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Accident and Serious Incident Reports: AW

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Category: Airworthiness Airworthiness
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Definition

A selection of reports relating to accidents and serious incidents which involved Airworthiness as a factor.

The reports are listed below in two groups, the first of which lists the event according to the system affected. The second group identifies events in which Airworthiness was a contributing factor and lists the events by category.

Group 1 - Systems

Airframe

  • A306, vicinity New York JFK, 2001 (On 12 November 2001, an Airbus A300-600 encountered mild wake turbulence as it climbed after departing New York JFK to which the First Officer responded with a series of unnecessary and excessive control inputs involving cyclic full-deflection rudder pedal inputs. Within less than 7 seconds, these caused detachment of the vertical stabiliser from the aircraft resulting in loss of control and ground impact with a post crash fire. The Investigation concluded that elements of the company pilot training process and the design of the A300-600 rudder system had contributed to this excessive use of the rudder and its consequences.)
  • 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.)
  • 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.)
  • 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.)
  • A388, en-route, northern Afghanistan, 2014 (On 5 January 2014, an Airbus A380-800 en route to Singapore at night made an emergency descent and diversion to Baku after a loss of cabin pressure without further event. The Investigation attributed the pressure loss to a fatigue crack in a door skin which was initiated due to a design issue with door Cover Plates, which had not been detected when the Cover Plate was replaced with an improved one eighteen months earlier. Safety Issues related to cabin crew use of emergency oxygen and diversions to aerodromes with a fire category less than that normally required were also identified.)
  • 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.)

... further results

Air Conditioning and Pressurisation

  • A319, en-route, east of Dublin Ireland, 2008 (On 27 May 2008 an Airbus A319-100 being operated by Germanwings on a scheduled passenger flight from Dublin to Cologne was 30nm east of Dublin and passing FL100 in the climb in unrecorded daylight flight conditions when the Purser advised the flight crew by intercom that “something was wrong”, that almost all the passengers had fallen asleep, and that at least one of the cabin crew seated nearby was “unresponsive”. Following a review of this information and a check of the ECAM pressurisation page which showed no warnings or failures, a decision was taken to don oxygen masks and the aircraft returned uneventfully to Dublin without any further adverse effects on the 125 occupants. A MAYDAY was declared during the diversion.)
  • A320, en route, north of Marseilles France, 2013 (On 12 September 2013, pressurisation control failed in an A320 after a bleed air fault occurred following dispatch with one of the two pneumatic systems deactivated under MEL provisions. The Investigation found that the cause of the in-flight failure was addressed by an optional SB not yet incorporated. Also, relevant crew response SOPs lacking clarity and a delay in provision of a revised MEL procedure meant that use of the single system had not been optimal and after a necessary progressive descent to FL100 was delayed by inadequate ATC response, and ATC failure to respond to a PAN call required it to be upgraded to MAYDAY.)
  • 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 Dublin Ireland, 2015 (On 3 October 2015, an Airbus A320 which had just taken off from Dublin experienced fumes from the air conditioning system in both flight deck and cabin. A 'PAN' was declared and the aircraft returned with both pilots making precautionary use of their oxygen masks. The Investigation found that routine engine pressure washes carried out prior to departure have been incorrectly performed and a contaminant was introduced into the bleed air supply to the air conditioning system as a result. The context for the error was found to be the absence of any engine wash procedure training for the Operator's engineers.)
  • 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.)
  • B734, en-route, east northeast of Tanegashima Japan, 2015 (On 30 June 2015, both bleed air supplies on a Boeing 737-400 at FL370 failed in quick succession resulting in the loss of all pressurisation and, after making an emergency descent to 10,000 feet QNH, the flight was continued to the planned destination, Kansai. The Investigation found that both systems failed due to malfunctioning pre-cooler control valves and that these malfunctions were due to a previously identified risk of premature deterioration in service which had been addressed by an optional but “recommended” Service Bulletin which had not been taken up by the operator of the aircraft involved.)

... further results

Autoflight

  • 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, Munich Germany, 2017 (On 3 July 2017, an Airbus A319 sustained significant landing gear damage during the First Officer’s manual landing at Munich which recorded a vertical acceleration exceeding the threshold for a mandatory airworthiness inspection. That inspection found damage to nose and one main landing gear legs and, following Airbus advice, all three were replaced before release to service. The Investigation was unable to explain why neither pilot detected the incorrect pitch attitude and excessive rate of descent in time to take corrective action and noted that a reversion to manual flight during intermediate approach had been due to a technical malfunction.)
  • 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.)
  • B38M, en-route south east of Addis Ababa Ethiopia, 2019 (On 10 March 2019, left air data system faults on a Boeing 737-MAX 8 soon after departing Addis Ababa were followed by autopilot disconnection, left stick shaker activation and two successive periods of automatic nose down stabiliser causing EGPWS ‘DON’T SINK’ alerts. Recovery was achieved using manual stabiliser trim but prior to a third automatic pitch down, the trim system was switched off as per the runaway stabiliser drill but briefly reinstated to help recover from it. Recovery from a fourth automatic pitch down was not achieved and a high speed dive led to terrain impact six minutes after takeoff.)
  • 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.)
  • B743, vicinity Tehran Mehrabad Iran, 2015 (On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.)

... further results

Communications

  • A319, en-route, Nantes France, 2006 (On 15 September 2006, an Easyjet Airbus A319, despatched under MEL provision with one engine generator inoperative and the corresponding electrical power supplied by the Auxiliary Power Unit generator, suffered a further en route electrical failure which included power loss to all COM radio equipment which could not then be re-instated. The flight was completed as flight planned using the remaining flight instruments with the one remaining transponder selected to the standard emergency code. The incident began near Nantes, France.)
  • B732, Manchester UK, 1985 (On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.)
  • E195, en-route, Edinburgh UK, 2009 (On 15 January 2009, an Embraer 195-200 being operated by UK Regional Airline Flybe was passing overhead Edinburgh UK at FL370 at night when communications problems between the flight deck and cabin crew occurred following the selection of emergency power as a precautionary measure after smoke, considered to possibly be of electrical origin, had been observed in the galley. An en route diversion with an uneventful outcome was accomplished.)
  • UAV, manoeuvring, north of Reims France, 2006 (On 29 February 2016, control of a 50 kg, 3.8 metre wingspan UAV was lost during a flight test being conducted in a Temporary Segregated Area in northern Belgium. The UAV then climbed to 4,000 feet and took up a south south-westerly track across Belgium and into northern France where it crash-landed after the engine stopped. The Investigation found that control communications had been interrupted because of an incorrectly manufactured co-axial cable assembly and a separate autopilot software design flaw not previously identified. This then prevented the default recovery process from working. A loss of prescribed traffic separation was recorded.)

Electrical Power

  • A319, London Heathrow UK, 2009 (On 15 March 2009, an Airbus A319-100 being operated by British Airways on a scheduled passenger flight from London Heathrow to Edinburgh experienced an electrical malfunction which blanked the EFIS displays following engine start with some electrical fumes but no smoke. The engines were shut down, a PAN was declared to ATC and the aircraft was towed back onto the gate where passengers disembarked normally via the airbridge.)
  • A319, en-route, Nantes France, 2006 (On 15 September 2006, an Easyjet Airbus A319, despatched under MEL provision with one engine generator inoperative and the corresponding electrical power supplied by the Auxiliary Power Unit generator, suffered a further en route electrical failure which included power loss to all COM radio equipment which could not then be re-instated. The flight was completed as flight planned using the remaining flight instruments with the one remaining transponder selected to the standard emergency code. The incident began near Nantes, France.)
  • 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, 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.)
  • 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.)
  • A388, en-route, north east of Singapore, 2011 (On 31 January 2011, a Singapore Airlines Airbus A380-800 was in the cruise when there was sudden loud noise and signs of associated electrical smoke and potential burning in a toilet compartment with a corresponding ECAM smoke alert. After a fire extinguisher had been discharged into the apparent source, there were no further signs of fire or smoke. Subsequent investigation found signs of burning below the toilet floor and it was concluded that excessive current caused by a short circuit which had resulted from a degraded cable had been the likely cause, with over current protection limiting the damage caused by overheating.)

