measures at the airport had been inadequate.

On 21 June 2017, an Airbus A320 number 2 engine began vibrating during the takeoff roll at Delhi after a bird strike. After continuing the takeoff, the Captain subsequently shut down the serviceable engine and set the malfunctioning one to TO/GA and it was several minutes before the error was recognised. After an attempted number 1 engine restart failed because an incorrect procedure was followed, a second attempt succeeded. By this time inattention to airspeed loss had led to ALPHA floor protection activation. Eventual recovery was followed by a return to land with the malfunctioning engine at flight idle.

Aircraft Loading

On 3 February 2022, a Boeing 737-200F collided with a tree shortly after a daylight normal visibility takeoff from Puerto Carreño which resulted in engine stoppage although a subsequent restart was partially successful and a return to land was subsequently completed without further event. The collision was attributed to a combination of a slightly overweight takeoff and a slight delay in rotation which in the prevailing density altitude conditions prevented the rate of climb necessary to clear the obstacle. The context for the accident was assessed as a deficient operational safety culture at the company involved. 

On 27 January 2020, an MD83 made an unstabilised tailwind non-precision approach to Mahshahr with a consistently excessive rate of descent and corresponding EGPWS Warnings followed by a very late nose-gear-first touchdown. It then overran the runway end, continued through the airport perimeter fence and crossed over a ditch before coming to a stop partly blocking a busy main road. The aircraft sustained substantial damage and was subsequently declared a hull loss but all occupants completed an emergency evacuation uninjured. The accident was attributed to the actions of the Captain which included not following multiple standard operating procedures.

On 21 July 2020, a Boeing 737-800 flight crew identified significant discrepancies when comparing their Operational Flight Plan weights and passengers by category with those on the Loadsheet presented. After examining them and concluding that the differences were plausible based on past experience, the loadsheet figures were used for takeoff performance purposes with no adverse consequences detected. It was found that a system-wide IT upgrade issue had led to the generation of incorrect loadsheets and that ineffective communication and an initially ineffective response within the operator had delayed effective risk resolution although without any known flight safety-related consequences.

On 17 December 2017, it was discovered after completion of an Airbus A330-300 passenger flight from Sydney to Bejing that freight loading had not been correctly documented on the load and trim sheet presented to and accepted by the Captain and as a result, the aircraft had exceeded its certified MTOW on departure. The Investigation found that the overload finding had not been promptly reported or its safety significance appreciated, that the error had its origin in related verbal communications during loading and noted that the aircraft operator had since made a series of improvements to its freight loading procedures.

On 4 August 2018, a Junkers Ju-52 making a low level sightseeing flight through the Swiss Alps crashed killing all 20 occupants after control was lost when it stalled after encountering unexceptional windshear. The Investigation found that the pilots had created the conditions which led to the stall and then been unable to recover from it and concluded that the accident was a direct consequence of their risky behaviour. It found that such behaviour was common at the operator, that the operator was being managed without any regard to operational risk and that safety regulatory oversight had been systemically deficient.

Malicious Interference

On 8 January 2020, a Boeing 737-800 was destroyed by a ground to air missile when climbing through approximately 4800 feet aal three minutes after takeoff from Tehran for Kiev and its 176 occupants were killed. The Investigation is continuing but it has been confirmed that severe damage and an airborne fire followed the detonation of a proximity missile after a military targeting error, with subsequent ground impact. It is also confirmed that the flight was following its ATC clearance and that a sequence of four separate errors led to two missiles being fired at the aircraft.

Temporary Control Loss

On 6 November 2018, an Airbus A340-600 in the cruise northbound over the Swiss Alps received an overspeed warning after encountering an unexpected wind velocity change but the crew failed to follow the prescribed response procedure. This led initially to a climb above their cleared level and further inappropriate actions were then followed by PAN and MAYDAY declarations as control of the aircraft was briefly lost in a high speed descent to below their cleared level. The operator subsequently enhanced pilot training realism by providing it in a simulator configured for the aircraft variant operated and introduced ‘upset recovery training’.

