On 24 February 2020, a Sikorsky S92 crew departing at night from an oil rig platform in the Norwegian sector of the North Sea in adverse weather conditions temporarily lost pitch control of their helicopter after both pilots became spatially disorientated prior to reaching the minimum speed for autopilot engagement. Recovery was successful and the remainder of the flight was uneventful but the Investigation concluded that operator procedures were insufficiently robust and that helicopters engaged in offshore operations could usefully be equipped with low speed flight modes to mitigate the consequences of pilot spatial disorientation during low level manoeuvring.

On 25 October 2021, a Boeing 737-800 had just reached its cruise altitude after takeoff from Perth when a fuel imbalance message was displayed on the system panel. Despite specified indications for a fuel leak as the cause of this message not being met, it was determined that the left engine should be shut down. A ‘PAN’ was declared and a diversion to Kalgoorlie completed. Inspection there found the fuel imbalance was within normal limits and that crew diagnosis of a fuel leak had been flawed. Non-standard closure of the crossfeed valve was suspected as the origin of the imbalance.

On 21 June 2018, an Airbus 220-300 completed its landing at Riga on the third attempt but after pilot mismanagement of directional control inputs once on the ground, a minor and brief veer off the side of the runway and associated edge lighting damage occurred. The Investigation was hindered because the aircraft operator did not promptly report the occurrence to the State Safety Investigation Agency. This was found to be attributable to an absence of corresponding procedures or recognition of the associated regulatory responsibility at the airline concerned.

On 15 January 2023, an ATR 72-500 positioning visually for an approach to Pokhara suddenly departed controlled flight and impacted terrain. The aircraft was destroyed by the impact and all 71 occupants were killed. A type-experienced Training Captain was overseeing new airport familiarisation for a Line Captain acting as Pilot Flying. The Training Captain unintentionally feathered both propellers in response to a call for Flaps 30 but did not recognise their error or respond to calls that no power was coming from the engines. The airline’s operational safety-related processes and Regulatory oversight of them were both assessed as comprehensively inadequate.

On 12 September 2020, during a largely autopilot-controlled ILS glideslope capture from above and despite being unstabilised after the crew had intentionally ignored required approach management procedures, a flight was continued without hesitation to a landing. The Investigation found that the operator’s oversight of operating standards relating to unstabilised approaches was systemically flawed and also insufficiently supportive of their ‘Evidence Based Training’ method used for pilot training. It was also noted that the Captain involved had stated to the Investigation that “he considered this flight as a non event”.

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 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 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 23 February 2018, an Embraer 195LR and an Airbus A320 on SIDs departing Brussels lost separation after the 195 was given a radar heading to resolve a perceived third aircraft conflict which led to loss of separation between the two departing aircraft. STCA and coordinated TCAS RA activations followed but only one TCAS RA was followed and the estimated minimum separation was 400 feet vertically when 1.36 nm apart. The Investigation found that conflict followed an error by an OJTI-supervised trainee controller receiving extended revalidation training despite gaining his licence and having almost 10 years similar experience in Latvia.

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 19 December 2008, an Aeroflot Airbus A320 descended significantly below its cleared and acknowledged altitude after the crew lost situational awareness at night whilst attempting to establish on the ILS at Oslo from an extreme intercept track after a late runway change and an unchallenged incorrect readback. The Investigation concluded that the response to the EGPWS warning which resulted had been “late and slow” but that the risk of CFIT was “present but not imminent”. The context for the event was considered to have been poor communications between ATC and the aircraft in respect of changes of landing runway.

On 10 February 2011, control of a Spanish-operated Fairchild SA227 operating a scheduled passenger flight from Belfast UK to Cork, Ireland was lost during an attempt to commence a third go around due to fog from 100 feet below the approach minimum height. The Investigation identified contributory causes including serial non-compliance with many operational procedures and inadequate regulatory oversight of the Operator. Complex relationships were found to prevail between the Operator and other parties, including “Manx2”, an Isle of Man-based Ticket Seller under whose visible identity the aircraft operated. Most resultant Safety Recommendations concerned systemic improvement in regulatory oversight effectiveness.

On 17 July 2011, an Aer Arann ATR 72-200 made a bounced daylight landing at Shannon in gusty crosswind conditions aggravated by the known effects of a nearby large building. The nose landing gear struck the runway at 2.3g and collapsed with subsequent loss of directional control and departure from the runway. The aircraft was rendered a hull loss but there was no injury to the 25 occupants. The accident was attributed to an excessive approach speed and inadequate control of aircraft pitch during landing. Crew inexperience and incorrect power handling technique whilst landing were also found to have contributed.

On 18 November 2009, an IAI Westwind on a medevac mission failed to make a planned night landing at Norfolk Island in unanticipated adverse weather and was intentionally ditched offshore because of insufficient fuel to reach the nearest alternate. The fuselage broke in two on water contact but all six occupants escaped from the rapidly sinking wreckage and were eventually rescued. The Investigation initially completed in 2012 was reopened after concerns about its conduct and a new Final Report in 2017 confirmed that the direct cause was flawed crew decision-making but also highlighted ineffective regulatory oversight and inadequate Operator procedures.

On 16 September 2007, an MD-82 being operated by One Two Go Airlines attempted a missed approach from close to the runway at Phuket but after the flight crew failed to ensure that the necessary engine thrust was applied, the aircraft failed to establish a climb and after control was lost, the aircraft impacted the ground within the airport perimeter and was destroyed by the impact and a subsequent fire. Ninety of the 130 occupants were killed, 26 suffered serious injuries and 14 suffered minor injuries.