... further results

Equipment/Furnishings

  • A320, Halifax NS Canada, 2015 (On 29 March 2015, an Airbus A320 crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.)
  • A320, en-route, east of Cork Ireland, 2017 (On 2 November 2017, the flight crew of an Airbus A320 climbing out of Cork detected a “strong and persistent” burning smell and after declaring a MAYDAY returned to Cork where confusing instructions from the crew resulted in a combination of the intended precautionary rapid disembarkation and an emergency evacuation using escape slides. The Investigation highlighted the necessity of clear and unambiguous communications with passengers which distinguish these two options and in particular noted the limitations in currently mandated pre flight briefings for passengers seated at over wing emergency exits.)
  • B732, Manchester UK, 1985 (On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.)
  • B732, Pekanbaru Indonesia, 2002 (On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
  • B734, Barcelona Spain, 2004 (On 28 November 2004, a KLM B737-400 departed laterally from the runway on landing at Barcelona due to the effects on the nosewheel steering of a bird strike which had occured as the aircraft took off from Amsterdam.)
  • 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.)

... further results

Fire Protection

  • 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.)
  • A388, en-route, north east of Singapore, 2011 (On 31 January 2011, a Singapore Airlines Airbus A380-800 was in the cruise when there was sudden loud noise and signs of associated electrical smoke and potential burning in a toilet compartment with a corresponding ECAM smoke alert. After a fire extinguisher had been discharged into the apparent source, there were no further signs of fire or smoke. Subsequent investigation found signs of burning below the toilet floor and it was concluded that excessive current caused by a short circuit which had resulted from a degraded cable had been the likely cause, with over current protection limiting the damage caused by overheating.)
  • B732, Manchester UK, 1985 (On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.)
  • B738, en-route, southern Austria, 2010 (On 9 May 2010, Boeing 737-800 being operated by Swedish operator Viking Airlines on a public transport charter flight from Sharm el Sheikh, Egypt to Manchester UK and which had earlier suffered a malfunction which affected the level of redundancy in the aircraft pressurisation system, experienced a failure of the single air conditioning pack in use when over southern Austria and an emergency descent and en route diversion to Vienna were made. There were no injuries to any of the 196 occupants.)
  • B744, en-route, East China Sea, 2011 (On 28 July 2011, 50 minutes after take off from Incheon, the crew of an Asiana Boeing 747-400F declared an emergency advising a main deck fire and an intention to divert to Jeju. The effects of the rapidly escalating fire eventually made it impossible to retain control and the aircraft crashed into the sea. The Investigation concluded that the origin of the fire was two adjacent pallets towards the rear of the main deck which contained Dangerous Goods shipments including Lithium ion batteries and flammable substances and that the aircraft had broken apart in mid-air following the loss of control.)
  • 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.)

... further results

Flight Controls

  • A169, Leicester UK, 2018 (On 27 October 2018, a single pilot Augusta Westland AW169 lifted off from within the Leicester City Football Club Stadium, but after a failure of the tail rotor control system, a loss of yaw control occurred a few hundred feet above ground. The helicopter began to descend with a high rotation rate and soon afterward impacted the ground and almost immediately caught fire, which prevented those onboard surviving. An Investigation is being conducted by the UK AAIB.)
  • 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.)
  • A319, Munich Germany, 2017 (On 3 July 2017, an Airbus A319 sustained significant landing gear damage during the First Officer’s manual landing at Munich which recorded a vertical acceleration exceeding the threshold for a mandatory airworthiness inspection. That inspection found damage to nose and one main landing gear legs and, following Airbus advice, all three were replaced before release to service. The Investigation was unable to explain why neither pilot detected the incorrect pitch attitude and excessive rate of descent in time to take corrective action and noted that a reversion to manual flight during intermediate approach had been due to a technical malfunction.)
  • 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.)
  • 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

Fuel

  • 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.)
  • 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.)
  • AT72, en-route, Mediterranean Sea near Palermo Italy, 2005 (On 6 August 2005, a Tuninter ATR 72-210 was ditched near Palermo after fuel was unexpectedly exhausted en route. The aircraft broke into three sections on impact and 16 of the 39 occupants died. The Investigation found that insufficient fuel had been loaded prior to flight because the flight crew relied exclusively upon the fuel quantity gauges which had been fitted incorrectly by maintenance personnel. It was also found that the pilots had not fully followed appropriate procedures after the engine run down and that if they had, it was at least possible that a ditching could have been avoided.)
  • 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.)
  • B743, vicinity Tehran Mehrabad Iran, 2015 (On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.)

... further results

Hydraulic Power

  • A332, Karachi Pakistan, 2014 (On 4 October 2014, the fracture of a hydraulic hose during an A330-200 pushback at night at Karachi was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. After some delay, during which a delay in isolating the APU air bleed exacerbated the ingress of fumes, the aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it which prevented use of the exit adjacent to it for evacuation.)
  • A343, Helsinki Finland, 2009 (On 22 June 2009, an Airbus A340-300 being operated by Finnair suffered a single tyre failure during take off on a scheduled passenger flight to Helsinki and malfunction assessed as consequential by the flight crew occurred to the hydraulic system. The flight proceeded to destination and carried out a daylight landing there in normal visibility without any further aircraft damage. Because of a further deterioration in the status of the aircraft hydraulic systems during the landing roll, the aircraft was stopped on the runway and then towed into the gate. No persons were injured in this incident.)
  • B733, Paris CDG France, 2011 (On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were injured.)
  • B743, vicinity Tehran Mehrabad Iran, 2015 (On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.)
  • B752, London Gatwick, 2013 (An announcement by the Captain of a fully-boarded Boeing 757-200 about to depart which was intended to initiate a Precautionary Rapid Disembarkation due to smoke from a hydraulic leak was confusing and a partial emergency evacuation followed. The Investigation found that Cabin Crew only knew of this via the announcement and noted subsequent replacement of the applicable procedures by an improved version, although this was still considered to lack resilience in one respect. The event was considered to have illustrated the importance of having cabin crew close to doors when passengers are on board aircraft on the ground.)
  • B752, vicinity Keflavik Iceland, 2013 (On 26 February 2013, the crew of a Boeing 752 temporarily lost full control of their aircraft on a night auto-ILS approach at Keflavik when an un-commanded roll occurred during flap deployment after an earlier partial loss of normal hydraulic system pressure. The origin of the upset was found to have been a latent fatigue failure of a roll spoiler component, the effect of which had only become significant in the absence of normal hydraulic pressure and had been initially masked by autopilot authority until this was exceeded during flap deployment.)

... further results

Ice and Rain Protection

  • A320, Toronto ON Canada, 2017 (On 25 February 2017, an Airbus A320 left the side of the landing runway at Toronto when, for undetermined reasons, the Captain, as Pilot Flying, set up a drift to the right just before touchdown. This was then followed by a lateral runway excursion into wet grass in rain-reduced visibility which continued for 1,650 metres before the aircraft regained the runway and stopped. The Investigation noted that both the absence of runway centreline lighting and the aircraft operator’s policy of not activating the aircraft rain repellent system or applying the alternative hydrophobic windshield coating may have increased the excursion risk.)
  • 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, 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, Helsinki Finland, 2010 (On 11 January 2010, a British Aerospace ATP crew attempting to take off from Helsinki after a two-step airframe de/anti icing treatment (Type 2 and Type 4 fluids) were unable to rotate and the take off was successfully rejected from above V1. The Investigation found that thickened de/anti ice fluid residues had frozen in the gap between the leading edge of the elevator and the horizontal stabiliser and that there had been many other similarly-caused occurrences to aircraft without powered flying controls. There was concern that use of such thickened de/anti ice fluids was not directly covered by safety regulation.)
  • CRJ2, en-route, Fort St. John BC Canada, 2006 (On 21 November 2006, an Air Canada Jazz CL-600-2B19 on a scheduled flight from Vancouver to Prince George was cleared for a non-precision approach at destination. During a missed approach because of worse than forecast weather conditions, the crew were unable to retract the flaps from their 45 degree landing setting. A diversion to the designated alternate was commenced but en route, ATC were requested to provide radar vectors to Fort St. John and an emergency was declared due to a low fuel prediction on arrival. The aircraft subsequently landed without further problem at Fort St. John with about 500 pounds of fuel remaining, equivalent to less than 10 minutes of flight time.)
  • F70, vicinity Munich Germany, 2004 (On 5 January 2004, a Fokker 70, operated by Austrian Airlines, carried out a forced landing in a field 2.5 nm short of Munich Runway 26L following loss of thrust from both engines due to icing.)