On 25 July 2021, a Boeing 737-800 which had previously been manoeuvring visually around storm cells over the Alps during the initial descent into Nice turned back on track believing the avoidance action was complete but was then unable to avoid penetrating a further cell during which severe turbulence caused a serious injury to one of the cabin crew and a lesser injury to another. Multiple aircraft in the area had been simultaneously requesting track deviations at the time with ATC displays not showing weather returns. In the absence of plans to introduce this, a corresponding safety recommendation was made.

On 11 September 2021, a Boeing 737-800 was instructed to discontinue an ILS approach to runway 34 at Aberdeen, climb to 3000 feet and turn left onto a westerly heading. With the Autopilot disconnected it approached the cleared altitude but before reaching it rapidly descended to just over 1500 feet above terrain before climbing away, the whole event occurring in IMC. The episode was attributed to crew overload in manual flight consequent upon the combination of the heading instructions, flap configuration changes and a complete absence of pitch trim. Both pilots’ pandemic-related lack of the usual operational recency was noted.

On 20 December 2019, an Airbus A318 making a tailwind ILS approach to Toulon-Hyères with the autopilot engaged and expecting to intercept the glideslope from above had not done so when reaching the pre-selected altitude and after levelling off, it then rapidly entered a steep climb as it captured the glideslope false upper lobe and the automated stall protection system was activated. Not fully following  the recovery procedure caused a second stall protection activation before a sustained recovery was achieved. The Investigation noted Captain's  relative inexperience in that rank and a First Officer's inexperience on type.

On 26 July 2017, a Hawker Beechcraft 850 left wing sustained extensive damage when it contacted the runway at Mykonos during a 2.7g touchdown after an unstabilised approach in benign weather conditions had been continued. The Investigation found that the aircraft was airworthy prior to a temporary loss of control at touchdown which occurred after stick pusher activation due to the airspeed being more than 20 knots below the applicable reference speed and only three knots above the applicable stall speed. The monitoring of the First Officer’s approach by the Captain was minimal and late with few alert calls given.

Extreme Bank

On 25 July 2021, a Boeing 737-800 which had previously been manoeuvring visually around storm cells over the Alps during the initial descent into Nice turned back on track believing the avoidance action was complete but was then unable to avoid penetrating a further cell during which severe turbulence caused a serious injury to one of the cabin crew and a lesser injury to another. Multiple aircraft in the area had been simultaneously requesting track deviations at the time with ATC displays not showing weather returns. In the absence of plans to introduce this, a corresponding safety recommendation was made.

On 6 February 1996, a Boeing 757-200 took off from Puerto Plata at night despite awareness at the 80 knot check that the Captains altimeter was not working. Thereafter, the crew became confused as to their actual airspeed and lost control before the aircraft hit the sea surface less than five minutes after takeoff. The Investigation found that the Captain’s pitot probe was blocked and that the three pilots on the flight deck had become confused about which airspeed indications were reliable and had then not recovered from an aerodynamic stall which followed the wholly avoidable mismanagement of the aircraft flight path.

On 23 January 2020, a Cessna S550 departed George to conduct a calibration flight under VFR with three persons on board and was about to begin a DME arc at 4,000 feet QNH when control was lost after entering IMC. Recovery from a significant descent which followed was not achieved before the aircraft hit mountainous terrain 1,800 feet below and was destroyed killing all occupants. The Investigation considered that the transition into IMC had probably occurred without preparation and that the inability of the crew to perform a prompt recovery reflected unfavourably on the conduct of the aircraft operator.

On 21 January 2019, a Piper PA46-310P en-route north northwest of Guernsey was reported missing and subsequently confirmed to have broken up in flight during an uncontrolled descent. The Investigation found that neither the pilot nor the aircraft involved were able to be used for commercial passenger flight operations but also found that although the direct cause of loss of control was unproven, it was most likely the consequence of carbon monoxide poisoning originating from an exhaust system leak. The safety implications arising from operation of private flights for commercial passenger transport purposes contrary to regulatory requirements were also highlighted.

On 30 August 2018, a Boeing 747-400F making a crosswind landing at Hong Kong which was well within limits veered and rolled abnormally immediately after touchdown and runway impact damaged the two right side engines. The Investigation found that the flight was an experienced Captain’s line check handling sector and concluded that a succession of inappropriate control inputs made at and immediately after touchdown which caused the damage may have been a consequence of the Check Captain’s indication just before touchdown that he was expecting a landing using an alternative technique to the one he was familiar with.

