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Accident and Serious Incident Reports: LOC

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Category: Loss of Control Loss of Control
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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

  • A139, vicinity Sky Shuttle Heliport Hong Kong China, 2010 (On 3 July 2010, an AW 139 helicopter was climbing through 350 feet over water two minutes after take off when the tail rotor fell off. A transition to autorotation was accomplished and a controlled ditching followed. All on board were rescued, some sustained minor injuries. The failure was attributed entirely to manufacturing defects but no action was taken until two similar accidents had occurred in Qatar (non-fatal) and Brazil (fatal) the following year and two Safety Recommendations had been issued from this Investigation after which a comprehensive review of the manufacturing process resulted in numerous changes monitored by EASA.)
  • A306, vicinity JFK New York USA, 2001 (On November 12, 2001, an Airbus Industries A300-600 operated by American Airlines crashed into a residential area of Belle Harbour, New York, after take-off from John F. Kennedy International Airport, New York. Shortly after take off, the aircraft encountered mild wake turbulence from a departing Boeing 747-400.)
  • A310, en-route, Florida Keys USA, 2005 (On 6 March 2005, an Airbus A310-300 being operated by Canadian airline Air Transat on a passenger charter flight from Varadero Cuba to Quebec City was in the cruise in daylight VMC at FL350 seventeen minutes after departure and overhead the Florida Keys when the flight crew heard a loud bang and felt some vibration. The aircraft entered a Dutch roll which was eventually controlled in manual flight after a height excursion. During descent for a possible en route diversion, the intensity of the Dutch Roll lessened and then stopped and the crew decided to return to Varadero. It was found during landing there that rudder control inputs were not effective and after taxi in and shutdown at the designated parking position, it was discovered that the aircraft rudder was missing. One of the cabin crew sustained a minor back injury during the event but no others from the 271 occupants were injured.)
  • A332, vicinity Perth Australia, 2014 (On 9 June 2014, a 'burning odour' of undetermined origin became evident in the rear galley of an Airbus A330 as soon as the aircraft powered up for take off. Initially, it was dismissed as not uncommon and likely to soon dissipate, but it continued and affected cabin crew were unable to continue their normal duties and received oxygen to assist recovery. En route diversion was considered but flight completion chosen. It was found that the rear pressure bulkhead insulation had not been correctly refitted following maintenance and had collapsed into and came into contact with APU bleed air duct.)
  • AT43, Bergen Norway, 2005 (On 31 January 2005, an ATR 42-300 being operated by Danish Air Transport on a scheduled passenger flight from Bergen to Florø in day VMC encountered pitch control difficulties during rotation and subsequent climb and after declaring an emergency made a successful return to land on the departure runway seven minutes later. None of the 25 occupants were injured and the only damage found was to the elevator and its leading edge fairings.)
  • AT73, en-route, Roselawn IN USA, 1994 (On 31 October 1994, an ATR 72 exited controlled flight after a flap retraction when descending through 9000 feet was followed by autopilot disconnect and rapid and very large un-commanded roll inputs from which recovery, not within the scope of received crew training, was not achieved. The investigation found this roll upset had been due to a sudden and unexpected aileron hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-icing boots during earlier holding in icing conditions which had been - unknown to the crew - outside the icing certification envelope.)
  • B732, en-route, Maui Hawaii, 1988 (On 28 April 1988, a Boeing 737-200, operated by Aloha Airlines experienced an explosive depressurisation and structural failure at FL 240. Approximately 5.5 metres (or 18 feet) of cabin covering and structure was detached from the aircraft during flight. As result of the depressurisation, a member of the cabin crew was fatally injured. The flight crew performed an emergency descent, landing at Kahului Airport on the Island of Maui, Hawaii.)
  • B733, en-route, north of Yuma AZ USA, 2011 (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.)
  • B738, Dubai UAE, 2013 (On 6 December 2013, a Boeing 737-800 passenger aircraft was flown from Amman to Dubai out of revenue service with a quantity of 'live' boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance. As a result of the investigation, a previously unreported flight by the same operator in revenue service which had also carried live oxygen generators was disclosed.)
  • B738, vicinity Faro Portugal, 2011 (On 24 October 2011, the crew of a Ryanair Boeing 737-800 operating the first flight after an unexpectedly severe overnight storm found that after take off, an extremely large amount of rudder trim was required to fly ahead. Following an uneventful return to land, previously undetected damage to the rudder assembly was found which was attributed to the effects of the storm. It was found that pre flight checks required at the time could not have detected the damage and noted that the wind speeds which occurred were much higher than those anticipated by the applicable certification requirements.)
  • B739, en-route, east of Denver CO USA, 2012 (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.)
  • B741, en-route, East Moriches NY USA, 1996 (On 17 July 1996, a Boeing 747, operated by TWA, experienced an in-flight breakup and then crashed into the Atlantic Ocean near East Moriches, New York, USA.)
  • … further results


Significant Systems or Systems Control Failure

  • A139, vicinity Sky Shuttle Heliport Hong Kong China, 2010 (On 3 July 2010, an AW 139 helicopter was climbing through 350 feet over water two minutes after take off when the tail rotor fell off. A transition to autorotation was accomplished and a controlled ditching followed. All on board were rescued, some sustained minor injuries. The failure was attributed entirely to manufacturing defects but no action was taken until two similar accidents had occurred in Qatar (non-fatal) and Brazil (fatal) the following year and two Safety Recommendations had been issued from this Investigation after which a comprehensive review of the manufacturing process resulted in numerous changes monitored by EASA.)
  • A319, London Heathrow UK, 2013 (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.)
  • A319, en-route, Free State Province South Africa, 2008 (On 7 September 2008 a South African Airways Airbus A319 en route from Cape Town to Johannesburg at FL370 received an ECAM warning of the failure of the No 1 engine bleed system. The crew then closed the No. 1 engine bleed with the applicable press button on the overhead panel. The cabin altitude started to increase dramatically and the cockpit crew advised ATC of the pressurisation problem and requested an emergency descent to a lower level. During the emergency descent to 11000 ft amsl, the cabin altitude warning sounded at 33000ft and the flight crew activated the cabin oxygen masks. The APU was started and pressurisation was re-established at 15000ft amsl. The crew completed the flight to the planned destination without any further event. The crew and passengers sustained no injuries and no damage was caused to the aircraft.)
  • A319, south of London UK, 2005 (On 22 October 2005, a British Airways Airbus A319 climbing en route to destination over south east England at night in VMC experienced a major but temporary electrical failure. Most services were re-instated within a short time and the flight was continued. However, during the subsequent Investigation, which took over two years, a series of significant deficiencies were identified in the design of the A320 series electrical system and the manufacturer-recommended responses to failures in it and in response, Airbus developed solutions to most of them.)
  • A320, en-route, north of Öland Sweden, 2011 (On 5 March 2011, a Finnair Airbus A320 was westbound in the cruise in southern Swedish airspace after despatch with Engine 1 bleed air system inoperative when the Engine 2 bleed air system failed and an emergency descent was necessary. The Investigation found that the Engine 2 system had shut down due to overheating and that access to proactive and reactive procedures related to operations with only a single bleed air system available were deficient. The crew failure to make use of APU air to help sustain cabin pressurisation during flight completion was noted.)
  • A321, Manchester UK, 2008 (2) (On 28 July 2008, the crew flying an Airbus A321-200 departing Manchester UK were unable to raise the landing gear. The fault was caused by damage to the Nose Landing Gear sustained on the previous flight which experienced a heavy landing.)
  • A321, en-route, near Pamplona Spain, 2014 (On 5 November 2014, the crew of an Airbus A321 temporarily lost control of their aircraft in the cruise and were unable to regain it until 4000 feet of altitude had been lost. An investigation into the causes is continuing but it is already known that blockage of more than one AOA probe resulted in unwanted activation of high AOA protection which could not be stopped by normal sidestick inputs until two of the three ADRs had been intentionally deactivated in order to put the flight control system into Alternate Law.)
  • A333, Hong Kong China, 2010 (On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.)
  • A333, en-route, West of Learmonth Australia, 2008 (On 7 October 2008, an Airbus A330-300 aircraft experienced multiple system failure indications followed by uncommanded pitch-down events which resulted in serious injuries to passengers and cabin crew.)
  • A333, en-route, near Bournemouth UK, 2012 (On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.)
  • A333, en-route, south of Moscow Russia, 2010 (On 22 December 2010, a Finnair Airbus A330-300 inbound to Helsinki and cruising in very cold air at an altitude of 11,600 metres lost cabin pressurisation in cruise flight and completed an emergency descent before continuing the originally intended flight at a lower level. The subsequent Investigation was carried out together with that into a similar occurrence to another Finnair A330 which had occurred 11 days earlier. It was found that in both incidents, both engine bleed air systems had failed to function normally because of a design fault which had allowed water within their pressure transducers to freeze.)
  • A346, en-route, Amsterdam Netherlands, 2005 (On 8 February 2005, a Virgin Atlantic Airways A340-600 experienced in-flight fuel management problem which led to loss of power of No 1 engine and temporary power loss of No 4. The captain decided to divert to Amsterdam where the aircraft landed safely on three engines.)
  • … further results


Degraded flight instrument display

  • A319, south of London UK, 2005 (On 22 October 2005, a British Airways Airbus A319 climbing en route to destination over south east England at night in VMC experienced a major but temporary electrical failure. Most services were re-instated within a short time and the flight was continued. However, during the subsequent Investigation, which took over two years, a series of significant deficiencies were identified in the design of the A320 series electrical system and the manufacturer-recommended responses to failures in it and in response, Airbus developed solutions to most of them.)
  • A321, en-route, Gimpo South Korea, 2006 (On 9 June 2006, an Airbus 321-100, operated by Asiana Airlines, encountered a thunderstorm accompanied by Hail around 20 miles southeast of Anyang VOR at an altitude of 11,500 ft, while descending for an approach to Gimpo Airport. The radome was detached and the cockpit windshield was cracked due to impact with Hail.)
  • A321, en-route, Northern Sudan, 2010 (On 24 August 2010, an Airbus A321-200 being operated by British Midland on a scheduled public transport service from Khartoum to Beirut experienced, during cruise at FL360 in night IMC, an electrical malfunction which was accompanied by intermittent loss of the display on both pilots’ EFIS and an uncommanded change to a left wing low attitude. De-selection of the No 1 generator and subsequent return of the rudder trim, which had not previously been intentionally moved, to neutral removed all abnormalities and the planned flight was completed without further event with no damage to the aircraft or injuries to the 49 occupants.)
  • A332, en-route, Atlantic Ocean, 2009 (On 1 June 2009, an Airbus A330-200 being operated by Air France on a scheduled passenger flight from Rio de Janeiro to Paris CDG as AF447 exited controlled flight and crashed into the sea with the loss of the aircraft and all 228 occupants. It was found that the loss of control followed an inappropriate response by the flight crew to a transient loss of airspeed indications in the cruise which resulted from the vulnerability of the pitot heads to ice crystal icing.)
  • ATP, en-route, Oxford UK, 1991 (On 11 August 1991, an British Aerospace ATP, during climb to flight level (FL) 160 in icing conditions, experienced a significant degradation of performance due to propeller icing accompanied by severe vibration that rendered the electronic flight instruments partially unreadable. As the aircraft descended below cloud, control was regained and the flight continued uneventfully.)
  • B712, en-route, Union Start MO USA, 2005 (On 12 May 2005, the crew of a Midwest Airlines Boeing 717 climbed at night in IMC without selecting appropriate anti icing systems on and as a result lost control. Their non-standard response led to a split in control columns some two minutes into the eight minute period of pitch excursions over a 13000 feet height band at recorded ground speeds between 290 and 552 knots prior to eventual recovery. The investigation concluded that the aircraft had been fully serviceable with “all deviations from normal flight having been initiated or exacerbated by the control inputs of the flight crew”.)
  • B735, vicinity London Heathrow UK, 2007 (On 7 June 2007, a Boeing 737-500 operated by LOT Polish Airlines, after daylight takeoff from London Heathrow Airport lost most of the information displayed on Electronic Flight Instrument System (EFIS). The information in both Electronic Attitude Director Indicator (EADI) and Electronic Horizontal Situation Indicators (EHSI) disappeared because the flight crew inadvertently mismanaged the Flight Management System (FMS). Subsequently the crew had difficulties both in maintaining the aircraft control manually using the mechanical standby instruments and communicating adequately with ATC due to insufficient language proficiency. Although an emergency situation was not declared, the ATC realized the seriousness of the circumstances and provided discrete frequency and a safe return after 27 minutes of flight was achieved.)
  • B739, en-route, east of Denver CO USA, 2012 (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.)
  • B744, en-route NNW of Bangkok Thailand, 2008 (On 7 January 2008, a Boeing 747-400 being operated by Qantas on a scheduled passenger flight from London Heathrow to Bangkok was descending through FL100 about 13.5 nm NNW of destination in day VMC when indications of progressive electrical systems failure began to be annunciated. As the aircraft neared the end of the radar downwind leg, only the AC4 bus bar was providing AC power and the aircraft main battery was indicating discharge. A manual approach to a normal landing was subsequently accomplished and the aircraft taxied to the designated gate where passenger disembarkation took place. None of the 365 occupants, who included two heavy crew members who were present in the flight deck throughout the incident, had sustained any injury and the aircraft was undamaged.)
  • B744, vicinity Dubai UAE, 2010 (On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.)
  • B752, Chicago O’Hare IL USA, 2008 (On 22 September 2008, a Boeing 757-200 being operated by American Airlines on a scheduled passenger flight from Seattle/Tacoma WA to New York JFK lost significant electrical systems functionality en route. A diversion with an emergency declared was made to Chicago O’Hare where after making a visual daylight approach, the aircraft was intentionally steered off the landing runway when the aircraft commander perceived that an overrun would occur. None of the 192 occupants were injured and there was only minor damage to the aircraft landing gear.)
  • B752, en-route, Northern Ghana, 2009 (On 28 January 2009 the crew of a Boeing 757-200 continued takeoff from Accra Ghana despite becoming aware of an airspeed discrepancy during the take off roll. An attempt to resolve the problem failed and the consequences led to confusion as to what was happening which prompted them to declare a MAYDAY and return - successfully - to Accra. The left hand pitot probe was found to be blocked by an insect. The Investigation concluded that a low speed rejected takeoff would have been more appropriate than the continued take off in the circumstances which had prevailed.)
  • … further results


