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On 16 January 2013, an Augusta 109E helicopter positioning by day on an implied (due to adverse weather conditions) SVFR clearance collided with a crane attached to a tall building under construction. It and associated debris fell to street level and the pilot and a pedestrian were killed and several others on the ground injured. It was concluded that the pilot had not seen the crane or seen it too late to avoid whilst flying by visual reference in conditions which had become increasingly challenging. The Investigation recommended improvements in the regulatory context in which the accident had occurred.  +
On 20 April 2010, the left wing of an Antonov Design Bureau An124-100 which was taxiing in to park after a night landing at Zaragoza under marshalling guidance was in collision with two successive lighting towers on the apron. Both towers and the left wingtip of the aircraft were damaged. The subsequent investigation attributed the collision to allocation of an unsuitable stand and lack of appropriate guidance markings.  +
On 5 June 2014, an AW139 about to depart from its Ottawa home base on a positioning flight exceeded its clearance limit and began to hover taxi towards the main runway as an A300 was about to touch down on it. The TWR controller immediately instructed the helicopter to stop which it did, just clear of the runway. The A300 reached taxi speed just prior to the intersection. The Investigation attributed the error to a combination of distraction and expectancy and noted that the AW139 pilot had not checked actual or imminent runway occupancy prior to passing his clearance limit.  +
On 3 July 2010, an AW139 helicopter was climbing through 350 feet over Victoria Harbour Hong Kong just after takeoff when the tail rotor detached. A transition to autorotation was accomplished and a controlled ditching followed. All occupants were rescued but some sustained minor injuries. The failure was attributed entirely to manufacturing defects but no corrective manufacturer or regulatory action was taken until two similar accidents had occurred in Qatar (non-fatal) and Brazil (fatal) the following year and two interim Safety Recommendations were issued from this Investigation after which a comprehensive review of the manufacturing process led to numerous changes.  +
On 10 August 2014, one of the engines of an Antonov 140-100 departing Tehran Mehrabad ran down after V1 and prior to rotation. The takeoff was continued but the crew were unable to keep control and the aircraft stalled and crashed into terrain near the airport. The Investigation found that a faulty engine control unit had temporarily malfunctioned and that having taken off with an inappropriate flap setting, the crew had attempted an initial climb with a heavy aircraft without the failed engine propeller initially being feathered, with the gear remaining down and with the airspeed below V2.  +
On 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.  +
On 5 April 1996 a significant loss of separation occurred when a B744, taking off from runway 27R at London Heathrow came into conflict to the west of Heathrow Airport with an A306 which had carried out a missed approach from the parallel runway 27L. Both aircraft were following ATC instructions. Both aircraft received and correctly followed TCAS RAs, the B744 to descend and the A306 to adjust vertical speed, which were received at the same time as corrective ATC clearances.  +
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.  +
On 30 July 1997, an Airbus A300-600 being operated by Emirates Airline was departing on a scheduled passenger flight from Paris Charles de Gaulle in daylight when, as the aircraft was accelerating at 40 kts during the take off roll, it pitched up and its tail touched the ground violently. The crew abandoned the takeoff and returned to the parking area. The tail of the aircraft was damaged due to the impact with the runway when the plane pitched up.  +
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.  +
On 17 May 2015, an Airbus A300-600 crew descended their aircraft below the correct vertical profile on a visual daytime approach at Yerevan and then landed on a closed section of the runway near the displaced runway threshold. The Investigation found that the crew had failed to review relevant AIS information prior to departing from Tehran and had not been expecting anything but a normal approach and landing. The performance of the Dispatcher in respect of briefing and the First Officer in respect of failure to adequately monitor the Captain's flawed conduct of the approach was highlighted.  +
On 14 August 2013, a UPS Airbus A300-600 crashed short of the runway at Birmingham Alabama on a night IMC non-precision approach after the crew failed to go around at 1000ft aal when unstabilised and then continued descent below MDA until terrain impact. The Investigation attributed the accident to the individually poor performance of both pilots, to performance deficiencies previously-exhibited in recurrent training by the Captain and to the First Officer's failure to call in fatigued and unfit to fly after mis-managing her off duty time. A Video was produced by NTSB to further highlight human factors aspects.  +
On 12 January 2011, an Airbus A300-600 being operated by Monarch Airlines on a passenger flight from London Gatwick to Chania, Greece experienced activations of the stall protection system after an unintended configuration change shortly after take off but following recovery, the flight continued as intended without further event. There were no abrupt manoeuvres and no injuries to the 347 occupants.  +
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.  +
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.  +
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.  +
On 27 June 2000 an Airbus A300-600 being operated by American Airlines on a scheduled passenger service from London Heathrow to New York JFK was being flown manually in the day VMC climb and approaching FL220 when a loud bang was heard and there was a simultaneous abrupt disturbance to the flight path. The event appeared to the flight crew to have been a disturbance in yaw with no obvious concurrent lateral motion. Although following the disturbance, the aircraft appeared to behave normally, the aircraft commander decided to return to London Heathrow rather than commence a transatlantic flight following what was suspected to have been an un-commanded flight control input. An uneventful return was made followed by an overweight landing 50 minutes after take off.  +
On 21 February 2001, a level bust 10 nm north of Oslo Airport by a climbing PIA A310 led to loss of separation with an SAS B736 in which response to a TCAS RA by the A310 not being in accordance with its likely activation (descend). The B736 received and correctly actioned a Climb RA.  +
On 16 May 2018, an Airbus A310 and a Cessna 421 being positioned for ILS approaches to adjacent parallel runways at Montréal by different controllers lost separation. One controller incorrectly believed that he had transferred control of the Cessna to the other when the shift supervisor re-opened a sector which had been temporarily combined with his. The Investigation attributed the conflict to multiple deviations from standard procedures, memory lapses relating to controller information exchange of information and a loss of full situational awareness compounded by the shift supervisor also acting as an instructor whilst being distracted by his other duties.  +
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.  +
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.  +
On 2 March 2013, the crew of an Airbus A310 mishandled a night tailwind touchdown at Ponta Delgada after a stabilised ILS approach had been flown and, after an initial bounce, the pitch was increased significantly and the main landing gear was fully compressed during the subsequent touchdown resulting in a tail strike and substantial related structural damage. The mishandling was attributed to deviation from the recommended 'light bounce' recovery technique. The absence of an instrument approach to the reciprocal (into wind) direction of the runway was noted and a recommendation that an RNAV procedure be made available was made.  +
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.  +
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.  +
On 30 January 2000, an Airbus 310 took off from Abidjan (Ivory Coast) at night bound for Lagos, Nigeria then Nairobi, Kenya. Thirty-three seconds after take-off, the airplane crashed into the Atlantic Ocean, 1.5 nautical miles south of the runway at Abidjan Airport. 169 persons died and 10 were injured in the accident.  +
On 24 November 2006, an A310 descended significantly below cleared altitude during a radar vectored approach positioning, as a result of the flight crew's failure to set the QNH, which was unusually low.  +
On 29 June 2009, an Airbus A310-300 making a dark-night visual circling approach to Moroni crashed into the sea and was destroyed. The Investigation found that the final impact had occurred with the aircraft stalled and in the absence of appropriate prior recovery actions and that this had been immediately preceded by two separate GWPS 'PULL UP' events. It was concluded that the attempted circling procedure had been highly unstable with the crew's inappropriate actions and inactions probably attributable to their becoming progressively overwhelmed by successive warnings and alerts caused by their poor management of the aircraft's flight path.  +
On 24 September 1994, lack of understanding of automatic flight control modes, by the crew of an Airbus A-310, led to a full stall. The aircraft was recovered and subsequently landed without further event at Paris Orly.  +
On 5 March 2008, an Air Transat A310-300 was unintentionally mishandled by the flight crew during and shortly after departure from Quebec and effective control of the aircraft was temporarily lost. Whilst it was concluded that the origin of the initial difficulties in control were a result of confusion which began on the take off roll and led to a take off at excessive speed followed by subsequent mismanagement and overload, the inappropriate steep descent that followed was attributed to the effect of somatogravic illusion in respect of aircraft attitude control in conjunction with a singular focus on airspeed.  +
On 8 June 2009, an Airbus A318-100 being operated by Air France on a scheduled passenger flight from Belgrade, Serbia to Paris CDG in day VMC came into conflict with a Boeing 737-800 being operated by Ryanair on a scheduled passenger flight from Nottingham East Midlands UK to Bergamo Italy. The conflict was resolved mainly by TCAS RA response and there were no injuries to any occupants during the avoidance manoeuvres carried out by both aircraft.  +
On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.  +
On 6 December 2007 an Airbus A318 being operated by Air France on a scheduled passenger flight from Lyon to Amsterdam carried out missed approach from runway 18C at destination and lost separation in night VMC against a Boeing 737-900 being operated by KLM on a scheduled passenger flight from Amsterdam to London Heathrow which had just departed from runway 24. The conflict was resolved by correct responses to the respective coordinated TCAS RAs after which the A318 passed close behind the 737. There were no abrupt manoeuvres and none of the 104 and 195 occupants respectively on board were injured.  +
On 5 July 2012, an Airbus A319 entered its departure runway at Naha without clearance ahead of an A320 already cleared to land on the same runway. The A320 was sent around. The Investigation concluded that the A319 crew - three pilots including one with sole responsibility for radio communications and a commander supervising a trainee Captain occupying the left seat - had misunderstood their clearance and their incorrect readback had not been detected by the TWR controller. It was concluded that the controller's non-use of a headset had contributed to failure to detect the incorrect readback.  +
On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.  +
On 6 August 2011 an Easyjet Airbus A319 on which First Officer Line Training was in progress exceeded its cleared level during the climb after a different level to that correctly read back was set on the FMS. As a result, it came into conflict with an Alitalia A321 and this was resolved by responses to coordinated TCAS RAs. STCA alerts did not enable ATC resolution of the conflict and it was concluded that a lack of ATC capability to receive Mode S EHS DAPs - since rectified - was a contributory factor to the outcome.  +
On 27 June 2016, an Airbus A319 narrowly avoided a mid-air collision with an AS532 Cougar helicopter whose single transponder had failed earlier whilst conducting a local pre-delivery test flight whilst both were positioning visually as cleared to land at Marseille and after the helicopter had also temporarily disappeared from primary radar. Neither aircraft crew had detected the other prior to their tracks crossing at a similar altitude. The Investigation attributed the conflict to an inappropriate ATC response to the temporary loss of radar contact with the helicopter aggravated by inaccurate position reports and non-compliance with the aerodrome circuit altitude by the helicopter crew.  +
On 7 September 2012, the crew of an Air France Airbus A319 failed to follow their arrival clearance at destination and turned directly towards the ILS FAF and thereby into conflict with a Boeing 737-500 on an ILS approach. When instructed to turn left (and clear of the ILS) by the controller, the crew replied that they were "following standard arrival" which was not the case. As the separation between the two aircraft reduced, the controller repeated the instruction to the A319 to turn left and this was acknowledged. Minimum lateral separation was 1.7nm, sufficient to activate STCA.  +
On 23 November 2002, an A319, landing on Rwy16 at Zurich Switzerland, narrowly missed collision with a B737-600 cleared for take off on an intersecting runway.  +
On 26 May 2013, an A319 in Swiss Class 'C' airspace received a TCAS 'Level Off' RA against a 737 above after being inadvertently given an incorrect climb clearance by ATC. The opposing higher-altitude 737 began a coordinated RA climb from level flight and this triggered a second conflict with another 737 also in the cruise 1000 feet above which resulted in coordinated TCAS RAs for both these aircraft. Correct response to all RAs resulted in resolution of both conflicts after prescribed minimum separations had been breached to as low as 1.5nm when 675 feet apart vertically.  +
On 10 January 2008, an Air Canada Airbus A319 en route over the north western USA encountered unexpected sudden wake vortex turbulence from an in trail Boeing 747-400 nearly 11nm ahead to which the pilots who then responded with potentially hazardous flight control inputs which led to reversion to Alternate Control Law and aggravated the external /disturbance to the aircraft trajectory with roll up to 55° and an unintended descent of 1400 feet which with cabin service in progress and sea belt signs off led to cabin service carts hitting the cabin ceiling and several passenger injuries, some serious.  +
On 10 June 2011 an ATC error put a German Wings A319 and a Hahn Air Raytheon 390 on conflicting tracks over Switzerland and a co-ordinated TCAS RA followed. The aircraft subsequently passed in very close proximity without either sighting the other after the Hahn Air crew, contrary to Company procedures, followed an ATC descent clearance issued during their TCAS ‘Climb’ RA rather than continuing to fly the RA. The Investigation could find no explanation for this action by the experienced crew - both Hahn Air management pilots. The recorded CPA was 0.6 nm horizontally at 50 feet vertically.  +
On 5 February 2011, an Airbus A319-100 being operated by Air Berlin on a passenger flight departing Stockholm inadvertently proceeded beyond the given clearance limit for runway 19R and although it subsequently stopped before runway entry had occurred, it was by then closer to high speed departing traffic than it should have been. There was no abrupt stop and none of the 103 occupants were injured.  +
On 26 June 2017, an Airbus A319 which had just taken off from Stuttgart came into conflict in Class ‘D’ airspace with a VFR light aircraft crossing its track and when, at 1,200 feet agl, the TCAS RA to descend which resulted was followed, an EGPWS Mode 3 Alert was generated. Clear of Conflict was annunciated after 10 seconds and climb resumed. The Investigation concluded that the light aircraft pilot had failed to follow the clearance which had been accepted and had caused the flight path conflict which was resolved by the response of the A319 to the TCAS RA.  +
On 6 January 2011 an Easyjet Airbus A319 experienced the sudden onset of thick "smoke" in the cabin as the aircraft cleared the runway after landing. The aircraft was stopped and an evacuation was carried out during which one of the 52 occupants received a minor injury. The subsequent investigation attributed the occurrence to the continued use of reverse idle thrust after clearing the runway onto a little used taxiway where the quantity of de-ice fluid residue was much greater than on the runway.  +
On 8 August 2011 an Air France Airbus A319 crew failed to correctly identify the runway on which they were cleared to land off a visual approach at Casablanca and instead landed on the parallel runway. ATC, who had already cleared another aircraft to cross the same runway, did not notice until this other aircraft crew, who had noticed the apparently abnormal position of the approaching aircraft and remained clear of the runway as a precaution, advised what had happened. Investigation was hindered by the stated perception of the Air France PIC that the occurrence was not a Serious Incident.  +
On 21 September 2012, an SAS A319 which had just landed normally under the control of an experienced pilot left the paved surface when attempting to make a turn off the RET at a taxi speed greater than appropriate. The pilot was familiar with the airport layout and the misjudgement was attributed in part to the fact that the pilot involved had recently converted to their first Airbus type after a long period operating the DC9/MD80/90 series which had a different pilot eye height and was fitted with steel rather than the more modern carbon brakes.  +
