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AT76, Fez Morocco, 2018

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Revision as of 21:15, 30 June 2020 by Editor.1 (talk | contribs) (What Happened)
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Summary
On 6 July 2018, an ATR 72-600 followed an unstable approach at Fez with a multiple-bounce landing including a tail strike which caused rear fuselage deformation. The aircraft then continued in operation and the damage was not discovered until first flight preparations the following day. The Investigation found that the Captain supervising a trainee First Officer as handling pilot failed to intervene appropriately during the approach and thereafter had failed to act responsibly. The context for poor performance was assessed as systemic weakness in both the way the ATR fleet was being run and in regulatory oversight of the Operator.
Event Details
When July 2018
Actual or Potential
Event Type
Airworthiness, Human Factors, Loss of Control
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft ATR ATR-72-600
Operator White Airways
Domicile
Type of Flight Public Transport (Passenger)
Origin Lisbon Portela Airport
Intended Destination Fes-Saiss Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Landing
LDG
Location - Airport
Airport Fes-Saiss Airport
General
Tag(s) Flight Crew Training,
Approach not stabilised,
Event reporting non compliant,
Inadequate Airworthiness Procedures,
Inadequate Aircraft Operator Procedures,
Ineffective Regulatory Oversight,
Landing Flare Difficulty,
Deficient Crew Knowledge-systems,
Copilot less than 500 hours on Type,
CVR overwritten
HF
Tag(s) Flight / Cabin Crew Co-operation,
Flight Crew Visual Inspection,
Inappropriate crew response - skills deficiency,
Ineffective Monitoring,
Manual Handling,
Procedural non compliance,
Ineffective Monitoring - SIC as PF
LOC
Tag(s) Flight Management Error,
Hard landing
Outcome
Damage or injury Yes
Aircraft damage Major
Injuries Few occupants
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness
Investigation Type
Type Independent

Description

On 6 July 2018, an ATR 72-600 (CS-DJG) being operated by White Airways for TAP Express on a scheduled international passenger flight from Lisbon, Portugal, to Fez, Morocco, as TP1428 with First Officer line training in progress made a multiple bounce hard landing in day VMC at destination. During the landing the lower rear fuselage hit the runway and sustained deformation damage. The aircraft was then operated back to Lisbon in service whilst not airworthy due to the damage which was not noticed until the following morning prior to the intended first flight of the day, at which point it was withdrawn from service for repair. The Senior Cabin Crew Member (SCCM) sustained a minor back injury as a result of the impact of the fuselage with the runway, but the other 61 occupants were uninjured.

Investigation

The Portuguese Air and Rail Accident Investigation Agency (GPIAAF) was notified of the event by the BEA Morocco, which delegated the conduct of the necessary Accident Investigation to Portugal. It was noted that the GPIAAF only became “formally aware” of the accident when it “received a brief description of the event and the actions taken by the Operator with the aircraft ferried to Cascais and subsequent contact with the manufacturer”. The FDR and CVR were both removed from the aircraft but useful data could only be downloaded from the FDR as relevant CVR data had been overwritten.

It was found that the 47 year-old Training Captain had a total of 5,734 flying hours which included 2,956 hours on type. He had held an ATPL for 4 years and had been employed by the airline as a direct entry Captain in October 2016. It was noted that at that time, he had been permitted to act as an aircraft commander after just 3 supervised flights which, along with most other elements of the Company induction process, was not in compliance with that process. It was observed that “direct commander entry, within a short time interval, does not promote the correct understanding of procedural information, operator policies and culture to commanders, who in return, cannot actively contribute to spread the message to the new co-pilots arriving at the operator”. It was the Captain’s first flight with the trainee First Officer but he was aware from her training file of her continuing difficulties in manual handling of the aircraft.

The 33 year-old trainee First Officer who had been PF for the accident flight, had a total of 269 flying hours which included 47 hours on type and, having been employed by the operator four months earlier, was in her first job as a professional pilot. She had been signed off the day prior to the accident by the Operator’s Safety Manager as able to continue training without a safety pilot after completing 26 line training sectors.