Uncommanded AP disconnect

  • A319, London Heathrow UK, 2013 (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.)
  • A320, en-route Karimata Strait Indonesia, 2014 (On 28 December 2014, an A320 crew took unapproved action in response to a repeating system caution shortly after levelling at FL320. The unexpected consequences degraded the flight control system and obliged manual control. Gross mishandling followed which led to a stall, descent at a high rate and sea surface impact with a 20º pitch attitude and a 50º angle of attack four minutes later. The Investigation noted the accident origin as a repetitive minor system fault but demonstrated that the subsequent loss of control followed a combination of explicitly inappropriate pilot action and the absence of appropriate pilot action.)
  • A321, en-route, Gimpo South Korea, 2006 (On 9 June 2006, an Airbus 321-100, operated by Asiana Airlines, encountered a thunderstorm accompanied by Hail around 20 miles southeast of Anyang VOR at an altitude of 11,500 ft, while descending for an approach to Gimpo Airport. The radome was detached and the cockpit windshield was cracked due to impact with Hail.)
  • A321, en-route, Northern Sudan, 2010 (On 24 August 2010, an Airbus A321-200 being operated by British Midland on a scheduled public transport service from Khartoum to Beirut experienced, during cruise at FL360 in night IMC, an electrical malfunction which was accompanied by intermittent loss of the display on both pilots’ EFIS and an uncommanded change to a left wing low attitude. De-selection of the No 1 generator and subsequent return of the rudder trim, which had not previously been intentionally moved, to neutral removed all abnormalities and the planned flight was completed without further event with no damage to the aircraft or injuries to the 49 occupants.)
  • A321, en-route, Vienna Austria, 2003 (On 26th May 2003, a British Midland A321 suffered severe damage from hail en route near Vienna.)
  • A332 MRTT, en-route, south eastern Black Sea, 2014 (On 9 February 2014, the Captain of a military variant of the Airbus A330 suddenly lost control during the cruise on a passenger flight. A violent, initially negative 'g', pitch down occurred which reached 15800 fpm as the speed rose to Mach 0.9. In the absence of any effective crew intervention, recovery was achieved entirely by the aircraft Flight Envelope Protection System. The Investigation found that the upset had occurred when the Captain moved his seat forward causing its left arm rest to contact the personal camera he had placed behind the sidestick, forcing the latter fully forward.)
  • A332, en-route, Atlantic Ocean, 2009 (On 1 June 2009, an Airbus A330-200 being operated by Air France on a scheduled passenger flight from Rio de Janeiro to Paris CDG as AF447 exited controlled flight and crashed into the sea with the loss of the aircraft and all 228 occupants. It was found that the loss of control followed an inappropriate response by the flight crew to a transient loss of airspeed indications in the cruise which resulted from the vulnerability of the pitot heads to ice crystal icing.)
  • A332, en-route, near Dar es Salaam Tanzania, 2012 (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.)
  • A333, en-route, West of Learmonth Australia, 2008 (On 7 October 2008, an Airbus A330-300 aircraft experienced multiple system failure indications followed by uncommanded pitch-down events which resulted in serious injuries to passengers and cabin crew.)
  • A346, en route, eastern Indian Ocean, 2013 (On 3 February 2013, an Airbus A340 crew in the cruise in equatorial latitudes at FL350 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL350 and reversion to Alternate Law. Excessive vibration on the left engine then began and a diversion was made. The engine remained in use and was subsequently found undamaged with the fault attributed to ice/water ingress due to seal failure.)
  • AT72, vicinity Manchester UK, 2016 (On 4 March 2015, the flight crew of an ATR72 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.)
  • AT73, en-route, Roselawn IN USA, 1994 (On 31 October 1994, an ATR 72 exited controlled flight after a flap retraction when descending through 9000 feet was followed by autopilot disconnect and rapid and very large un-commanded roll inputs from which recovery, not within the scope of received crew training, was not achieved. The investigation found this roll upset had been due to a sudden and unexpected aileron hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-icing boots during earlier holding in icing conditions which had been - unknown to the crew - outside the icing certification envelope.)
  • … further results


AP Status Awareness

  • A321, en-route, Vienna Austria, 2003 (On 26th May 2003, a British Midland A321 suffered severe damage from hail en route near Vienna.)
  • A332 MRTT, en-route, south eastern Black Sea, 2014 (On 9 February 2014, the Captain of a military variant of the Airbus A330 suddenly lost control during the cruise on a passenger flight. A violent, initially negative 'g', pitch down occurred which reached 15800 fpm as the speed rose to Mach 0.9. In the absence of any effective crew intervention, recovery was achieved entirely by the aircraft Flight Envelope Protection System. The Investigation found that the upset had occurred when the Captain moved his seat forward causing its left arm rest to contact the personal camera he had placed behind the sidestick, forcing the latter fully forward.)
  • A343, en-route, mid North Atlantic Ocean, 2011 (On 22 July 2011 an Air France A340-300 en route over the North Atlantic at FL350 in night IMC encountered moderate turbulence following "inappropriate use of the weather radar" which led to an overspeed annunciation followed by the aircraft abruptly pitching up and gaining over 3000 feet in less than a minute before control was regained and it was returned to the cleared level. There Investigation concluded that "the incident was due to inadequate monitoring of the flight parameters, which led to the failure to notice AP disengagement and the level bust, following a reflex action on the controls.”)
  • AT76, en route, west-southwest of Sydney Australia, 2014 (On 20 February 2014, an ATR 72-600 crew mishandled their response to an intended airspeed adjustment whilst using VS mode during descent to Sydney and an upset involving opposite control inputs from the pilots caused an elevator disconnect. The senior cabin attendant sustained serious injury. After recovery of control, the flight was completed without further event. Post flight inspection did not discover damage to the aircraft which exceeded limit and ultimate loads on the stabilisers and the aircraft remained in service for a further five days until it was grounded for replacement of both horizontal and vertical stabilisers.)
  • B733, vicinity Sharm El-Sheikh Egypt, 2004 (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.)
  • B734, en-route, Sulawesi Indonesia, 2007 (On 1 January 2007, a B737-400 crashed into the sea off Sulawesi, Indonesia, after the crew lost control of the aircraft having become distracted by a minor technical problem.)
  • B735, vicinity Kazan Russia, 2013 (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.)
  • B735, vicinity Perm Russian Federation, 2008 (On September 13 2008, at night and in good visual conditions*, a Boeing 737-500 operated by Aeroflot-Nord executed an unstabilised approach to Runway 21 at Bolshoye Savino Airport (Perm) which subsequently resulted in loss of control and terrain impact.)
  • B738, en-route, south south west of Brisbane Australia, 2013 (On 25 February 2013, a Boeing 737-800 about to commence descent from FL390 began to climb. By the time the crew recognised the cause and began to correct the deviation - their unintended selection of a inappropriate mode - the cleared level had been exceeded by 900 feet. During the recovery, a deviation from track occurred because the crew believed the autopilot had been re-engaged when it had not. The Investigation noted the failure to detect either error until flight path deviation occurred and attributed this to non-compliance with various operator procedures related to checking and confirmation of crew actions.)
  • B738, en-route, south west of Beirut Lebanon, 2010 (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.)
  • B738, vicinity Douala Cameroon, 2007 (On 5 May 2007, a Kenya Airways Boeing 737-800 departing Douala at night crashed shortly after take-off following an unsuccessful attempt at recovery after late recognition of a progressive right roll which led to spiral dive. The Investigation was unable to positively establish the reason for the unintended roll, but noted that it ad not been possible to determine whether the pilots, and in particular the aircraft commander, had been aware of the fact that the AP was not engaged.)
  • B752, en route, western Ireland, 2013 (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.)
  • … further results


Non-normal FBW flight control status

  • A319 / B744, en-route near Oroville WA USA, 2008 (On 10 January 2008, an Air Canada Airbus A319 en route over the north western USA encountered unexpected sudden wake vortex turbulence from an in trail Boeing 747-400 nearly 11nm ahead to which the pilots who then responded with potentially hazardous flight control inputs which led to reversion to Alternate Control Law and aggravated the external /disturbance to the aircraft trajectory with roll up to 55° and an unintended descent of 1400 feet which with cabin service in progress and sea belt signs off led to cabin service carts hitting the cabin ceiling and several passenger injuries, some serious.)
  • A319, vicinity Wuxi China, 2010 (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.)
  • A320, en-route Karimata Strait Indonesia, 2014 (On 28 December 2014, an A320 crew took unapproved action in response to a repeating system caution shortly after levelling at FL320. The unexpected consequences degraded the flight control system and obliged manual control. Gross mishandling followed which led to a stall, descent at a high rate and sea surface impact with a 20º pitch attitude and a 50º angle of attack four minutes later. The Investigation noted the accident origin as a repetitive minor system fault but demonstrated that the subsequent loss of control followed a combination of explicitly inappropriate pilot action and the absence of appropriate pilot action.)
  • A320, vicinity Frankfurt Germany, 2001 (On 21 March 2001 an Airbus A320-200, operated by Lufthansa, experienced a flight controls malfunctions shortly after take-off which resulted in loss of control and subsequent near terrain impact. The uncontrolled roll, due to the malfunction of the pilot flying's sidestick, was recovered by the other pilot and the aircraft safely returned to land in Frankfurt without further incident.)
  • A321, en-route, Northern Sudan, 2010 (On 24 August 2010, an Airbus A321-200 being operated by British Midland on a scheduled public transport service from Khartoum to Beirut experienced, during cruise at FL360 in night IMC, an electrical malfunction which was accompanied by intermittent loss of the display on both pilots’ EFIS and an uncommanded change to a left wing low attitude. De-selection of the No 1 generator and subsequent return of the rudder trim, which had not previously been intentionally moved, to neutral removed all abnormalities and the planned flight was completed without further event with no damage to the aircraft or injuries to the 49 occupants.)
  • A321, en-route, near Pamplona Spain, 2014 (On 5 November 2014, the crew of an Airbus A321 temporarily lost control of their aircraft in the cruise and were unable to regain it until 4000 feet of altitude had been lost. An investigation into the causes is continuing but it is already known that blockage of more than one AOA probe resulted in unwanted activation of high AOA protection which could not be stopped by normal sidestick inputs until two of the three ADRs had been intentionally deactivated in order to put the flight control system into Alternate Law.)
  • A332 MRTT, en-route, south eastern Black Sea, 2014 (On 9 February 2014, the Captain of a military variant of the Airbus A330 suddenly lost control during the cruise on a passenger flight. A violent, initially negative 'g', pitch down occurred which reached 15800 fpm as the speed rose to Mach 0.9. In the absence of any effective crew intervention, recovery was achieved entirely by the aircraft Flight Envelope Protection System. The Investigation found that the upset had occurred when the Captain moved his seat forward causing its left arm rest to contact the personal camera he had placed behind the sidestick, forcing the latter fully forward.)
  • A332, en-route, Atlantic Ocean, 2009 (On 1 June 2009, an Airbus A330-200 being operated by Air France on a scheduled passenger flight from Rio de Janeiro to Paris CDG as AF447 exited controlled flight and crashed into the sea with the loss of the aircraft and all 228 occupants. It was found that the loss of control followed an inappropriate response by the flight crew to a transient loss of airspeed indications in the cruise which resulted from the vulnerability of the pitot heads to ice crystal icing.)
  • A332, vicinity Brisbane Australia, 2013 (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