Extreme Pitch

On 11 October 2019, an Embraer ERJ195LR abandoned an initial landing attempt at Warsaw after a hard bounce but the correct go-around procedure was not followed. The rate of climb rapidly increased to over 4000 feet per minute. Concurrently, the required engine thrust was not set and airspeed rapidly diminished to a point where the stick shaker was activated. Stall and Upset Recovery procedures were not correctly followed and the aircraft commander was slow to take control of the situation. Full control was regained at 1,200 feet above ground level and a subsequent approach and landing were without further event.

On 6 February 1996, a Boeing 757-200 took off from Puerto Plata at night despite awareness at the 80 knot check that the Captains altimeter was not working. Thereafter, the crew became confused as to their actual airspeed and lost control before the aircraft hit the sea surface less than five minutes after takeoff. The Investigation found that the Captain’s pitot probe was blocked and that the three pilots on the flight deck had become confused about which airspeed indications were reliable and had then not recovered from an aerodynamic stall which followed the wholly avoidable mismanagement of the aircraft flight path.

On 20 December 2019, an Airbus A318 making a tailwind ILS approach to Toulon-Hyères with the autopilot engaged and expecting to intercept the glideslope from above had not done so when reaching the pre-selected altitude and after levelling off, it then rapidly entered a steep climb as it captured the glideslope false upper lobe and the automated stall protection system was activated. Not fully following  the recovery procedure caused a second stall protection activation before a sustained recovery was achieved. The Investigation noted Captain's  relative inexperience in that rank and a First Officer's inexperience on type.

On 23 January 2020, a Cessna S550 departed George to conduct a calibration flight under VFR with three persons on board and was about to begin a DME arc at 4,000 feet QNH when control was lost after entering IMC. Recovery from a significant descent which followed was not achieved before the aircraft hit mountainous terrain 1,800 feet below and was destroyed killing all occupants. The Investigation considered that the transition into IMC had probably occurred without preparation and that the inability of the crew to perform a prompt recovery reflected unfavourably on the conduct of the aircraft operator.

On 21 January 2019, a Piper PA46-310P en-route north northwest of Guernsey was reported missing and subsequently confirmed to have broken up in flight during an uncontrolled descent. The Investigation found that neither the pilot nor the aircraft involved were able to be used for commercial passenger flight operations but also found that although the direct cause of loss of control was unproven, it was most likely the consequence of carbon monoxide poisoning originating from an exhaust system leak. The safety implications arising from operation of private flights for commercial passenger transport purposes contrary to regulatory requirements were also highlighted.

Last Minute Collision Avoidance

On 14 February 2012 a Latvian-operated Saab 340 acknowledged an ATC clearance to make a procedural ILS approach to Mariehamn and then completely disregarded the clearance by setting course direct to the aerodrome. Subsequently, having lost situational awareness, repeated GPWS PULL UP warnings at night in VMC were ignored as control of the aircraft was lost with a recovery only achieved an estimated 2 seconds before ground impact would have occurred and then followed by more ignored PULL UP Warnings due to continued proximity to terrain before the runway was sighted and a landing achieved.

On 15 December 2014, the Captain of a Saab 2000 lost control of his serviceable aircraft after a lightning strike when he attempted to control the aircraft manually without first disconnecting the autopilot and despite the annunciation of a series of related alerts. The aircraft descended from 4,000 feet to 1,100 feet at up to 9,500 fpm and 80 knots above Vmo. A fortuitous transient data transmission fault caused autopilot disconnection making it possible to respond to EGPWS 'SINK RATE' and 'PULL UP' Warnings. The Investigation concluded that limitations on autopilot disconnection by pilot override were contrary to the type certification of most other transport aircraft.

On 3 January 3 2004, a Boeing 737-300 being operated by Flash Airlines on a passenger charter flight from Sharm el-Sheikh Egypt to Cairo for a refuelling stop en route to Paris CDG crashed into the sea 2½ minutes after a night take off into VMC and was destroyed and all 148 occupants killed. The Investigation was unable to establish a Probable Cause but found evidence of AP status confusion and the possibility of distraction leading to insufficient attention being paid to flight path control.