... further results

Indicating / Recording Systems

  • 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.)
  • A319, London Heathrow UK, 2009 (On 15 March 2009, an Airbus A319-100 being operated by British Airways on a scheduled passenger flight from London Heathrow to Edinburgh experienced an electrical malfunction which blanked the EFIS displays following engine start with some electrical fumes but no smoke. The engines were shut down, a PAN was declared to ATC and the aircraft was towed back onto the gate where passengers disembarked normally via the airbridge.)
  • 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, 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 Perth Australia, 2015 (On 12 September 2015, an Airbus A320 autopilot and autothrust dropped out as it climbed out of Perth and multiple ECAM system messages were presented with intermittent differences in displayed airspeeds. During the subsequent turn back in Alternate Law, a stall warning was disregarded with no actual consequence. The Investigation attributed the problems to intermittently blocked pitot tubes but could not establish how this had occurred. It was also found that the priority for ECAM message display during the flight had been inappropriate and that the key procedure contained misleading information. These ECAM issues were subsequently addressed by the aircraft manufacturer.)
  • 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.)

... further results

Landing Gear

  • A30B, Bratislava Slovakia, 2012 (On 16 November 2012, an Air Contractors Airbus A300 departed the left the side of the landing runway at Bratislava after an abnormal response to directional control inputs. Investigation found that incorrect and undetected re-assembly of the nose gear torque links had led to the excursion and that absence of clear instructions in maintenance manuals, since rectified, had facilitated this. It was also considered that the absence of any regulation requiring equipment in the vicinity of the runway to be designed to minimise potential damage to aircraft departing the paved surface had contributed to the damage caused by the accident.)
  • 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.)
  • A320, Khartoum Sudan, 2005 (On 11 March 2005, an Airbus A321-200 operated by British Mediterranean Airways, executed two unstable approaches below applicable minima in a dust storm to land in Khartoum Airport, Sudan. The crew were attempting a third approach when they received information from ATC that visibility was below the minimum required for the approach and they decided to divert to Port Sudan where the A320 landed without further incident.)
  • A320, Los Angeles USA, 2005 (On 21 September 2005, an Airbus A320 operated by Jet Blue Airways made a successful emergency landing at Los Angeles Airport, California, with the nose wheels cocked 90 degrees to the fore-aft position after an earlier fault on gear retraction.)
  • A320, Singapore, 2015 (On 16 October 2015, the unlatched fan cowl doors of the left engine on an A320 fell from the aircraft during and soon after takeoff. The one which remained on the runway was not recovered for nearly an hour afterwards despite ATC awareness of engine panel loss during takeoff and as the runway remained in use, by the time it was recovered it had been reduced to small pieces. The Investigation attributed the failure to latch the cowls shut to line maintenance and the failure to detect the condition to inadequate inspection by both maintenance personnel and flight crew.)
  • A321, Fuerteventura Spain, 2016 (On 16 July 2016, an Airbus A321’s unstabilised approach at Fuerteventura during pilot line training was not discontinued and takeover of control and commencement of a go-around had occurred just before a very hard runway contact. The subsequent landing was successful but serious damage to the main landing gear was not rectified before the next flight. The Investigation found that the hard touchdown had been recorded as in excess of 3.3g and that the return flight had been “risky and unsafe” after failure of the Captain and maintenance personnel at the Operator to recognise the seriousness of the hard landing.)

... further results

Navigation

  • A320, en-route, Sydney Australia, 2007 (On 11 January 2007, an Air New Zealand Airbus A320 which had just departed Sydney Australia for Auckland, New Zealand was observed to have turned onto a heading contrary to the ATC-issued radar heading. When so advised by ATC, the crew checked the aircraft compasses and found that they were reading approximately 40 degrees off the correct heading.)
  • 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.)
  • B744, en-route, South China Sea, 2008 (On 25 July 2008, a Boeing 747 suffered a rapid depressurisation of the cabin following the sudden failure of an oxygen cylinder, which had ruptured the aircraft's pressure hull. The incident occurred 475 km north-west of Manila, Philippines.)
  • B788, London Heathrow UK, 2013 (On 12 July 2013 an unoccupied and unpowered Boeing 787-8, remotely parked at London Heathrow after an arrival earlier the same day caught fire. An investigation found that the source of the fire was an uncontained thermal runaway in the lithium-metal battery within an Emergency Locator Transmitter (ELT). Fifteen Safety Recommendations, all but one to the FAA, were made as a result of the Investigation.)
  • E190, en-route, southwest Vermont USA, 2016 (On 25 May 2016, an Embraer ERJ 190 experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.)
  • FA20, vicinity Kish Island Iran, 2014 (On 3 March 2014, a Dassault Falcon 20 engaged in navigation aid calibration for the Regulator was flown into the sea near Kish Island in dark night conditions. The Investigation concluded that the available evidence indicated that the aircraft had been inadvertently flown into the sea as the consequence of the crew experiencing somatogravic illusion. It was also noted that the absence of a functioning radio altimeter and pilot fatigue attributable to the long duty period was likely to have exacerbated the pilots' vulnerability to this illusion.)

... further results

Oxygen

  • 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.)
  • B744, en-route, South China Sea, 2008 (On 25 July 2008, a Boeing 747 suffered a rapid depressurisation of the cabin following the sudden failure of an oxygen cylinder, which had ruptured the aircraft's pressure hull. The incident occurred 475 km north-west of Manila, Philippines.)
  • B772, Cairo Egypt, 2011 (On 29 July 2011 an oxygen-fed fire started in the flight deck of an Egypt Air Boeing 777-200 about to depart from Cairo with most passengers boarded. The fire rapidly took hold despite attempts at extinguishing it but all passengers were safely evacuated via the still-attached air bridge access to doors 1L and 2L. The flight deck and adjacent structure was severely damaged. The Investigation could not conclusively determine the cause of the fire but suspected that wiring damage attributable to inadequately secured cabling may have provided a source of ignition for an oxygen leak from the crew emergency supply)
  • RJ1H, en-route, South West of Stockholm Sweden, 2007 (On 22 March 2007, climbing out of Stockholm Sweden, the crew of a Malmö Aviation Avro RJ100 failed to notice that the aircraft was not pressurised until cabin crew advised them of automatic cabin oxygen mask deployment.)

Airborne Auxiliary Power (APU)

  • A333, London Heathrow UK, 2016 (On 26 June 2016, thick white smoke suddenly appeared in the cabin of a fully loaded Airbus A330-300 prior to engine start with the door used for boarding still connected to the air bridge. An emergency evacuation initiated by cabin crew was accomplished without injury although amidst some confusion due to a brief conflict between flight crew and cabin crew instructions. The Investigation found that the smoke had been caused when an APU seal failed and hot oil entered the bleed air supply and pyrolysed. Safety Recommendations in respect of both crew communication and procedures and APU auto-shutdown were made.)
  • B773, Paris CDG France, 2013 (On 28 July 2013, with passengers still boarding an Air France Boeing 777-300, an abnormal 'burnt' smell was detected by the crew and then thin smoke appeared in the cabin. A MAYDAY was declared and the Captain made a PA telling the cabin crew to "evacuate the passengers via the doors, only via the doors". The resulting evacuation process was confused but eventually completed. The Investigation attributed the confused evacuation to the way it had been ordered and established that a fault in the APU had caused the smoke and fumes which had the potential to be toxic.)
  • E145, Kemi-Tornio Finland 2008 (On 11 December 2008 an EMB 145 being operated by Finnish Commuter Airlines on a scheduled passenger flight caught fire during the taxi in after a night landing after the APU failed to start and a major electrical power failure occurred simultaneously. The fire was not detected until after the aircraft arrived on stand when, with the passengers still on board, a member of the ground crew saw signs of fire at the back of the aircraft. The aircraft’s own fire suppression system was successfully used to extinguish the fire, the passengers left the aircraft and there were no injuries and only minor damage to the aircraft.)
  • E145, vicinity Manchester UK, 2001 (On 25 September 2001, an Embraer 145 in descent to Manchester sustained a low power lightning strike which was followed, within a few seconds, by the left engine stopping without failure annunciation. A successful single engine landing followed. The Investigation concluded that the cause of failure of the FADEC-controlled AE3007 engine (which has no surge recovery logic) was the aero-thermal effects of the strike to which all aircraft with relatively small diameter fuselages and close mounted engines are vulnerable. It was considered that there was a risk of simultaneous double engine flameout in such circumstances which was impossible to quantify.)
  • F100, Nuremburg Germany, 2015 (On 20 January 2015, The APU of a Fokker 100 being routinely de-iced prior to departing Nuremburg oversped as a result of the ignition of ingested de-icing fluid in the APU. This led to its explosive uncontained failure as the result of which ejected debris entered the aft cabin and smoke occurred. No occupants were injured and all were promptly disembarked. The Investigation found that the de-icing contractor involved had not followed manufacturer-issued aircraft-specific de-icing procedures and in the continued absence of any applicable safety regulatory oversight of ground de-icing activity, corresponding Safety Recommendations were made.)