  • A306, East Midlands UK, 2011 (On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.)
  • A310, Vienna Austria, 2000 (On 12 July 2000, a Hapag Lloyd Airbus A310 was unable to retract the landing gear normally after take off from Chania for Hannover. The flight was continued towards the intended destination but the selection of an en route diversion due to higher fuel burn was misjudged and useable fuel was completely exhausted just prior to an intended landing at Vienna. The aeroplane sustained significant damage as it touched down unpowered inside the aerodrome perimeter but there were no injuries to the occupants and only minor injuries to a small number of them during the subsequent emergency evacuation.)
  • A319, London Heathrow UK, 2013 (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.)
  • A319, vicinity Zurich Switzerland, 2014 (On 17 October 2014, two recently type-qualified Airbus A319 pilots responded in a disorganised way after a sudden malfunction soon after take-off from Zurich required one engine to be shutdown. The return to land was flown manually and visually at an excessive airspeed and rate of descent with idle thrust on the remaining engine all the way to a touchdown which occurred without a landing clearance. The Investigation concluded that the poor performance of the pilots had been founded on a lack of prior analysis of the situation, poor CRM and non-compliance with system management and operational requirements.)
  • A320, vicinity Auckland New Zealand, 2012 (On 20 June 2012, the right V2500 engine compressor of an Airbus A320 suddenly stalled on final approach. The crew reduced the right engine thrust to flight idle and completed the planned landing uneventfully. Extensive engine damage was subsequently discovered and the investigation conducted attributed this to continued use of the engine in accordance with required maintenance procedures following bird ingestion during the previous sector. No changes to procedures for deferral of a post bird strike boroscope inspection for one further flight in normal service were proposed but it was noted that awareness of operations under temporary alleviations was important.)
  • A320, vicinity LaGuardia New York USA, 2009 (On 15 January 2009, a United Airlines Airbus A320-200 approaching 3000 feet agl in day VMC following take-off from New York La Guardia experienced an almost complete loss of thrust in both engines after encountering a flock of Canada Geese . In the absence of viable alternatives, the aircraft was successfully ditched in the Hudson River about. Of the 150 occupants, one flight attendant and four passengers were seriously injured and the aircraft was substantially damaged. The subsequent investigation led to the issue of 35 Safety Recommendations mainly relating to ditching, bird strike and low level dual engine failure.)
  • A332, en-route, North Atlantic Ocean, 2001 (On 24 August 2001, an Air Transat Airbus A330-200 eastbound across the North Atlantic at night experienced a double-engine flameout after which Lajes on Terceira Island in the Azores was identified as the best diversion and a successful glide approach and landing there was subsequently achieved. The Investigation found that the flameouts had been the result of fuel exhaustion after a fuel leak from the right engine caused by a pre flight maintenance error. Fuel exhaustion was found to have occurred because the flight crew did not perform the QRH procedure applicable to an in-flight fuel leak.)
  • A333, Hong Kong China, 2010 (On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.)
  • A346, en-route, Amsterdam Netherlands, 2005 (On 8 February 2005, a Virgin Atlantic Airways A340-600 experienced in-flight fuel management problem which led to loss of power of No 1 engine and temporary power loss of No 4. The captain decided to divert to Amsterdam where the aircraft landed safely on three engines.)
  • A388, en-route Batam Island Indonesia, 2010 (On 4 November 2010, a Qantas Airbus A380 climbing out of Singapore experienced a sudden and uncontained failure of one of its Rolls Royce Trent 900 engines which caused considerable collateral damage to the airframe and some of the aircraft systems. A ‘PAN’ was declared and after appropriate crew responses including aircraft controllability checks, the aircraft returned to Singapore. The root cause of the failure was found to have been an undetected component manufacturing fault. The complex situation which resulted from the failure in flight was found to have exceeded the currently anticipated secondary damage from such an event.)
  • AS32, en-route, North Sea Norway, 1998 (On 20 October 1998, in the North Sea, an Eurocopter AS332L Super Puma operated by Norsk HeliKopter AS, experienced engine failure with autorotation and subsequent lost of height. The crew misidentified the malfunctioning engine and reduced the power of the remaining serviceable engine. However, the mistake was realised quickly enough for the crew to recover control of the helicopter.)
  • AS32, en-route, near Peterhead Scotland UK, 2009 (On 1 April 2009, the flight crew of a Bond Helicopters’ Eurocopter AS332 L2 Super Puma en route from the Miller Offshore Platform to Aberdeen at an altitude of 2000 feet lost control of their helicopter when a sudden and catastrophic failure of the main rotor gearbox occurred and, within less than 20 seconds, the hub with the main rotor blades attached separated from the helicopter causing it to fall into the sea at a high vertical speed The impact destroyed the helicopter and all 16 occupants were killed. Seventeen Safety Recommendations were made as a result of the investigation.)
  • … further results


Crew Incapacitation

  • B733, en-route, northwest of Athens Greece, 2005 (On 14 August 2005, a Boeing 737-300 was released to service with the cabin pressurisation set to manual. This abnormal setting was not detected by the flight crew involved during standard checks. They took no corrective action after take-off when a cabin high altitude warning occurred. The crew lost consciousness as the aircraft climbed on autopilot and after eventual fuel exhaustion, the aircraft departed controlled flight and impacted terrain. The Investigation found that inadequate crew performance had occurred within a context of systemic organisational safety deficiencies at the Operator compounded by inadequate regulatory oversight.)
  • B738, en-route, south east of Marseilles France, 2011 (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.)
  • B744, vicinity Dubai UAE, 2010 (On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.)
  • BE20, vicinity Stapleford UK, 2015 (On 3 October 2015, the pilot of a Beech Super King Air on a business flight lost control in IMC shortly after take-off and the aircraft subsequently impacted terrain at high speed. The Investigation concluded on the balance of probabilities that pilot medical incapacitation was likely to have occurred. It was noted that the aircraft had not been fitted with TAWS nor was it required to be but it was found that alerting from such a system would have increased the chances of the only passenger, another professional pilot, successfully taking over and three corresponding Safety Recommendations were made.)
  • D228, vicinity Bodø Norway, 2003 (On 4 December 2003, the crew of a Dornier 228 approaching Bodø lost control of their aircraft after a lightning strike which temporarily blinded both pilots and damaged the aircraft such that the elevator was uncontrollable. After regaining partial pitch control using pitch trim, a second attempt at a landing resulted in a semi-controlled crash which seriously injured both pilots and damaged the aircraft beyond repair. The Investigation concluded that the energy in the lightning had probably exceeded certification resilience requirements and that up to 30% of the bonding wiring in the tail may have been defective before lightning struck.)
  • DH8D, vicinity Medford OR USA, 2003 (On 8 January 2003, a DHC8-400 sustained multiple bird strikes during a night visual circuit at the Medford airport, OR, USA, resulting in loss of flight displays, multiple false system warnings and the shattering of the LH windscreen. The Captain sustained significant facial injuries and temporary incapacitation with a successful approach and landing being completed by the co-pilot.)
  • HAWK, vicinity Bournemouth, UK 2011 (On 20 August 2011, a RAF Aerobatic Team Hawk failed to complete a formation break to land near Bournemouth and the aircraft flew into the ground, destroying the aircraft and killing the pilot. The subsequent Inquiry concluded that the pilot had become semi conscious as the result of the sudden onset of G-induced impairment characterised as A-LOC. It was found that the manoeuvre as flown was not radically different to usual and that the context for the accident was to be found in a range of organisational failures in risk management.)
  • MD11, en-route, near Cape Ashizuri, Japan, 2007 (On 10 January 2007, a Transmile Air Services Boeing MD11F First Officer became suddenly incapacitated by seizure during a flight from Anchorage to Hong Kong. A diversion was made and the affected pilot hospitalised where the cause was identified as a previously non-symptomatic brain tumour.)


Flight Management Error

  • A306, vicinity Nagoya Japan, 1994 (On 26 April 1994, the crew of an Airbus A300-600 lost control of their aircraft on final approach to Nagoya and the aircraft crashed within the airport perimeter. The Investigation found that an inadvertent mode selection error had triggered control difficulties which had been ultimately founded on an apparent lack understanding by both pilots of the full nature of the interaction between the systems controlling thrust and pitch on the aircraft type which were not typical of most other contemporary types. It was also concluded that the Captain's delay in taking control from the First Officer had exacerbated the situation.)
  • A310, Vienna Austria, 2000 (On 12 July 2000, a Hapag Lloyd Airbus A310 was unable to retract the landing gear normally after take off from Chania for Hannover. The flight was continued towards the intended destination but the selection of an en route diversion due to higher fuel burn was misjudged and useable fuel was completely exhausted just prior to an intended landing at Vienna. The aeroplane sustained significant damage as it touched down unpowered inside the aerodrome perimeter but there were no injuries to the occupants and only minor injuries to a small number of them during the subsequent emergency evacuation.)
  • A310, vicinity Quebec Canada, 2008 (On 5 March 2008, an Air Transat A310-300 was unintentionally mishandled by the flight crew during and shortly after departure from Quebec and effective control of the aircraft was temporarily lost. Whilst it was concluded that the origin of the initial difficulties in control were a result of confusion which began on the take off roll and led to a take off at excessive speed followed by subsequent mismanagement and overload, the inappropriate steep descent that followed was attributed to the effect of somatogravic illusion in respect of aircraft attitude control in conjunction with a singular focus on airspeed.)
  • A318/B738, Nantes France, 2010 (On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.)
  • A319, Montego Bay Jamaica, 2014 (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.)
  • A319, vicinity Tunis Tunisia, 2012 (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”.)
  • A319, vicinity Wuxi China, 2010 (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.)
  • A320, en-route, north of Öland Sweden, 2011 (On 5 March 2011, a Finnair Airbus A320 was westbound in the cruise in southern Swedish airspace after despatch with Engine 1 bleed air system inoperative when the Engine 2 bleed air system failed and an emergency descent was necessary. The Investigation found that the Engine 2 system had shut down due to overheating and that access to proactive and reactive procedures related to operations with only a single bleed air system available were deficient. The crew failure to make use of APU air to help sustain cabin pressurisation during flight completion was noted.)
  • A320, vicinity Melbourne Australia, 2007 (On 21 July 2007, an Airbus A320-232 being operated by Australian Operator Jetstar Airways and on final approach to Melbourne after a passenger flight from Christchurch, New Zealand intended to make a go around after the required visual reference at Decision Altitude was not available, but the intended action was mis-managed such that safe control of the aircraft was temporarily lost. Recovery was achieved and there were no further abnormalities of flight during a second missed approach at Melbourne or the subsequent diversion to Avalon.)
  • A320, vicinity Perpignan France, 2008 (On 27 November 2008, the crew of an XL Airways A320 on an airworthiness function flight following aircraft repainting lost control of the aircraft after fail to take the action necessary to recover from a full stall which had resulted from their continued airspeed reduction during a low speed handling test when Stall Protection System (SPS) activation did nor occur at the likely airspeed because two of the three angle of attack sensors were blocked by ice formed by water ingress during preparation for the repainting. This condition rendered angle of attack protection in normal law inoperative.)
  • A320, vicinity Tel Aviv Israel, 2012 (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.)
  • A321, Incheon South Korea, 2013 (On 16 April 2013, an A321 sustained significant damage during a tail strike during a bounced landing which followed loss of airspeed and an increase in sink rate shortly before touchdown after an otherwise stabilised approach. The Investigation attributed the tail strike to a failure to follow the recommended bounced landing response and noted the inadequate training provided by Asiana for bounced landing recovery.)
  • … further results