On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an Airbus A319 taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.  +
On 19 June 2016, an Airbus A320 failed to follow the clearly-specified and ground-marked self-positioning exit from a regularly used gate at Ibiza and its right wing tip collided with the airbridge, damaging both it and the aircraft. The Investigation found that the crew had attempted the necessary left turn using the Operator’s ‘One Engine Taxi Departure’ procedure using the left engine but then failed to follow the marked taxi guideline by a significant margin. It was noted that there had been no other such difficulties with the same departure in the previous four years it had been in use.  +
On 30 January 2006 the Captain of an Airbus A319 inadvertently lined up and commenced a night rolling take off from Las Vegas on the runway shoulder instead of the runway centreline despite the existence of an illuminated lead on line to the centre of the runway from the taxiway access used. The aircraft was realigned at speed and the take off was completed. ATC were not advised and broken edge light debris presented a potential hazard to other aircraft until eventually found. The Investigation found that other similar events on the same runway had not been reported at all.  +
On 12 February 2007, an Airbus A319-100 being operated by British Airways on a scheduled passenger flight into London Heathrow made unintended contact in normal daylight visibility with the stationary airbridge at the arrival gate. This followed an emergency stop made after seeing hand signals from ground staff whilst following SEGS indications which appeared to suggest that there was a further 5 metres to run to the correct parking position. There was no damage to the aircraft, only minimal damage to the airbridge and there were no injuries to the aircraft occupants or any other person  +
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.  +
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.  +
On 14 February 2011, an Easyjet Airbus A319 being flown by a trainee Captain under supervision initiated a go around from below 50 feet agl after a previously stabilised approach at Luton and a very hard three point landing followed before the go around climb could be established. The investigation found that the Training Captain involved, although experienced, had only limited aircraft type experience and that, had he taken control before making a corrective sidestick input opposite to that of the trainee, it would have had the full instead of a summed effect and may have prevented hard runway contact.  +
On 10 May 2014 the crew of an Airbus A319 failed to manage their daylight non-precision approach at destination effectively and it culminated in a very hard touchdown which exceeded landing gear design criteria. The Investigation concluded that the comprehensively poor performance of both pilots during the preparation for and execution of the approach could be attributed to both their repeated failure to follow SOPs and retain adequate situational awareness and to a failure of the aircraft operator to fully deliver effective training even though both this training and its SMS met relevant regulatory requirements and guidance.  +
On 12 April 2013, an Airbus A319 landed without clearance on a runway temporarily closed for routine inspection after failing to check in with TWR following acceptance of the corresponding frequency change. Two vehicles on the runway saw the aircraft approaching on short final and successfully vacated. The Investigation concluded that the communication failure was attributable entirely to the Check Captain who was in command of the flight involved and was acting as 'Pilot Monitoring'. It was considered that the error was probably attributable to the effects of operating through the early hours during which human alertness is usually reduced.  +
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.  +
On 29 August 2019, an Airbus A319 crew used more runway than expected during a reduced thrust takeoff from Nice, although not enough to justify increasing thrust. It was subsequently found that an identical error made by both pilots when independently calculating takeoff performance data for the most limiting runway intersection had resulted in use of data for a less limiting intersection than the one eventually used. The Investigation concluded that the only guaranteed way to avoid such an error would be an automatic cross check, a system upgrade which was not possible on the particular aircraft involved.  +
On 19 July 2017, an Airbus A319 crew ignored the prescribed non-precision approach procedure for which they were cleared at Rio de Janeiro Galeão in favour of an unstabilised “dive and drive” technique in which descent was then continued for almost 200 feet below the applicable MDA and led to an EGPWS terrain proximity warning as a go around was finally commenced in IMC with a minimum recorded terrain clearance of 162 feet. The Investigation noted the comprehensive fight crew non-compliance with a series of applicable SOPs and an operational context which was conducive to this although not explicitly causal.  +
On 10 October 2016, an Airbus 319 was cleared to divert to its first alternate after failing to land off its Cat II ILS approach at Porto and obliged to land at its second alternate with less than final reserve fuel after the first alternate declined acceptance due to lack of parking capacity. The Investigation concluded that adjacent ATC Unit coordination in respect of multiple diversions was inadequate and also found that the crew had failed to adequately appraise ATC of their fuel status. It also noted that the unsuccessful approach at the intended destination had violated approach ban visibility conditions.  +
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.  +
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.  +
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.  +
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.  +
On 30 September 2018, an Airbus A319 Captain had to complete a flight into Glasgow on his own when the First Officer left the flight deck after suffering a flying-related anxiety attack. After declaring a ‘PAN’ to ATC advising that the aircraft was being operated by only one pilot, the flight was completed without further event. The Investigation found that the First Officer had been “frightened” after the same Captain had been obliged to take control during his attempted landing the previous day and had “felt increasingly nervous” during his first ‘Pilot Flying’ task since the event the previous day.  +
On 12 March 2014, an Airbus A319 left engine stopped without any apparent cause on approach to Paris CDG. The crew then started the APU which also stopped. The Investigation found that the cause was engine and APU fuel starvation caused by non-identification of a recurring intermittent malfunction in the fuel quantity indicating system because of a combination of factors including crew failure to record fuel status in line with clear instructions and an inadequate maintenance troubleshooting manual. An inadequately-written abnormal crew drill and the crew’s inadequate fuel system knowledge then resulted in the fuel crossfeed valve not being opened.  +
On 24 March 2012, an Air France Airbus A319 Captain continued descent towards destination Tunis at high speed with the landing runway in sight well beyond the point where a stabilised approach was possible. With 5nm to go, airspeed was over 100 KIAS above the applicable VApp and the aircraft was descending at over 4000fpm with flaps zero. EGPWS activations for Sink Rate, PULL UP and Too Low Terrain apparently went unnoticed but at 400 feet agl, ATC granted a crew request for a 360° turn. The subsequent approach/landing was without further event. Investigation attributed the event to “sloppy CRM”.  +
On 14 September 2010, the crew of a Sichuan Airlines Airbus A319 continued an ILS approach into Wuxi despite awareness of adverse convective weather conditions at the airport. Their inattention to automation management then led to a low energy warning and the inappropriate response to this led to the activation of flight envelope protection quickly followed by a stall warning. Inappropriate response to this was followed by loss of control and a full stall and high rate of descent from which recovery was finally achieved less than 900 feet agl.  +
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.  +
On 29 June 2010, an Easyjet Switzerland Airbus A319 inbound to Basle-Mulhouse and an Air France Airbus A319 outbound from Basle-Mulhouse lost separation after an error made by a trainee APP controller under OJTI supervision during procedural service. The outcome was made worse by the excessive rate of climb of the Air France aircraft approaching its cleared level and both an inappropriate response to an initial preventive TCAS RA and a change of track during the ensuing short sequence of RAs by the Training Captain in command of and flying the Easyjet aircraft attributed by him to his situational ‘anxiety’.  +
On 8 February 2012, a TCAS RA occurred between an Airbus A330 and an Airbus A319 both under ATC control for landing on runway 25R at Barcelona as a result of an inappropriate plan to change the sequence. The opposite direction aircraft both followed their respective RAs and minimum separation was 1.4 nm horizontally and 400 feet vertically. The Investigation noted that the use of Spanish to communicate with one aircraft and English to communicate with the other had compromised situational awareness of the crew of the latter who had also not had visual contact with the other aircraft.  +
On 8 July 2010 an Easyjet Airbus A319 on which line training was being conducted mis-set a descent level despite correctly reading it back and, after subsequently failing to notice an ATC re-iteration of the same cleared level, continued descent to 1000 feet below it in day VMC and into conflict with crossing traffic at that level, a Boeing 737. The 737 received and actioned a TCAS RA ‘CLIMB’ and the A319, which received only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.  +
On 27 May 2018, four losses of separation on final approach during use of dependent parallel landing runways occurred within 30 minutes at Madrid following a non-scheduled weather-induced runway configuration change. This continuing situation was then resolved by reverting to a single landing runway. The Investigation attributed these events to “the complex operational situation” which had prevailed following a delayed decision to change runway configuration after seven consecutive go-arounds in 10 minutes using the previous standard runway configuration. The absence of sufficient present weather information for the wider Madrid area to adequately inform ATC tactical strategy was assessed as contributory.  +
On 29 May 2012, a British Airways Airbus A320 departing Zürich and in accordance with its SID in a climbing turn received and promptly and correctly actioned a TCAS RA 'CLIMB'. The conflict which caused this was with an AW 139 also departing Zürich IFR in accordance with a SID but, as this aircraft was only equipped with a TAS to TCAS 1 standard, the crew independently determined from their TA that they should descend and did so. The conflict, in Class 'C' airspace, was attributed to inappropriate clearance issue by the TWR controller and their inappropriate separation monitoring thereafter.  +
On 15 March 2011 two Swiss International Airlines’ Airbus A320 aircraft were cleared for simultaneous take off on intersecting runways at Zurich by the same controller. As both approached the intersection at high speed, the Captain of one saw the other and immediately rejected take off from 130 knots, stopping just at the edge of the intersection shortly after the other aircraft had flown low overhead unaware of the conflict. The Investigation noted a long history of similar incidents at Zurich and concluded that systemic failure of risk management had not been addressed by the air traffic control agency involved.  +
On 25 July 2016, an Airbus A320 and an Airbus A321 both departing Barcelona and following their ATC instructions came into conflict and the collision risk was removed by the TCAS RA CLIMB response of the A320. Minimum separation was 1.2 nm laterally and 200 feet vertically with visual acquisition of the other traffic by both aircraft. The Investigation found that the controller involved had become preoccupied with an inbound traffic de-confliction task elsewhere in their sector and, after overlooking the likely effect of the different rates of climb of the aircraft, had not regarded monitoring their separation as necessary.  +
On 18 January 2012, ATC error resulted in two aircraft on procedural clearances in oceanic airspace crossing the same waypoint within an estimated 2 minutes of each other without the prescribed 1000 feet vertical separation when the prescribed minimum separation was 15 minutes unless that vertical separation existed. By the time ATC identified the loss of separation and sent a CPDLC message to the A340 to descend in order to restore separation, the crew advised that such action was already being taken. The Investigation identified various organisational deficiencies relating to the provision of procedural service by the ANSP concerned.  +
On 18 September 2017, a departing Airbus A320 was instructed to line up and wait at Yangon but not given takeoff clearance until an ATR72 was less than a minute from touchdown and the prevailing runway traffic separation standard was consequently breached. The Investigation found that the TWR controller had been a temporarily unsupervised trainee who, despite good daylight visibility, had instructed the A320 to line up and wait and then forgotten about it. When the A320 crew, aware of the approaching ATR72, reminded her, she “did not know what to do” and the trainee APP controller had to intervene.  +
On 27 May 2012, an Airbus A320 departing Barcelona was cleared by GND to taxi across an active runway on which a Boeing 737-800 was about to land. Whilst still moving but before entering the runway, the A320 crew, aware of the aircraft on approach, queried their crossing clearance but the instruction to stop was given too late to stop before crossing the unlit stop bar. The 737 was instructed to go around and there was no actual risk of collision. The Investigation attributed the controller error to lack of familiarisation with the routine runway configuration change in progress.  +
On 30 October 2014, a descending Airbus A320 came close to a Boeing 737-800 at around FL 220 after the A320 crew significantly exceeded a previously-instructed 2,000 fpm maximum rate of descent assuming it no longer applied when not reiterated during re-clearance to a lower altitude. Their response to a TCAS RA requiring descent at not above 1,000 fpm was to further increase it from 3,200 fpm. Lack of notification delayed the start of an independent Investigation but it eventually found that although the A320 TCAS equipment had been serviceable, its crew denied failing to correctly follow their initial RA.  +
On 4 June 2016, a Boeing 737-800 instructed to climb from FL340 to FL380 by the controller of one sector in Bulgarian upper airspace came into sufficiently close proximity to an Airbus A320 under the control of a different sector controller to trigger co-ordinated TCAS RAs. Separation was eventually restored after the 737 followed its RA despite the A320, which had already deviated from its clearance on the basis of a prior TCAS TA without informing ATC, ignoring their RA. The Investigation found that the root cause of the conflict had been inadequate coordination between two vertically separated ATC sectors.  +
On 6 July 2018, a Boeing 737-800 being positioned to join the intermediate approach sequence in the Barcelona CTR was obliged to take lateral avoiding action against an Airbus A320 ahead. The Investigation found that although both aircraft were in the same sector at the time, the controller had overlooked the presence of the A320 which had been transferred to the next sector before entering it prior to the controller involved routinely taking over the position. An on-screen alert to the developing conflict had not been seen by the controller. Minimum separation was 1.1nm laterally and 200 feet vertically.  +
On 30 January 2016, an Airbus A320 crew cleared for an ILS approach to runway 11 at Delhi reported established on the runway 11 LLZ but were actually on the runway 09 LLZ in error and continued on that ILS finally crossing in front of a Boeing 737-800 on the ILS for runway 10. The Investigation found that the A320 crew had not noticed they had the wrong ILS frequency set and that conflict with the 737 occurred because Approach transferred the A320 to TWR whilst a conflict alert was active and without confirming it was complying with its clearance.  +
On 22 April 2012, an Airbus A320 and a Boeing 737 came into close proximity near Dubai whilst on the same ATC frequency and correctly following their ATC clearances shortly after they had departed at night from Sharjah and Dubai respectively. The Investigation found that correct response by both aircraft to coordinated TCAS RAs eliminated any risk of collision. The fact that the controller involved had only just taken over the radar position involved and was only working the two aircraft in conflict was noted, as was the absence of STCA at the unit due to set up difficulties.  +
On 1 May 2008 an Airbus A320-200 being operated by JetStar on a scheduled passenger flight from Melbourne to Launceston, Tasmania was making a missed approach from runway 32L when it came into close proximity in night VMC with a Boeing 737-800 being operated by Virgin Blue and also inbound to Launceston from Melbourne which was manoeuvring about 5nm north west of the airport after carrying out a similar missed approach. Minimum separation was 3 nm at the same altitude and the situation was fully resolved by the A320 climbing to 4000 feet.  +