Propellers

  • AT72, Copenhagen Denmark, 2013 (On 14 January 2013, selection of the power levers to ground idle after an ATR 72-200 touchdown at Copenhagen produced only one of the two expected low pitch indications. As the First Officer called 'one low pitch' in accordance with SOP, the Captain selected both engines into reverse. He was unable to prevent the resultant veer off the runway. After travelling approximately 350 metres on grass alongside the runway as groundspeed reduced, the runway was regained. A propeller control fault which would have prevented low pitch transition on the right engine was recorded but could not subsequently be replicated.)
  • AT75, en-route, north of Visby Sweden, 2014 (On 30 November 2014, an ATR 72-500 suddenly experienced severe propeller vibrations whilst descending through approximately 7,000 feet with the power levers at flight idle. The vibrations "subsided" after the crew feathered the right engine propeller and then shut the right engine down. The flight was completed without further event. Severe damage to the right propeller mechanism was found with significant consequential damage to the engine. Several other similar events were found to have occurred to other ATR72 aircraft and, since the Investigation could not determine the cause, the EASA was recommended to impose temporary operating limitations pending OEM resolution.)
  • 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.)
  • 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.)
  • 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.)
  • SB20, en-route, Muzzano Switzerland, 2013 (On 28 November 2013, a Saab 2000 departing Lugano suffered an engine failure for no apparent reason and the crew determined that diversion to Milan was preferable to return to Lugano or continued climb over high terrain to reach intended destination Zurich. The Investigation found that the loss of engine power experienced was due to a double FADEC failure with a transient malfunction of one channel resulting in an automated transfer to the other channel which already had an undetected permanent fault attributable to maintenance error. It was noted that the airline involved had contracted out all continuing airworthiness responsibilities.)

... further results

Rotors

  • 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.)
  • A169, Leicester UK, 2018 (On 27 October 2018, a single pilot Augusta Westland AW169 lifted off from within the Leicester City Football Club Stadium, but after a failure of the tail rotor control system, a loss of yaw control occurred a few hundred feet above ground. The helicopter began to descend with a high rotation rate and soon afterward impacted the ground and almost immediately caught fire, which prevented those onboard surviving. An Investigation is being conducted by the UK AAIB.)
  • AS3B, en-route, northern North Sea UK, 2008 (On 22 February 2008, a Eurocopter AS332 L2 Super Puma flying from an offshore oil platform to Aberdeen was struck by lightning. There was no apparent consequence and so, although this event required a landing as soon as possible, the commander decided to continue the remaining 165nm to the planned destination which was achieved uneventfully. Main rotor blade damage including some beyond repairable limits was subsequently discovered. The Investigation noted evidence indicating that this helicopter type had a relatively high propensity to sustain lightning strikes but noted that, despite the risk of damage, there was currently no adverse safety trend.)
  • B734, vicinity East Midlands UK, 1989 (On 8 January 1989, the crew of a British Midland Boeing 737-400 lost control of their aircraft due to lack of engine thrust shortly before reaching a planned en route diversion being made after an engine malfunction and it was destroyed by terrain impact with fatal or serious injuries sustained by almost all the occupants. The crew response to the malfunction had been followed by their shutdown of the serviceable rather the malfunctioning engine. The Investigation concluded that the accident was entirely the consequence of inappropriate crew response to a non-critical loss of powerplant airworthiness.)
  • B752, Las Vegas NV USA, 2008 (On 22 December 2008, a Boeing 757-200 on a scheduled passenger flight departing Las Vegas for New York JFK experienced sudden failure of the right engine as take off thrust was set and the aircraft was stopped on the runway for fire services inspection. Fire service personnel observed a hole in the bottom of the right engine nacelle and saw a glow inside so they discharged a fire bottle into the nacelle through the open pressure relief doors. In the absence of any contrary indications, this action was considered to have extinguished any fire and the aircraft was then taxied back to the gate on the remaining serviceable engine for passenger disembarkation. None of the 263 occupants were injured but the affected engine suffered significant damage.)
  • DH8D, en-route, South West Norway, 2004 (On 19 May 2004, a Bombardier DHC8-400 being operated on a scheduled passenger flight from Sandefjord to Bergen by Norwegian airline Wideroe was climbing through 13500 feet approximately 20nm west north west of Sandefjord in day VMC when there was a loud 'bang' from the left engine followed quickly by total power failure and a fire warning for that engine. The crew carried out the QRH drill, declared an emergency and made a return to Sandefjord. Although the left hand engine was shut down and both engine fire bottles had been discharged, the engine warning remained illuminated throughout the remainder of the flight. The aircraft was stopped on the runway after landing and a successful emergency evacuation of all 31 occupants was carried out with no injuries whilst the Airport Fire Service attended to the fire source.)

... further results

Engine - General

  • A140, vicinity Tehran Mehrabad Iran, 2014 (On 10 August 2014, one of the engines of an Antonov 140-100 departing Tehran Mehrabad ran down after V1 and prior to rotation. The takeoff was continued but the crew were unable to keep control and the aircraft stalled and crashed into terrain near the airport. The Investigation found that a faulty engine control unit had temporarily malfunctioned and that having taken off with an inappropriate flap setting, the crew had attempted an initial climb with a heavy aircraft without the failed engine propeller initially being feathered, with the gear remaining down and with the airspeed below V2.)
  • A306, Stockholm Sweden, 2010 (On 16 January 2010, an Iran Air Airbus A300-600 veered off the left side of the runway after a left engine failure at low speed whilst taking off at Stockholm. The directional control difficulty was attributed partly to the lack of differential braking but also disclosed wider issues about directional control following sudden asymmetry at low speeds. The Investigation concluded that deficiencies in the type certification process had contributed to the loss of directional control. It was concluded that the engine malfunction was due to the initiation of an engine stall by damage caused by debris from a deficient repair.)
  • 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, Singapore, 2015 (On 16 October 2015, the unlatched fan cowl doors of the left engine on an A320 fell from the aircraft during and soon after takeoff. The one which remained on the runway was not recovered for nearly an hour afterwards despite ATC awareness of engine panel loss during takeoff and as the runway remained in use, by the time it was recovered it had been reduced to small pieces. The Investigation attributed the failure to latch the cowls shut to line maintenance and the failure to detect the condition to inadequate inspection by both maintenance personnel and flight crew.)
  • A320, São Paulo Congonhas Brazil, 2007 (On 17 July 2007, the commander of a TAM Airlines Airbus A320 being operated with one thrust reverser locked out was unable to stop the aircraft leaving the landing runway at Congonhas at speed and it hit buildings and was destroyed by the impact and fire which followed killing all on board and others on the ground. The investigation attributed the accident to pilot failure to realise that the thrust lever of the engine with the locked out reverser was above idle, which by design then prevented both the deployment of ground spoilers and the activation of the pre-selected autobrake.)

... further results

Engine Fuel and Control

  • 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, Irkutsk Russia, 2006 (On 8 July 2006, S7 Airlines A310 overran the runway on landing at Irkutsk at high speed and was destroyed after the Captain mismanaged the thrust levers whilst attempting to apply reverse only on one engine because the flight was being conducted with one reverser inoperative. The Investigation noted that the aircraft had been despatched on the accident flight with the left engine thrust reverser de-activated as permitted under the MEL but also that the previous two flights had been carried out with a deactivated right engine thrust reverser.)
  • A310, Khartoum Sudan, 2008 (On 10 June 2008, a Sudan Airways Airbus A310 made a late night touchdown at Khartoum and the actions of the experienced crew were subsequently unable to stop the aircraft, which was in service with one thrust reverser inoperative and locked out, on the wet runway. The aircraft stopped essentially intact some 215 metres beyond the runway end after overrunning on smooth ground but a fuel-fed fire then took hold which impeded evacuation and eventually destroyed the aircraft.)
  • A320, Phoenix AZ USA, 2002 (On 28 August 2002, an America West Airbus A320 operating under an ADD for an inoperative left engine thrust reverser veered off the side of the runway during the landing roll at Phoenix AZ after the Captain mismanaged the thrust levers and lost directional control as a consequence of applying asymmetric thrust. Substantial damage occurred to the aircraft but most occupants were uninjured.)
  • 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, 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.)

