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

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

On 31 July 2012, a Boeing 737-900 struck a single large bird whilst descending to land at Denver in day VMC and passing approximately 6000 feet aal, sustaining damage to the radome, one pitot head and the vertical stabiliser. The flight crew declared an emergency and continued the approach with ATC assistance to an uneventful landing. The bird involved was subsequently identified as a White Faced Ibis, a species which normally has a weight around 500 gm but can exceptionally reach a weight of 700 gm. The hole made in the radome was 60 cm x 30 cm.

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

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

Significant Systems or Systems Control Failure

On 4 July 2019, the operator of an Alauda Airspeeder UAV lost control of it and it climbed to 8000 feet into controlled airspace at a designated holding pattern for London Gatwick before falling at 5000 fpm and impacting the ground close to housing. The Investigation was unable to establish the cause of the loss of control but noted that the system to immediately terminate a flight in such circumstances had also failed, thereby compromising public safety. The approval for operation of the UAV was found to been poorly performed and lacking any assessment of the airworthiness of the UAS.

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.

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

On 23 February 2020, a Bombardier Challenger 605 making a flapless landing after a system failure during descent briefly lost control when reverse thrust selection after a normal touchdown was followed by the aircraft becoming airborne before stick push activation was followed by a hard second touchdown. Structural and abrasion fuselage damage was caused. The Investigation attributed the flap failure to corrosion within the specified maintenance inspection interval and the brief loss of control during landing to a combination of inadequate crew preparation for the landing and the fact that simulator replication of aircraft handling did not correspond to reality. 

On 27 July 2019, a fuel configuration advisory was annunciated on a Boeing 767-300 about to depart Auckland as a result of wing tank imbalance. Having established there was no evidence of a fuel leak, they planned to correct the imbalance in flight but then delayed this until it had exceeded the permitted limits. The fault was only verbally reported after flight and the aircraft continued to operate without centre tank use with maintenance remaining unaware of the fault for several days. The cause of imbalance was a fuel system fault subject to a crew response which was not followed.

Degraded flight instrument display

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

On 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 31 July 2012, a Boeing 737-900 struck a single large bird whilst descending to land at Denver in day VMC and passing approximately 6000 feet aal, sustaining damage to the radome, one pitot head and the vertical stabiliser. The flight crew declared an emergency and continued the approach with ATC assistance to an uneventful landing. The bird involved was subsequently identified as a White Faced Ibis, a species which normally has a weight around 500 gm but can exceptionally reach a weight of 700 gm. The hole made in the radome was 60 cm x 30 cm.

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 3 February 2016, a Sikorsky S76C on a flight from an offshore platform to Lagos was ditched when the crew believed that it was no longer possible to complete their intended flight to Lagos. After recovering the helicopter from the seabed, the Investigation concluded that the crew had failed to perform a routine standard procedure after takeoff - resetting the compass to ‘slave rather than ‘free’ mode - and had then failed to recognise that this was the cause of the flight path control issues which they were experiencing or disconnect the autopilot and fly the aircraft manually.

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 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.

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.

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 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 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 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 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.

On 21 November 2013, an A330 rejected its take off from Brisbane after an airspeed indication failure. Following maintenance intervention, a similar airspeed indication fault on the subsequent departure was reported to have been detected after V1. Once airborne, reversion to Alternate Law occurred and slat retraction failed. After an air turnback, it was discovered that the cause of both events was blockage of the No. 1 Pitot Head by a mud-dauber wasp nest which was created during the initial two hour turnround at Brisbane. Investigation of a 2014 event to a Boeing 737 at Brisbane with exactly the same causation was noted.

Loss of Engine Power

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

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

On 7 December 2016, the crew of an ATR 42-500 lost control after airworthiness-related complications followed shutdown of the left engine whilst in the cruise and high speed terrain impact followed. The Investigation concluded that three pre-existing faults with the left engine and its propeller control mechanism had led to a loss of power which had necessitated its shutdown but that these faults had then caused much higher left side drag than would normally result from an engine shutdown and made it progressively more difficult to maintain control. Recovery from a first loss of control was followed by another without recovery.

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

Crew Incapacitation

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.