Hard landing

On 11 October 2019, an Embraer ERJ195LR abandoned an initial landing attempt at Warsaw after a hard bounce but the correct go-around procedure was not followed. The rate of climb rapidly increased to over 4000 feet per minute. Concurrently, the required engine thrust was not set and airspeed rapidly diminished to a point where the stick shaker was activated. Stall and Upset Recovery procedures were not correctly followed and the aircraft commander was slow to take control of the situation. Full control was regained at 1,200 feet above ground level and a subsequent approach and landing were without further event.

On 27 January 2020, an MD83 made an unstabilised tailwind non-precision approach to Mahshahr with a consistently excessive rate of descent and corresponding EGPWS Warnings followed by a very late nose-gear-first touchdown. It then overran the runway end, continued through the airport perimeter fence and crossed over a ditch before coming to a stop partly blocking a busy main road. The aircraft sustained substantial damage and was subsequently declared a hull loss but all occupants completed an emergency evacuation uninjured. The accident was attributed to the actions of the Captain which included not following multiple standard operating procedures.

On 8 February 2021, an Embraer 500 Phenom 100 (9H-FAM) crew lost control of their aircraft shortly before the intended touchdown when it stalled due to airframe ice contamination. The resulting runway impact collapsed the nose and main gear, the latter causing fuel leak and resultant fire as the aircraft slid along the runway before veering off it. The Investigation found that flight in icing conditions during the approach had not been accompanied by the prescribed use of the airframe de-icing system and that such non compliance appeared to be routine and its dangers unappreciated.

On 23 October 2020, a Bombardier DHC8-400 was mishandled during the final stages of landing in slightly turbulent conditions when the Captain responded to a momentary increase in the rate of descent in the flare by increasing the pitch attitude instead of adding power which resulted in a tailstrike as the maximum pitch attitude without this happening was exceeded and structural damage resulted. The pilot involved had very considerable flying experience on other types but relatively little on the accident type and although the First Officer had more type experience he was less than half the age of the Captain.

On 25 December 2016, a type-experienced ATR72-600 Captain bounced the aircraft twice nose gear first whilst attempting a night landing at Semarang and during a third bounce on the right main gear only, it collapsed. The aircraft drifted right and after two further bounces began to decelerate and came to a stop. The Investigation found that after a normally-flown approach, the aircraft had not been flared and effective recovery action had not followed the bounce. It was concluded that the Captain had been subject to a visual illusion which had distorted his perception of height above the runway.

Take off Trim Setting

On 2 April 2012, the crew of an ATR72-200 which had just taken off from Tyumen lost control of their aircraft when it stalled after the flaps were retracted and did not recover before it crashed and caught fire killing or seriously injuring all occupants. The Investigation found that the Captain knew that frozen deposits had accumulated on the airframe but appeared to have been unaware of the danger of not having the airframe de-iced. It was also found that the crew had not recognised the stall when it occurred and had overpowered the stick pusher and pitched up.

On 25 January 2010, a Boeing 737-800 being operated by Ethiopian Airlines on a scheduled passenger flight from Beirut to Addis Ababa in night IMC disappeared from ATC radar soon after departure from Runway 21 and was subsequently found to have impacted the sea in an unintentional out of control condition some five miles south west of the airport less than five minutes after getting airborne Impact resulted in the destruction of the aircraft and the death of all 90 occupants.

On 18 January 2007 an ATR 42-300 freighter developed a control difficulty just after a night take off from Stansted UK, which led the flight crew to declare an emergency and undertake an immediate return to land. The landing was uneventful but the approach flown was unstable, with EGPWS warnings, and the origin of the handling difficulty was considered to be, in part, due to inappropriate control inputs by one of the pilots.

Incorrect Thrust Computed

On 27 January 2020, an MD83 made an unstabilised tailwind non-precision approach to Mahshahr with a consistently excessive rate of descent and corresponding EGPWS Warnings followed by a very late nose-gear-first touchdown. It then overran the runway end, continued through the airport perimeter fence and crossed over a ditch before coming to a stop partly blocking a busy main road. The aircraft sustained substantial damage and was subsequently declared a hull loss but all occupants completed an emergency evacuation uninjured. The accident was attributed to the actions of the Captain which included not following multiple standard operating procedures.