... further results

Bleed Air

  • 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.)
  • 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 Dublin Ireland, 2015 (On 3 October 2015, an Airbus A320 which had just taken off from Dublin experienced fumes from the air conditioning system in both flight deck and cabin. A 'PAN' was declared and the aircraft returned with both pilots making precautionary use of their oxygen masks. The Investigation found that routine engine pressure washes carried out prior to departure have been incorrectly performed and a contaminant was introduced into the bleed air supply to the air conditioning system as a result. The context for the error was found to be the absence of any engine wash procedure training for the Operator's engineers.)
  • A332, Karachi Pakistan, 2014 (On 4 October 2014, the fracture of a hydraulic hose during an A330-200 pushback at night at Karachi was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. After some delay, during which a delay in isolating the APU air bleed exacerbated the ingress of fumes, the aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it which prevented use of the exit adjacent to it for evacuation.)
  • 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.)
  • 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.)

... further results

Other

  • A320, en-route, east of Cork Ireland, 2017 (On 2 November 2017, the flight crew of an Airbus A320 climbing out of Cork detected a “strong and persistent” burning smell and after declaring a MAYDAY returned to Cork where confusing instructions from the crew resulted in a combination of the intended precautionary rapid disembarkation and an emergency evacuation using escape slides. The Investigation highlighted the necessity of clear and unambiguous communications with passengers which distinguish these two options and in particular noted the limitations in currently mandated pre flight briefings for passengers seated at over wing emergency exits.)
  • B190 / BE9L, Quincy IL USA, 1996 (On 19 November 1996, a Beech 1900C which had just landed and a Beech King Air A90 which was taking off collided at the intersection of two runways at the non-Towered Quincy Municipal Airport. Both aircraft were destroyed by impact forces and fire and all occupants of both aircraft were killed. The Investigation found that the King Air pilots had failed to monitor the CTAF or properly scan visually for traffic. The loss of life of the Beech 1900 occupants, who had probably survived the impact, was attributed largely to inability to open the main door of the aircraft.)
  • B463, Khark Island Iran, 2016 (On 19 June 2016, a BAe 146-300 landed long at Khark Island and overran the end of the runway at speed with the aircraft only stopping because the nose landing gear collapsed on encountering uneven ground. The Investigation attributed the accident - which caused enough structural damage for the aircraft to be declared a hull loss - entirely to the decisions and actions of the aircraft commander who failed to go around from an unstabilised approach, landed long and then did not ensure maximum deceleration was achieved. The monitoring role of the low experience First Officer was ineffective.)
  • 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.)
  • BA11, en-route, Didcot Oxfordshire UK, 1990 (On 10 June 1990, a BAC 1-11 operated by British Airways, during climb, experienced sudden explosive depressurisation which resulted in loss of the left hand windscreen. The commander was sucked in the windscreen aperture and was successfully secured by the cabin crew, while the first officer executed a safe landing.)
  • C402, Virgin Gorda British Virgin Islands, 2017 (On 11 February 2017, a Cessna 402 failed to stop on the runway when landing at Virgin Gorda and was extensively damaged. The Investigation noted that the landing distance required was very close to that available with no safety margin so that although touchdown was normal, when the brakes failed to function properly, there was no possibility of safely rejecting the landing or stopping normally on the runway. Debris in the brake fluid was identified as causing brake system failure. The context was considered as the Operator’s inadequate maintenance practices and a likely similar deficiency in operational procedures and processes.)

... further results

Emergency Evacuation

  • 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.)
  • A332, Karachi Pakistan, 2014 (On 4 October 2014, the fracture of a hydraulic hose during an A330-200 pushback at night at Karachi was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. After some delay, during which a delay in isolating the APU air bleed exacerbated the ingress of fumes, the aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it which prevented use of the exit adjacent to it for evacuation.)
  • B732, Manchester UK, 1985 (On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.)
  • B732, Pekanbaru Indonesia, 2002 (On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
  • B753, London Gatwick UK, 2014 (On 31 October 2014, indications of a malfunction of the right over wing emergency exit slide on take off were followed during the return to land by the complete detachment of the slide and un-commanded but controllable roll. The Investigation found that "a series of technical issues with the slide panel and carrier locking devices caused the slide carrier to deploy and the slide to unravel". Although an SB existed to address some of these issues, it had not been actioned on the aircraft. Two operational matters encountered during the Investigation were the subject of Safety Recommendations.)
  • HUNT, manoeuvring, vicinity Shoreham UK, 2015 (On 22 August 2015 the pilot of a civil-operated Hawker Hunter carrying out a flying display sequence at Shoreham failed to complete a loop and partial roll manoeuvre and the aircraft crashed into road traffic unrelated to the airshow and exploded causing multiple third party fatalities and injuries. The Investigation found that the pilot had failed to enter the manoeuvre correctly and then failed to abandon it when it should have been evident that it could not be completed. It was concluded that the wider context for the accident was inadequate regulatory oversight of UK civil air display flying risk management.)

... further results

Rotary Aircraft Transmission

  • EC25, vicinity Bergen Norway, 2016 (On 29 April 2016, an Airbus EC225 Super Puma main rotor detached without warning en-route to Bergen. Control was lost and it crashed and was destroyed. Rotor detachment was attributed to undetected development of metal fatigue in the same gearbox component which caused an identical 2009 accident to a variant of the same helicopter type. Despite this previous accident, the failure mode involved had not been properly understood or anticipated. The investigation identifies significant lessons to be learned related to gearbox design, risk assessment, fatigue evaluation, gearbox condition monitoring, type certification and continued airworthiness, which may also be valid for other helicopter types.)
  • S92, en-route, east of St John’s Newfoundland Canada, 2009 (On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.)

Lights

None on SKYbrary

Group 2 - Contributors

Maintenance Error (valid guidance available)

  • A30B, Bratislava Slovakia, 2012 (On 16 November 2012, an Air Contractors Airbus A300 departed the left the side of the landing runway at Bratislava after an abnormal response to directional control inputs. Investigation found that incorrect and undetected re-assembly of the nose gear torque links had led to the excursion and that absence of clear instructions in maintenance manuals, since rectified, had facilitated this. It was also considered that the absence of any regulation requiring equipment in the vicinity of the runway to be designed to minimise potential damage to aircraft departing the paved surface had contributed to the damage caused by the accident.)
  • 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.)
  • A320, Singapore, 2015 (On 16 October 2015, the unlatched fan cowl doors of the left engine on an A320 fell from the aircraft during and soon after takeoff. The one which remained on the runway was not recovered for nearly an hour afterwards despite ATC awareness of engine panel loss during takeoff and as the runway remained in use, by the time it was recovered it had been reduced to small pieces. The Investigation attributed the failure to latch the cowls shut to line maintenance and the failure to detect the condition to inadequate inspection by both maintenance personnel and flight crew.)
  • A320, Toronto Canada, 2000 (On 13 September 2000, an Airbus A320-200 being operated by Canadian airline Skyservice on a domestic passenger charter flight from Toronto to Edmonton was departing in day VMC when, after a “loud bang and shudder” during rotation, evidence of left engine malfunction occurred during initial climb and the flight crew declared an emergency and returned for an immediate overweight landing on the departure runway which necessitated navigation around several pieces of debris, later confirmed as the fan cowlings of the left engine. There were no injuries to the occupants.)
  • A320, en-route, Sydney Australia, 2007 (On 11 January 2007, an Air New Zealand Airbus A320 which had just departed Sydney Australia for Auckland, New Zealand was observed to have turned onto a heading contrary to the ATC-issued radar heading. When so advised by ATC, the crew checked the aircraft compasses and found that they were reading approximately 40 degrees off the correct heading.)

... further results

Maintenance Error (invalid guidance available)

  • 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.)
  • 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.)
  • A388, en-route, north east of Singapore, 2011 (On 31 January 2011, a Singapore Airlines Airbus A380-800 was in the cruise when there was sudden loud noise and signs of associated electrical smoke and potential burning in a toilet compartment with a corresponding ECAM smoke alert. After a fire extinguisher had been discharged into the apparent source, there were no further signs of fire or smoke. Subsequent investigation found signs of burning below the toilet floor and it was concluded that excessive current caused by a short circuit which had resulted from a degraded cable had been the likely cause, with over current protection limiting the damage caused by overheating.)
  • 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.)
  • B733, Paris CDG France, 2011 (On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were 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.)