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

On 17 November 2017, an Airbus A320 flight crew were both partially incapacitated by the effect of fumes described as acrid and stinging which they detected when following another smaller aircraft to the holding point at Geneva and then waiting in line behind it before taking off, the effect of which rapidly worsened en-route and necessitated a precautionary diversion to Marseilles. The very thorough subsequent Investigation was unable to determine the origin or nature of the fumes encountered but circumstantial evidence pointed tentatively towards ingestion of engine exhaust from the aircraft ahead in one or both A320 engines.

On 6 July 2011 the First Officer of a Ryanair Boeing 737-800 was suddenly incapacitated during a passenger flight from Pisa to Las Palmas. The Captain declared a medical emergency and identified the First Officer as the affected person before diverting uneventfully to Girona. The subsequent investigation focused particularly on the way the event was perceived as a specifically medical emergency rather than also being an operational emergency as well as on the operator procedures for the situation encountered.

Flight Management Error

On 28 January 2019, an Airbus A320 became unstabilised below 1000 feet when continuation of an ILS approach at Muscat with insufficient thrust resulted in increasing pitch which eventually triggered an automatic thrust intervention which facilitated completion of a normal landing. The Investigation found that having temporarily taken control from the First Officer due to failure to follow radar vectors to the ILS, the Captain had then handed control back with the First Officer unaware that the autothrust had been disconnected. The context for this was identified as a comprehensive failure to follow multiple operational procedures and practice meaningful CRM.

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

On 23 February 2020, a Bombardier Challenger 605 making a flapless landing after a system failure during descent briefly lost control when reverse thrust selection after a normal touchdown was followed by the aircraft becoming airborne before stick push activation was followed by a hard second touchdown. Structural and abrasion fuselage damage was caused. The Investigation attributed the flap failure to corrosion within the specified maintenance inspection interval and the brief loss of control during landing to a combination of inadequate crew preparation for the landing and the fact that simulator replication of aircraft handling did not correspond to reality. 

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

On 24 July 2019, whilst a Sikorsky S92A was commencing a second missed approach at the intended destination platform, visual contact was acquired and it was decided that an immediate visual approach could be made. However control was then temporarily lost and the aircraft almost hit the sea surface before recovery involving engine overtorque and diversion back to Halifax. The Investigation concluded that the crew had failed to safely control the aircraft energy state in a degraded visual environment allowing it to enter a vortex ring condition. As context, operator procedures, Flight Manual content and regulatory requirements were all faulted. 

Flight Control Error

Environmental Factors

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

On 17 September 2020, a Bombardier Global 6000 which had completed a circling approach to land at Biggin Hill in day VMC touched down with an inappropriate pitch and roll attitude which caused the right wingtip to contact the runway surface. The Investigation found that the landing technique just before touchdown was not in accordance with the manufacturer’s crosswind landing technique although the roll rate achieved could not be accounted for by the roll control input alone and was probably increased by localised wind velocity variations despite the absence of any such variations being reported by ATC.

On 16 January 2020 an Airbus A380 in the cruise at FL 400 in an area of correctly forecast convective turbulence encountered severe turbulence not anticipated by the crew who had not put on the seatbelt signs or alerted the cabin crew in time for the cabin to be secured. An unsecured passenger was seriously injured and several other passengers and an unsecured member of cabin crew were lifted off their feet but managed to avoid injury. The Investigation concluded that the flight crew had not made full use of the capabilities of the available on board weather radar equipment.

On 20 January 2020, a Bombardier DHC8-300 crew opted for a visual approach into Schefferville and after the First Officer significantly misjudged the approach, it was continued to a landing despite being well outside the operator’s stabilised approach criteria with the high rate of descent and excessive nose-up attitude resulting in structural damage to the aircraft. The Investigation noted the context for the event was inadequate operator procedures, pilot training and monitoring of procedural compliance in the presence of systemically ineffective regulatory oversight and observed that it appeared that unstabilised approaches at the operator may be occurring with unacceptable regularity.

On 10 July 2019 an Airbus A380 in the cruise at night at FL 400 encountered unexpectedly severe turbulence approximately 13 hours into the 17 hour flight and 27 occupants were injured as a result, one seriously. The detailed Investigation concluded that the turbulence had occurred in clear air in the vicinity of a significant area of convective turbulence and a jet stream. A series of findings were related to both better detection of turbulence risks and ways to minimise injuries if unexpectedly encountered with particular reference to the aircraft type and operator but with wider relevance.