On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.  +
On 7 July 2017 the crew of an Airbus A320, cleared for an approach and landing on runway 28R at San Francisco in night VMC, lined up for the visual approach for which it had been cleared on the occupied parallel taxiway instead of the runway extended centreline and only commenced a go-around at the very last minute, having descended to about 60 feet agl whilst flying over two of the four aircraft on the taxiway. The Investigation determined that the sole direct cause of the event was the poor performance of the A320 flight crew.  +
On 17 August 2012, a Swiss A320 being positioned under radar vectors for arrival at Geneva was inadvertently vectored into conflict with a Cessna Citation already established on the ILS LOC for runway 23 at Geneva. Controller training was in progress and the Instructor had just taken control because of concerns at the actions of the Trainee. An error by the Instructor was recognised and de-confliction instructions were given but a co-ordinated TCAS RA still subsequently occurred. STCA was activated but constraints on access to both visual and aural modes of the system served to diminish its value.  +
On 10 July 2014, the crew of a Bombardier CRJ200 on a visual go around from an approach to runway 26 at Port Elizabeth took visual avoiding action overhead of the aerodrome to ensure safe separation from an Airbus A320 which had just taken off. Both aircraft also received TCAS RAs. Minimum achieved separation from radar was 370 metres laterally and 263 feet vertically. The Investigation noted that the go around resulted from the TWR controller, who was supervising a student controller, clearing the A320 to enter the runway and take off when the CRJ200 was on short final to land.  +
On 13 April 2007 in day VMC, an Air France A320 departing Sofia lined up contrary to an ATC Instruction to remain at the holding point and be ready immediate. The controller did not immediately notice and after subsequently giving a landing clearance for the same runway, was obliged to cancel it send the approaching aircraft around. An Investigation attributed the incursion to both the incorrect terminology used by TWR and the failure to challenge the incomplete clearance read back by the A320 crew.  +
On 27 September 2019, an Airbus A320 and an Embraer 145 both inbound to Barcelona and being positioned for the same Transition for runway 25R lost separation and received and followed coordinated TCAS RAs after which the closest point of approach was 0.8nm laterally when 200 feet vertically apart. The Investigation found that the experienced controller involved had initially created the conflict whilst seeking to resolve another potential conflict between one of the aircraft and a third aircraft inbound for the same Transition and having identified it had then implemented a faulty recovery plan and executed it improperly.  +
On 23 February 2018, an Embraer 195LR and an Airbus A320 on SIDs departing Brussels lost separation after the 195 was given a radar heading to resolve a perceived third aircraft conflict which led to loss of separation between the two departing aircraft. STCA and coordinated TCAS RA activations followed but only one TCAS RA was followed and the estimated minimum separation was 400 feet vertically when 1.36 nm apart. The Investigation found that conflict followed an error by an OJTI-supervised trainee controller receiving extended revalidation training despite gaining his licence and having almost 10 years similar experience in Latvia.  +
On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.  +
On 6 April 2015, the crew of an A320 under radar control in Class E airspace and approaching 4000 feet made a very late sighting of a glider being flown by a student pilot which appeared ahead at a similar altitude. The glider pilot reported having seen a 'cone of light' coming towards him. Both aircraft took avoiding action as practicable and passed within a recorded 450 metres with the A320 passing an estimated 250 feet over the glider. The glider was not fitted with a transponder and was not required to be, and the controller had only secondary radar.  +
On 12 February 2019, an Airbus A320 under the command of a Captain reportedly undergoing line training supervised by a Training Captain occupying the supernumerary crew seat was slow to follow ATC instructions after breaking off from an unstabilised approach at London Stansted caused by the First Officer’s mismanagement of the approach and lost separation at night as it crossed approximately 600 feet above a Saab 340B climbing after takeoff. The Investigation found that flight crew workload had been exacerbated after the Captain under supervision unnecessarily delayed taking over control and had then not done so in the prescribed way.  +
On 2 December 2016, the crew of an Airbus A320 passing 100 knots on takeoff at Calgary saw another aircraft crossing an intersection ahead but continued because they considered that, as the other aircraft was already more than half way across, it would be clear before they reached that point. The Investigation found that the GND Controller had cleared the other aircraft to cross after forgetting that the runway was active and under TWR control. It was concluded that the response of the ANSP SMS process to a history of identical controller errors and related reports had been inadequate.  +
On 3 February 2018, a runway inspection vehicle was cleared onto the active runway at London Gatwick ahead of an aircraft which had just touched down and driven towards it having been cleared to do so because the aircraft crew’s confirmation that they would clear the runway before reaching the vehicle was considered by the controller as a clearance limit. The Investigation found that the associated runway inspection procedure had not been adequately risk-assessed and noted that many issues raised by it had still not been addressed by the time it was completed eighteen months later.  +
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.  +
On 29 March 2006, an Eirjet Airbus 320 was operating a scheduled passenger flight from Liverpool to Londonderry Airport in Northern Ireland for Ryanair in daylight. At 8nm from LDY, the operating crew reported that they were having problems with the ILS glideslope on approach to Runway 26. They judged that they were too high to carry out a safe landing from the ILS approach and requested permission from ATC to carry out a visual approach. The aircraft, with the commander as PF, then flew a right hand descending orbit followed by a visual circuit from which it landed. Upon landing, the crew were advised by Londonderry ATC, who had had the aircraft in sight when it called Finals and had then cleared it to land that they had, in fact, landed at Ballykelly airfield, a military helicopter base 5nm to the east-north-east of Londonderry.  +
On 6 October 2014, an A320 crew requested, accepted and commenced an intersection takeoff at Basel using reduced thrust performance data based on the originally anticipated full length takeoff which would have given 65% more TODA. Recognition of the error and application of TOGA allowed the aircraft to get airborne just before the runway end but the Investigation found that a rejected take off from high speed would have resulted in an overrun and noted that despite changes to crew procedures after a similar event involving the same operator a year earlier, the relevant procedures were still conducive to error.  +
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.  +
On 8 April 2015, an Airbus A320 crew lost their previously-acquired and required visual reference for the intended landing runway at Brasilia but continued descent in heavy rain and delayed beginning a go around until the aircraft was only 40 feet above the runway threshold but had not reached it. A premature touchdown prior to the runway then occurred and the aircraft travelled over 30 metres on the ground before becoming airborne again. The Investigation was unable to establish any explanation for the failure to begin a go around once sufficient visual reference was no longer available.  +
On 23 March 2019, the crew of a fully-loaded Airbus A320 about to depart Bristol detected an abnormal noise from the nose landing gear as a towbarless tug was being attached. Inspection found that the aircraft nose gear had been impact-damaged rendering the aircraft no longer airworthy and the passengers were disembarked. The Investigation noted that tug driver training had been in progress and that the tug had not been correctly aligned with the nose wheels, possibly due to a momentary lapse in concentration causing the tug being aligned with the nose leg rather than the nose wheels.  +
On 7 July 2014, an Airbus A320 landing at Brunei departed the side of the runway almost immediately after touchdown and continued to gradually diverge from the runway axis until stopping after a ground run of approximately 1,050 metres. The Investigation concluded that the aircraft commander, having taken over control from the First Officer when the latter lost their previously-acquired prescribed visual reference below Decision Altitude due to a sudden-onset intense rain shower ahead, had then continued the approach without recognising that the only lights still visible to him were those at the right hand edge of the runway.  +
On 20 June 2019, an Airbus A320 about to touchdown at night at Calicut drifted to the right once over the runway when the rain intensity suddenly increased and briefly left the runway before regaining it and completing the landing and taxi in. Runway edge lighting and the two main gear tyres were damaged. The Investigation attributed the excursion to loss of enough visual reference to maintain the centreline until touchdown followed by late recognition of the deviation and delayed response to it. The visibility reduction was considered to have created circumstances in which a go-around would have been advisable.  +
On 29 August 2011, an Airbus A320 which had up to that point made a stabilised auto ILS approach at destination deviated from the runway centreline below 200 feet aal but continued to a night touchdown which occurred on the edge of the 3400 metre runway and was followed by exit from the side onto soft ground before eventually coming to a stop adjacent to the runway about a third of the way along it. The subsequent investigation attributed the event to poor crew performance in reduced visibility  +
On 27 September 2017, an Airbus A320 being manoeuvred off the departure gate at Dublin by tug was being pulled forward when the tow bar shear pin broke and the tug driver lost control. The tug then collided with the right engine causing significant damage. The tug driver and assisting ground crew were not injured. The Investigation concluded that although the shear pin failure was not attributable to any particular cause, the relative severity of the outcome was probably increased by the wet surface, a forward slope on the ramp and fact that an engine start was in progress.  +
On 18 December 2017, an A320 crew found that only one thrust reverser deployed when the reversers were selected shortly after touchdown but were able to retain directional control. The Investigation found that the aircraft had been released to service in Adelaide with the affected engine reverser lockout pin in place. This error was found to have occurred in a context of multiple failures to follow required procedures during the line maintenance intervention involved for which no mitigating factors of any significance could be identified. A corrective action after a previous similar event at the same maintenance facility was also found not to have been fully implemented.  +
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.  +
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.  +
On 25 November 2004, a MyTravel Airways Airbus A320 departed the side of the runway at Harstad, Norway at a low speed after loss of directional control when thrust was applied for a night take off on a runway with below normal surface friction characteristics. It was found that the crew had failed to follow an SOP designed to ensure that any accumulated fan ice was shed prior to take off and also failed to apply take off thrust as prescribed, thus delaying their appreciation of the uneven thrust produced.  +
On 14 April 2015, a night RNAV(GNSS) approach to Hiroshima by an Airbus A320 was continued below minima without the prescribed visual reference and subsequently touched down 325 metres before the runway after failing to transition to a go around initiated from a very low height. The aircraft hit a permitted ground installation, then slid onto the runway before veering off it and stopping. The aircraft sustained extensive damage and an emergency evacuation followed with 28 of the 81 occupants sustaining minor injuries. The Investigation noted the unchallenged gross violation of minima by the Captain.  +
On 5 January 2014, an Airbus A320 was unable to land at Delhi due to visibility below crew minima and during subsequent diversion to Jaipur, visibility there began to deteriorate rapidly. A Cat I ILS approach was continued below minima without any visual reference because there were no other alternates within the then-prevailing fuel endurance. The landing which followed was made in almost zero visibility and the aircraft sustained substantial damage after touching down to the left of the runway. The Investigation found that the other possible alternate on departure from Delhi had materially better weather but had been ignored.  +
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.  +
On 19 May 2015, an Airbus A319 crew attempted to taxi into a nose-in parking position at Lisbon despite the fact that the APIS, although switched on, was clearly malfunctioning whilst not displaying an unequivocal ‘STOP’. The aircraft continued 6 metres past the applicable apron ground marking by which time it had hit the airbridge. The marshaller in attendance to oversee the arrival did not signal the aircraft or manually select the APIS ‘STOP’ instruction. The APIS had failed to detect the dark-liveried aircraft and the non-display of a steady ‘STOP’ indication was independently attributed to a pre-existing system fault.  +
On 16 September 2019, an Airbus A320 departing Lisbon only became airborne 110 metres before the end of runway 21 and had a high speed rejected takeoff been required, it was likely to have overrun the runway. The Investigation found that both pilots had inadvertently calculated reduced thrust takeoff performance using the full 3705 metre runway length and then failed to identify their error before FMS entry. They also did not increase the thrust to TOGA on realising that the runway end was fast approaching. This was the operator’s third almost identical event at Lisbon in less than five months.  +
On 26 June 2006, after an uneventful pre-flight pushback of a British Airways Airbus A320-200 at London Heathrow Airport, the aircraft started moving under its own power and, shortly afterwards, collided with the tractor that had just performed the pushback, damaging both the right engine and the tractor.  +
On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.  +
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.  +
On 28 August 2018, an Airbus A320 bounced touchdown in apparently benign conditions resulted in nose gear damage and debris ingestion into both engines, in one case sufficient to significantly reduce thrust. The gear could not be raised at go around and height loss with EGPWS and STALL warnings occurred when the malfunctioning engine was briefly set to idle. Recovery was followed by a MAYDAY diversion to Shenzen and an emergency evacuation. The Investigation attributed the initial hard touchdown to un-forecast severe very low level wind shear and most of the damage to the negative pitch attitude during the second post-bounce touchdown.  +
On 12 November 2018, an Airbus A320 took off from Macau in good daylight visibility whilst a same-direction runway inspection was in progress but became airborne well before reaching it. The conflict was not recognised until an aural conflict alert was activated, at which point the ATC Assistant took the microphone and instructed the vehicle to clear the runway. The Investigation found that the TWR Controller had forgotten that the vehicle was still on the runway until alerted by the audible alarm and had not checked either the flight progress board or the surface radar before issuing the takeoff clearance.  +
On 7 September 2018, an Airbus A320 was inadvertently landed on an under- construction runway at Malé in daylight VMC but met no significant obstructions and sustained only minor damage. The Investigation attributed the error to confusion generated by a combination of pilot inattention to clearly relevant notification, controller distraction, the failure of the airport operator to follow required procedures and the failure of the safety regulator to ensure that sufficient arrangements to ensure safety were in place and complied with.  +
On 25 February 2010, an Aeroflot Airbus A320-200 unintentionally made a daylight take off from Oslo in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation identified contributory factors attributable to the airline, the airport and the ANSP.  +
On 12 March 2013, a Tunis Air Airbus A320 landed on runway 08 at Paris Orly and, having slowed to just over 40 knots, were expecting, despite the covering of dry snow and some slush pre-notified and found on the runway, to vacate it without difficulty at the mid point. ATC then requested that the aircraft roll to the end of the runway before clearing. However, after a slight increase in speed, the crew were unable to subsequently slow the aircraft as the runway end approached and it overran at a low groundspeed before coming to a stop 4 seconds later.  +
On 14 August 2018, an Airbus A320 departed Perth without full removal of its main landing gear ground locks and the unsecured components fell unseen from the aircraft during taxi and takeoff, only being recovered after runway FOD reports. The Investigation identified multiple contributory factors including an inadequately-overseen recent transfer of despatch responsibilities, the absence of adequate ground lock use procedures, the absence of required metal lanyards linking the locking components not attached directly to each gear leg flag (as also found on other company aircraft) and pilot failure to confirm that all components were in the flight deck stowage.  +