What Happened

An ILS approach to the 3,200 metre-long runway 27 at Fez was being flown in relatively benign weather conditions - the ATIS gave surface wind velocity of 350°/8 knots in CAVOK (cloud and visibility OK) conditions. The approach proceeded normally until the AP was disconnected at 1300 feet aal but thereafter the achieved vertical flight path became somewhat erratic compared to the ILS GS and the PAPI and the airspeed varied both above and below the calculated VAPP. The Captain made two “Speed” calls but took no other action as the approach continued to be unstable.

As the aircraft passed DA, the aircraft was on the ILS GS and descending at 800 fpm at VAPP + 7 knots with 25% torque set. This rate of descent continued to 80 feet agl and at 50 feet agl, the flare was commenced with the torque at 3% and the pitch angle increased to 6.4°. At 20 feet agl, the PM applied back pressure to his control column whilst the First Officer continued to hold almost the same pressure on hers. Neither pilot added any power to reduce the rate of descent and a first touchdown occurred 350 metres past the threshold at a recorded +2.88g with a tail strike. A momentary bounce was followed by a second touchdown at +1.4g and after a second momentary bounce the final touchdown followed and the landing roll and taxi in continued without further event.

The Investigation’s examination of the aircraft found that readily visible damage to the rear fuselage was evident to both the tailskid assembly and the underside of the rear fuselage. This was subsequently found to have resulted in “permanent deformation of the fuselage between frames 35 and 38”. Deformation of frame 39 next to stringer 21RH, superficial damage to frame 36 between stringers 21LH and 21RH was also found as was the fact that the rivets of frame 39 had been sheared off between stringers 20RH and 21RH. Since the airport authorities at Fez were unaware of the fuselage/runway impact at the time, no precautionary runway inspection was carried out, although when it eventually was, it was reported that no evidence of such damage was found.

Once the passengers had disembarked, the Captain walked to the rear of the passenger cabin in order to carry out the required external pre flight inspection and when nearing the main exit observed a ceiling panel near to the SCCM station which had detached during the hard landing and refitted it in the presence of the cabin crew “without commenting or explaining what (had) happened during the landing”. He then completed his inspection - in his own words - “without detecting any anomalies in the aircraft”.

The Captain stated that he had subsequently attempted to access the ‘g’ loadings recorded on the airplane condition monitoring system (ACMS) during the landing but had been unable to do so. He therefore made no defect entry in the Aircraft Technical Log either at Fez (where there was no contracted engineering support) or on arrival in Lisbon on what was the final flight of the day. At no time prior to or after the flight back to Lisbon did the Captain make any attempt to contact any company flight operations or engineering personnel to report the hard landing.

The context for the Accident and its aftermath was analysed in depth and the following were some of the (summarised) issues looked at in relation to White Airways’ operation of their ATR 72-600 fleet:

  • All pilot simulator training was outsourced to one of three external Authorized Training Organisations and provided on simulators configured as the -500 variant of the ATR 72 rather than the -600 version. However, the regulatory requirement for differences training before operating the -600 version after simulator training on the -500 was found to have been ignored.
  • The Operator’s actual ratio of crews per aircraft at the time of the accident had been rather less than the planned 5 for the fleet of 8 aircraft in service even if First Officers’ still in training were included, thereby placing pressure on reliable service delivery of the contracted TAP Express flights and providing a situation where a trainee pilot was as useful in the short term as a qualified one provided a supernumerary qualified safety pilot was not considered necessary. In particular, “the Operator’s pilot shortage, particularly in terms of qualified First Officers, may have conditioned the trainee First Officer’s release for continued line training without a safety pilot on board, even though she continued to reveal aircraft handling difficulties during landing phase”.
  • Although the Operator’s OPM Part A contained a requirement for all approaches to be stabilised with a go around to be flown if the specified ‘gates’ at 1000 feet agl in IMC or 500 feet agl in VMC were not met in a stabilised condition, there was “no reference to a stable approach policy or criteria, nor does it include any instruction on when the go-around should be performed”.
  • The applicable OPM Part B for use by the ATR 72 fleet “is not specific to fleet or aircraft type”. It “primarily consists of tables with references to the different OEMs’ documentation for the Boeing, Airbus and ATR types in the operator’s fleet (and) does not include any procedures per se but rather provides references to other documents”, mainly the Flight Crew Operating Manual (FCOM) and AFM. There are also “indications that the operator's crews must follow the published operating procedures in the ATR FCTM”. It was observed that such a regime “is not a particularly effective means of creating robust and standardised SOPs, which have been assessed according to the specific requirements of the operation and adopted as the operator’s own, to foster a greater sense of ownership, acceptance and adherence by crew”.
  • The tail strike was inevitable when the main landing gear was fully depressed during the first touchdown with the aircraft pitch angle at that time exceeding that at which this will occur (5.94°).
  • Despite regulatory audits of the Operator’s process for the supervision of crew training returning “a positive result”, the multiple deficiencies in this process found during the Investigation showed that “these control measures were not effective” nor were others also mandated under applicable regulatory requirements.
  • Although the Training Captain involved in this event stated that there was nothing he could have done to prevent the damaging landing, the evidence indicated otherwise and his insistence that “if the trainee First Officer was unable to land the aircraft, he could do it without any problems […] suggested an overconfident behaviour leading to an attitude of invulnerability”.
  • The Operator “did not demonstrate a structured approach to monitoring operational safety performance (or) to validating the effectiveness of safety risk controls” in relation to continued airworthiness and in general, there were no risk assessment processes which effectively addressed a poor occurrence reporting culture within a systemically deficient safety culture.
  • The tail skid system on the aircraft type involved does not trigger an alert in the flight deck if ground contact occurs and the maximum permitted fuselage angle limit is exceeded but if the skid is fully compressed, two fibreglass sacrificial elements at its base are worn away. Such wear will result in the red witness marks (see the illustration below) no longer being visible which “indicates that the fuselage has been under over-stress”. Any pre flight inspection after a landing known to have been hard and involving a touchdown at a potentially excessive fuselage angle could reasonably be expected to pay particular attention to inspection of the tail skid and its witness marks.
The tail skid in its normal condition. [Reproduced from the Official Report]
  • In general, it was observed that during the Investigation, “it was not possible to collect evidence of effective operator supervision of […] the three main vectors: training, operations manuals and procedures and especially the operator’s safety management system.

Formally documented Findings included, but were not limited to, the following:

  • The event flight training of the First Officer as PF, while complying with the established number of flights by law, was not effective and sufficient to provide the necessary knowledge for the decision-making process and effective aircraft control capabilities.
  • The Training Captain’s actions and statements indicated that his knowledge and understanding of the aircraft systems were not adequate. His aeronautical decision making during the approach and flare suggests that he may not have considered the PF’s knowledge and the stage of her training on the event flight. He also did not demonstrate effective CRM practices and tools within the cockpit and between the cockpit and the cabin.
  • The Operator lacked flight crew in numbers and with the necessary skills for the size of the operation.
  • The mitigation measures put in place by the Operator’s training department regarding integration into the operation of inexperienced pilots were not effective.
  • The operator did not demonstrate effectiveness in the internal communication process of specific alerts or operation procedures.
  • Stabilised approach criteria are not defined in the customised Operator Manuals.
  • The Investigation identified weaknesses in the oversight of the Operator by the National Civil Aviation Authority in the following respects:
    • the approval of the operating manuals when without specific operational criteria, for example but not limited to, stable approach criteria,
    • training as defined in the OM-D, including assessment of the simulator service provider,
    • effective CRM implementation on the operator, criteria and validations of their instructors,
    • supervising the operation of the ATR72 fleet, notably through operational performance indicators such as the number of reports and their mitigation actions by the safety management system,
    • the operator's risk assessment control of the ATR72 fleet operation.