Bird or Animal Strike

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 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 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 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.

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.

Aircraft Loading

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.

On 29 April 2013, a Boeing 747-400 freighter departed controlled flight and impacted terrain shortly after taking off from Bagram and was destroyed by the impact and post crash fire and all occupants were killed. The Investigation found that a sudden and significant load shift had occurred soon after take off which damaged hydraulic systems Nos. 1 and 2 and the horizontal stabilizer drive mechanism components as well as moving the centre of gravity aft and out of the allowable flight envelope. The Load shift was attributed to the ineffective securing techniques employed.

On 2 July 2014, a Fokker 50 fully loaded - and probably overloaded - with a cargo of qat crashed into a building and was destroyed soon after its night departure from Nairobi after failing to climb due to a left engine malfunction which was evident well before V1. The Investigation attributed the accident to the failure of the crew to reject the takeoff after obvious malfunction of the left engine soon after they had set takeoff power which triggered a repeated level 3 Master Warning that required an automatic initiation of a rejected takeoff.

On 30 May 2019, a DHC8-200 departing from Nuuk could not be rotated at the calculated speed even using full aft back pressure and the takeoff was rejected with the aircraft coming to a stop with 50 metres of the 950 metre long dry runway remaining. The initial Investigation focus was on a potential airworthiness cause associated with the flight control system but it was eventually found that the actual weights of both passengers and cabin baggage exceeded standard weight assumptions with the excess also resulting in the aircraft centre of gravity being outside the range certified for safe flight.

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 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.

On 24 July 2019, whilst a Sikorsky S92A was commencing a second missed approach at the intended destination platform, visual contact was acquired and it was decided that an immediate visual approach could be made. However control was then temporarily lost and the aircraft almost hit the sea surface before recovery involving engine overtorque and diversion back to Halifax. The Investigation concluded that the crew had failed to safely control the aircraft energy state in a degraded visual environment allowing it to enter a vortex ring condition. As context, operator procedures, Flight Manual content and regulatory requirements were all faulted. 

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

On 7 December 2016, the crew of an ATR 42-500 lost control after airworthiness-related complications followed shutdown of the left engine whilst in the cruise and high speed terrain impact followed. The Investigation concluded that three pre-existing faults with the left engine and its propeller control mechanism had led to a loss of power which had necessitated its shutdown but that these faults had then caused much higher left side drag than would normally result from an engine shutdown and made it progressively more difficult to maintain control. Recovery from a first loss of control was followed by another without recovery.

On 14 November 2016, an ATR72-600 crew lost control at FL150 in severe icing conditions. Uncontrolled rolls and a 1,500 feet height loss followed during an apparent stall. After recovery, the Captain announced to the alarmed passengers that he had regained control and the flight was completed without further event. The Investigation found that the crew had been aware that they had encountered severe icing rather than the forecast moderate icing but had attempted to continue to climb which took the aircraft outside its performance limitations. The recovery from the stall was non-optimal and two key memory actions were overlooked.

Extreme Bank

On 17 September 2020, a Bombardier Global 6000 which had completed a circling approach to land at Biggin Hill in day VMC touched down with an inappropriate pitch and roll attitude which caused the right wingtip to contact the runway surface. The Investigation found that the landing technique just before touchdown was not in accordance with the manufacturer’s crosswind landing technique although the roll rate achieved could not be accounted for by the roll control input alone and was probably increased by localised wind velocity variations despite the absence of any such variations being reported by ATC.

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.

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

On 9 January 2021, contact was lost with a Boeing 737-500 as it approached 11,000 feet less than five minutes after departing Jakarta in daylight. It was subsequently found to have entered a rapid descent whilst in unexceptional weather conditions and been destroyed by sea surface impact which killed all 62 occupants. The Investigation is ongoing but is currently focusing on finding an explanation for the apparently uncommanded but progressive asymmetric thrust reduction which culminated in a wing drop and a consequent loss of control. An initial recommendation has been made requiring effective Upset Prevention and Recovery Training.