Flight Control Error

  • A306, East Midlands UK, 2011 (On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.)
  • A306, vicinity JFK New York USA, 2001 (On November 12, 2001, an Airbus Industries A300-600 operated by American Airlines crashed into a residential area of Belle Harbour, New York, after take-off from John F. Kennedy International Airport, New York. Shortly after take off, the aircraft encountered mild wake turbulence from a departing Boeing 747-400.)
  • A306, vicinity London Gatwick, 2011 (On 12 January 2011, an Airbus A300-600 being operated by Monarch Airlines on a passenger flight from London Gatwick to Chania, Greece experienced activations of the stall protection system after an unintended configuration change shortly after take off but following recovery, the flight continued as intended without further event. There were no abrupt manoeuvres and no injuries to the 347 occupants.)
  • A306, vicinity Nagoya Japan, 1994 (On 26 April 1994, the crew of an Airbus A300-600 lost control of their aircraft on final approach to Nagoya and the aircraft crashed within the airport perimeter. The Investigation found that an inadvertent mode selection error had triggered control difficulties which had been ultimately founded on an apparent lack understanding by both pilots of the full nature of the interaction between the systems controlling thrust and pitch on the aircraft type which were not typical of most other contemporary types. It was also concluded that the Captain's delay in taking control from the First Officer had exacerbated the situation.)
  • A310, Ponta Delgada Azores Portugal, 2013 (On 2 March 2013, the crew of an Airbus A310 mishandled a night tailwind touchdown at Ponta Delgada after a stabilised ILS approach had been flown and, after an initial bounce, the pitch was increased significantly and the main landing gear was fully compressed during the subsequent touchdown resulting in a tail strike and substantial related structural damage. The mishandling was attributed to deviation from the recommended 'light bounce' recovery technique. The absence of an instrument approach to the reciprocal (into wind) direction of the runway was noted and a recommendation that an RNAV procedure be made available was made.)
  • A310, vicinity Paris Orly France, 1994 (On 24 September 1994, lack of understanding of automatic flight control modes, by the crew of an Airbus A-310, led to a full stall. The aircraft was recovered and subsequently landed without further event at Paris Orly.)
  • A310, vicinity Quebec Canada, 2008 (On 5 March 2008, an Air Transat A310-300 was unintentionally mishandled by the flight crew during and shortly after departure from Quebec and effective control of the aircraft was temporarily lost. Whilst it was concluded that the origin of the initial difficulties in control were a result of confusion which began on the take off roll and led to a take off at excessive speed followed by subsequent mismanagement and overload, the inappropriate steep descent that followed was attributed to the effect of somatogravic illusion in respect of aircraft attitude control in conjunction with a singular focus on airspeed.)
  • A319 / B744, en-route near Oroville WA USA, 2008 (On 10 January 2008, an Air Canada Airbus A319 en route over the north western USA encountered unexpected sudden wake vortex turbulence from an in trail Boeing 747-400 nearly 11nm ahead to which the pilots who then responded with potentially hazardous flight control inputs which led to reversion to Alternate Control Law and aggravated the external /disturbance to the aircraft trajectory with roll up to 55° and an unintended descent of 1400 feet which with cabin service in progress and sea belt signs off led to cabin service carts hitting the cabin ceiling and several passenger injuries, some serious.)
  • A319, Luton UK, 2012 (On 14 February 2011, an Easyjet Airbus A319 being flown by a trainee Captain under supervision initiated a go around from below 50 feet agl after a previously stabilised approach at Luton and a very hard three point landing followed before the go around climb could be established. The investigation found that the Training Captain involved, although experienced, had only limited aircraft type experience and that, had he taken control before making a corrective sidestick input opposite to that of the trainee, it would have had the full instead of a summed effect and may have prevented hard runway contact.)
  • A319, vicinity Tunis Tunisia, 2012 (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”.)
  • A320, Hamburg Germany, 2008 (On 1 March 2008 an Airbus A320 being operated by Lufthansa on a scheduled passenger flight from Munich to Hamburg experienced high and variable wind velocity on short finals in good daylight visibility and during the attempt at landing on runway 23 with a strong crosswind component from the right, a bounced contact of the left main landing gear with the runway was followed by a left wing down attitude which resulted in the left wing tip touching the ground. A rejected landing was then flown and after radar vectoring, a second approach to runway 33 was made to a successful landing. No aircraft occupants were injured but the aircraft left wing tip was found to have been damaged by the runway contact. The track of the aircraft and spot wind velocities given by ATC at key points are shown on the illustration below.)
  • A320, en-route Karimata Strait Indonesia, 2014 (On 28 December 2014, an A320 crew took unapproved action in response to a repeating system caution shortly after levelling at FL320. The unexpected consequences degraded the flight control system and obliged manual control. Gross mishandling followed which led to a stall, descent at a high rate and sea surface impact with a 20º pitch attitude and a 50º angle of attack four minutes later. The Investigation noted the accident origin as a repetitive minor system fault but demonstrated that the subsequent loss of control followed a combination of explicitly inappropriate pilot action and the absence of appropriate pilot action.)
  • … further results


Environmental Factors

  • A319, vicinity Wuxi China, 2010 (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.)
  • A320, Hamburg Germany, 2008 (On 1 March 2008 an Airbus A320 being operated by Lufthansa on a scheduled passenger flight from Munich to Hamburg experienced high and variable wind velocity on short finals in good daylight visibility and during the attempt at landing on runway 23 with a strong crosswind component from the right, a bounced contact of the left main landing gear with the runway was followed by a left wing down attitude which resulted in the left wing tip touching the ground. A rejected landing was then flown and after radar vectoring, a second approach to runway 33 was made to a successful landing. No aircraft occupants were injured but the aircraft left wing tip was found to have been damaged by the runway contact. The track of the aircraft and spot wind velocities given by ATC at key points are shown on the illustration below.)
  • A320, en-route, North East Spain 2006 (On 28 May 2006, a Vueling Airbus A320 encountered sudden significant turbulence at FL325 and, during a temporary loss of control, was forced down to FL310 before recovery was achieved. Seven occupants sustained minor injuries and there was some internal damage caused by an unrestrained cabin service cart. The origin of the disturbance was found to have been wake vortices from an Airbus A340-300 which was 10nm ahead and 500 feet above on the same airway but the Investigation found that the crew response had been inappropriate and could have served to exacerbate the effects of the external disturbance.)
  • A321, Hakodate Japan, 2002 (On 21 January 2002, an Airbus A321-100 being operated by All Nippon Airways on a scheduled passenger flight from Nagoya to Hakodate encountered sudden negative windshear just prior to planned touchdown and the pitch up which followed resulted in the aft fuselage being damaged prior to the initiation of a climb away to position for a further approach which led to a normal landing. Three of the cabin crew sustained minor injuries but the remaining 90 occupants were uninjured.)
  • A321, en-route, Gimpo South Korea, 2006 (On 9 June 2006, an Airbus 321-100, operated by Asiana Airlines, encountered a thunderstorm accompanied by Hail around 20 miles southeast of Anyang VOR at an altitude of 11,500 ft, while descending for an approach to Gimpo Airport. The radome was detached and the cockpit windshield was cracked due to impact with Hail.)
  • A321, en-route, Vienna Austria, 2003 (On 26th May 2003, a British Midland A321 suffered severe damage from hail en route near Vienna.)
  • A332, en-route, near Dar es Salaam Tanzania, 2012 (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.)
  • A333, en-route, south of Moscow Russia, 2010 (On 22 December 2010, a Finnair Airbus A330-300 inbound to Helsinki and cruising in very cold air at an altitude of 11,600 metres lost cabin pressurisation in cruise flight and completed an emergency descent before continuing the originally intended flight at a lower level. The subsequent Investigation was carried out together with that into a similar occurrence to another Finnair A330 which had occurred 11 days earlier. It was found that in both incidents, both engine bleed air systems had failed to function normally because of a design fault which had allowed water within their pressure transducers to freeze.)
  • A343, en-route, mid North Atlantic Ocean, 2011 (On 22 July 2011 an Air France A340-300 en route over the North Atlantic at FL350 in night IMC encountered moderate turbulence following "inappropriate use of the weather radar" which led to an overspeed annunciation followed by the aircraft abruptly pitching up and gaining over 3000 feet in less than a minute before control was regained and it was returned to the cleared level. There Investigation concluded that "the incident was due to inadequate monitoring of the flight parameters, which led to the failure to notice AP disengagement and the level bust, following a reflex action on the controls.”)
  • A346, en route, eastern Indian Ocean, 2013 (On 3 February 2013, an Airbus A340 crew in the cruise in equatorial latitudes at FL350 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL350 and reversion to Alternate Law. Excessive vibration on the left engine then began and a diversion was made. The engine remained in use and was subsequently found undamaged with the fault attributed to ice/water ingress due to seal failure.)
  • A388/A320, vicinity Frankfurt Germany, 2011 (On 13 December 2011, an Airbus 320 was allowed to depart from runway 25C at Frankfurt on a left turning SID just prior to the touchdown of an A380 on runway 25L. The A380 had then initiated a low go around which put it above, ahead of and parallel to the A320 with a closest proximity of 1nm / 200 ft, in breach of the applicable wake vortex separation minima of 7nm / 1000ft. The Investigation found that there had been no actual encounter with the A380 wake vortices but that systemic ATC operational risk management was inadequate.)
  • AS32, en-route, North Sea UK, 2002 (On 28th February 2002, an Aerospatiale AS332L Super Puma helicopter en route approximately 70 nm northeast of Scatsa, Shetland Islands was in the vicinity of a storm cell when a waterspout was observed about a mile abeam. Soon afterwards, violent pitch, roll and yaw with significant negative and positive ‘g’ occurred. Recovery to normal flight was achieved after 15 seconds and after a control check, the flight was completed. After flight, all five tail rotor blades and tail pylon damage were discovered. It was established that this serious damage was the result of contact between the blades and the pylon.)
  • … further results


Bird or Animal Strike

  • A320, vicinity Auckland New Zealand, 2012 (On 20 June 2012, the right V2500 engine compressor of an Airbus A320 suddenly stalled on final approach. The crew reduced the right engine thrust to flight idle and completed the planned landing uneventfully. Extensive engine damage was subsequently discovered and the investigation conducted attributed this to continued use of the engine in accordance with required maintenance procedures following bird ingestion during the previous sector. No changes to procedures for deferral of a post bird strike boroscope inspection for one further flight in normal service were proposed but it was noted that awareness of operations under temporary alleviations was important.)
  • A332, vicinity Brisbane Australia, 2013 (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.)
  • A333, vicinity Orlando FL USA, 2013 (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.)
  • B734, Amsterdam Netherlands, 2010 (1) (On 6 June 2010, a Boeing 737-400 being operated by Atlas Blue, a wholly owned subsidiary of Royal Air Maroc, on a passenger flight from Amsterdam to Nador, Morocco encountered a flock of geese just after becoming airborne from runway 18L in day VMC close to sunset and lost most of the thrust on the left engine following bird ingestion. A MAYDAY was declared and a minimal single engine climb out was followed by very low level visual manoeuvring not consistently in accordance with ATC radar headings before the aircraft landed back on runway 18R just over 9 minutes later.)
  • B738, Djalaluddin Indonesia, 2013 (On 6 August 2013, a Boeing 737-800 encountered cows ahead on the runway after landing normally in daylight following an uneventful approach and was unable to avoid colliding with them at high speed and as a result departed the runway to the left. Parts of the airport perimeter fencing were found to have been either missing or inadequately maintained for a significant period prior to the accident despite the existence of an airport bird and animal hazard management plan. Corrective action was taken following the accident.)
  • B741, vicinity London Heathrow UK, 1997 (On 6 December 1997, a British Airways Boeing 747-100, departing from London Heathrow airport, had an engine bird strike just after take off, causing substantial damage and falling debris.)
  • B763, Melbourne Australia, 2006 (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.)
  • B763, vicinity London Heathrow UK, 1998 (On 1 September 1998, a Boeing 767-300 had a bird strike with a large flock of geese moments before touchdown at London Heathrow airport, causing substantial damage.)
  • C172, McKinney TX USA, 2003 (On 8 July 2003, a Cessna 172S on an instructional flight hit a vulture which caused significant structural damage to the left wing. During the attempted forced landing which followed, control of the aircraft was lost and the aircraft crashed into terrain near McKinney TX USA.)
  • C310, vicinity Wolf Point MT USA, 2000 (On 25 May 2000, a commercially operated Cessna 310R on a positioning flight encountered a flock of geese in VMC at about 600 feet agl after a daylight take off from Wolf Point MT and one of the geese impacted and broke through the windscreen causing the pilot to loose control and the aircraft to crash.)
  • C500, vicinity Wiley Post Airport, Oklahoma City OK USA, 2008 (On 4 August 2008, a Cessna 500 on a business charter flight encountered a flock of very large birds shortly after take off from a small Oklahoma City airport. Wing damage from at least one bird collision with a force significantly greater than covered by the applicable certification requirements made it impossible for the pilot to retain control of the aircraft. Terrain impact followed. Both engines also ingested a bird. The Investigation noted that neither pilot nor aircraft operator were approved to operate commercial charter flights but concluded that this was not directly connected to the loss of the aircraft.)
  • D228, vicinity Kathmandu Nepal, 2012 (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.)
  • … further results