... further results

Inadequate Maintenance Schedule

  • 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, Irkutsk Russia, 2006 (On 8 July 2006, S7 Airlines A310 overran the runway on landing at Irkutsk at high speed and was destroyed after the Captain mismanaged the thrust levers whilst attempting to apply reverse only on one engine because the flight was being conducted with one reverser inoperative. The Investigation noted that the aircraft had been despatched on the accident flight with the left engine thrust reverser de-activated as permitted under the MEL but also that the previous two flights had been carried out with a deactivated right engine thrust reverser.)
  • A320, en-route, east of Cork Ireland, 2017 (On 2 November 2017, the flight crew of an Airbus A320 climbing out of Cork detected a “strong and persistent” burning smell and after declaring a MAYDAY returned to Cork where confusing instructions from the crew resulted in a combination of the intended precautionary rapid disembarkation and an emergency evacuation using escape slides. The Investigation highlighted the necessity of clear and unambiguous communications with passengers which distinguish these two options and in particular noted the limitations in currently mandated pre flight briefings for passengers seated at over wing emergency exits.)
  • 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, Paris CDG France, 2011 (On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were injured.)
  • B744, Johannesburg South Africa, 2009 (On 11 May 2009, a British Airways Boeing 747-400 departing Johannesburg came close to stalling following a stall protection system activation during night rotation which continued until landing gear retraction despite immediate appropriate crew response. Subsequent investigation found that loss of lift on rotation had resulted from the unanticipated effect of a design modification in respect of thrust reverser unlocked signals with the aircraft in ‘ground’ status. The Investigation found that the potential effects of this on the transition from ‘ground’ to ‘air’ status including the lower stalling angle of attack in ground effect had not been foreseen.)

... further results

Inadequate Maintenance Inspection

  • A306, Stockholm Sweden, 2010 (On 16 January 2010, an Iran Air Airbus A300-600 veered off the left side of the runway after a left engine failure at low speed whilst taking off at Stockholm. The directional control difficulty was attributed partly to the lack of differential braking but also disclosed wider issues about directional control following sudden asymmetry at low speeds. The Investigation concluded that deficiencies in the type certification process had contributed to the loss of directional control. It was concluded that the engine malfunction was due to the initiation of an engine stall by damage caused by debris from a deficient repair.)
  • A320, Halifax NS Canada, 2015 (On 29 March 2015, an Airbus A320 crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.)
  • A320, Singapore, 2015 (On 16 October 2015, the unlatched fan cowl doors of the left engine on an A320 fell from the aircraft during and soon after takeoff. The one which remained on the runway was not recovered for nearly an hour afterwards despite ATC awareness of engine panel loss during takeoff and as the runway remained in use, by the time it was recovered it had been reduced to small pieces. The Investigation attributed the failure to latch the cowls shut to line maintenance and the failure to detect the condition to inadequate inspection by both maintenance personnel and flight crew.)
  • 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 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, Fuerteventura Spain, 2016 (On 16 July 2016, an Airbus A321’s unstabilised approach at Fuerteventura during pilot line training was not discontinued and takeover of control and commencement of a go-around had occurred just before a very hard runway contact. The subsequent landing was successful but serious damage to the main landing gear was not rectified before the next flight. The Investigation found that the hard touchdown had been recorded as in excess of 3.3g and that the return flight had been “risky and unsafe” after failure of the Captain and maintenance personnel at the Operator to recognise the seriousness of the hard landing.)

... further results

Inadequate QRH Drills

  • A320, en route, north of Marseilles France, 2013 (On 12 September 2013, pressurisation control failed in an A320 after a bleed air fault occurred following dispatch with one of the two pneumatic systems deactivated under MEL provisions. The Investigation found that the cause of the in-flight failure was addressed by an optional SB not yet incorporated. Also, relevant crew response SOPs lacking clarity and a delay in provision of a revised MEL procedure meant that use of the single system had not been optimal and after a necessary progressive descent to FL100 was delayed by inadequate ATC response, and ATC failure to respond to a PAN call required it to be upgraded to MAYDAY.)
  • 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.)
  • A333, London Heathrow UK, 2016 (On 26 June 2016, thick white smoke suddenly appeared in the cabin of a fully loaded Airbus A330-300 prior to engine start with the door used for boarding still connected to the air bridge. An emergency evacuation initiated by cabin crew was accomplished without injury although amidst some confusion due to a brief conflict between flight crew and cabin crew instructions. The Investigation found that the smoke had been caused when an APU seal failed and hot oil entered the bleed air supply and pyrolysed. Safety Recommendations in respect of both crew communication and procedures and APU auto-shutdown were made.)
  • A388, en-route, northern Afghanistan, 2014 (On 5 January 2014, an Airbus A380-800 en route to Singapore at night made an emergency descent and diversion to Baku after a loss of cabin pressure without further event. The Investigation attributed the pressure loss to a fatigue crack in a door skin which was initiated due to a design issue with door Cover Plates, which had not been detected when the Cover Plate was replaced with an improved one eighteen months earlier. Safety Issues related to cabin crew use of emergency oxygen and diversions to aerodromes with a fire category less than that normally required were also identified.)
  • AS3B, vicinity Den Helder Netherlands, 2006 (On 21 November 2006, the crew of a Bristow Eurocopter AS332 L2 making an unscheduled passenger flight from an offshore platform to Den Helder in night VMC decided to ditch their aircraft after apparent malfunction of an engine and the flight controls were perceived as rendering it unable to safely complete the flight. All 17 occupants survived but the evacuation was disorganised and both oversight of the operation by and the actions of the crew were considered to have been inappropriate in various respects. Despite extensive investigation, no technical fault which would have rendered it unflyable could be confirmed.)
  • AT72, Helsinki Finland, 2012 (On 19 August 2012, the crew of a Flybe Finland ATR 72-200 approaching Helsinki failed to respond appropriately to a fault which limited rudder travel and were then unable to maintain directional control after touchdown with a veer off the runway then following. It was concluded that as well as prioritising a continued approach over properly dealing with the annunciated caution, crew technical knowledge in respect of the fault encountered had been poor and related training inadequate. Deficiencies found in relevant aircraft manufacturer operating documentation were considered to have been a significant factor and Safety Recommendations were made accordingly.)

... further results

OEM Design fault

  • 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.)
  • A140, vicinity Tehran Mehrabad Iran, 2014 (On 10 August 2014, one of the engines of an Antonov 140-100 departing Tehran Mehrabad ran down after V1 and prior to rotation. The takeoff was continued but the crew were unable to keep control and the aircraft stalled and crashed into terrain near the airport. The Investigation found that a faulty engine control unit had temporarily malfunctioned and that having taken off with an inappropriate flap setting, the crew had attempted an initial climb with a heavy aircraft without the failed engine propeller initially being feathered, with the gear remaining down and with the airspeed below V2.)
  • 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, en-route, Nantes France, 2006 (On 15 September 2006, an Easyjet Airbus A319, despatched under MEL provision with one engine generator inoperative and the corresponding electrical power supplied by the Auxiliary Power Unit generator, suffered a further en route electrical failure which included power loss to all COM radio equipment which could not then be re-instated. The flight was completed as flight planned using the remaining flight instruments with the one remaining transponder selected to the standard emergency code. The incident began near Nantes, France.)
  • 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.)
  • A320, São Paulo Congonhas Brazil, 2007 (On 17 July 2007, the commander of a TAM Airlines Airbus A320 being operated with one thrust reverser locked out was unable to stop the aircraft leaving the landing runway at Congonhas at speed and it hit buildings and was destroyed by the impact and fire which followed killing all on board and others on the ground. The investigation attributed the accident to pilot failure to realise that the thrust lever of the engine with the locked out reverser was above idle, which by design then prevented both the deployment of ground spoilers and the activation of the pre-selected autobrake.)

... further results

Damage Tolerance

  • 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.)
  • 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.)
  • A320, Los Angeles USA, 2005 (On 21 September 2005, an Airbus A320 operated by Jet Blue Airways made a successful emergency landing at Los Angeles Airport, California, with the nose wheels cocked 90 degrees to the fore-aft position after an earlier fault on gear retraction.)
  • 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.)
  • 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.)
  • A343, Helsinki Finland, 2009 (On 22 June 2009, an Airbus A340-300 being operated by Finnair suffered a single tyre failure during take off on a scheduled passenger flight to Helsinki and malfunction assessed as consequential by the flight crew occurred to the hydraulic system. The flight proceeded to destination and carried out a daylight landing there in normal visibility without any further aircraft damage. Because of a further deterioration in the status of the aircraft hydraulic systems during the landing roll, the aircraft was stopped on the runway and then towed into the gate. No persons were injured in this incident.)

