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 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 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.

On 9 September 2017, an ATR 72-500 crew temporarily lost control of their aircraft when it stalled whilst climbing in forecast moderate icing conditions after violation of applicable guidance. Recovery was then delayed because the correct stall recovery procedure was not followed. A MAYDAY declaration due to a perception of continuing control problems was followed by a comprehensively unstabilised ILS approach to Madrid. The Investigation concluded that the stall and its sequel were attributable to deficient flight management and inappropriate use of automation. The operator involved was recommended to implement corrective actions to improve the competence of its crews.

On 28 July 2018, a right engine compressor stall on an ATR72-500 bound for Port Vila followed by smoke in the passenger cabin led to a MAYDAY declaration and shutdown of the malfunctioning engine. The subsequent single engine landing at destination ended in a veer-off and collision with two unoccupied parked aircraft. The Investigation noted the disorganised manner in which abnormal/emergency and normal checklists had been actioned and found that the Before Landing Checklist had not been run which resulted in the rudder limiter being left in high speed mode making single engine directional control on the ground effectively impossible.

On 12 July 2018, a Boeing 737-800 was climbing through FL135 soon after takeoff from Sydney with First Officer line training in progress when the cabin altitude warning horn sounded because both air conditioning packs had not been switched on. The Captain took control and descended the aircraft to FL100 until the situation had been normalised and the intended flight was completed. The Investigation noted that although both pilots were experienced in command on other aircraft types, both had limited time on the 737 and concluded that incorrect system configuration was consequent on procedures and checklists not being managed appropriately.

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 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 9 November 2005, a McDonnell Douglas DC10-30F almost failed to get airborne before the end of the runway on a night takeoff from Macau and its main landing gear then hit lighting and ILS equipment as it climbed at a very shallow angle. After flight, two wheel changes were required due to tyre damage. The Investigation was hindered by the failure of the State of the Operator to assist the Investigation but concluded that the aircraft had been correctly loaded and that the extended take off roll had been due to use of the wrong flap setting.

On 10 August 2014, one of the engines of an Antonov 140-100 departing Tehran Mehrabad ran down after V1 and prior to rotation. The takeoff was continued but the crew were unable to keep control and the aircraft stalled and crashed into terrain near the airport. The Investigation found that a faulty engine control unit had temporarily malfunctioned and that having taken off with an inappropriate flap setting, the crew had attempted an initial climb with a heavy aircraft without the failed engine propeller initially being feathered, with the gear remaining down and with the airspeed below V2.

On 13 June 2013, a rushed and unstable visual approach to Marsh Harbour by a Saab 340B was followed by a mishandled landing and a runway excursion. The Investigation concluded that the way the aircraft had been operated had been contrary to expectations in almost every respect. This had set the scene for the continuation of a visual approach to an attempted landing in circumstances where there had been multiple indications that there was no option but to break off the approach, including a total loss of forward visibility in very heavy rain as the runway neared.

On 10 May 2014 the crew of an Airbus A319 failed to manage their daylight non-precision approach at destination effectively and it culminated in a very hard touchdown which exceeded landing gear design criteria. The Investigation concluded that the comprehensively poor performance of both pilots during the preparation for and execution of the approach could be attributed to both their repeated failure to follow SOPs and retain adequate situational awareness and to a failure of the aircraft operator to fully deliver effective training even though both this training and its SMS met relevant regulatory requirements and guidance.

On 19 March 2016, a Boeing 737-800 making a second night ILS approach to Rostov-on-Don failed to complete a go around commenced after becoming unstable in turbulent conditions and crashed at high speed within the airport perimeter killing all 62 people on board. The Investigation concluded that the Captain had lost spatial awareness and then failed to configure the aircraft correctly or control its flightpath as intended and that although the First Officer had recognised this, he had tried to coach the Captain rather than take over. It was noted that the flight up to this point had been conducted normally.