Aircraft Loading

  • A306, Paris CDG France, 1997 (On 30 July 1997, an Airbus A300-600 being operated by Emirates Airline was departing on a scheduled passenger flight from Paris Charles de Gaulle in daylight when, as the aircraft was accelerating at 40 kts during the take off roll, it pitched up and its tail touched the ground violently. The crew abandoned the takeoff and returned to the parking area. The tail of the aircraft was damaged due to the impact with the runway when the plane pitched up.)
  • A332, Sydney Australia 2009 (On 4 July 2009, an Airbus A332 being operated by Jetstar Airways on a scheduled passenger flight from Sydney to Melbourne carried a 750 kg ULD which had been expressly rejected by the aircraft commander during the loading operation without flight crew awareness. There was no reported effect on aircraft handling during the flight.)
  • AT76, en route, west-southwest of Sydney Australia, 2014 (On 20 February 2014, an ATR 72-600 crew mishandled their response to an intended airspeed adjustment whilst using VS mode during descent to Sydney and an upset involving opposite control inputs from the pilots caused an elevator disconnect. The senior cabin attendant sustained serious injury. After recovery of control, the flight was completed without further event. Post flight inspection did not discover damage to the aircraft which exceeded limit and ultimate loads on the stabilisers and the aircraft remained in service for a further five days until it was grounded for replacement of both horizontal and vertical stabilisers.)
  • B190, vicinity Charlotte NC USA, 2003 (On 8 January 2003, a B190, operated by Air Midwest, crashed shortly after take off from Charlotte, NC, USA, following loss of pitch control during takeoff. The accident was attributed to incorrect rigging of the elevator control system compounded by the airplane being outside load and balance limitations.)
  • B722, Cotonou Benin, 2003 (On 25 December 2003, a Boeing 727-200 being operated by UTA (Guinea) on a scheduled passenger flight from Cotonou to Beirut with a planned stopover at Kufra, Libya, failed to get properly airborne in day VMC from the 2400 metre departure runway and hit a small building 2.45 metres high situated on the extended centreline 118 metres beyond the end of the runway. The right main landing gear broke off and ripped off a part of the trailing edge flaps on the right wing. The airplane then banked slightly to the right and crashed onto the beach where it broke into several pieces and ended up in the sea where the depth of water varied between three and ten metres. Of the estimated 163 occupants, 141 were killed and the remainder seriously injured.)
  • B738, Goteborg Sweden, 2003 (On 7 December 2003, a Boeing 737-800 being operated by SAS on a passenger charter flight from Salzburg, Austria to Stockholm Arlanda with an intermediate stop at Goteborg made a high speed rejected take off during the departure from Goteborg because of an un-commanded premature rotation. There were no injuries to any occupants and no damage to the aircraft which taxied back to the gate.)
  • B738, Rotterdam Netherlands, 2003 (On 12 January 2003, a Boeing 737-800 being operated by Dutch airline Transavia on a passenger charter flight initially going from Rotterdam to Maastrict-Aachen was obliged to reject its take off on Runway 24 at Rotterdam after it pitched nose-up just after take-off thrust had been selected. The pitch up movement only stopped when the aft fuselage and the tailskid assembly contacted the runway and only when the flight crew rejected the take-off did the aircraft nose gear regain ground contact. The aircraft was damaged and unfit for flight but able to taxi back to the terminal to allow the uninjured passengers to disembark.)
  • B744, Bagram Afghanistan, 2013 (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.)
  • B744, Gardermoen Norway, 2004 (On 21 September 2004, a Korean Air Boeing 747-400F experienced handling difficulties on take off due to the Centre of Gravity (CofG) being aft of the limit as a result of misloading.)
  • C208, vicinity Pelee Island Canada, 2004 (On 17 January, 2004 a Cessna 208 Caravan operated by Georgian Express, took off from Pellee Island, Ontario, Canada, at a weight significantly greater than maximum permitted and with ice visible on the airframe. Shortly after take off, the pilot lost control of the aircraft and it crashed into a frozen lake.)
  • DC3, vicinity Yellowknife Canada, 2013 (On 19 August 2013, a fire occurred in the right engine of a Douglas DC3-C on take off from Yellowknife. After engine shutdown, a right hand circuit was made in an attempt to land back on another runway but trees were struck and the aircraft crash-landed south of it. Emergency evacuation was successful. The Investigation found that a pre-existing cylinder fatigue crack had caused the engine failure/fire and that the propeller feathering pump had malfunctioned. It was found that an overweight take off had occurred and that various unsafe practices had persisted despite the regulatory approval of the Operator's SMS.)
  • F27, vicinity Guernsey Channel Islands, 1999 (On 12 January 1999, control of a Fokker F27-600 was lost on approach to Guernsey Airport, Channel Islands, as a consequence of the aircraft being operated outside the load and balance limitations.)
  • … further results


Malicious Interference

Temporary Control Loss

  • A306, East Midlands UK, 2011 (On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.)
  • A306, vicinity London Gatwick, 2011 (On 12 January 2011, an Airbus A300-600 being operated by Monarch Airlines on a passenger flight from London Gatwick to Chania, Greece experienced activations of the stall protection system after an unintended configuration change shortly after take off but following recovery, the flight continued as intended without further event. There were no abrupt manoeuvres and no injuries to the 347 occupants.)
  • A310, en-route, Florida Keys USA, 2005 (On 6 March 2005, an Airbus A310-300 being operated by Canadian airline Air Transat on a passenger charter flight from Varadero Cuba to Quebec City was in the cruise in daylight VMC at FL350 seventeen minutes after departure and overhead the Florida Keys when the flight crew heard a loud bang and felt some vibration. The aircraft entered a Dutch roll which was eventually controlled in manual flight after a height excursion. During descent for a possible en route diversion, the intensity of the Dutch Roll lessened and then stopped and the crew decided to return to Varadero. It was found during landing there that rudder control inputs were not effective and after taxi in and shutdown at the designated parking position, it was discovered that the aircraft rudder was missing. One of the cabin crew sustained a minor back injury during the event but no others from the 271 occupants were injured.)
  • A310, vicinity Paris Orly France, 1994 (On 24 September 1994, lack of understanding of automatic flight control modes, by the crew of an Airbus A-310, led to a full stall. The aircraft was recovered and subsequently landed without further event at Paris Orly.)
  • A310, vicinity Quebec Canada, 2008 (On 5 March 2008, an Air Transat A310-300 was unintentionally mishandled by the flight crew during and shortly after departure from Quebec and effective control of the aircraft was temporarily lost. Whilst it was concluded that the origin of the initial difficulties in control were a result of confusion which began on the take off roll and led to a take off at excessive speed followed by subsequent mismanagement and overload, the inappropriate steep descent that followed was attributed to the effect of somatogravic illusion in respect of aircraft attitude control in conjunction with a singular focus on airspeed.)
  • A319 / B744, en-route near Oroville WA USA, 2008 (On 10 January 2008, an Air Canada Airbus A319 en route over the north western USA encountered unexpected sudden wake vortex turbulence from an in trail Boeing 747-400 nearly 11nm ahead to which the pilots who then responded with potentially hazardous flight control inputs which led to reversion to Alternate Control Law and aggravated the external /disturbance to the aircraft trajectory with roll up to 55° and an unintended descent of 1400 feet which with cabin service in progress and sea belt signs off led to cabin service carts hitting the cabin ceiling and several passenger injuries, some serious.)
  • A319, Luton UK, 2012 (On 14 February 2011, an Easyjet Airbus A319 being flown by a trainee Captain under supervision initiated a go around from below 50 feet agl after a previously stabilised approach at Luton and a very hard three point landing followed before the go around climb could be established. The investigation found that the Training Captain involved, although experienced, had only limited aircraft type experience and that, had he taken control before making a corrective sidestick input opposite to that of the trainee, it would have had the full instead of a summed effect and may have prevented hard runway contact.)
  • A319, vicinity Wuxi China, 2010 (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.)
  • A320, Hamburg Germany, 2008 (On 1 March 2008 an Airbus A320 being operated by Lufthansa on a scheduled passenger flight from Munich to Hamburg experienced high and variable wind velocity on short finals in good daylight visibility and during the attempt at landing on runway 23 with a strong crosswind component from the right, a bounced contact of the left main landing gear with the runway was followed by a left wing down attitude which resulted in the left wing tip touching the ground. A rejected landing was then flown and after radar vectoring, a second approach to runway 33 was made to a successful landing. No aircraft occupants were injured but the aircraft left wing tip was found to have been damaged by the runway contact. The track of the aircraft and spot wind velocities given by ATC at key points are shown on the illustration below.)
  • A320, en-route, North East Spain 2006 (On 28 May 2006, a Vueling Airbus A320 encountered sudden significant turbulence at FL325 and, during a temporary loss of control, was forced down to FL310 before recovery was achieved. Seven occupants sustained minor injuries and there was some internal damage caused by an unrestrained cabin service cart. The origin of the disturbance was found to have been wake vortices from an Airbus A340-300 which was 10nm ahead and 500 feet above on the same airway but the Investigation found that the crew response had been inappropriate and could have served to exacerbate the effects of the external disturbance.)
  • A320, vicinity Frankfurt Germany, 2001 (On 21 March 2001 an Airbus A320-200, operated by Lufthansa, experienced a flight controls malfunctions shortly after take-off which resulted in loss of control and subsequent near terrain impact. The uncontrolled roll, due to the malfunction of the pilot flying's sidestick, was recovered by the other pilot and the aircraft safely returned to land in Frankfurt without further incident.)
  • A320, vicinity Melbourne Australia, 2007 (On 21 July 2007, an Airbus A320-232 being operated by Australian Operator Jetstar Airways and on final approach to Melbourne after a passenger flight from Christchurch, New Zealand intended to make a go around after the required visual reference at Decision Altitude was not available, but the intended action was mis-managed such that safe control of the aircraft was temporarily lost. Recovery was achieved and there were no further abnormalities of flight during a second missed approach at Melbourne or the subsequent diversion to Avalon.)
  • … further results