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.  +
On 1 October 2013, an Airbus A320 took off from a runway intersection at Porto which provided 1900 metres TORA using take off thrust that had been calculated for the full runway length of 3480 metres TORA. It became airborne 350 metres prior to the end of the runway but the subsequent Investigation concluded that it would not have been able to safely reject the take-off or continue it, had an engine failed at high speed. The event was attributed to distraction and the inappropriate formulation of the operating airline's procedures for the pre take-off phase of flight.  +
On 1 December 2017, an Airbus A320 made an unintentional - and unrecognised - hard landing at Pristina. As the automated system for alerting outside-limits hard landings was only partially configured and output from the sole available channel was not available, the aircraft continued in service for a further eight sectors before an exceedance was confirmed and the aircraft grounded. The Investigation noted that whilst the aircraft Captain is responsible for recording potential hard landings, the aircraft operator involved should ensure that at least one of the available automated alerting channels is always functional in support of crew subjective judgement.  +
On 14 December 2016, an Airbus A320 made a 2.5g initial runway contact when landing at Raipur after the trainee First Officer failed to flare the aircraft adequately and the Training Captain took over too late to prevent a bounce followed by a 3.2g final touchdown. The Investigation found that despite the Training Captain’s diligent coaching, the First Officer had failed to respond during the final stages of the approach and that the takeover of control should have occurred earlier so that the mishandled final stage of the approach could have been discontinued and go around flown.  +
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.  +
On 4 October 2017, an Airbus A320 slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.  +
On 30 September 2017, an Airbus A320 touched down late after an ILS approach to runway 32 at Sylt with a significant tailwind component being reported and failed to stop before overrunning the end of the runway and subsequently stopped on grass 80 metres beyond it. The Investigation noted that the calculated required landing distance was close to the landing distance available, the actual approach speed was 20 knots above the calculated one and that the aircraft had floated in the flare above a wet runway. It was concluded that the runway excursion was attributable to non-performance of a go-around.  +
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.  +
On 13 August 2016, an Airbus A320 departed the side of the runway at low speed during takeoff from Tehran Mehrabad and became immobilised in soft ground. The Investigation found that the Captain had not ensured that both engines were simultaneously stabilised before completing the setting of takeoff thrust and that his subsequent response to the resulting directional control difficulties had been inappropriate and decision to reject the takeoff too late to prevent the excursion. Poor CRM on the flight deck was identified as including but not limited to the First Officer’s early call to reject the takeoff being ignored.  +
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.  +
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.  +
On 31 January 2010, an Airbus A320-200 being operated by the Canadian Airline Skyservice on a passenger flight from Toronto Canada to Varadero Cuba made a procedural night ILS approach to destination in heavy rain and, soon after touchdown on a flooded runway, drifted off the side and travelled parallel to it for a little over 500 metres before subsequently re-entering it at low speed. There were no injuries to the 186 occupants and the aircraft sustained only minor damage.  +
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.  +
On 24 March 2015, after waiting for the Captain to leave the flight deck and preventing his return, a Germanwings A320 First Officer put his aircraft into a continuous descent from FL380 into terrain killing all 150 occupants. Investigation concluded the motive was suicide, noted a history of mental illness dating from before qualification as a pilot and found that prior to the crash he had been "experiencing mental disorder with psychotic symptoms" which had not been detected through the applicable "process for medical certification of pilots". Conflict between the principles of medical confidentiality and wider public interest was identified.  +
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.  +
On 21 October 2009, an Airbus 320-200 being operated by Northwest Airlines on a scheduled passenger flight from San Diego to Minneapolis-St Paul, with the Captain as PF, overflew its destination at cruise level in VMC at night by more than 100 nm, after the two pilots had become distracted in conversation and lost situational awareness. They failed to maintain radio communications with a series of successive ATC units for well over an hour. After a routine inquiry from the cabin crew as to the expected arrival time, the flight crew realised what had happened and re-established ATC contact after which the flight was completed without further incident.  +
On 2 March 2009, communication difficulties and inadequate operator procedures led to an Airbus A320-200 being de-iced inappropriately prior to departure from Vasteras and fumes entered the air conditioning system via the APU. Although steps were then taken before departure in an attempt to clear the contamination, it returned once airborne. The flight crew decided to don their oxygen masks and complete the flight to Poznan. Similar fumes in the passenger cabin led to only temporary effects which were alleviated by the use of therapeutic oxygen. The Investigation concluded that no health risks arose from exposure to the fumes involved.  +
On 28 May 2006, a Vueling Airbus A320 encountered sudden significant turbulence at FL325 and, during a temporary loss of control, was forced down to FL310 before recovery was achieved. Seven occupants sustained minor injuries and there was some internal damage caused by an unrestrained cabin service cart. The origin of the disturbance was found to have been wake vortices from an Airbus A340-300 which was 10nm ahead and 500 feet above on the same airway but the Investigation found that the crew response had been inappropriate and could have served to exacerbate the effects of the external disturbance.  +
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.  +
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.  +
On 27 August 2018, an Airbus A320 level at FL 300 encountered unanticipated turbulence which caused one of the cabin crew to fall and sustain what was belatedly diagnosed as spinal fracture. The Investigation found that the aircraft had flown through the decaying wake vortex from an almost opposite direction Boeing 747-400F at FL310 which had been observed to cross what was subsequently found to be 13.8 nm ahead of the A320 prior to the latter crossing its track 1 minute 40 seconds later that coincided with a very brief period in which vertical acceleration varied between +0.19g and +1.39g.  +
On 17 November 2017, an Airbus A320 flight crew were both partially incapacitated by the effect of fumes described as acrid and stinging which they detected when following another smaller aircraft to the holding point at Geneva and then waiting in line behind it before taking off, the effect of which rapidly worsened en-route and necessitated a precautionary diversion to Marseilles. The very thorough subsequent Investigation was unable to determine the origin or nature of the fumes encountered but circumstantial evidence pointed tentatively towards ingestion of engine exhaust from the aircraft ahead in one or both A320 engines.  +
On 7 September 2012, the crew of an Aer Lingus Airbus A320-200 mis-set their descent clearance. When discovering this as the actual cleared level was being approached, the AP was disconnected and the unduly abrupt control input made led to an injury to one of the cabin crew. The original error was attributed to ineffective flight deck monitoring and the inappropriate corrective control input to insufficient appreciation of the aerodynamic handling aspects of flight at high altitude. A Safety Recommendation to the Operator to review relevant aspects of its flight crew training was made.  +
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.  +
On 21 February 2017, an Airbus A320 despatched with the APU inoperative experienced successive failures of both air conditioning and pressurisation systems, the second of which occurred at FL300 and prompted the declaration of a MAYDAY and an emergency descent followed by an uneventful diversion to Alicante. The Investigation found that the cause of the dual failure was likely to have been the undetectable and undetected degradation of the aircraft bleed air regulation system and whilst noting a possibly contributory maintenance error recommended that a new scheduled maintenance task to check components in the aircraft type bleed system be established.  +
On 5 March 2018, the crew of an Airbus A320 in descent towards Karachi observed a slow but continuous drop in cabin pressure which eventually triggered an excessive cabin altitude warning which led them to don oxygen masks, commence an emergency descent and declare a PAN to ATC until the situation had been normalised. The Investigation found that the cause was the processing of internally corrupted data in the active cabin pressure controller which had used a landing field elevation of over 10,000 feet. It noted that Airbus is developing a modified controller that will prevent erroneous data calculations occurring.  +
On 16 November 2012, Captain of an A320 positioning for approach to Abu Dhabi at night became incapacitated due to a stroke. The First Officer took over control and declared a MAYDAY to ATC. The subsequent approach and landing were uneventful but since the First Officer was not authorised to taxi the aircraft, it was towed to the gate for passenger disembarkation. The investigation found that the Captain had an undiagnosed medical condition which predisposed him towards the formation of blood clots in arteries and veins.  +
On 31 March 2003, an A320, operated by British Mediterranean AW, narrowly missed colliding with terrain during a non-precision approach to Addis Ababa, Ethiopia.  +
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.  +
On 23 August 2000, a Gulf Air Airbus A320 flew at speed into the sea during an intended dark night go around at Bahrain and all 143 occupants were killed. It was subsequently concluded that, although a number of factors created the scenario in which the accident could occur, the most plausible explanation for both the descent and the failure to recover from it was the focus on the airspeed indication at the expense of the ADI and the effect of somatogravic illusion on the recently promoted Captain which went unchallenged by his low-experience First Officer.  +
On 26 August 2019, an Airbus A320 attempted two autopilot-engaged non-precision approaches at Birmingham in good weather before a third one was successful. Both were commenced late and continued when unstable prior to eventual go-arounds, for one of which the aircraft was mis-configured causing an ‘Alpha Floor’ protection activation. A third non-precision approach was then completed without further event. The Investigation noted an almost identical event involving the same operator four months later, observing that all three discontinued approaches appeared to have originated in confusion arising from a slight difference between the procedures of the aircraft operator and AIP plates.  +
On 21 June 2017, an Airbus A320 number 2 engine began vibrating during the takeoff roll at Delhi after a bird strike. After continuing the takeoff, the Captain subsequently shut down the serviceable engine and set the malfunctioning one to TO/GA and it was several minutes before the error was recognised. After an attempted number 1 engine restart failed because an incorrect procedure was followed, a second attempt succeeded. By this time inattention to airspeed loss had led to ALPHA floor protection activation. Eventual recovery was followed by a return to land with the malfunctioning engine at flight idle.  +
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.  +
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.  +
An Airbus A322 being operated by British Airways on a scheduled passenger flight from London Heathrow to Glasgow was being radar vectored in day IMC towards an ILS approach to runway 23 at destination when an EGPWS Mode 2 Hard Warning was received and the prescribed response promptly initiated by the flight crew with a climb to MSA.  +
On 27 February 2016, an Airbus A320 making an into-sun visual approach to Jaipur in hazy conditions lined up on a road parallel to the intended landing runway and continued descent until an EGPWS ‘TOO LOW TERRAIN’ Alert occurred at 200 feet agl upon which a go-around was initiated. The Investigation found that although the First Officer had gained visual reference with both road and runway at 500 feet agl, the Captain had seen only the road and continued asking the First Officer to continue descent towards it despite the First Officer’s attempts to alert him to his error.  +
On 22 May 2020, an Airbus A320 made an extremely high speed unstabilised ILS approach to runway 25L at Karachi and did not extend the landing gear for touchdown. It continued along the runway resting on both engines before getting airborne again with the crew announcing their intention to make another approach. Unfortunately, both engines failed due to the damage sustained and the aircraft crashed in a residential area near the airport and was destroyed by impact forces and a post-crash fire. 97 of the 99 occupants died and four persons on the ground were injured with one subsequently dying.  +
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.  +
On 24 June 2018, the Captain of an Airbus A320 which had just departed Liverpool inadvertently selected flaps/slats up when “gear up” was called. The error was quickly recognised and corrective action taken but the Investigation was unable to determine why the error occurred or identify circumstances directly conducive to it. It noted that they had previously investigated four similar events to the same operator’s A320s which had occurred over a period of less than 18 months with the operator introducing a requirement for a “pause” before gear or flap selection to allow time for positive checking before selector movement.  +
On 23 September 2019, the flight crew of an Airbus A320 on approach to London Heathrow detected strong acrid fumes on the flight deck and after donning oxygen masks completed the approach and landing, exited the runway and shut down on a taxiway. After removing their masks, one pilot became incapacitated and the other unwell and both were taken to hospital. The other occupants, all unaffected, were disembarked to buses. The very comprehensive investigation was unable to establish the origin of the fumes but did identify a number of circumstantial factors which corresponded to those identified in previous similar events.  +
On 11 April 2012, a Hermes Airlines A320 commanded by a Training Captain who was also in charge of Air Operations for the airline was supervising a trainee Captain on a night passenger flight. The aircraft failed to establish on the Lyons ILS and, in IMC, descended sufficiently to activate both MSAW and EGPWS 'PULL UP' warnings which eventually prompted recovery. The Investigation concluded that application of both normal and emergency procedures had been inadequate and had led to highly degraded situational awareness for both pilots. The context for this was assessed as poor operational management at the airline.  +
On 21 July 2007, an Airbus A320-232 being operated by Australian Operator Jetstar Airways and on final approach to Melbourne after a passenger flight from Christchurch, New Zealand intended to make a go around after the required visual reference at Decision Altitude was not available, but the intended action was mis-managed such that safe control of the aircraft was temporarily lost. Recovery was achieved and there were no further abnormalities of flight during a second missed approach at Melbourne or the subsequent diversion to Avalon.  +
On 28 April 2014, an Airbus A320 making a precision radar approach at Naha in IMC began descent from 1,000 feet QNH at 6nm from touchdown with the autopilot engaged and continued it until successive EGPWS 'PULL UP' Warnings occurred soon after the radar controller had advised four miles from touchdown. Minimum recorded radio height was 242 feet with neither the sea nor the runway in sight. The Investigation noted ineffective alerting by the First Officer, the radar controller's failure to notice the error until just before the EGPWS Warnings and the absence of MSAW annunciations at the controller's position.  +
On 10 February 2007, smoke was observed coming from an overhead locker on an Airbus A320 which had just departed from New York JFK. It was successfully dealt by cabin crew fire extinguisher use whilst an emergency was declared and a precautionary air turn back made with the aircraft back on the ground six minutes later. The subsequent investigation attributed the fire to a short circuit of unexplained origin in one of a number of spare lithium batteries contained in a passenger's camera case, some packaged an some loose which had led to three of then sustaining fire damage.  +