On 14 November 2016, an ATR72-600 crew lost control at FL150 in severe icing conditions. Uncontrolled rolls and a 1,500 feet height loss followed during an apparent stall. After recovery, the Captain announced to the alarmed passengers that he had regained control and the flight was completed without further event. The Investigation found that the crew had been aware that they had encountered severe icing rather than the forecast moderate icing but had attempted to continue to climb which took the aircraft outside its performance limitations. The recovery from the stall was non-optimal and two key memory actions were overlooked.

Extreme Pitch

On 23 February 2020, a Bombardier Challenger 605 making a flapless landing after a system failure during descent briefly lost control when reverse thrust selection after a normal touchdown was followed by the aircraft becoming airborne before stick push activation was followed by a hard second touchdown. Structural and abrasion fuselage damage was caused. The Investigation attributed the flap failure to corrosion within the specified maintenance inspection interval and the brief loss of control during landing to a combination of inadequate crew preparation for the landing and the fact that simulator replication of aircraft handling did not correspond to reality. 

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.

On 14 November 2016, an ATR72-600 crew lost control at FL150 in severe icing conditions. Uncontrolled rolls and a 1,500 feet height loss followed during an apparent stall. After recovery, the Captain announced to the alarmed passengers that he had regained control and the flight was completed without further event. The Investigation found that the crew had been aware that they had encountered severe icing rather than the forecast moderate icing but had attempted to continue to climb which took the aircraft outside its performance limitations. The recovery from the stall was non-optimal and two key memory actions were overlooked.

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.

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 20 January 2020, a Bombardier DHC8-300 crew opted for a visual approach into Schefferville and after the First Officer significantly misjudged the approach, it was continued to a landing despite being well outside the operator’s stabilised approach criteria with the high rate of descent and excessive nose-up attitude resulting in structural damage to the aircraft. The Investigation noted the context for the event was inadequate operator procedures, pilot training and monitoring of procedural compliance in the presence of systemically ineffective regulatory oversight and observed that it appeared that unstabilised approaches at the operator may be occurring with unacceptable regularity.

On 13 September 2016, a Boeing 737-300 made an unstabilised approach to Wamena and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in collapse of the main landing gear, loss of directional control and a lateral runway excursion. The Investigation found that the approach had been carried out with both the cloudbase and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.

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

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

On 14 December 2016, an Airbus A320 made a 2.5g initial runway contact when landing at Raipur after the trainee First Officer failed to flare the aircraft adequately and the Training Captain took over too late to prevent a bounce followed by a 3.2g final touchdown. The Investigation found that despite the Training Captain’s diligent coaching, the First Officer had failed to respond during the final stages of the approach and that the takeover of control should have occurred earlier so that the mishandled final stage of the approach could have been discontinued and go around flown.

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

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.

On 29 April 2011, an Airbus A321-200 being operated by Thomas Cook Airlines on a passenger service from Manchester UK to Iraklion, Greece took off in day VMC but failed to establish a climb at the expected speed until the aircraft pitch attitude was reduced below that prescribed for the aircraft weight which had been entered into the FMS. No abnormal manoeuvres occurred and none of the 231 occupants were injured.

On 12 December 2009, an Airbus A340-600 being operated by Virgin Atlantic Airways on a scheduled passenger flight departing from London Heathrow in night VMC was slow to rotate and the aircraft settled at an initial climb speed below VLS - defined as the lowest selectable speed which provides an appropriate margin above the stall speed. This prompted the PF to reduce the aircraft pitch attitude in order to accelerate which resulted in a poor rate of climb of between 500 and 600 fpm. The flaps were retracted on schedule and the aircraft continued its climb. At no time was full takeoff thrust selected. Later in the climb, the crew looked again at the take off data calculation and realised that they had made the departure with insufficient thrust set and using Vr and V2 speeds which were too low for the actual aircraft weight. The flight to the planned destination was completed.

Unintended transitory terrain contact

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

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 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.

On 17 October 2011, the pilot of a Merpati DHC6 attempting to land at Dabra on a scheduled passenger flight lost control of the aircraft when several bounces were followed by the aircraft leaving the runway and hitting some banana trees before re entering the runway whereupon a ground loop was made near the end of the runway to prevent an overrun onto unfavourable terrain. The aircraft was damaged but none of the occupants were injured. The mis-managed landing was attributed to an unstabilised approach.