Extreme Bank

  • A310, vicinity Paris Orly France, 1994 (On 24 September 1994, lack of understanding of automatic flight control modes, by the crew of an Airbus A-310, led to a full stall. The aircraft was recovered and subsequently landed without further event at Paris Orly.)
  • A319 / B744, en-route near Oroville WA USA, 2008 (On 10 January 2008, an Air Canada Airbus A319 en route over the north western USA encountered unexpected sudden wake vortex turbulence from an in trail Boeing 747-400 nearly 11nm ahead to which the pilots who then responded with potentially hazardous flight control inputs which led to reversion to Alternate Control Law and aggravated the external /disturbance to the aircraft trajectory with roll up to 55° and an unintended descent of 1400 feet which with cabin service in progress and sea belt signs off led to cabin service carts hitting the cabin ceiling and several passenger injuries, some serious.)
  • A320, en-route Karimata Strait Indonesia, 2014 (On 28 December 2014, an A320 crew took unapproved action in response to a repeating system caution shortly after levelling at FL320. The unexpected consequences degraded the flight control system and obliged manual control. Gross mishandling followed which led to a stall, descent at a high rate and sea surface impact with a 20º pitch attitude and a 50º angle of attack four minutes later. The Investigation noted the accident origin as a repetitive minor system fault but demonstrated that the subsequent loss of control followed a combination of explicitly inappropriate pilot action and the absence of appropriate pilot action.)
  • A332, en-route, Atlantic Ocean, 2009 (On 1 June 2009, an Airbus A330-200 being operated by Air France on a scheduled passenger flight from Rio de Janeiro to Paris CDG as AF447 exited controlled flight and crashed into the sea with the loss of the aircraft and all 228 occupants. It was found that the loss of control followed an inappropriate response by the flight crew to a transient loss of airspeed indications in the cruise which resulted from the vulnerability of the pitot heads to ice crystal icing.)
  • AS65, vicinity North Morecambe Platform Irish Sea UK, 2006 (On 27 December 2006, an AS365 Dauphin 2, operated by CHC Scotia, crashed into the sea adjacent to a gas platform in Morecambe Bay, UK, at night, following loss of control.)
  • AT43, en-route, Folgefonna Norway, 2005 (On 14 September 2005, an ATR 42-320 operated by Coast Air AS experienced a continuous build up of ice in the climb, despite the activation of de-icing systems aircraft entered an uncontrolled roll and lost 1500ft in altitude. The crew initiated recovery actions, the aircraft was stabilised, and the flight continued without further event.)
  • AT43, vicinity Stansted UK, 2007 (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.)
  • AT45, vicinity Prague Czech Republic, 2012 (On 31 October 2012, the crew of an ATR42 on a handover airworthiness function flight out of Prague briefly lost control in a full stall with significant wing drop after continuing a prescribed Stall Protection System (SPS) test below the appropriate speed and then failing to follow the correct stall recovery procedure. Failure of the attempted SPS test was subsequently attributed to both AOA vanes having become contaminated with water during earlier aircraft repainting at a specialist contractor and consequently being constrained in a constant position whilst the SPS test was being conducted at well above the prevailing freezing level.)
  • AT45, vicinity Sienajoki Finland, 2007 (On 1 January 2007, the crew of a ATR 42-500 carried out successive night approaches into Seinajoki Finland including three with EGPWS warnings, one near stall, and one near loss of control, all attributed to poor flight crew performance including use of the wrong barometric sub scale setting.)
  • AT72, en-route, southern Scotland UK, 2011 (On 15 March 2011, an ATR 72-200 on a non revenue positioning flight from Edinburgh to Paris CDG in night VMC with just the two pilots on board began to experience roll and directional control difficulties as the aircraft accelerated upon reaching the planned cruise altitude of FL230. A ‘PAN’ call was made to ATC and a return to Edinburgh was made with successful containment of the malfunctioning flying controls.)
  • AT73, en-route, Roselawn IN USA, 1994 (On 31 October 1994, an ATR 72 exited controlled flight after a flap retraction when descending through 9000 feet was followed by autopilot disconnect and rapid and very large un-commanded roll inputs from which recovery, not within the scope of received crew training, was not achieved. The investigation found this roll upset had been due to a sudden and unexpected aileron hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-icing boots during earlier holding in icing conditions which had been - unknown to the crew - outside the icing certification envelope.)
  • AT76, vicinity Taipei Songshan Taiwan, 2015 (On 4 February 2015, a TransAsia Airways ATR 72-600 crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. They did not realise this until recovery from loss of control due to a stall was no longer possible. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off. Failure to follow SOPs and deficiencies in those procedures were identified as causal.)
  • … further results


Extreme Pitch

  • A310, vicinity Paris Orly France, 1994 (On 24 September 1994, lack of understanding of automatic flight control modes, by the crew of an Airbus A-310, led to a full stall. The aircraft was recovered and subsequently landed without further event at Paris Orly.)
  • A310, vicinity Quebec Canada, 2008 (On 5 March 2008, an Air Transat A310-300 was unintentionally mishandled by the flight crew during and shortly after departure from Quebec and effective control of the aircraft was temporarily lost. Whilst it was concluded that the origin of the initial difficulties in control were a result of confusion which began on the take off roll and led to a take off at excessive speed followed by subsequent mismanagement and overload, the inappropriate steep descent that followed was attributed to the effect of somatogravic illusion in respect of aircraft attitude control in conjunction with a singular focus on airspeed.)
  • A320, en-route Karimata Strait Indonesia, 2014 (On 28 December 2014, an A320 crew took unapproved action in response to a repeating system caution shortly after levelling at FL320. The unexpected consequences degraded the flight control system and obliged manual control. Gross mishandling followed which led to a stall, descent at a high rate and sea surface impact with a 20º pitch attitude and a 50º angle of attack four minutes later. The Investigation noted the accident origin as a repetitive minor system fault but demonstrated that the subsequent loss of control followed a combination of explicitly inappropriate pilot action and the absence of appropriate pilot action.)
  • A320, vicinity Perpignan France, 2008 (On 27 November 2008, the crew of an XL Airways A320 on an airworthiness function flight following aircraft repainting lost control of the aircraft after fail to take the action necessary to recover from a full stall which had resulted from their continued airspeed reduction during a low speed handling test when Stall Protection System (SPS) activation did nor occur at the likely airspeed because two of the three angle of attack sensors were blocked by ice formed by water ingress during preparation for the repainting. This condition rendered angle of attack protection in normal law inoperative.)
  • A321, Hurghada Egypt, 2013 (On 28 February 2013, the initial night landing attempt of a Ural Airlines Airbus A321 at Hurghada was mishandled in benign conditions resulting in a tail strike due to over-rotation. The Investigation noted that a stabilised approach had been flown by the First Officer but found that the prescribed recovery from the effects of a misjudged touchdown had not then been followed. It was also concluded that communication between the two pilots had been poor and that the aircraft commander's monitoring role had been ineffective. The possibility of the effects of fatigue was noted.)
  • A321, en-route, near Pamplona Spain, 2014 (On 5 November 2014, the crew of an Airbus A321 temporarily lost control of their aircraft in the cruise and were unable to regain it until 4000 feet of altitude had been lost. An investigation into the causes is continuing but it is already known that blockage of more than one AOA probe resulted in unwanted activation of high AOA protection which could not be stopped by normal sidestick inputs until two of the three ADRs had been intentionally deactivated in order to put the flight control system into Alternate Law.)
  • A332 MRTT, en-route, south eastern Black Sea, 2014 (On 9 February 2014, the Captain of a military variant of the Airbus A330 suddenly lost control during the cruise on a passenger flight. A violent, initially negative 'g', pitch down occurred which reached 15800 fpm as the speed rose to Mach 0.9. In the absence of any effective crew intervention, recovery was achieved entirely by the aircraft Flight Envelope Protection System. The Investigation found that the upset had occurred when the Captain moved his seat forward causing its left arm rest to contact the personal camera he had placed behind the sidestick, forcing the latter fully forward.)
  • A332, en-route, Atlantic Ocean, 2009 (On 1 June 2009, an Airbus A330-200 being operated by Air France on a scheduled passenger flight from Rio de Janeiro to Paris CDG as AF447 exited controlled flight and crashed into the sea with the loss of the aircraft and all 228 occupants. It was found that the loss of control followed an inappropriate response by the flight crew to a transient loss of airspeed indications in the cruise which resulted from the vulnerability of the pitot heads to ice crystal icing.)
  • A332, en-route, near Dar es Salaam Tanzania, 2012 (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.)
  • A333, en-route, West of Learmonth Australia, 2008 (On 7 October 2008, an Airbus A330-300 aircraft experienced multiple system failure indications followed by uncommanded pitch-down events which resulted in serious injuries to passengers and cabin crew.)
  • A343, en-route, mid North Atlantic Ocean, 2011 (On 22 July 2011 an Air France A340-300 en route over the North Atlantic at FL350 in night IMC encountered moderate turbulence following "inappropriate use of the weather radar" which led to an overspeed annunciation followed by the aircraft abruptly pitching up and gaining over 3000 feet in less than a minute before control was regained and it was returned to the cleared level. There Investigation concluded that "the incident was due to inadequate monitoring of the flight parameters, which led to the failure to notice AP disengagement and the level bust, following a reflex action on the controls.”)
  • A343, vicinity Paris CDG France, 2012 (On 13 March 2012, an A340-300 crew cleared for a Cat 3 ILS approach at Paris CDG with LVP in force failed to descend at a rate which would allow the aircraft to capture the ILS GS and at 2nm from the runway, when still 2500 feet above runway height, the ILS GS mode engaged on a false upper lobe of about 10° and as a result of the consequent rapid pitch up and speed reduction, aircraft control was almost lost. After a period of further confusion, a go around was initiated and the subsequent approach was uneventful.)
  • … further results


Last Minute Collision Avoidance

  • B733, vicinity Sharm El-Sheikh Egypt, 2004 (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.)
  • SB20, vicinity Sumburgh, UK 2014 (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.)
  • SF34, vicinity Mariehamn Finland, 2012 (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.)


Hard landing

  • A306, East Midlands UK, 2011 (On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.)
  • A310, Ponta Delgada Azores Portugal, 2013 (On 2 March 2013, the crew of an Airbus A310 mishandled a night tailwind touchdown at Ponta Delgada after a stabilised ILS approach had been flown and, after an initial bounce, the pitch was increased significantly and the main landing gear was fully compressed during the subsequent touchdown resulting in a tail strike and substantial related structural damage. The mishandling was attributed to deviation from the recommended 'light bounce' recovery technique. The absence of an instrument approach to the reciprocal (into wind) direction of the runway was noted and a recommendation that an RNAV procedure be made available was made.)
  • A319, Montego Bay Jamaica, 2014 (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.)
  • A320, Bilbao Spain, 2001 (On 7th February 2001, an Iberia A320 was about to make a night touch down at Bilbao in light winds when it experienced unexpected windshear. The attempt to counter the effect of this by initiation of a go around failed because the automatic activation of AOA protection in accordance with design criteria which opposed the crew pitch input. The aircraft then hit the runway so hard that a go around was no longer possible. Severe airframe structural damage and evacuation injuries to some of the occupants followed. A mandatory modification to the software involved was subsequently introduced.)
  • A321, Incheon South Korea, 2013 (On 16 April 2013, an A321 sustained significant damage during a tail strike during a bounced landing which followed loss of airspeed and an increase in sink rate shortly before touchdown after an otherwise stabilised approach. The Investigation attributed the tail strike to a failure to follow the recommended bounced landing response and noted the inadequate training provided by Asiana for bounced landing recovery.)
  • A321, Manchester UK, 2008 (1) (On 18 July 2008, an Airbus A321-200 operated by Thomas Cook Airlines experienced hard landing during night line training with significant aircraft damage not found until several days later. The hard landing was subsequently partially attributed to the inability to directly observe the trainee pitch control inputs on side stick of the A321.)
  • A321, Manchester UK, 2008 (2) (On 28 July 2008, the crew flying an Airbus A321-200 departing Manchester UK were unable to raise the landing gear. The fault was caused by damage to the Nose Landing Gear sustained on the previous flight which experienced a heavy landing.)
  • A332, Caracas Venezuela, 2013 (On 13 April 2013, an Air France Airbus A330-200 was damaged during a hard (2.74 G) landing at Caracas after the aircraft commander continued despite the aircraft becoming unstabilised below 500 feet agl with an EGPWS ‘SINK RATE’ activation beginning in the flare. Following a superficial inspection, maintenance personnel determined that no action was required and released the aircraft to service. After take off, it was impossible to retract the landing gear and the aircraft returned. Considerable damage from the earlier landing was then found to both fuselage and landing gear which had rendered the aircraft unfit to fly.)
  • A333, en-route, near Bournemouth UK, 2012 (On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.)
  • A346, Quito Ecuador, 2007 (On 31 August 2007 an Airbus A340-600 being operated by Iberia on a scheduled passenger flight from Madrid to Quito made a hard landing with drift /side slip after a circling approach in normal day visibility and was disabled on the runway after sustaining significant damage to the landing gear, particularly many of the tyres. There was no other damage to the aircraft and there were no injuries to the 320 occupants who eventually disembarked normally from the aircraft at its final resting position.)
  • B712, Darwin Australia, 2008 (On 7 February 2008, a Boeing 717-200 being operated by Australian airline National Jet on a scheduled passenger service from Nhulunbuy (Gove) to Darwin flew an unstabilised night visual approach at the destination and made a very hard landing. The landing roll was completed and the aircraft taxied to the terminal. None of the 94 occupants were injured but the aircraft was suffered substantial structural damage and damage to the left hand main landing gear.)
  • B722, Hamilton OT Canada 2008 (On 22 July 2008, a Kelowna Flightcraft Air Charter Ltd. Boeing 727-200 was operating a cargo flight from Moncton NB, to Hamilton, OT. After radar vectoring for an approach to Runway 06 at Hamilton, the aircraft touched down hard and bounced before touching down hard a second time. Immediately after the second touchdown, a go-around was initiated. During rotation, the tailskid made contact with the runway. The thrust reverser actuator fairing and the number 2 engine tailpipe made contact with the ground off the departure end of the runway. The aircraft climbed away and then returned for a normal landing on Runway 12. There were no injuries; the aircraft sustained only minor damage.)
  • … further results


Take off Trim Setting

  • AT43, vicinity Stansted UK, 2007 (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.)
  • AT72, vicinity Tyumen Russian Federation, 2012 (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.)
  • B738, en-route, south west of Beirut Lebanon, 2010 (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.)