On 26 February 2020, an Airbus A330-300 tailstrike occurred during rotation for takeoff from Zurich and was not detected by the crew who completed the planned 7½ hour flight to Nairobi before learning that the aircraft was not airworthy as a result. The Investigation concluded that the tailstrike had been the direct result of the crew’s use of inappropriate inputs to their takeoff performance calculation on the variable headwind encountered during the takeoff and noted a very similar event had previously occurred to the same aircraft type operated by an airline within the same overall ownership.

On 14 April 2012, a Titan Airways Boeing 737-300 attempted to take off from Chambery with incorrect reference speeds taken from the EFB used for performance calculations. As a consequence, the pressure hull was damaged by a tail strike during take off, although not sufficiently to affect cabin pressure during the subsequent flight. The Investigation concluded that the accident raised regulatory issues in respect of the general design and use of EFB computers to calculate performance data.

On 27 October 2017, an Embraer E195-200 missed approach was attempted in response to a predictive windshear alert on short final at Salzburg without ensuring sufficient engine thrust was set and when a stall warning followed, the correct recovery procedure was not initiated until over a minute had elapsed. Thereafter, following two holds, an approach and landing was completed without further event. The operator did not report the event in a timely or complete manner and it was therefore not possible to identify it as a Serious Incident requiring an independent investigation until almost three months after it had occurred.

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

Unintended transitory terrain contact

On 6 May 2022, a Boeing 737-800 sustained a tail strike during takeoff from Kathmandu during a flight being used to revalidate a Captain’s airport familiarisation training. Running the applicable non-normal procedure was delayed until above the unusually high minimum safe altitude but when actioned, some of its requirements were not initially or fully followed. A precautionary diversion to Kolkata was subsequently completed. The Investigation found that an excessive pitch rate during rotation had resulted in the pitch angle limit being exceeded. The absence of sufficient procedural guidance on tail strike response and some crew unfamiliarity with depressurisation procedures was noted.

On 2 January 2022, an Airbus A350-1000 floated during the landing flare at London Heathrow and when a go-around was commenced, a tail strike accompanied main landing gear runway contact. A subsequent further approach during which the Captain took over as handling pilot was completed uneventfully. The Investigation attributed the tailstrike to a full pitch up input made simultaneously with the selection of maximum thrust when very close to the runway surface, noting that although the initial touchdown had been just beyond the touchdown zone, 2,760 metres of runway remained ahead when the go around decision was made.

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 26 February 2020, an Airbus A330-300 tailstrike occurred during rotation for takeoff from Zurich and was not detected by the crew who completed the planned 7½ hour flight to Nairobi before learning that the aircraft was not airworthy as a result. The Investigation concluded that the tailstrike had been the direct result of the crew’s use of inappropriate inputs to their takeoff performance calculation on the variable headwind encountered during the takeoff and noted a very similar event had previously occurred to the same aircraft type operated by an airline within the same overall ownership.

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.

Collision Damage

On 15 January 2021, the pilot of a DJI Inspire 2 UAV being operated on a contracted aerial work task under a conditional permit lost control of it and, after it exitied the approved operating area, the UAV collided with the window of a hotel guest room causing consequential minor injuries to the occupant. The Investigation found that the loss of control was attributable to “strong magnetic interference” almost immediately after takeoff which caused the compass to feed unreliable data to the Internal Management Unit which destabilised its accelerometer and led to the loss of directional control which resulted in the collision.

On 16 June 2021, a Boeing 737-400 was taxiing for departure at night after push back from stand when the ground crew who completed the push back arrived back at their base in the tug and realised that the tow bar they had used was not attached to it. The aircraft was prevented from taking off and it was then found that it had taxied over the unseen towbar and sustained damage to both nose gear tyres such that replacement was necessary. The Investigation concluded neither ground crew had checked that the area immediately ahead of the aircraft was clear.

On 30 August 2018, a Boeing 747-400F making a crosswind landing at Hong Kong which was well within limits veered and rolled abnormally immediately after touchdown and runway impact damaged the two right side engines. The Investigation found that the flight was an experienced Captain’s line check handling sector and concluded that a succession of inappropriate control inputs made at and immediately after touchdown which caused the damage may have been a consequence of the Check Captain’s indication just before touchdown that he was expecting a landing using an alternative technique to the one he was familiar with.