On 19 December 2008, an Aeroflot Airbus A320 descended significantly below its cleared and acknowledged altitude after the crew lost situational awareness at night whilst attempting to establish on the ILS at Oslo from an extreme intercept track after a late runway change and an unchallenged incorrect readback. The Investigation concluded that the response to the EGPWS warning which resulted had been “late and slow” but that the risk of CFIT was “present but not imminent”. The context for the event was considered to have been poor communications between ATC and the aircraft in respect of changes of landing runway.  +
On 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.  +
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.  +
On 7 July 2016, an Airbus A320 crew cleared for a dusk visual approach to Rapid City mis-identified runway 13 at Ellsworth AFB as runway 14 at their intended destination and landed on it after recognising their error just before touchdown. The Investigation concluded that the crew had failed to use the available instrument approach guidance to ensure their final approach was made on the correct extended centreline and noted that it had only been possible to complete the wrong approach by flying an abnormally steep unstabilised final approach. Neither pilot was familiar with Rapid City Airport.  +
On 3 May 2006, an Airbus 320 crew failed to correctly fly a night IMC go around at Sochi and the aircraft crashed into the sea and was destroyed. The Investigation found that the crew failed to reconfigure the aircraft for the go around and, after having difficulties with the performance of an auto go-around, had disconnected the autopilot. Inappropriate control inputs, including simultaneous (summed) sidestick inputs by both pilots were followed by an EGPWS PULL UP Warning. There was no recovery and about a minute into the go around, a steep descent into the sea at 285 knots occurred.  +
On 28 February 2018, an Airbus A320 would not rotate for a touch-and-go takeoff and flightpath control remained temporarily problematic and the aircraft briefly settled back onto the runway with the gear in transit damaging both engines. A very steep climb was then followed by an equally steep descent to 600 feet agl with an EGPWS ‘PULL UP’ activation before recovery. Pitch control was regained using manual stabiliser trim but after both engines stopped during a MAYDAY turnback, an undershoot touchdown followed. The root cause of loss of primary pitch control was determined as unapproved oil in the stabiliser actuator.  +
On 3 April 2012, the crew of an Air France Airbus A320 came close to loosing control of their aircraft after accepting, inadequately preparing for and comprehensively mismanaging it during an RNAV VISUAL approach at Tel Aviv and during the subsequent attempt at a missed approach. The Investigation identified significant issues with crew understanding of automation - especially in respect of both the use of FMS modes and operations with the AP off but the A/T on - and highlighted the inadequate provision by the aircraft operator of both procedures and pilot training for this type of approach.  +
On 22 December 2016, an Airbus A320 cleared for a night approach to runway 16L at Haneda, which involved circling to the right from an initial VOR approach, instead turned left and began an approach to a closed but partially lit runway. ATC noticed and intervened to require a climb away for repositioning to the correct runway using radar vectors. The Investigation found that the context for the crew’s visual positioning error was their failure to adequately prepare for the approach before commencing it and that the new-on-type First Officer had not challenged the experienced Captain’s inappropriate actions and inactions.  +
On 4 August 2012 an Easyjet Airbus A320 on approach to London Gatwick was given landing clearance in IMC for a runway occupied by a Boeing 737-400 waiting for take off which heard this transmission. Despite normal ground visibility and an unrestricted view of the runway, ATC failed to recognise their error and, after two unsuccessful attempts to advise them of it, the commander of the 737 instructed the A320 to go around which it did. Only upon hearing this did the controller realise what had happened.  +
On 2 September 2013, a B737 crew were not instructed to go around from their approach by ATC as it became increasingly obvious that an A320 departing the same runway would not be airborne in time for a landing clearance to be issued. They initiated a go around over the threshold and then twice came into conflict with the A320 as both climbed on similar tracks without ATC de-confliction, initially below the height where TCAS RAs are functional. Investigation attributed the conflict to ATC but the failure to effectively deal with the consequences jointly to ATC and both aircraft crews.  +
On March 20 2012 a Ural Airlines Airbus A320 failed to taxi as instructed after vacating the landing runway 12L at Dubai and crossed the lit stop bar of an intersection access to runway 12R before stopping just in time to prevent a collision with a Boeing 777-300ER about to pass the intersection at very high speed on take off. Taxi clearance had been correctly given and acknowledged. The aircraft commander had extensive aircraft type experience but the inexperienced First Officer appeared to be undergoing early stage line training with a Safety Pilot present. The Investigation is continuing.  +
On 6 February 2013, ATC mismanagement of an Airbus A320 instructed to go around resulted in loss of separation in IMC against the Embraer 190 ahead which was obliged to initiate a go around when no landing clearance had been issued due to a Boeing 737-800 still on the runway after landing. Further ATC mismanagement then resulted in a second IMC loss of separation between the Embraer 190 and a Boeing 717 which had just take off from the parallel runway. Controller response to the STCA Alerts generated was found to be inadequate and ANSP procedures in need of improvement.  +
On 25 November 2015, an Airbus A321 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 737 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. On reaching the lit stop bar protecting the runway, the crew queried their clearance and were told to hold position. Noting that the event had occurred at the time of a routine twice-daily runway configuration change and two previous very similar events in 2012 and 2014, further safety recommendations on risk management of runway configuration change were made.  +
On 21 May 2011, a Monarch Airlines A321 taxiing for departure at Dublin inadvertently taxied onto an active runway after failing to follow its taxi clearance. The incursion was not noticed by ATC but the crew of a Boeing 737 taking off from the same runway did see the other aircraft and initiated a very high speed rejected take off stopping 360 metres from it. The incursion occurred in a complex manoeuvring area to a crew unfamiliar with the airport at a location which was not a designated hot spot. Various mitigations against incursions at this position have since been implemented.  +
On 8 September 2016, an Airbus A321 en route in Bulgarian airspace at FL 350 was given and acknowledged a descent but then climbed and came within 1.2nm of a descending Boeing 737. The Investigation found that the inexperienced A321 First Officer had been temporarily alone when the instruction was given and had insufficient understanding of how to control the aircraft. It was also found that despite an STCA activation of the collision risk, the controller, influenced by a Mode ‘S’ downlink of the correctly-set A321 cleared altitude, had then added to the risk by instructing the 737 to descend.  +
On 15 August 2015, an Airbus A321 on approach to Charlotte commenced a go around but following a temporary loss of control as it did so then struck approach and runway lighting and the undershoot area sustaining a tail strike before climbing away. The Investigation noted that the 2.1g impact caused substantial structural damage to the aircraft and attributed the loss of control to a small microburst and the crew’s failure to follow appropriate and recommended risk mitigations despite clear evidence of risk given by the aircraft when it went around and available visually.  +
On 21 February 2006, an Airbus A321-200 being operated by China Eastern on a scheduled passenger flight from Daegu to Shanghai Pudong failed to follow the marked taxiway centreline when taxiing for departure in normal daylight visibility and a wing tip impacted an adjacent building causing minor damage to both building and aircraft. None of the 166 occupants were injured.  +
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.  +
On 24 November 2019, as an Airbus A321 taking off from the 2665 metre-long runway 05 at Glasgow approached the calculated V1 with the flex thrust they had set, the aircraft was not accelerating as expected and they applied TOGA thrust. This resulted in the aircraft becoming airborne with less than 400 metres of runway remaining. The Investigation confirmed what the crew had subsequently discovered for themselves - that they had both made an identical error in their independent EFB performance calculations which the subsequent standard procedures and checks had not detected. The operator is reviewing its related checking procedures.  +
On 21 January 2002, an Airbus A321-100 being operated by All Nippon Airways on a scheduled passenger flight from Nagoya to Hakodate encountered sudden negative windshear just prior to planned touchdown and the pitch up which followed resulted in the aft fuselage being damaged prior to the initiation of a climb away to position for a further approach which led to a normal landing. Three of the cabin crew sustained minor injuries but the remaining 90 occupants were uninjured.  +
On 28 February 2013, the initial night landing attempt of a Ural Airlines Airbus A321 at Hurghada was mishandled in benign conditions resulting in a tail strike due to over-rotation. The Investigation noted that a stabilised approach had been flown by the First Officer but found that the prescribed recovery from the effects of a misjudged touchdown had not then been followed. It was also concluded that communication between the two pilots had been poor and that the aircraft commander's monitoring role had been ineffective. The possibility of the effects of fatigue was noted.  +
On 16 April 2013, an A321 sustained significant damage during a tail strike during a bounced landing which followed loss of airspeed and an increase in sink rate shortly before touchdown after an otherwise stabilised approach. The Investigation attributed the tail strike to a failure to follow the recommended bounced landing response and noted the inadequate training provided by Asiana for bounced landing recovery.  +
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.  +
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.  +
On 29 April 2011, an Airbus A321-200 being operated by Thomas Cook Airlines on a passenger service from Manchester UK to Iraklion, Greece took off in day VMC but failed to establish a climb at the expected speed until the aircraft pitch attitude was reduced below that prescribed for the aircraft weight which had been entered into the FMS. No abnormal manoeuvres occurred and none of the 231 occupants were injured.  +
On 23 December 2011, an Austrian Airlines Airbus A321 sustained a tail strike at Manchester as the main landing gear contacted the runway during a night go around initiated at a very low height after handling difficulties in the prevailing wind shear. The remainder of the go around and subsequent approach in similar conditions was uneventful and the earlier tail strike was considered to have been the inevitable consequence of initiating a go around so close to the ground after first reducing thrust to idle. Damage to the aircraft rendered it unfit for further flight until repaired but was relatively minor.  +
A321 experienced minimal braking action during the daylight landing roll in wet snow conditions and normal visibility and an overrun occurred. The aircraft came to a stop positioned sideways in relation to the runway centreline with the right hand main landing gear 2 metres beyond the limit of the paved surface.  +
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.  +
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.  +
On 26th May 2003, a British Midland A321 suffered severe damage from hail en route near Vienna.  +
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.  +
On 26 September 2013, an Airbus A321 approaching Deauville in day VMC was advised that only a GNSS instrument approach - for which the crew were not approved - was available for the active runway. During the subsequent visual approach, the crew lost sight of the runway whilst over the sea and descended to almost the same height as the land ahead, eventually triggering an EGPWS ‘PULL UP’ Warning. The approach was subsequently abandoned after an EGPWS ‘SINK RATE’ Alert on short finals and non-standard positioning to the opposite runway direction, followed by a landing in the originally expected direction.  +
On 28 July 2010, the crew of an Airbus A321 lost contact with the runway at Islamabad during a visual circling approach and continued in IMC outside the protected area and flying into terrain after repeatedly ignoring EGPWS Terrain Alerts and PULL UP Warnings. The Investigation concluded that the Captain had pre-planned a non-standard circuit which had been continued into IMC and had then failed to maintain situational awareness, control the aircraft through correct FMU inputs or respond to multiple EGPWS Warnings. The inexperienced First Officer appeared unwilling to take control in the absence of corrective action by the Captain.  +
On 26 February 2020, after difficulty starting an Airbus A321 left engine for the first flight of the day, the same difficulty recurred on the third flight followed by subsequent en-route abnormalities affecting both engines. After no fault was found during post flight maintenance investigation, similar problems occurred starting the left engine and after takeoff from Gatwick, both engines malfunctioned and a MAYDAY return followed. The continuing Investigation has already found that the engine problems were attributable to fuel system contamination following the addition of 37 times the maximum permitted dosage of Kathon biocide during prior scheduled maintenance work.  +
On 27 May 2010 an Airbus A321-200 being operated by Australian operator JetStar on a passenger flight from Darwin to Singapore continued an initial approach at destination in day VMC with the aircraft inappropriately configured before a late go around was commenced which was also flown in a configuration contrary to prescribed SOPs. A subsequent second approach proceeded to an uneventful landing. There were no unusual or sudden manoeuvres during the event and no injuries to the occupants.  +
On 20 September 2013, a loss of separation occurred between two en route Airbus A330s under radar surveillance in controlled airspace near Adelaide. The potential conflict was resolved with TCAS RA action by one of the aircraft involved but the TCAS equipment on board the other aircraft appeared to have malfunctioned and did not display any traffic information or generate an RA. The complex pattern of air routes in the vicinity of the event was identified by the Investigation as a Safety Issue requiring resolution by the ANSP and the response subsequently received was assessed as satisfactory.  +
On 31 March 2012, after the implementation of contingency ATC procedures for a period of 5 hours due to controller shortage, two Garuda A330 aircraft which had been transiting an associated Temporary Restricted Area (TRA) prior to re-entering controlled airspace were separately involved in losses of separation assurance, one when unexpectedly entering adjacent airspace from the TRA, the other when the TRA ceased and controlled airspace was restored. The Investigation did not find that any actual loss of separation had occurred but identified four Safety Issues in relation to the inadequate handling of the TRA activation by ANSP Airservices Australia.  +
On 31 October 2004, a Loss of Separation occurred between an A330-200, on a low go-around from Rwy 14 at Zurich Switzerland, and an Avro RJ100 which had been cleared for take-off on Rwy 10 and was on a convergent flight path.  +
On 17 October 2014, an Airbus A330-200 crew taking off from Madrid at night detected non-runway lights ahead as they accelerated through approximately 90 knots. ATC were unaware what they might be and the lights subsequently disappeared, and the crew continued the takeoff. A reportedly unlit vehicle at the side of the runway was subsequently passed just before rotation. The Investigation found that the driver of an external contractor's vehicle had failed to correctly route to the parallel runway which was closed overnight for maintenance but had not realised this until he saw the lights of an approaching aircraft.  +
On 9 February 2014, the Captain of a military variant of the Airbus A330 suddenly lost control during the cruise on a passenger flight. A violent, initially negative 'g', pitch down occurred which reached 15800 fpm as the speed rose to Mach 0.9. In the absence of any effective crew intervention, recovery was achieved entirely by the aircraft Flight Envelope Protection System. The Investigation found that the upset had occurred when the Captain moved his seat forward causing its left arm rest to contact the personal camera he had placed behind the sidestick, forcing the latter fully forward.  +
On 30 January 2012, an Airbus A330 departing Abu Dhabi at night lined up on the runway edge lights in the prevailing low visibility and attempted to take off. The take off was eventually rejected and the aircraft towed away from the runway. Damage was limited to that resulting from the impact of the aircraft landing gear with runway edge lights and the resultant debris. An Investigation is continuing into the circumstances and causation of the incident.  +
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.  +
On 23 October 2014 an Airbus A330-200 made a sharp brake application to avoid overrunning the turn onto the parking gate at Dubai after flight. A cabin crew member who had left their seat prior to the call from the flight deck to prepare doors, fell and sustained serious neck and back injuries. The investigation found that the sudden braking had led to the fall but concluded that the risk had arisen because required cabin crew procedures had not been followed.  +