... further results

Contributing ADD

  • A310, Irkutsk Russia, 2006 (On 8 July 2006, S7 Airlines A310 overran the runway on landing at Irkutsk at high speed and was destroyed after the Captain mismanaged the thrust levers whilst attempting to apply reverse only on one engine because the flight was being conducted with one reverser inoperative. The Investigation noted that the aircraft had been despatched on the accident flight with the left engine thrust reverser de-activated as permitted under the MEL but also that the previous two flights had been carried out with a deactivated right engine thrust reverser.)
  • A319, en-route, Nantes France, 2006 (On 15 September 2006, an Easyjet Airbus A319, despatched under MEL provision with one engine generator inoperative and the corresponding electrical power supplied by the Auxiliary Power Unit generator, suffered a further en route electrical failure which included power loss to all COM radio equipment which could not then be re-instated. The flight was completed as flight planned using the remaining flight instruments with the one remaining transponder selected to the standard emergency code. The incident began near Nantes, France.)
  • A320, Phoenix AZ USA, 2002 (On 28 August 2002, an America West Airbus A320 operating under an ADD for an inoperative left engine thrust reverser veered off the side of the runway during the landing roll at Phoenix AZ after the Captain mismanaged the thrust levers and lost directional control as a consequence of applying asymmetric thrust. Substantial damage occurred to the aircraft but most occupants were uninjured.)
  • 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.)
  • 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.)
  • A388, en-route, northern Afghanistan, 2014 (On 5 January 2014, an Airbus A380-800 en route to Singapore at night made an emergency descent and diversion to Baku after a loss of cabin pressure without further event. The Investigation attributed the pressure loss to a fatigue crack in a door skin which was initiated due to a design issue with door Cover Plates, which had not been detected when the Cover Plate was replaced with an improved one eighteen months earlier. Safety Issues related to cabin crew use of emergency oxygen and diversions to aerodromes with a fire category less than that normally required were also identified.)

... further results

Component Fault in Service

  • 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, 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.)
  • 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.)
  • A319, London Heathrow UK, 2009 (On 15 March 2009, an Airbus A319-100 being operated by British Airways on a scheduled passenger flight from London Heathrow to Edinburgh experienced an electrical malfunction which blanked the EFIS displays following engine start with some electrical fumes but no smoke. The engines were shut down, a PAN was declared to ATC and the aircraft was towed back onto the gate where passengers disembarked normally via the airbridge.)
  • 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.)

... further results

Component Fault After Installation

  • A306, Stockholm Sweden, 2010 (On 16 January 2010, an Iran Air Airbus A300-600 veered off the left side of the runway after a left engine failure at low speed whilst taking off at Stockholm. The directional control difficulty was attributed partly to the lack of differential braking but also disclosed wider issues about directional control following sudden asymmetry at low speeds. The Investigation concluded that deficiencies in the type certification process had contributed to the loss of directional control. It was concluded that the engine malfunction was due to the initiation of an engine stall by damage caused by debris from a deficient repair.)
  • 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.)
  • 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.)
  • 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.)
  • A343, Helsinki Finland, 2009 (On 22 June 2009, an Airbus A340-300 being operated by Finnair suffered a single tyre failure during take off on a scheduled passenger flight to Helsinki and malfunction assessed as consequential by the flight crew occurred to the hydraulic system. The flight proceeded to destination and carried out a daylight landing there in normal visibility without any further aircraft damage. Because of a further deterioration in the status of the aircraft hydraulic systems during the landing roll, the aircraft was stopped on the runway and then towed into the gate. No persons were injured in this incident.)
  • AT72, Zurich Switzerland, 2014 (On 4 December 2014, directional control of an ATR 72-200 was compromised shortly after touchdown at Zurich after slightly misaligned nose wheels caused both tyres to be forced off their wheels leaving the wheel rims in direct contact with the runway surface. The Investigation found that the cause of the misalignment was the incorrect installation of a component several months earlier and the subsequent failure to identify the error. Previous examples of the same error were found and a Safety Recommendation was made that action to make the component involved less vulnerable to incorrect installation should be taken.)

... further results

Pilot Verbal-only Defect Communication

  • B734, Barcelona Spain, 2004 (On 28 November 2004, a KLM B737-400 departed laterally from the runway on landing at Barcelona due to the effects on the nosewheel steering of a bird strike which had occured as the aircraft took off from Amsterdam.)
  • 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.)
  • B737, manoeuvring, west of Norwich UK 2009 (On 12 January 2009, the flight crew of an Easyjet Boeing 737-700 on an airworthiness function flight out of Southend lost control of the aircraft during a planned system test. Controlled flight was only regained after an altitude loss of over 9000 ft, during which various exceedences of the AFM Flight Envelope occurred. The subsequent investigation found that the Aircraft Operators procedures for such flights were systemically flawed.)
  • B742, vicinity Stansted UK, 1999 (On 22 December 1999, a KAL Boeing 747 freighter crashed shortly after take-off from Stansted UK, following an ADI malfunction.)
  • F27, vicinity Jersey Channel Islands, 2001 (Shortly after take-off from Jersey Airport, Channel Islands, a F27 experienced an uncontained engine failure and a major fire external to the engine nacelle. The fire was extinguished and the aircraft landed uneventfully back at Jersey.)
  • LJ35, Aberdeen SD USA, 1999 (On 25 October 1999, a Learjet 35, being operated on a passenger charter flight by Sunjet Aviation, crashed in South Dakota following loss of control attributed to crew incapacitation.)

Corrosion/Disbonding/Fatigue

  • 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, Stockholm Sweden, 2010 (On 16 January 2010, an Iran Air Airbus A300-600 veered off the left side of the runway after a left engine failure at low speed whilst taking off at Stockholm. The directional control difficulty was attributed partly to the lack of differential braking but also disclosed wider issues about directional control following sudden asymmetry at low speeds. The Investigation concluded that deficiencies in the type certification process had contributed to the loss of directional control. It was concluded that the engine malfunction was due to the initiation of an engine stall by damage caused by debris from a deficient repair.)
  • 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.)
  • A332, Karachi Pakistan, 2014 (On 4 October 2014, the fracture of a hydraulic hose during an A330-200 pushback at night at Karachi was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. After some delay, during which a delay in isolating the APU air bleed exacerbated the ingress of fumes, the aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it which prevented use of the exit adjacent to it for evacuation.)
  • AT43, Jersey Channel Islands, 2012 (On 16 July 2012, the left main landing gear of a Blue Islands ATR 42-300 collapsed during landing at Jersey. The aircraft stopped quickly on the runway as the left wing and propeller made ground contact. Although the crew saw no imminent danger once the aircraft had stopped, the passengers thought otherwise and perceived the need for an emergency evacuation which the sole cabin crew facilitated. The Investigation found that the fatigue failure of a side brace had initiated the gear collapse and that the origin of this was a casting discontinuity in a billet of aluminium produced to specification.)
  • AT72, vicinity Budapest Hungary, 2016 (On 16 March 2016, an engine fire occurred to an ATR 72-200 departing Budapest and after declaring a MAYDAY, it was landed in the reciprocal direction on the departure runway without further event. The Investigation found that the failure had been initiated by the fatigue-induced failure of a single blade in the power turbine assembly but with insufficient evidence to ascribe a cause for this. A number of almost identical instances of engine failure initiated by failure of a single turbine blade were noted. Opportunities for both ATC procedures and flight crew response to mandatory emergency procedures were also identified.)

... further results

Cross Connection

  • 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.)
  • IL76, St John's Newfoundland Canada, 2012 (On 13 August 2012, an Ilyushin IL76 freighter overran landing runway 11 at St John's at 40 knots. The Investigation established that although a stabilised approach had been flown, the aircraft had been allowed to float in the presence of a significant tail wind component and had not finally touched down until half way along the 2590 metre long runway. It was also found that reverse thrust had then not been fully utilised and that cross connection of the brake lines had meant that the anti skid pressure release system worked in reverse sense, thus reducing braking effectiveness.)

Engine Compressor Washing

  • A320, vicinity Dublin Ireland, 2015 (On 3 October 2015, an Airbus A320 which had just taken off from Dublin experienced fumes from the air conditioning system in both flight deck and cabin. A 'PAN' was declared and the aircraft returned with both pilots making precautionary use of their oxygen masks. The Investigation found that routine engine pressure washes carried out prior to departure have been incorrectly performed and a contaminant was introduced into the bleed air supply to the air conditioning system as a result. The context for the error was found to be the absence of any engine wash procedure training for the Operator's engineers.)
  • B735, en-route, SE of Kushimoto Wakayama Japan, 2006 (On 5 July 2006, during daytime, a Boeing 737-500, operated by Air Nippon Co., Ltd. took off from Fukuoka Airport as All Nippon Airways scheduled flight 2142. At about 08:10, while flying at 37,000 ft approximately 60 nm southeast of Kushimoto VORTAC, a cabin depressurization warning was displayed and the oxygen masks in the cabin were automatically deployed. The aircraft made an emergency descent and, at 09:09, landed on Chubu International Airport.)
  • DH8C, vicinity Abu Dhabi UAE, 2012 (On 9 September 2012, the crew of a DHC8-300 climbing out of Abu Dhabi declared a PAN and returned after visual evidence of the right engine overheating were seen from the passenger cabin. The Investigation found that the observed signs of engine distress were due to hot gas exiting through the cavity left by non-replacement of one of the two sets of igniters on the engine after a pressure wash carried out overnight prior to the flight and that the left engine was similarly affected. The context for the error was identified as a dysfunctional maintenance organisation at the Operator.)