On 24 January 2012, a Swiftair Boeing MD83 about to touch down on runway 05 at Kandahar lost alignment with the extended runway centreline when initiating the daylight landing flare for a landing and a corrective roll resulted in the right wing tip striking the ground 20 metres prior to the runway threshold before completing the landing. The Investigation found that the prior approach had been unstable both at the prescribed ‘gate’ and thereafter and should have led to a go around. It was also found that neither the operator nor the crew were authorised to make the GPS approach used.

Collision Damage

On 14 July 2019, after control of a DJI-Inspire 2 UAV 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 UAV 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 UAV. 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.

On 31 July 2008, the crew of an HS125-800 attempted to reject a landing at Owatonna MN after a prior deployment of the lift dumping system but their aircraft overran the runway then briefly became airborne before crashing. The aircraft was destroyed and all 8 occupants were killed. The Investigation attributed the accident to poor crew judgement and general cockpit indiscipline in the presence of some fatigue and also considered that it was partly consequent upon the absence of any regulatory requirement for either pilot CRM training or operator SOP specification for the type of small aircraft operation being undertaken.

On 17 October 2011, the pilot of a Merpati DHC6 attempting to land at Dabra on a scheduled passenger flight lost control of the aircraft when several bounces were followed by the aircraft leaving the runway and hitting some banana trees before re entering the runway whereupon a ground loop was made near the end of the runway to prevent an overrun onto unfavourable terrain. The aircraft was damaged but none of the occupants were injured. The mis-managed landing was attributed to an unstabilised approach.

On 24 January 2012, a Swiftair Boeing MD83 about to touch down on runway 05 at Kandahar lost alignment with the extended runway centreline when initiating the daylight landing flare for a landing and a corrective roll resulted in the right wing tip striking the ground 20 metres prior to the runway threshold before completing the landing. The Investigation found that the prior approach had been unstable both at the prescribed ‘gate’ and thereafter and should have led to a go around. It was also found that neither the operator nor the crew were authorised to make the GPS approach used.

Incorrect Aircraft Configuration

On 26 August 2019, an Airbus A320 attempted two autopilot-engaged non-precision approaches at Birmingham in good weather before a third one was successful. Both were commenced late and continued when unstable prior to eventual go-arounds, for one of which the aircraft was mis-configured causing an ‘Alpha Floor’ protection activation. A third non-precision approach was then completed without further event. The Investigation noted an almost identical event involving the same operator four months later, observing that all three discontinued approaches appeared to have originated in confusion arising from a slight difference between the procedures of the aircraft operator and AIP plates.

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.

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

Aerodynamic Stall

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

On 7 December 2016, the crew of an ATR 42-500 lost control after airworthiness-related complications followed shutdown of the left engine whilst in the cruise and high speed terrain impact followed. The Investigation concluded that three pre-existing faults with the left engine and its propeller control mechanism had led to a loss of power which had necessitated its shutdown but that these faults had then caused much higher left side drag than would normally result from an engine shutdown and made it progressively more difficult to maintain control. Recovery from a first loss of control was followed by another without recovery.

On 11 March 2018 an Unreliable Speed Alert occurred on a Bombardier Challenger, the Captain’s airspeed increasing whilst the First Officer’s decreased. The First Officer attempted to commence the corresponding drill but the Captain’s interruptions prevented this and a (false) overspeed warning followed. The Captain’s response to both alerts was to reduce thrust which led to a Stall Warning followed, after no response, by stick pusher activation which was repeatedly opposed by the Captain despite calls to stop from the First Officer. The stalled condition continued for almost five minutes until a 30,000 feet descent was terminated by terrain impact.

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.

On 4 March 2013, a Beechcraft Premier 1A stalled and crashed soon after take off from Annemasse. The Investigation concluded that the loss of control was attributable to taking off with frozen deposits on the wings which the professional pilot flying the privately-operated aircraft had either not been aware of or had considered insignificant. It was found that the aircraft had been parked outside overnight and that overnight conditions, particularly the presence of a substantial quantity of cold-soaked fuel, had been conducive to the formation of frost and that no airframe de/anti icing facilities had been available at Annemasse.

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 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 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.

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