On 13 December 2013, an Airbus A330 encountered very heavy rain below 100 feet agl just after the autopilot had been disconnected for landing off an ILS approach at Jakarta. The aircraft Commander, as pilot flying, lost visual reference but the monitoring First Officer did not. A go around was neither called nor flown and after drifting in the flare, the aircraft touched down with the right main landing gear on the grass and continued like this for 500 metres before regaining the runway. The Investigation noted that prevailing SOPs clearly required that a go around should have been flown.  +
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.  +
On 28 October 2008, an Airbus A330-200 could not be rotated for liftoff whist making a night takeoff from Montego Bay until the Captain had increased the reduced thrust set to TOGA, after which the aircraft became airborne prior to the end of the runway and climbed away normally. The Investigation found that the takeoff performance data used had been calculated for the flight by Company Despatch and the fact that it had been based on a takeoff weight which was 90 tonnes below the actual take off weight had not been noticed by any of the flight crew.  +
On 26 November 2014, an Airbus A330-200 was struck by lightning just after arriving at its allocated stand following a one hour post-landing delay after suspension of ramp operations due to an overhead thunderstorm. Adjacent ground services operatives were subject to electrical discharge from the strike and one who was connected to the aircraft flight deck intercom was rendered unconscious. The Investigation found that the equipment and procedures for mitigation of risk from lightning strikes were not wholly effective and also that perceived operational pressure had contributed to a resumption of ground operations which hindsight indicated had been premature.  +
On 4 July 2009, an Airbus A332 being operated by Jetstar Airways on a scheduled passenger flight from Sydney to Melbourne carried a 750 kg ULD which had been expressly rejected by the aircraft commander during the loading operation without flight crew awareness. There was no reported effect on aircraft handling during the flight.  +
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.  +
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.  +
On 6 February 2019, an Airbus A330-200 Captain’s Audio Control Panel (ACP) malfunctioned and began to emit smoke and electrical fumes after coffee was spilt on it. Subsequently, the right side ACP also failed, becoming hot enough to begin melting its plastic. Given the consequent significant communications difficulties, a turnback to Shannon was with both pilots taking turns to go on oxygen. The Investigation found that flight deck drinks were routinely served in unlidded cups with the cup size in use incompatible with the available cup holders. Pending provision of suitably-sized cups, the operator decided to begin providing cup lids.  +
On 2 September 2013, an Airbus A330-200 crossing the ITCZ at FL400 at night encountered sudden severe turbulence unanticipated by the crew resulting in serious injuries to a few cabin crew / passengers and minor injuries to twelve others. An en route diversion to Fortaleza was made. The Investigation found that the origin of the turbulence was severe convective weather and failure to detect it in an area where it had been forecasted indicated that it was probably associated with sub-optimal use of the on-board weather radar with the severity of the encounter possibly aggravated by inappropriate contrary control inputs.  +
On 4 May 2016, an Airbus A330-200 in the cruise in day VMC at FL390 in the vicinity of a highly active thunderstorm cell described by the crew afterwards as ‘cumulus cloud’ encountered a brief episode of severe clear air turbulence which injured 24 passengers and crew, seven of them seriously as well as causing some damage to cabin fittings and equipment. The Investigation was unable to determine how close to the cloud the aircraft had been but noted the absence of proactive risk management and that most of the injured occupants had not been secured in their seats.  +
On 27 February 2012, the crew of an Airbus A330 en route at night and crossing the East African coast at FL360 encountered sudden violent turbulence as they flew into a convective cell not seen on their weather radar and briefly lost control as their aircraft climbed 2000 feet with resultant minor injuries to two occupants. The Investigation concluded that the isolated and rapidly developing cell had not been detected because of crew failure to make proper use of their weather radar, but noted that activation of flight envelope protection and subsequent crew action to recover control had been appropriate.  +
On 21 November 2013, an A330 rejected its take off from Brisbane after an airspeed indication failure. Following maintenance intervention, a similar airspeed indication fault on the subsequent departure was reported to have been detected after V1. Once airborne, reversion to Alternate Law occurred and slat retraction failed. After an air turnback, it was discovered that the cause of both events was blockage of the No. 1 Pitot Head by a mud-dauber wasp nest which was created during the initial two hour turnround at Brisbane. Investigation of a 2014 event to a Boeing 737 at Brisbane with exactly the same causation was noted.  +
On 8 March 2013, the crew of a Qantas A330 descended below controlled airspace and to 600 feet agl when still 9nm from the landing runway at Melbourne in day VMC after mismanaging a visual approach flown with the AP engaged. An EGWS Terrain Alert was followed by an EGPWS PULL UP Warning and a full recovery manoeuvre was flown. The Investigation found degraded situational awareness had followed inappropriate use of Flight Management System  +
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.  +
On 12 May 2010, an Afriqiyah Airways Airbus A330 making a daylight go around from a non precision approach at Tripoli which had been discontinued after visual reference was not obtained at MDA did not sustain the initially established IMC climb and, following flight crew control inputs attributed to the effects of somatogravic illusion and poor CRM, descended rapidly into the ground with a high vertical and forward speed, The aircraft was destroyed by impact forces and the consequent fire and all but one of the 104 occupants were killed.  +
On 30 September 2010, an A330-200 was about to take off from Khartoum at night in accordance with its clearance when signalling from a hand-held flashlight and a radio call from another aircraft led to this not taking place. The other (on-stand) aircraft crew had found that they had been hit by the A330 as it had taxied past en route to the runway. The Investigation found that although there was local awareness that taxiway use and the provision of surface markings at Khartoum did not ensure safe clearance between aircraft, this was not being communicated by NOTAM or ATIS.  +
On 13 November 2012, a Garuda Airbus A330 and a KLM Boeing 737 lost separation against each other whilst correctly following radar vectors to parallel approaches at Amsterdam but there was no actual risk of collision as each aircraft had the other in sight and no TCAS RA occurred. The Investigation found that one of the controllers involved had used permitted discretion to override normal procedures during a short period of quiet traffic but had failed to restore normal procedures when it became necessary to do so, thus creating the conflict and the ANSP was recommended to review their procedures.  +
On 3 May 2017, an Airbus A330 and an Airbus A319 lost prescribed separation whilst tracking in opposite directions on a radar-controlled ATS route in eastern Myanmar close to the Chinese border. The Investigation found that the response of the A330 crew to a call for another aircraft went undetected and they descended to the same level as the A319 with the lost separation only being mitigated by intervention from the neighbouring Chinese ACC which was able to give the A319 an avoiding action turn. At the time of the conflict, the A330 had disappeared from the controlling ACCs radar.  +
On 14 February 2017, an Airbus A330-300 preparing to depart Narita entered the active runway at night without clearance as another Airbus A330-300 was approaching the same runway with a landing clearance. ATC observed the conflict after an alert was activated on the surface display system and instructed the approaching aircraft, which was passing approximately 400 feet and had not observed the incursion, to go around. The Investigation attributed the departing aircraft crew’s failure to comply with their clearance to distraction and noted that the stop bar lighting system was not in use because procedures restricted its use to low visibility conditions.  +
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.  +
On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.  +
On 4 March 2015, the crew of a Turkish Airlines A333 continued an automatic non precision RNAV approach below the prescribed minimum descent altitude without having obtained any element of visual reference and when this was acquired a few seconds before the attempted landing, the aircraft was not aligned with the runway centreline and during a 2.7g low-pitch landing, the left main gear touched down on the grass. The aircraft then left the runway completely before stopping with a collapsed nose gear and sufficient damage to be assessed a hull loss. None of 235 occupants sustained serious injury.  +
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.  +
On 7 October 2013 a fire was discovered in the rear hold of an Airbus A330 shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.  +
On 15 September 2020, an Airbus A330-300 touched down at Medan partially off the runway as a result of misjudgement by the right seat handling pilot before regaining it and completing the landing roll. The aircraft and some runway lights were damaged. The handling pilot was an A320/A330 dual-rated Instructor Pilot conducting standardisation training on a new Captain who had not flown for 7½ months having himself not flown from the right seat for six months. The continuing Investigation has recommended that the State Safety Regulator issues guidance in support of its temporary alleviations to pilot recency requirements.  +
On 7 October 2014, an Airbus A330-300 failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.  +
On 25 December 2013, an Airbus A330-300 conducted a stable night non-precision approach at St. Lucia but the crew found that after touchdown, atypical intervention was needed to ensure direction along the runway was maintained and also detected both ‘juddering’ and a more significant rate of deceleration than usual. Considerable impact damage to the lower fuselage and below-floor systems was subsequently discovered. The Investigation concluded that this damage had resulted from impact with water from a diverted river channel which had burst its banks and flooded the touchdown area of the runway to a depth of up to 60 cm.  +
On 17 December 2017, it was discovered after completion of an Airbus A330-300 passenger flight from Sydney to Bejing that freight loading had not been correctly documented on the load and trim sheet presented to and accepted by the Captain and as a result, the aircraft had exceeded its certified MTOW on departure. The Investigation found that the overload finding had not been promptly reported or its safety significance appreciated, that the error had its origin in related verbal communications during loading and noted that the aircraft operator had since made a series of improvements to its freight loading procedures.  +
On 22 June 2009, an Airbus A330-300 being operated by Qantas on a scheduled passenger flight from Hong Kong to Perth encountered an area of severe convective turbulence in night IMC in the cruise at FL380 and 10 of the 209 occupants sustained minor injuries and the aircraft suffered minor internal damage. The injuries were confined to passengers and crew who were not seated at the time of the incident. After consultations with ground medical experts, the aircraft commander determined that the best course of action was to complete the flight as planned, and this was uneventful.  +
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.  +
On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.  +
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.  +
On 16 August 2016, an Airbus A330-300 right engine failed just over two hours into a flight from Sydney to Kuala Lumpur. It was eventually shut down after two compressor stalls and increased vibration had followed ‘exploratory’ selection of increased thrust. A ‘PAN’ declaration was followed by diversion to Melbourne, during which two relight attempts were made, in preference to other nearer alternates without further event. The Investigation found that delayed shutdown and the relight attempts were contrary to applicable procedures and the failure to divert to the nearest suitable airport had extended the time in an elevated risk environment.  +
On 22 April 2013, a lower deck smoke warning occurred on an Airbus A330-300 almost 90 minutes into the cruise and over land. The warning remained on after the prescribed crew response and after an uneventful MAYDAY diversion was completed, the hold was found to be full of smoke and fire eventually broke out after all occupants had left the aircraft. The Investigation was unable to determine the fire origin but noted the success of the fire suppression system whilst the aircraft remained airborne and issues relating to the post landing response, especially communications with the fire service.  +
On 3 July 2017, an Airbus A330-300 was climbing through 2,300 feet after a night takeoff from Gold Coast when the number 2 engine began to malfunction. As a cabin report of fire in the same engine was received, it failed and a diversion to Brisbane was made. The Investigation found that the engine failure was entirely attributable to the ingestion of a single medium-sized bird well within engine certification requirements. It was concluded that the failure was the result of a sufficiently rare combination of circumstances that it would be extremely unlikely for multiple engines to be affected simultaneously.  +
On 19 January 2013, a Rolls Royce Trent 700-powered Virgin Atlantic Airbus A330-300 hit some medium sized birds shortly after take off from Orlando, sustaining airframe impact damage and ingesting one bird into each engine. Damage was subsequently found to both engines although only one indicated sufficient malfunction - a complete loss of oil pressure - for an in-flight shutdown to be required. After declaration of a MAYDAY, the return to land overweight was completed uneventfully. The investigation identified an issue with the response of the oil pressure detection and display system to high engine vibration events and recommended modification.  +
On 16 December 2002, approximately 1735 UTC, an Airbus A330-330, operating as Philippine Airlines flight 110, struck power lines while executing a localizer-only Instrument Landing System (ILS) approach to runway 6L at A.B. Pat Won Guam International Airport, Agana, Guam. Instrument meteorological conditions prevailed during the approach. Following a ground proximity warning system (GPWS) alert, the crew executed a missed approach and landed successfully after a second approach to the airport.  +
On 24 April 2005, an Airbus A340-200 landed short of the temporarily displaced runway threshold at Perth in good daylight visibility despite their prior awareness that there was such a displacement. The Investigation concluded that the crew had failed to correctly identify the applicable threshold markings because the markings provided were insufficiently clear to them and probably also because of the inappropriately low intensity setting of the temporary PAPI. No other Serious Incidents were reported during the same period of runway works.  +
On 15 October 2007, an Airbus 340-300 being operated on a scheduled passenger flight by Air Lanka with a heavy crew in the flight deck was taxiing towards the departure runway at London Heathrow at night in normal visibility when the right wing tip hit and sheared off the left hand winglet of a stationary British Airways Boeing 747-400 which was in a queue on an adjacent taxiway. The Airbus 340 sustained only minor damage to the right winglet and navigation light.  +
On 20 July 1998, after an ATC error south of Newfoundland, an Air France A340 and an Air Canada 747-400 were on directly converging tracks and at the same level. Collision was avoided by the correct actioning of coordinated TCAS RAs by both aircraft.  +
On 23 November 1995, in normal daylight visibility, an Airbus A340-300 being operated by Gulf Air on a scheduled international passenger flight from London Heathrow taxied past a Boeing 757-200 being operated by British Airways on a scheduled domestic passenger flight and also departing from London Heathrow which had stopped on a diverging taxiway within the departure holding area for Runway 27R such that the wing tip of the Airbus impacted the tail fin of other aircraft. Two of the 378 occupants of the two aircraft suffered minor injuries and both aircraft were damaged. Passengers were deplaned uneventfully from both aircraft.  +
On 5 July 2014, an Airbus A340-300 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 767 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. Sighting by both aircraft resulted in an accelerated crossing and a very low go around. The Investigation noted the twice-daily runway configuration change made due to noise abatement reasons was imminent. It was also noted that airport procedure involved use of stop bars even on inactive runways and that their operation was then the responsibility of ground controllers.  +
On 11 August 2012, the augmenting crew member in the flight deck of an Airbus A340 about to join final approach to Zurich in Class 'C' airspace as cleared suddenly saw a glider on a collision course with the aircraft. The operating crew were alerted and immediately executed a "pronounced avoiding manoeuvre" and the two aircraft passed at approximately the same level with approximately 260 metres separation. The Investigation attributed the conflict to airspace incursion by the glider and issue of a clearance to below MRVA to the A340 and noted the absence of relevant safety nets.  +