Incorrect Thrust Computed

  • A321, Manchester UK, 2011 (1) (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.)
  • A346, London Heathrow UK, 2009 (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.)
  • B733, Chambery France, 2012 (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.)
  • DHC6, vicinity Saint Barthelemy French Antilles, 2001 (On 24 March 2001, a De Havilland DHC-6, operated by Caraïbes Air Transport, lost control during a VFR approach to Saint Barthelemy airport in the French Antilles. On short final the aircraft took a sharp left turn which resulted in impact with the terrain.)
  • F50, vicinity Luxembourg, 2002 (On 6 November 2002, a Fokker 50 operated by Luxair, crashed on approach to Luxembourg Airport following loss of control attributed to intentional operation of power levers in the ground range, contrary to SOPs.)
  • LJ35, Lyon France, 2000 (On 2 May 2000, the crew of a LJ35 lost control of the aircraft, as a result of incorrect manual flying inputs, and crashed just before touchdown at Lyon, following an unstable single engine approach.)


Unintended transitory terrain contact

  • A306, Paris CDG France, 1997 (On 30 July 1997, an Airbus A300-600 being operated by Emirates Airline was departing on a scheduled passenger flight from Paris Charles de Gaulle in daylight when, as the aircraft was accelerating at 40 kts during the take off roll, it pitched up and its tail touched the ground violently. The crew abandoned the takeoff and returned to the parking area. The tail of the aircraft was damaged due to the impact with the runway when the plane pitched up.)
  • A310, Ponta Delgada Azores Portugal, 2013 (On 2 March 2013, the crew of an Airbus A310 mishandled a night tailwind touchdown at Ponta Delgada after a stabilised ILS approach had been flown and, after an initial bounce, the pitch was increased significantly and the main landing gear was fully compressed during the subsequent touchdown resulting in a tail strike and substantial related structural damage. The mishandling was attributed to deviation from the recommended 'light bounce' recovery technique. The absence of an instrument approach to the reciprocal (into wind) direction of the runway was noted and a recommendation that an RNAV procedure be made available was made.)
  • A319, Luton UK, 2012 (On 14 February 2011, an Easyjet Airbus A319 being flown by a trainee Captain under supervision initiated a go around from below 50 feet agl after a previously stabilised approach at Luton and a very hard three point landing followed before the go around climb could be established. The investigation found that the Training Captain involved, although experienced, had only limited aircraft type experience and that, had he taken control before making a corrective sidestick input opposite to that of the trainee, it would have had the full instead of a summed effect and may have prevented hard runway contact.)
  • A321, Hakodate Japan, 2002 (On 21 January 2002, an Airbus A321-100 being operated by All Nippon Airways on a scheduled passenger flight from Nagoya to Hakodate encountered sudden negative windshear just prior to planned touchdown and the pitch up which followed resulted in the aft fuselage being damaged prior to the initiation of a climb away to position for a further approach which led to a normal landing. Three of the cabin crew sustained minor injuries but the remaining 90 occupants were uninjured.)
  • A321, Hurghada Egypt, 2013 (On 28 February 2013, the initial night landing attempt of a Ural Airlines Airbus A321 at Hurghada was mishandled in benign conditions resulting in a tail strike due to over-rotation. The Investigation noted that a stabilised approach had been flown by the First Officer but found that the prescribed recovery from the effects of a misjudged touchdown had not then been followed. It was also concluded that communication between the two pilots had been poor and that the aircraft commander's monitoring role had been ineffective. The possibility of the effects of fatigue was noted.)
  • A321, Incheon South Korea, 2013 (On 16 April 2013, an A321 sustained significant damage during a tail strike during a bounced landing which followed loss of airspeed and an increase in sink rate shortly before touchdown after an otherwise stabilised approach. The Investigation attributed the tail strike to a failure to follow the recommended bounced landing response and noted the inadequate training provided by Asiana for bounced landing recovery.)
  • A321, Manchester UK, 2011 (2) (On 23 December 2011, an Austrian Airlines Airbus A321 sustained a tail strike at Manchester as the main landing gear contacted the runway during a night go around initiated at a very low height after handling difficulties in the prevailing wind shear. The remainder of the go around and subsequent approach in similar conditions was uneventful and the earlier tail strike was considered to have been the inevitable consequence of initiating a go around so close to the ground after first reducing thrust to idle. Damage to the aircraft rendered it unfit for further flight until repaired but was relatively minor.)
  • A333, Chicago O'Hare IL USA, 2013 (On 5 March 2013, the aft-stationed cabin crew of an Airbus A330-300 being operated by Lufthansa on a scheduled international passenger flight from Chicago O'Hare to Munich advised the flight crew after the night normal visibility take-off that they had heard "an unusual noise" during take-off. Noting that nothing unusual had been heard in the flight deck and that there were no indications of any abnormal system status, the Captain decided, after consulting Company maintenance, that the flight should be completed as planned. The flight proceeded uneventfully but on arrival in Munich, it became clear that the aircraft had sustained "substantial damage" due to a tail strike on take-off and was unfit for flight.)
  • AT76, vicinity Taipei Songshan Taiwan, 2015 (On 4 February 2015, a TransAsia Airways ATR 72-600 crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. They did not realise this until recovery from loss of control due to a stall was no longer possible. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off. Failure to follow SOPs and deficiencies in those procedures were identified as causal.)
  • B722, Hamilton OT Canada 2008 (On 22 July 2008, a Kelowna Flightcraft Air Charter Ltd. Boeing 727-200 was operating a cargo flight from Moncton NB, to Hamilton, OT. After radar vectoring for an approach to Runway 06 at Hamilton, the aircraft touched down hard and bounced before touching down hard a second time. Immediately after the second touchdown, a go-around was initiated. During rotation, the tailskid made contact with the runway. The thrust reverser actuator fairing and the number 2 engine tailpipe made contact with the ground off the departure end of the runway. The aircraft climbed away and then returned for a normal landing on Runway 12. There were no injuries; the aircraft sustained only minor damage.)
  • B733, Nottingham East Midlands, UK 2006 (On 15 June 2006 a TNT Belgium-operated Boeing 737-300 on diversion to East Midlands because of poor destination weather made an unintended ground contact 90 metres to one side of the intended landing runway whilst attempting to initiate a go around after a mis-flown daylight Cat 3A ILS approach. The RH MLG assembly broke off before the aircraft left the ground again and climbed away after which it was then flown to nearby Birmingham for a successful emergency landing. The subsequent investigation attributed the poor aircraft management which led to the accident to pilot distraction.)
  • B738, Alicante Spain, 2013 (On 27 March 2013, a Ryanair Boeing 737-800 was mis-handled during take off and a minor tailstrike occurred. The crew were slow to respond and continued an uninterrupted climb to FL220 before deciding to return to land and beginning the corresponding QRH drill. When the cabin pressurisation outflow valve was fully opened at FL130, the cabin depressurised almost instantly and the crew temporarily donned oxygen masks. The Investigation noted the absence of any caution on the altitude at which the QRH drill should be used but also noted clear guidance that the procedure should be actioned without delay.)
  • … further results


Collision Damage

  • A310, Ponta Delgada Azores Portugal, 2013 (On 2 March 2013, the crew of an Airbus A310 mishandled a night tailwind touchdown at Ponta Delgada after a stabilised ILS approach had been flown and, after an initial bounce, the pitch was increased significantly and the main landing gear was fully compressed during the subsequent touchdown resulting in a tail strike and substantial related structural damage. The mishandling was attributed to deviation from the recommended 'light bounce' recovery technique. The absence of an instrument approach to the reciprocal (into wind) direction of the runway was noted and a recommendation that an RNAV procedure be made available was made.)
  • AT76, vicinity Taipei Songshan Taiwan, 2015 (On 4 February 2015, a TransAsia Airways ATR 72-600 crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. They did not realise this until recovery from loss of control due to a stall was no longer possible. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off. Failure to follow SOPs and deficiencies in those procedures were identified as causal.)
  • B744, vicinity Dubai UAE, 2010 (On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.)
  • B772, San Francisco CA USA, 2013 (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.)
  • DH8D, Saarbrucken Germany, 2015 (On 30 September 2015, the First Officer on an in-service airline-operated Bombardier DHC-8 400 selected the gear up without warning as the Captain was in the process of rotating the aircraft for take-off. The aircraft settled back on the runway wheels up and eventually stopped near the end of the 1,990 metre-long runway having sustained severe damage. The Investigation noted that a factor contributing to the First Officer's unintended action may have been her "reduced concentration level" but also highlighted the fact that the landing gear control design logic allowed retraction with the nose landing gear airborne.)
  • DH8D, Sault Ste. Marie ON Canada, 2013 (On 26 May 2013, a Porter Airlines DHC8-400 sustained substantial damage as a result of a mishandled night landing off a visual approach at Sault Ste. Marie which led to a 3g tail strike. The prior approach was stabilised at 500 feet but then unstabilised below that height. The handling pilot involved was a First Officer with 134 hours experience on the aircraft type, which was his first experience of multi crew transport aircraft after significant experience flying light aircraft. An absence of effective monitoring or intervention by the aircraft commander was identified during the Investigation.)
  • DHC6, Dabra Indonesia, 2011 (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.)
  • E135 / B738, en-route, Amazon Brazil, 2006 (On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer 135 at the same level. Control of the 737 was lost and it crashed killing all 154 occupants. The 135 crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the 135 to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently and unknowingly switched off their transponder. After the consequent disappearance of altitude from radar displays, ATC assumed the 135 had descended but did not confirm this.)
  • EC35, Sollihøgda Norway, 2014 (On 14 January 2014, the experienced pilot of an EC 135 HEMS aircraft lost control as a result of a collision with unseen and difficult to visually detect power lines as it neared the site of a road accident at Sollihøgda to which it was responding which damaged the main rotor and led to it falling rapidly from about 80 feet agl. The helicopter was destroyed by the impact which killed two of the three occupants and seriously injured the third. The Investigation identified opportunities to improve both obstacle documentation / pilot proactive obstacle awareness and on site emergency communications.)
  • GL6T, Prestwick UK, 2014 (On 6 March 2014, a Bombardier Global 6000 being landed by a pilot using a HUD at night was mishandled to the extent that one wing was damaged by ground contact due to excessive pitch just before touchdown. During the Investigation, a Global 6000 operated by a different operator was similarly damaged during a night landing. The Investigation discovered that relevant operational documentation was inconsistent and pilot training had (in both cases) been inappropriate. These issues were resolved by a combination of aircraft manufacturer and aircraft operator action)
  • H25B / AS29, en-route / manoeuvring, near Smith NV USA, 2006 (On 28 August 2006, a Hawker 800 collided with a glider at 16,000 feet in Class 'E' airspace. The glider became uncontrollable and its pilot evacuated by parachute. The Hawker was structurally damaged and one engine stopped but it was recovered to a nearby airport. The Investigation noted that the collision had occurred in an area well known for glider activity in which transport aircraft frequently avoided glider collisions using ATC traffic information or by following TCAS RAs. The glider was being flown by a visitor to the area with its transponder intentionally switched off to conserve battery power.)
  • H25B, vicinity Owatonna MN USA, 2008 (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.)
  • … further results