Ejected Engine Failure Debris

  • 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.)
  • B737, en-route, northwest of Philadelphia PA USA, 2018 (On 14 April 2018, a sudden uncontained left engine failure occurred to a CFM56-7B powered Boeing 737-70 as it climbed through approximately FL 320 abeam Philadelphia. Ejected debris broke a cabin window causing rapid decompression and the death of a passenger seated nearby. Diversion to Philadelphia followed without further significant event. The same day, the Investigation, which is continuing, found that the failure was due to metal fatigue in a single fan blade causing it to shear from the hub. The engine manufacturer subsequently issued inspection requirements for similar engines and Airworthiness Directives based on this were immediately issued.)
  • B743, vicinity Tehran Mehrabad Iran, 2015 (On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.)
  • B772, Las Vegas NV USA, 2015 (On 8 September 2015, a catastrophic uncontained failure of a GE90-85B engine on a Boeing 777-200 taking off from Las Vegas was immediately followed by a rejected takeoff. A fuel-fed fire took hold and a successful emergency evacuation was completed. The Investigation traced the failure to a fatigue crack in the high pressure compressor well within the manufacturer’s estimated crack initiation life and appropriate revisions to risk management have followed. The main operational risk concern of the Investigation was the absence of any procedural distinction in crew emergency responses for engine fires beginning in the air or on the ground.)
  • B773, Dhaka Bangladesh, 2016 (On 7 June 2016, a GE90-115B engined Boeing 777-300 made a high speed rejected takeoff on 3200 metre-long runway 14 at Dhaka after right engine failure was annunciated at 149KCAS - just below V1. Neither crew nor ATC requested a runway inspection and 12 further aircraft movements occurred before it was closed for inspection and recovery of 14 kg of debris. The Investigation found that engine failure had followed Super Absorbent Polymer (SAP) contamination of some of the fuel nozzle valves which caused them to malfunction leading to Low Pressure Turbine (LPT) mechanical damage. The contaminant origin was not identified.)
  • B773, Tokyo Japan, 2016 (On 27 May 2016, a Boeing 777-300 crew made a high speed rejected take off when departing from Tokyo after a number one engine failure warning was quickly followed by a fire warning for the same engine and ATC advice of fire visible. As the fire warning continued with the aircraft stopped, an emergency evacuation was ordered. The Investigation found that the engine failure and fire had occurred when the 1st stage disc of the High Pressure Turbine had suddenly failed as result of undetected fatigue cracking which had propagated from an undetected disc manufacturing fault.)

... further results

Dispatch of Unserviceable Aircraft

  • A321, Fuerteventura Spain, 2016 (On 16 July 2016, an Airbus A321’s unstabilised approach at Fuerteventura during pilot line training was not discontinued and takeover of control and commencement of a go-around had occurred just before a very hard runway contact. The subsequent landing was successful but serious damage to the main landing gear was not rectified before the next flight. The Investigation found that the hard touchdown had been recorded as in excess of 3.3g and that the return flight had been “risky and unsafe” after failure of the Captain and maintenance personnel at the Operator to recognise the seriousness of the hard 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.)
  • 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.)
  • ATP, Vilhelmina Sweden, 2016 (On 6 April 2016, a BAe ATP partly left the side of the runway soon after touchdown, regaining it after 155 metres before completing its landing roll. It sustained damage rendering it unfit to continue flying but this was not noticed until five further flights had been made. Investigation attributed the excursion to lack of pilot response to unexpected beta range power and the continued flying to the aircraft Captain's failure to ensure proper event recording, accurate operator notification or a post-excursion engineering inspection of the aircraft. Systemic inadequacy in safety management and culture at the operator was identified.)
  • IL76, vicinity Karachi Pakistan, 2010 (On 27 November 2010, collateral damage to the wing of an IL-76 in the vicinity of an uncontained engine failure, which occurred soon after take-off from Karachi, led to fuel in that wing igniting. Descent from a maximum height of 600 feet occurred accompanied by a steadily increasing right bank. Just under a minute after take-off ground impact occurred and impact forces and fire destroyed the aircraft. The Investigation concluded that the engine failure was attributable to component fatigue in the LP compressor and that it would have been impossible for the crew to retain control.)
  • SH36, vicinity Edinburgh UK, 2001 (On 27 February 2001, a Loganair SD3-60 lost all power on both engines soon after take off from Edinburgh. An attempt to ditch in the Firth or Forth in rough seas resulted in the break up and sinking of the aircraft and neither pilot survived. The loss of power was attributed to the release of previously accumulated frozen deposits into the engine core when the engine anti icing systems were selected on whilst climbing through 2200 feet. These frozen deposits were considered to have accumulated whilst the aircraft had been parked prior to flight without engine intake blanks fitted.)

Maintenance FOD

  • A320, Auckland New Zealand, 2017 (On 27 October 2017, an Airbus A320 returned to Auckland after advice from ATC that the right engine may have been affected by ingestion of FOD during engine start - a clipboard and paper left just inside the right hand engine by an employee of the airline’s ground handling contractor acting as the aircraft loading supervisor. The subsequent inspection found paper throughout the engine and minor damage to an engine fan blade and the fan case attrition liner. The Dispatcher overseeing the departure said she had seen the clipboard inside the engine but assumed it would be retrieved before departure.)
  • C402, Virgin Gorda British Virgin Islands, 2017 (On 11 February 2017, a Cessna 402 failed to stop on the runway when landing at Virgin Gorda and was extensively damaged. The Investigation noted that the landing distance required was very close to that available with no safety margin so that although touchdown was normal, when the brakes failed to function properly, there was no possibility of safely rejecting the landing or stopping normally on the runway. Debris in the brake fluid was identified as causing brake system failure. The context was considered as the Operator’s inadequate maintenance practices and a likely similar deficiency in operational procedures and processes.)

In flight separation of failed component

  • A320, Singapore, 2015 (On 16 October 2015, the unlatched fan cowl doors of the left engine on an A320 fell from the aircraft during and soon after takeoff. The one which remained on the runway was not recovered for nearly an hour afterwards despite ATC awareness of engine panel loss during takeoff and as the runway remained in use, by the time it was recovered it had been reduced to small pieces. The Investigation attributed the failure to latch the cowls shut to line maintenance and the failure to detect the condition to inadequate inspection by both maintenance personnel and flight crew.)
  • AT72, Zurich Switzerland, 2014 (On 4 December 2014, directional control of an ATR 72-200 was compromised shortly after touchdown at Zurich after slightly misaligned nose wheels caused both tyres to be forced off their wheels leaving the wheel rims in direct contact with the runway surface. The Investigation found that the cause of the misalignment was the incorrect installation of a component several months earlier and the subsequent failure to identify the error. Previous examples of the same error were found and a Safety Recommendation was made that action to make the component involved less vulnerable to incorrect installation should be taken.)
  • B772, en-route, Osaka Japan, 2017 (On 23 September 2017, a large wing-to-body fairing panel confirmed to have dropped from a Boeing 777-200 passing over the centre of Osaka after takeoff off from Kansai hit and significantly damaged a moving vehicle. The Investigation found that the panel involved had a sufficient history of attachment bracket failures for Boeing to have developed an improved thicker bracket for new-build aircraft which had then been advised as available as a replacement for in-service 777-200 aircraft in a Service Letter which KLM had decided not to follow. Although some incorrect bracket attachment bolts were found, this was not considered contributory.)
  • SF34, vicinity Sydney Australia, 2017 (On 17 March 2017, uncommanded engine indications on a Saab 340B en route to Sydney were followed by vibration of the right engine after which, as the crew commenced right engine shutdown, its propeller assembly separated from the engine. A PAN was declared and the flight subsequently reached Sydney without further event. The Investigation found that the propeller gearbox shaft had fractured because of undetected internal fatigue cracking in the shaft. Applicable in-service shaft inspection procedures were found to be inadequate and mandatory enhancements to these procedures have since been introduced.)