On 26 December 2016, the wing of an Airbus A340-300 being repositioned by towing at Copenhagen as cleared hit an Avro RJ100 which had stopped short of its stand when taxiing due to the absence of the expected ground crew. The RJ100 had been there for twelve minutes at the time of the collision. The Investigation attributed the collision to differing expectations of the tug driver, the Apron controller and the RJ100 flight crew within an overall context of complacency on the part of the tug driver whilst carrying out what would have been regarded as a routine, non-stressful task.  +
On 25 January 2002, in VMC at night, an Airbus A340-300 being operated by China Airlines successfully took-off from a parallel taxiway adjacent to the departure runway at Anchorage Alaska which was of less length than the calculated airplane take-off distance required.  +
On 18 May 2013 an Airbus A340 with the Captain acting as 'Pilot Flying' commenced its night take off from Auckland in good visibility on a fully lit runway without the crew recognising that it was lined up with the runway edge. After continuing ahead for approximately 1400 metres, the aircraft track was corrected and the take off completed. The incident was not reported to ATC and debris on the runway from broken edge lights was not discovered until a routine inspection almost three hours later. The Investigation concluded that following flights were put at risk by the failure to report.  +
On 11 March 2017, contrary to crew expectations based on their pre-flight takeoff performance calculation, an Airbus 340-300 taking off from the 3,800 metre-long at Bogata only became airborne just before the end of the runway. The Investigation found that the immediate reason for this was the inadequate rate of rotation achieved by the Training Captain performing the takeoff. However, it was also found that the operator’s average A340-300 rotation rate was less than would be achieved using handling recommendations which themselves would not achieve the expected performance produced by the Airbus takeoff performance software that reflected type certification findings.  +
On 19 August 2017, an Airbus A340-300 encountered significant unforecast windshear on rotation for a maximum weight rated-thrust night takeoff from Bogotá and was unable to begin its climb for a further 800 metres during which angle of attack flight envelope protection was briefly activated. The Investigation noted the absence of a windshear detection system and any data on the prevalence of windshear at the airport as well as the failure of ATC to relay in English reports of conditions from departing aircraft received in Spanish. The aircraft operator subsequently elected to restrict maximum permitted takeoff weights from the airport.  +
On 30 May 2007, at about 0555 hours local time, the crew of an Airbus A340-300 had to apply (Take-off Go Around) power and rotate abruptly at a high rate to become airborne while taking off from Runway 20C at Singapore Changi Airport, when they noticed the centreline lights were indicating the impending end of the available runway. The crew had calculated the take-off performance based on the full TORA (Take-off Run Available) of 4,000 m because they were unaware of the temporary shortening of Runway 20C to 2,500 m due to resurfacing works.  +
On 21 August 2008, an Airbus A340-300 being operated by an undisclosed operator by a German-licensed flight crew on a scheduled passenger flight from Teheran to Frankfurt collided with a stationary bus with only the driver on board whilst approaching the allocated parking gate in normal daylight visibility. The No 4 engine impacted the bus roof as shown in the photograph below reproduced from the official report. None of the occupants of either the aircraft or the bus were injured.  +
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.  +
On 27 November 2010, a Finnair Airbus A340-300 unintentionally attempted a night take off from Hong Kong in good visibility from the taxiway parallel to the runway for which take off clearance had been given. ATC observed the error and instructed the crew to abandon the take off, which they then did. The Investigation attributed the crew error partly to distraction. It was considered that the crew had become distracted and that supporting procedures and process at the Operator were inadequate.  +
On 5 November 1997, an Airbus A340-300 operated by Virgin Atlantic airlines experienced a landing gear malfunction. The crew executed a successful partial gear up landing at London Heathrow.  +
On 5 February 2012, an Airbus A340-300 started its takeoff from an intermediate point on the runway for which no regulated takeoff weight information was available and had only become airborne very close to the end of the runway and then climbed only very slowly. The Investigation found that as the full length of the planned departure runway was not temporarily unavailable, ATC had offered either the intersection subsequently used or the full length of the available parallel runway and that despite the absence of valid performance data for the intersection, the intersection had been used.  +
On 27 April 2008 an Airbus A340-300 crew lost previously-acquired visual reference in fog on a night auto ILS into Nairobi but continued to a touchdown which occurred with the aircraft heading towards the edge of the runway following an inappropriate rudder input. The left main gear departed the paved surface and a go around was initiated and a diversion made. The event was attributed to a delay in commencing the go around. No measured RVR from any source was passed by ATC although it was subsequently found to have been recorded as I excess of Cat 1 limits throughout.  +
On 8 December 2011, an Airbus A340-300 did not become airborne until it had passed the end of the takeoff runway at Rio de Janeiro Galeão, which was reduced in length due to maintenance. The crew were unaware of this fact nor the consequent approach lighting, ILS antennae and aircraft damage, and completed their intercontinental flight. The Investigation found that the crew had failed to use the full available runway length despite relevant ATIS and NOTAM information and that even using rated thrust from where they began their takeoff, they would not have become airborne before the end of the runway.  +
On 18 April 2013, an Airbus A340-300 was unintentionally taxied off the side of the runway during a 180° turn after backtracking the departure runway at Tabriz at night. The Investigation found that the prevailing wet runway conditions meant that the runway width alone was insufficient for the turn and full advantage had not been taken of a wide taxiway at the runway displaced threshold. It was also found that the technique used to turn had not been optimum and that the runway involved was for daylight use only and had a strength rating not compatible with A340 use.  +
On 2 August 2005, an Air France Airbus A340 attempted a daylight landing at destination on a rain-soaked runway during an active thunderstorm and overran for 300 metres ending up in a ravine from where, despite its destruction by fire, all occupants escaped. The Investigation recommendations focussed mainly on crew decision making in adverse weather conditions and issues related to the consequences of such an overrun on survivability.  +
On 22 July 2011 an Air France A340-300 en route over the North Atlantic at FL350 in night IMC encountered moderate turbulence following "inappropriate use of the weather radar" which led to an overspeed annunciation followed by the aircraft abruptly pitching up and gaining over 3000 feet in less than a minute before control was regained and it was returned to the cleared level. The Investigation concluded that "the incident was due to inadequate monitoring of the flight parameters, which led to the failure to notice AP disengagement and the level bust, following a reflex action on the controls.”  +
On 13 March 2012, an A340-300 crew cleared for a Cat 3 ILS approach at Paris CDG with LVP in force failed to descend at a rate which would allow the aircraft to capture the ILS GS and at 2nm from the runway, when still 2500 feet above runway height, the ILS GS mode engaged on a false upper lobe of about 10° and as a result of the consequent rapid pitch up and speed reduction, aircraft control was almost lost. After a period of further confusion, a go around was initiated and the subsequent approach was uneventful.  +
On 20 March 2009 an Airbus A340-500, operated by Emirates, commenced a take-off roll for a normal reduced-thrust take-off on runway 16 at Melbourne Airport. The attempt to get the aircraft airborne resulted in a tail strike and an overrun because insufficient thrust had been set based upon an incorrect flight crew data entry.  +
On 12 December 2009, an Airbus A340-600 being operated by Virgin Atlantic Airways on a scheduled passenger flight departing from London Heathrow in night VMC was slow to rotate and the aircraft settled at an initial climb speed below VLS - defined as the lowest selectable speed which provides an appropriate margin above the stall speed. This prompted the PF to reduce the aircraft pitch attitude in order to accelerate which resulted in a poor rate of climb of between 500 and 600 fpm. The flaps were retracted on schedule and the aircraft continued its climb. At no time was full takeoff thrust selected. Later in the climb, the crew looked again at the take off data calculation and realised that they had made the departure with insufficient thrust set and using Vr and V2 speeds which were too low for the actual aircraft weight. The flight to the planned destination was completed.  +
On 31 August 2007 an Airbus A340-600 made a hard landing with drift /side slip present after a making a circling approach in good visibility with a relatively high cloudbase and was disabled on the runway after sustaining significant damage to the landing gear. It was found that the visual circling segment had been flown too close to the runway and the subsequent final approach had been unstabilised with touchdown being made at an excessive rate of descent. The destination risk assessment carried out by the airline involved was found to inadequate as was pilot training for the approach flown.  +
During ground running of engines, the aircraft impacted a concrete wall at a ground speed of 30 kts following unintended movement and the aircraft was wrecked.  +
On 3 February 2013, an Airbus A340 crew in the cruise in equatorial latitudes at FL350 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL350 and reversion to Alternate Law. Excessive vibration on the left engine then began and a diversion was made. The engine remained in use and was subsequently found undamaged with the fault attributed to ice/water ingress due to seal failure.  +
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.  +
On 21 August 2019, an Airbus A340-600 encountered sudden-onset moderate to severe clear air turbulence whilst in the cruise at FL 360 over northern Turkey which resulted in a serious passenger injury. The Investigation found that the flight was above and in the vicinity of convective clouds exhibiting considerable vertical development but noted that neither the en-route forecast nor current alerting had given any indication that significant turbulence was likely to be encountered. It was noted the operator’s flight crew had not been permitted to upload weather data in flight but since this event, that restriction had been removed.  +
On 10 January 2008, an Airbus A380 was damaged during push back at Singapore Changi International airport when the aircraft right wing undercarriage became stuck in soft ground adjacent to the taxiway.  +
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.  +
On 10 July 2019 an Airbus A380 in the cruise at night at FL 400 encountered unexpectedly severe turbulence approximately 13 hours into the 17 hour flight and 27 occupants were injured as a result, one seriously. The detailed Investigation concluded that the turbulence had occurred in clear air in the vicinity of a significant area of convective turbulence and a jet stream. A series of findings were related to both better detection of turbulence risks and ways to minimise injuries if unexpectedly encountered with particular reference to the aircraft type and operator but with wider relevance.  +
On 2 February 2020, an Airbus A380 in the cruise at night at FL 330 encountered unforecast clear air turbulence with the seatbelt signs off and one unsecured passenger in a standard toilet compartment sustained a serious injury as a result. The Investigation noted that relevant airline policies and crew training had been in place but also observed a marked difference in the availability of handholds in toilet compartments provided for passengers with disabilities or other special needs and those in all other such compartments and made a corresponding safety recommendation to standardise and placard handhold provision in all toilet compartments.  +
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.  +
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.  +
On 18 October 2014, an Airbus A380 descending at night over north east India unexpectedly encountered what was subsequently concluded as likely to have been Clear Air Turbulence after diverting around convective weather. Although seat belt signs were already on, a flight deck instruction to cabin crew to be seated because of the onset of intermittent light to moderate turbulence was completed only seconds before the sudden occurrence of a short period of severe turbulence. Two unrestrained passengers and two of the cabin crew sustained serious injuries. There were other minor injuries and also some cabin trim impact damage.  +
On 30 September 2017, an Airbus A380-800 en-route over Greenland suffered a sudden explosive uncontained failure of the number 4 engine shortly after thrust was increased to adjust the cruise level to FL 370. Following recovery of a crucial piece of ejected debris, the Investigation was able to determine that the failure was attributable to a specific type of fatigue failure within a titanium alloy used in the manufacture of the engine fan hub. This risk had not been identifiable during manufacture or in-service and had not been recognised by the engine manufacturer or during the engine certification process.  +
On 10 September 2017, an Airbus A380-800 cleared for an ILS approach at Moscow Domodedovo in visual daylight conditions descended below its cleared altitude and reached 395 feet agl whilst still 7nm from the landing runway threshold with a resultant EGPWS ‘PULL UP’ warning. Recovery was followed by an inadequately prepared second approach which was discontinued and then a third approach to a landing. The Investigation attributed the crew’s difficulties primarily to failure to follow various routine operating procedures relating to use of automation but noted that there had been scope for better presentation of some of these procedures.  +
On 13 December 2011, an Airbus 320 was allowed to depart from runway 25C at Frankfurt on a left turning SID just prior to the touchdown of an A380 on runway 25L. The A380 had then initiated a low go around which put it above, ahead of and parallel to the A320 with a closest proximity of 1nm / 200 ft, in breach of the applicable wake vortex separation minima of 7nm / 1000ft. The Investigation found that there had been no actual encounter with the A380 wake vortices but that systemic ATC operational risk management was inadequate.  +
On 4 October 2007, an Antonov An-26B cargo aircraft being operated for an unidentified Hungarian-registered carrier by a Ukrainian crew on an empty positioning flight from Stuttgart to Kassel overran the destination runway during a daylight landing in normal ground visibility. None of the six crew on board were injured. There was no damage to the aircraft but some damage to ground installations.  +
On 29 March 2016, an Antonov AN-26B which had just taken off from Cox’s Bazar reported failure of the left engine and requested an immediate return. After twice attempting to position for a landing, first in the reciprocal runway direction then in the takeoff direction with both attempts being discontinued, control was subsequently lost during further manoeuvring and the aircraft crashed. The Investigation found that the engine malfunction occurred before the aircraft became airborne so that the takeoff could have been rejected and also that loss of control was attributable to insufficient airspeed during a low height left turn.  +
On 29 July 2017, an Antonov AN-74 crew sighted several previously unseen large “eagles” rising from the long grass next to the runway as they accelerated for takeoff at Sao Tome and, concerned about the risk of ingestion, made a high speed rejected takeoff but were unable to stop on the runway and entered a deep ravine just beyond it which destroyed the aircraft. The Investigation found that the reject had been unnecessarily delayed until above V1, that the crew forgot to deploy the spoilers which would have significantly increased the stopping distance and that relevant crew training was inadequate.  +
For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.  +
On 20 October 1998, in the North Sea, an Eurocopter AS332L Super Puma operated by Norsk HeliKopter AS, experienced engine failure with autorotation and subsequent lost of height. The crew misidentified the malfunctioning engine and reduced the power of the remaining serviceable engine. However, the mistake was realised quickly enough for the crew to recover control of the helicopter.  +
On 28th February 2002, an Aerospatiale AS332L Super Puma helicopter en route approximately 70 nm northeast of Scatsa, Shetland Islands was in the vicinity of a storm cell when a waterspout was observed about a mile abeam. Soon afterwards, violent pitch, roll and yaw with significant negative and positive ‘g’ occurred. Recovery to normal flight was achieved after 15 seconds and after a control check, the flight was completed. After flight, all five tail rotor blades and tail pylon damage were discovered. It was established that this serious damage was the result of contact between the blades and the pylon.  +