Incorrect Aircraft Configuration

  • A319, Montego Bay Jamaica, 2014 (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.)
  • A321, vicinity Singapore, 2010 (On 27 May 2010 an Airbus A321-200 being operated by Australian operator JetStar on a passenger flight from Darwin to Singapore continued an initial approach at destination in day VMC with the aircraft inappropriately configured before a late go around was commenced which was also flown in a configuration contrary to prescribed SOPs. A subsequent second approach proceeded to an uneventful landing. There were no unusual or sudden manoeuvres during the event and no injuries to the occupants.)
  • A333, Chicago O'Hare IL USA, 2013 (On 5 March 2013, the aft-stationed cabin crew of an Airbus A330-300 being operated by Lufthansa on a scheduled international passenger flight from Chicago O'Hare to Munich advised the flight crew after the night normal visibility take-off that they had heard "an unusual noise" during take-off. Noting that nothing unusual had been heard in the flight deck and that there were no indications of any abnormal system status, the Captain decided, after consulting Company maintenance, that the flight should be completed as planned. The flight proceeded uneventfully but on arrival in Munich, it became clear that the aircraft had sustained "substantial damage" due to a tail strike on take-off and was unfit for flight.)
  • B732, Medan Indonesia, 2005 (On 5 September 2005, a Boeing 737-200 being operated by Mandala Airlines on a scheduled domestic passenger flight from Medan, Indonesia to Jakarta failed to become properly airborne during the attempted take off from from runway 23 in day VMC and, after failing to remain airborne, overran the end of the runway at speed finally coming to a stop outside the airport perimeter. The aircraft was destroyed by impact forces and a subsequent fire and 100 of the 117 occupants were killed and 15 seriously injured. The aircraft collided with residential property, vehicles and various other obstructions and as a result a further 49 people on the ground were killed and a further 26 seriously injured.)
  • B733, vicinity Montpelier, France 2011 (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.)
  • BE20, vicinity Stapleford UK, 2015 (On 3 October 2015, the pilot of a Beech Super King Air on a business flight lost control in IMC shortly after take-off and the aircraft subsequently impacted terrain at high speed. The Investigation concluded on the balance of probabilities that pilot medical incapacitation was likely to have occurred. It was noted that the aircraft had not been fitted with TAWS nor was it required to be but it was found that alerting from such a system would have increased the chances of the only passenger, another professional pilot, successfully taking over and three corresponding Safety Recommendations were made.)
  • CRJ2, en-route, east of Barcelona Spain, 2006 (On 27 July 2006, a Bombardier CRJ200 being operated by Air Nostrum on a scheduled passenger flight from Barcelona to Basel, Switzerland in night VMC, suffered a sudden left hand engine failure and an associated engine fire when passing FL235 some 14 minutes after take off. An air turn back was made with indications of engine fire continuing until just three minutes before landing. An evacuation using the right hand exits was ordered by the Captain as soon as the aircraft had come to a stop and had been promptly actioned with the RFFS in attendance. There were no injuries to the 48 occupants during the evacuation and the only damage was to the affected engine.)
  • CRJ9, San Sebastian Spain, 2013 (On 25 October 2013, the crew of a Bombardier CRJ 900 made an unstable visual daytime approach to San Sebastian which culminated in a hard landing of sufficient severity to trigger an inspection in accordance with the AMM. The inspection did not occur and the aircraft made a further revenue flight before the hard landing was reported and substantial landing gear damage was discovered. The unstable approach at a Category 'C' airport was found to have been flown by the First Officer contrary to applicable regulatory requirements.)
  • DH8A, en-route SSE of Madang, Papua New Guinea, 2011 (On 13 October 2011, the Captain of a Bombardier DHC8-100 manually flying a low power, steep descent in an attempt to get below cloud to be able to see the destination aerodrome inadvertently allowed the speed to increase sufficiently to trigger an overspeed warning. In response, the power levers were rapidly retarded and both propellers entered the ground range and oversped. As a result, one engine was damaged beyond use and the other could not be unfeathered. A forced landing was made following which the aircraft caught fire. All three crew members but only one of the 29 passengers survived.)
  • E190, Amsterdam Netherlands, 2014 (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.)
  • MD82, Detroit MI USA, 1987 (On 16 August 1987, an MD-82 being operated by Northwest Airlines on a scheduled passenger flight from Detroit MI to Phoenix AZ failed to get properly airborne in day VMC and, after damaging impact with obstacles within the airport perimeter after climbing to a maximum height of just under 40 ft, impacted the ground causing the destruction of the aircraft by impact forces and a subsequent fire. All but one of the 157 occupants were killed with the single survivor suffering serious injury. On the ground, 2 people were killed, 2 more seriously injured and 4 more suffered minor injury with several buildings vehicles and structures damaged or destroyed.)
  • MD82, Madrid Barajas Spain, 2008 (On 20 August 2008, an MD82 aircraft operated by Spanair took off from Madrid Barajas Airport with flaps and slats retracted; the incorrect configuration resulted in loss of control, collision with the ground, and the destruction of the aircraft.)
  • … further results


Aerodynamic Stall

  • A306, vicinity Nagoya Japan, 1994 (On 26 April 1994, the crew of an Airbus A300-600 lost control of their aircraft on final approach to Nagoya and the aircraft crashed within the airport perimeter. The Investigation found that an inadvertent mode selection error had triggered control difficulties which had been ultimately founded on an apparent lack understanding by both pilots of the full nature of the interaction between the systems controlling thrust and pitch on the aircraft type which were not typical of most other contemporary types. It was also concluded that the Captain's delay in taking control from the First Officer had exacerbated the situation.)
  • A319, vicinity Wuxi China, 2010 (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.)
  • A320, en-route Karimata Strait Indonesia, 2014 (On 28 December 2014, an A320 crew took unapproved action in response to a repeating system caution shortly after levelling at FL320. The unexpected consequences degraded the flight control system and obliged manual control. Gross mishandling followed which led to a stall, descent at a high rate and sea surface impact with a 20º pitch attitude and a 50º angle of attack four minutes later. The Investigation noted the accident origin as a repetitive minor system fault but demonstrated that the subsequent loss of control followed a combination of explicitly inappropriate pilot action and the absence of appropriate pilot action.)
  • A320, vicinity Perpignan France, 2008 (On 27 November 2008, the crew of an XL Airways A320 on an airworthiness function flight following aircraft repainting lost control of the aircraft after fail to take the action necessary to recover from a full stall which had resulted from their continued airspeed reduction during a low speed handling test when Stall Protection System (SPS) activation did nor occur at the likely airspeed because two of the three angle of attack sensors were blocked by ice formed by water ingress during preparation for the repainting. This condition rendered angle of attack protection in normal law inoperative.)
  • A332, en-route, Atlantic Ocean, 2009 (On 1 June 2009, an Airbus A330-200 being operated by Air France on a scheduled passenger flight from Rio de Janeiro to Paris CDG as AF447 exited controlled flight and crashed into the sea with the loss of the aircraft and all 228 occupants. It was found that the loss of control followed an inappropriate response by the flight crew to a transient loss of airspeed indications in the cruise which resulted from the vulnerability of the pitot heads to ice crystal icing.)
  • AT43, Lubbock TX USA, 2009 (On 27 January 2009, an ATR 42-300 being operated by Empire Airlines on a scheduled cargo flight from Fort Worth Alliance to Lubbock was making a night ILS approach in IMC to runway 17R at destination when it stalled and crashed short of the runway. The aircraft caught fire and was in any case effectively already destroyed by the impact. Both crew members were injured, one seriously.)
  • AT43, vicinity Glasgow, UK 2012 (On 22 February 2012, the crew of an ATR 42 making a radar-vectored ILS approach to runway 23 at Glasgow at night allowed the airspeed of the aircraft to reduce and a stall warning followed. Corrective action then led to an overspeed and further corrective action almost led to a second stall warning. The Investigation concluded that SOPs were not followed, monitoring was ineffective and crew cooperation during recovery was poor. It was considered that crew performance may have been affected by inadequate rest prior to a night flying duty period.)
  • AT45, vicinity Prague Czech Republic, 2012 (On 31 October 2012, the crew of an ATR42 on a handover airworthiness function flight out of Prague briefly lost control in a full stall with significant wing drop after continuing a prescribed Stall Protection System (SPS) test below the appropriate speed and then failing to follow the correct stall recovery procedure. Failure of the attempted SPS test was subsequently attributed to both AOA vanes having become contaminated with water during earlier aircraft repainting at a specialist contractor and consequently being constrained in a constant position whilst the SPS test was being conducted at well above the prevailing freezing level.)
  • AT72, vicinity Tyumen Russian Federation, 2012 (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.)
  • AT76, vicinity Taipei Songshan Taiwan, 2015 (On 4 February 2015, a TransAsia Airways ATR 72-600 crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. They did not realise this until recovery from loss of control due to a stall was no longer possible. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off. Failure to follow SOPs and deficiencies in those procedures were identified as causal.)
  • ATP, en-route, Oxford UK, 1991 (On 11 August 1991, an British Aerospace ATP, during climb to flight level (FL) 160 in icing conditions, experienced a significant degradation of performance due to propeller icing accompanied by severe vibration that rendered the electronic flight instruments partially unreadable. As the aircraft descended below cloud, control was regained and the flight continued uneventfully.)
  • B712, vicinity Kalgoorlie Western Australia, 2010 (On 13 October 2010, a Boeing 717-200 being operated by Cobham Aviation Services Australia for QantasLink on a scheduled passenger flight from Perth to Kalgoorlie Western Australia carried out two consecutive approaches at destination in day VMC which resulted in stick shaker activations and subsequent go arounds. A third approach at a higher indicated airspeed was uneventful and continued to a landing. There were no abrupt manoeuvres and none of the 102 occupants were injured.)
  • … further results


Minimum Fuel Call

Flight Envelope Protection Activated

  • A319, vicinity Tunis Tunisia, 2012 (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”.)
  • A320, vicinity Tel Aviv Israel, 2012 (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.)
  • A321, en-route, near Pamplona Spain, 2014 (On 5 November 2014, the crew of an Airbus A321 temporarily lost control of their aircraft in the cruise and were unable to regain it until 4000 feet of altitude had been lost. An investigation into the causes is continuing but it is already known that blockage of more than one AOA probe resulted in unwanted activation of high AOA protection which could not be stopped by normal sidestick inputs until two of the three ADRs had been intentionally deactivated in order to put the flight control system into Alternate Law.)
  • A332 MRTT, en-route, south eastern Black Sea, 2014 (On 9 February 2014, the Captain of a military variant of the Airbus A330 suddenly lost control during the cruise on a passenger flight. A violent, initially negative 'g', pitch down occurred which reached 15800 fpm as the speed rose to Mach 0.9. In the absence of any effective crew intervention, recovery was achieved entirely by the aircraft Flight Envelope Protection System. The Investigation found that the upset had occurred when the Captain moved his seat forward causing its left arm rest to contact the personal camera he had placed behind the sidestick, forcing the latter fully forward.)
  • A332, en-route, near Dar es Salaam Tanzania, 2012 (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.)
  • A343, en-route, mid North Atlantic Ocean, 2011 (On 22 July 2011 an Air France A340-300 en route over the North Atlantic at FL350 in night IMC encountered moderate turbulence following "inappropriate use of the weather radar" which led to an overspeed annunciation followed by the aircraft abruptly pitching up and gaining over 3000 feet in less than a minute before control was regained and it was returned to the cleared level. There Investigation concluded that "the incident was due to inadequate monitoring of the flight parameters, which led to the failure to notice AP disengagement and the level bust, following a reflex action on the controls.”)
  • LJ24, vicinity Bornholm Denmark, 2012 (On 15 September 2012, a Learjet 24 experienced double engine failure in daylight VMC as it positioned visually on base leg at Bornholm and an emergency was declared. The subsequent handling of the aircraft then led to a stall from which recovery was not possible and terrain impact occurred in a standing crop at low forward speed shortly after crossing the coastline. The aircraft was destroyed and both occupants seriously injured. Investigation established that the engines had stopped due to fuel starvation resulting from mismanagement of the fuel system and had been preceded by a low fuel quantity warning.)


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