On 14 July 2019, after control of a DJI-Inspire 2 UA was lost, it descended into people on the ground under power causing multiple minor injuries. The Investigation found that “professional drone pilots” were operating the UA in gross breach of the approval obtained, had deleted all recorded controller evidence of the accident flight and that their account of the loss of control was not compatible with the evidence recovered from the UA. It also noted that the risk of injury to third parties was increased by the absence of protection around the propellers which was not a regulatory requirement.

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

Incorrect Aircraft Configuration

On 25 November 2021, a Fokker F50 departing Helsinki experienced an engine malfunction which resulted in un-commanded propeller feathering following which the associated engine continued to run until shutdown during which time it began to overspeed. Recovery to a landing was subsequently achieved but the failure experienced was untrained and this led to both direct and indirect consequences which resulted in a sub optimal crew response to the emergency. The Investigation also highlighted opportunities to improve aspects of the air traffic control emergency response during such emergencies and identified language proficiency certification issues.

On 3 August 2009, control of a rotary UAV being operated by an agricultural cooperative for routine crop spraying in the south western part of South Korea was lost and the remote pilot was fatally injured when it then collided with him. The Investigation found that an inappropriately set pitch trim switch went unnoticed and the consequentially unexpected trajectory was not recognised and corrected. The context was assessed as inadequacies in the operator’s safety management arrangements and the content of the applicable UAV Operations Manual as well as lack of recurrent training for the operators’ qualified UAV remote pilots.

On 15 August 2015, an Airbus A321 on approach to Charlotte commenced a go around but following a temporary loss of control as it did so then struck approach and runway lighting and the undershoot area sustaining a tail strike before climbing away. The Investigation noted that the 2.1g impact caused substantial structural damage to the aircraft and attributed the loss of control to a small microburst and the crew’s failure to follow appropriate and recommended risk mitigations despite clear evidence of risk given by the aircraft when it went around and available visually.

On 16 January 2018, a McDonnell Douglas MD-82 attempting to land at Tarbes was subject to gross mishandling by the crew and the approach became unstable. A subsequent low level go-around attempt was then made without setting sufficient thrust which resulted in sustained and close proximity to terrain at an airspeed close to stall entry before the required thrust was eventually applied. The Investigation was hindered by non-reporting of the event but was able to conclude that multiple pilot errors in a context of poor crew coordination during the approach had caused confusion when the go around was initiated.

On 23 February 2019, a Boeing 767-300 transitioned suddenly from a normal descent towards Houston into a steep dive and high speed terrain impact followed. The Investigation found that after neither pilot had noticed the First Officer’s inadvertent selection of go around mode during automated flight, the First Officer had then very quickly responded with an increasingly severe manual pitch-down, possibly influenced by a somatogravic illusion. He was found to have had a series of short air carrier employments terminating after failure to complete training, had deliberately and repeatedly sought to conceal this history and lacked sufficient aptitude and competency.

Aerodynamic Stall

On 11 October 2019, an Embraer ERJ195LR abandoned an initial landing attempt at Warsaw after a hard bounce but the correct go-around procedure was not followed. The rate of climb rapidly increased to over 4000 feet per minute. Concurrently, the required engine thrust was not set and airspeed rapidly diminished to a point where the stick shaker was activated. Stall and Upset Recovery procedures were not correctly followed and the aircraft commander was slow to take control of the situation. Full control was regained at 1,200 feet above ground level and a subsequent approach and landing were without further event.

On 20 January 2020, a DHC8-300 encountered severe icing conditions and both engines successively failed during its approach to Bergen. The automatic ignition system restarted the engines but for a short time the aircraft was completely without power. It was concluded that ice had accreted on and then detached from the engine air inlets and either entered the combustion chamber partly melted and caused a flameout or disrupted the airflow into the engine sufficiently to stall it. Shortcomings were identified in the operator’s documentation for operation in icing conditions and further review of weather radar use by ATC is recommended.

On 8 February 2021, an Embraer 500 Phenom 100 (9H-FAM) crew lost control of their aircraft shortly before the intended touchdown when it stalled due to airframe ice contamination. The resulting runway impact collapsed the nose and main gear, the latter causing fuel leak and resultant fire as the aircraft slid along the runway before veering off it. The Investigation found that flight in icing conditions during the approach had not been accompanied by the prescribed use of the airframe de-icing system and that such non compliance appeared to be routine and its dangers unappreciated.