The Probable Cause of the Accident was formally determined as “the flight crew performance during the landing manoeuvre, namely with poor aircraft energy management while performing an unstable approach".

Four Contributory Factors were also identified in respect of the crew performance during the landing in Fez:

  • The Captain’s non-compliance with the discontinued approach procedure.
  • The Captain not performing the appropriate flight supervision techniques and the proper aircraft recovery from an unsafe condition during the unstable approach.
  • The line training process and the consequent authorisation for the trainee First Officer to fly as PF without a safety pilot present given her known difficulties in controlling the aircraft during landing.
  • The absence of any explicit definition of stabilised approach criteria by the Operator.

Two further Contributory Factors were also identified in respect of the crew decision process to make the return flight to Lisbon:

  • An organisational culture with inadequate or non-existent procedures and individual-centred decision-making (on the flight deck) without effective implementation of the CRM philosophy.
  • The lack of oversight of the Operator by the National Civil Aviation Authority in respect of its compliance with certification regulations and non adoption of SARPs.

Safety Action: It was noted that during the course of the Investigation, White Airways had taken, in conjunction with its contract provider TAP, “actions to ensure that TAP ground service providers operate in accordance with approved and distributed procedures, including the specificities of aircraft type used at each line station”.

Six Safety Recommendations were made as a result of the Investigation and are reproduced below preceded by the following statement which introduced them:

The operator management system did not prepare or protect the fast-growing operation that was experienced with the introduction of the ATR fleet operating for TAP Express. This coincided with a period in the aviation industry with the highest demand for pilots that caused high rotation and significant shortage of pilots in the operator. As business pressure increased, the organization's vulnerabilities were exposed. The lack of documented or adequate procedures for the size of the operation is the first example of an organisation with misfit growth.
The relevant operational safety aspects identified in this report regarding not only the hard landing event, but especially how the consequences have been managed, show systemic failures in the operator safety management system and in the oversight process by ANAC, as certifying authority.
Due to the wide range of safety issues addressed, there was a need to concentrate and group the respective safety recommendations on the operator and the National Aviation Authority.
  • that White Airways reviews the operation manual by customising and detailing the specific technical aspects of each fleet, as an example, but not limited to, the stabilised approach criteria definition in the OMB. [2019-09]
  • that White Airways reviews its crew training criteria and procedures as defined in Part-ORO.FC.145, including the correct definition and approval of FSTD devices and aircraft type. Regarding training, it should also review the CRM training as defined in PartORO.FC.215 and the command course as defined in Part-ORO.FC.205. [2019-10]
  • that White Airways reviews its criteria and procedures for the training oversight of inexperienced crew members, customising Line Training criteria to its own operation and in accordance with ORO.FC.220 and their AMCs. [2019-11]
  • that White Airways ensures, by defining explicit procedures, that CVRs / FDRs are properly preserved and held in safe custody following a safety event and made available for safety investigation purposes only. [2019-12]
  • that White Airways reviews and strengthens its safety management system to establish, implement and maintain effective monitoring of the operation's compliance with the relevant requirements, while also ensuring the effective implementation required by ORO.GEN.200 Management System, AMCs and GMs.
  • that the National Civil Aviation Authority (ANAC) assesses White Airways’ oversight methods, criteria and procedures against those provided for in Commission Regulation (EU) 965/2012 Part-ARO and following the best practices for the ‘Resolution of Safety Concerns’, Critical Element (CE) 8 in the ICAO Safety Oversight Manual Part A ‘The Establishment and Management of a State’s Safety Oversight System’ (Doc 9734) with the aim of promoting conditions for the operation of risk mitigation, namely regarding the identified regulatory weaknesses documented as Findings in section 3.1.4 of the Report. It should (also) consider whether the subject matter of this recommendation is applicable to other operators’ supervision.

The Final Report of the Investigation was published on 27 December 2019.

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