On 15 January 2023, an ATR 72-500 positioning visually for an approach to Pokhara was observed to suddenly depart normal flight and impact terrain a few seconds later. All 72 occupants were killed and the aircraft destroyed by impact. A Preliminary Report published by the Accident Investigation Commission has indicated that a stall warning and subsequent loss of control was preceded by an apparently unintentional and subsequently undetected selection of both propellers to feather in response to a call for Flaps 30. The Training Captain in command was supervising the Captain flying during familiarisation training for the new Pokhara airport.

On 6 February 1996, a Boeing 757-200 took off from Puerto Plata at night despite awareness at the 80 knot check that the Captains altimeter was not working. Thereafter, the crew became confused as to their actual airspeed and lost control before the aircraft hit the sea surface less than five minutes after takeoff. The Investigation found that the Captain’s pitot probe was blocked and that the three pilots on the flight deck had become confused about which airspeed indications were reliable and had then not recovered from an aerodynamic stall which followed the wholly avoidable mismanagement of the aircraft flight path.

Minimum Fuel Call

On 2 March 2018, a Cessna 441 conducting a single-pilot scheduled passenger flight to Broome suffered successive failures of both engines due to fuel exhaustion and a MAYDAY was declared. Unable to reach the destination or any other aerodrome by the time this occurred, an uneventful landing was made on the area’s main highway. The Investigation found that the fuel quantity was over-reading due to water in the fuel tanks, that cross-checking of fuel used versus indicated fuel in tanks was not done and that when the possibility of fuel exhaustion was first indicated, an available diversion was not made.

On 10 October 2016, an Airbus 319 was cleared to divert to its first alternate after failing to land off its Cat II ILS approach at Porto and obliged to land at its second alternate with less than final reserve fuel after the first alternate declined acceptance due to lack of parking capacity. The Investigation concluded that adjacent ATC Unit coordination in respect of multiple diversions was inadequate and also found that the crew had failed to adequately appraise ATC of their fuel status. It also noted that the unsuccessful approach at the intended destination had violated approach ban visibility conditions.

Flight Envelope Protection Activated

On 19 August 2017, an Airbus A340-300 encountered significant unforecast windshear on rotation for a maximum weight rated-thrust night takeoff from Bogotá and was unable to begin its climb for a further 800 metres during which angle of attack flight envelope protection was briefly activated. The Investigation noted the absence of a windshear detection system and any data on the prevalence of windshear at the airport as well as the failure of ATC to relay in English reports of conditions from departing aircraft received in Spanish. The aircraft operator subsequently elected to restrict maximum permitted takeoff weights from the airport.

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 24 March 2012, an Air France Airbus A319 Captain continued descent towards destination Tunis at high speed with the landing runway in sight well beyond the point where a stabilised approach was possible. With 5nm to go, airspeed was over 100 KIAS above the applicable VApp and the aircraft was descending at over 4000fpm with flaps zero. EGPWS activations for Sink Rate, PULL UP and Too Low Terrain apparently went unnoticed but at 400 feet agl, ATC granted a crew request for a 360° turn. The subsequent approach/landing was without further event. Investigation attributed the event to “sloppy CRM”.

On 3 April 2012, the crew of an Air France Airbus A320 came close to loosing control of their aircraft after accepting, inadequately preparing for and comprehensively mismanaging it during an RNAV VISUAL approach at Tel Aviv and during the subsequent attempt at a missed approach. The Investigation identified significant issues with crew understanding of automation - especially in respect of both the use of FMS modes and operations with the AP off but the A/T on - and highlighted the inadequate provision by the aircraft operator of both procedures and pilot training for this type of approach.

On 27 February 2012, the crew of an Airbus A330 en route at night and crossing the East African coast at FL360 encountered sudden violent turbulence as they flew into a convective cell not seen on their weather radar and briefly lost control as their aircraft climbed 2000 feet with resultant minor injuries to two occupants. The Investigation concluded that the isolated and rapidly developing cell had not been detected because of crew failure to make proper use of their weather radar, but noted that activation of flight envelope protection and subsequent crew action to recover control had been appropriate.

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