On 1 April 2009, the flight crew of a Bond Helicopters’ Eurocopter AS332 L2 Super Puma en route from the Miller Offshore Platform to Aberdeen at an altitude of 2000 feet lost control of their helicopter when a sudden and catastrophic failure of the main rotor gearbox occurred and, within less than 20 seconds, the hub with the main rotor blades attached separated from the helicopter causing it to fall into the sea at a high vertical speed The impact destroyed the helicopter and all 16 occupants were killed. Seventeen Safety Recommendations were made as a result of the investigation.  +
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.  +
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.  +
On 23 August 2013, the crew of a Eurocopter AS332 L2 Super Puma helicopter making a non-precision approach to runway 09 at Sumburgh with the AP engaged in 3-axes mode descended below MDA without visual reference and after exposing the helicopter to vortex ring conditions were unable to prevent a sudden onset high rate of descent followed by sea surface impact and rapid inversion of the floating helicopter. Four of the 18 occupants died and three were seriously injured. The Investigation found no evidence of contributory technical failure and attributed the accident to inappropriate flight path control by the crew.  +
On August 8, 2009 a privately operated PA32 and a Eurocopter AS350BA helicopter being operated by Liberty Helicopters on a public transport sightseeing flight collided in VMC over the Hudson River near Hoboken, New Jersey whilst both operating under VFR. The three occupants of the PA32, which was en route from Wings Field PA to Ocean City NJ, and the six occupants of the helicopter, which had just left the West 30th Street Heliport, were killed and both aircraft received substantially damaged.  +
On 4 July 2011, an Airlift Eurocopter AS 350 making a passenger charter flight to a mountain cabin in day VMC appeared to suddenly depart controlled flight whilst making a tight right turn during positioning to land at the destination landing site and impacted terrain soon afterwards. The helicopter was destroyed by the impact and ensuing fire and all five occupants were fatally injured. The subsequent investigation came to the conclusion that the apparently abrupt manoeuvring may have led to an encounter with ‘servo transparency’ at a height from which the pilot was unable to recover before impact occurred.  +
On 23 September 2005, an AS350 helicopter, operated by Heli USA Airways, crashed into the sea off Hawaii following loss of control associated with flight into adverse weather conditions.  +
On 11 March 2018, an Airbus AS350 engine failed during a commercial sightseeing flight and autorotation was initiated. The pilot then noticed that the floor-mounted fuel cut-off had been operated by part of the tether system of one of the five passengers but there was insufficient time to restore power. On water contact, the automatic floatation system operated asymmetrically and the helicopter submerged before the occupants could evacuate. Only the pilot was able to release his harness and escape because the unapproved adapted passenger harnesses had no quick release mechanism. The Investigation found systemic inadequacy of the operator’s safety management system.  +
On 28th April 1999, an AS-355 helicopter suffered an in-flight fire attributed to an electrical fault which had originated from a prior maintenance error undetected during incomplete pre-flight inspections. The aircraft carried out an immediate landing allowing evacuation before the aircraft was destroyed by an intense fire.  +
On 27 December 2006, an AS365 Dauphin 2, operated by CHC Scotia, crashed into the sea adjacent to a gas platform in Morecambe Bay, UK, at night, following loss of control.  +
On 31 January 2005, an ATR 42-300 being operated by Danish Air Transport on a scheduled passenger flight from Bergen to Florø in day VMC encountered pitch control difficulties during rotation and subsequent climb and after declaring an emergency made a successful return to land on the departure runway seven minutes later. None of the 25 occupants were injured and the only damage found was to the elevator and its leading edge fairings.  +
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.  +
On 27 January 2009, an ATR 42-300 being operated by Empire Airlines on a scheduled cargo flight from Fort Worth Alliance to Lubbock was making a night ILS approach in IMC to runway 17R at destination when it stalled and crashed short of the runway. The aircraft caught fire and was in any case effectively already destroyed by the impact. Both crew members were injured, one seriously.  +
On 19 October 2013, an ATR42 freighter departing Madang had to reject its takeoff when it was impossible to rotate and it ended up semi-submerged in a shallow creek beyond the airfield perimeter. The Investigation found that loading had been contrary to instructions and the aircraft had a centre of gravity outside the permitted range and was overweight. This was attributed to the aircraft operator’s lack of adequate procedures for acceptance and loading of cargo. A lack of appreciation by all parties of the need to effectively mitigate runway overrun risk in the absence of a RESA was also highlighted.  +
On 14 September 2005, an ATR 42-320 operated by Coast Air AS experienced a continuous build up of ice in the climb, despite the activation of de-icing systems aircraft entered an uncontrolled roll and lost 1500ft in altitude. The crew initiated recovery actions, the aircraft was stabilised, and the flight continued without further event.  +
On 13 December 2017, an ATR 42-300 crashed shortly after a night takeoff from Fond-du-Lac and was destroyed. There was no fire and although all occupants were injured, nine seriously, there was only one fatality. Both engines were operating at impact and a significant wreckage path through trees led up to the impact site. It is also known that although the aircraft took off within the maximum allowable takeoff weight and within the permitted centre of gravity range, it was not de-iced prior to departure and some airframe ice contamination is reported to have been present. The Investigation is still ongoing as at July 2021.  +
On 29 March 2006 at about 1 mile from touchdown when in VMC on a night approach to destination Geneva, an ATR 42-300 being operated by Farnair on a cargo flight experienced a sudden electrical fire in the flight deck and an emergency was declared to ATC. Despite this situation the aircraft was able to land normally and vacate the runway via an RET after which it was forced to stop.  +
On 22 February 2012, the crew of an ATR 42 making a radar-vectored ILS approach to runway 23 at Glasgow at night allowed the airspeed of the aircraft to reduce and a stall warning followed. Corrective action then led to an overspeed and further corrective action almost led to a second stall warning. The Investigation concluded that SOPs were not followed, monitoring was ineffective and crew cooperation during recovery was poor. It was considered that crew performance may have been affected by inadequate rest prior to a night flying duty period.  +
On 26 August 2015, contact was lost with an ATR 42-300 making a descent to Oksibil supposedly using detailed Company-provided visual approach guidance over mountainous terrain. Its burnt out wreckage was subsequently located 10 nm from the airport at 4,300 feet aal. The Investigation found that the prescribed guidance had not been followed and that the Captain had been in the habit of disabling the EGPWS to prelude nuisance activations. It was concluded that a number of safety issues identified collectively indicated that the organisational oversight of the aircraft operator by the regulator was ineffective.  +
On 12 November 1999, a French-registered ATR 42-300 being operated by Italian airline Si Fly on a passenger charter flight from Rome to Pristina was positioning for approach at destination in day IMC when it hit terrain and was destroyed, killing all 24 occupants. A post crash fire broke out near the fuel tanks after the impact.  +
On 18 January 2007 an ATR 42-300 freighter developed a control difficulty just after a night take off from Stansted UK, which led the flight crew to declare an emergency and undertake an immediate return to land. The landing was uneventful but the approach flown was unstable, with EGPWS warnings, and the origin of the handling difficulty was considered to be, in part, due to inappropriate control inputs by one of the pilots.  +
On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .  +
During the hours of darkness at Munich on 3 May 2004, an ATR42-500 was given a conditional line up clearance for Runway 08R but contrary to this clearance then taxied onto that runway as a Boeing 737-300 was landing on it. The landing aircraft missed the right wingtip of the ATR-42, which continued taxing onto the runway as it approached, by “a few metres”.  +
On 11 December 2006, a Finnish Commuter Airlines ATR 42-500 veered off the runway on landing at Seinäjoki, Finland.  +
On 7 December 2016, the crew of an ATR 42-500 lost control after airworthiness-related complications followed shutdown of the left engine whilst in the cruise and high speed terrain impact followed. The Investigation concluded that three pre-existing faults with the left engine and its propeller control mechanism had led to a loss of power which had necessitated its shutdown but that these faults had then caused much higher left side drag than would normally result from an engine shutdown and made it progressively more difficult to maintain control. Recovery from a first loss of control was followed by another without recovery.  +
On 27 March 2016 an ATR 42-500 had just departed Esbjerg when the right engine flamed out. It was decided to complete the planned short flight to Billund but on the night IMC approach there, the remaining engine malfunctioned and lost power. The approach was completed and the aircraft evacuated after landing. The Investigation found the left engine failed due to fuel starvation resulting from a faulty fuel quantity indication probably present since recent heavy maintenance and that the right engine had emitted flames during multiple compressor stalls to which it was vulnerable due to in-service deterioration and hot section damage.  +
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.  +
On 1 January 2007, the crew of a ATR 42-500 carried out successive night approaches into Seinajoki Finland including three with EGPWS warnings, one near stall, and one near loss of control, all attributed to poor flight crew performance including use of the wrong barometric sub scale setting.  +
On 26 July 1999, an ATR 72-200 being operated by Mount Cook Airlines on a scheduled passenger flight from Christchurch to Queenstown entered the destination CTR without the required ATC clearance after earlier cancelling IFR and in marginal day VMC due to snow showers, separation was then lost against a Boeing 737-200 being operated IFR by Air New Zealand on a scheduled passenger flight from Auckland to Queenstown which was manoeuvring visually (circling) after making an offset VOR/DME approach in accordance with a valid ATC clearance.  +
On 20 June 2012, an ATR72-200 level at FL140 and a climbing opposite direction Jetstream 32 received and correctly responded to co-ordinated TCAS RAs after ATC error. The controller had not noticed visual MTCD and STCA alerts and had attempted to continue active controlling after a TCAS RA declaration. The Investigation observed that the ineffectiveness of visual conflict alerts had previously featured in a similar event at the same ACC and that the ANSP had advised then that its addition was planned. TCAS RA response controller training was considered to be in need of improvement to make it more effective.  +
On 27 April 2020, an ATR 72-200 freighter crew attempted a night takeoff in good visibility aligned with the edge of runway 06 and did not begin rejecting it until within 20 knots of the applicable V1 despite hearing persistent regular noises which they did not recognise as edge light impacts and so completed the rejection on the same alignment. The Investigation noted both pilots’ familiarity with the airport and their regular work together and attributed their error to their low attention level and a minor distraction during the turnround after backtracking.  +
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.  +
On 5 March 2002, an ATR72-202 departed from runway 22 at Dresden in good visibility at night aligned with the edge lights of the runway without the crew apparently being aware of their error. Damage to both the edge lights and the aircraft was subsequently discovered. The Investigation attributed the error to the crew, concluding that a contributing factor had been that the correctly promulgated and lit runway width represented a reduction from a previously greater width with the surface now outside the runway being of a similar appearance to the actual runway surface.  +
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.  +
On 25 January 2016, an ATR 72-200 crew departing from and very familiar with Karup aligned their aircraft with the runway edge lights instead of the lit runway centreline and began take-off, only realising their error when they collided with part of the arrester wire installation at the side of the runway after which the take-off was rejected. The Investigation attributed the error primarily to the failure of the pilots to give sufficient priority to ensuring adequate positional awareness and given the familiarity of both pilots with the aerodrome noted that complacency had probably been a contributor factor.  +
On 10 November 2010, a Kingfisher Airlines ATR 72-200 made an excessively steep and unstabilised tailwind approach in light rain to runway 27 at Mumbai in visual daylight conditions. After touching down late, the aircraft was steered off the side of the runway when it became obvious that an overrun would otherwise occur. The Investigation found that ATC had failed to advise of water patches on the runway and aquaplaning had occurred. It also found that without aquaplaning, the available distance from the actual touchdown point would have been sufficient to stop the aircraft in.  +
On 17 July 2011, an Aer Arann ATR 72-200 made a bounced daylight landing at Shannon in gusty crosswind conditions aggravated by the known effects of a nearby large building. The nose landing gear struck the runway at 2.3g and collapsed with subsequent loss of directional control and departure from the runway. The aircraft was rendered a hull loss but there was no injury to the 25 occupants. The accident was attributed to an excessive approach speed and inadequate control of aircraft pitch during landing. Crew inexperience and incorrect power handling technique whilst landing were also found to have contributed.  +
On 26 February 2014, an ATR 72-202 which had been substituted for the ATR42 which usually operated a series of night cargo flights was being marshalled out of its parking position with a new flight crew on board when the left wing was in collision with the structure of an adjacent hangar. The Investigation found that the aircraft type had not been changed on the applicable flight plan and ATC were consequently unaware that the aircraft had previously been parked in a position only approved for the use by the usual smaller aircraft type.  +
On 9 October 2018, an ATR 72-200 left the runway during a night landing at Trollhättan before regaining it undamaged and taxiing in normally. The excursion was not reported or observed except by the flight crew. The subsequent discovery of tyre mark evidence led to an Investigation which concluded that the cause of the excursion had been failure of the left seat pilot to adequately deflect the ailerons into wind on routinely taking over control from the other pilot after landing because there was no steering tiller on the right. The non-reporting was considered indicative of the operator’s dysfunctional SMS.  +
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.  +
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.  +
On 15 March 2011, an ATR 72-200 on a non revenue positioning flight from Edinburgh to Paris CDG in night VMC with just the two pilots on board began to experience roll and directional control difficulties as the aircraft accelerated upon reaching the planned cruise altitude of FL230. A ‘PAN’ call was made to ATC and a return to Edinburgh was made with successful containment of the malfunctioning flying controls.  +
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.  +
On 16 October 2013, the crew of an ATR72-600 unintentionally flew their aircraft into the ground in IMC during a go around from an unsuccessful non precision approach at destination Pakse. The Investigation concluded that although the aircraft had followed the prescribed track, the crew had been confused by misleading FD indications resulting from their failure to reset the selected altitude to the prescribed stop altitude so that the decision altitude they had used for the approach remained as the selected altitude. Thereafter, erratic control of aircraft altitude had eventually resulted in controlled flight into terrain killing all on board.  +
On 21 August 2010 a Golden Air Flyg ATR 72 under ATC control in Class ‘C’ airspace was vectored close to three parachutists who had been dropped from a helicopter as part of an air show because of confusion between the ATC unit with responsibility for the incident airspace and the adjacent unit to which that responsibility had been delegated because it was nearest to the air show site. Additional confusion was caused by poor R/T practice by both ATC units and by different portrayal of a holding pattern on charts held by ATC and he flight crew.  +
On 2 April 2012, the crew of an ATR72-200 which had just taken off from Tyumen lost control of their aircraft when it stalled after the flaps were retracted and did not recover before it crashed and caught fire killing or seriously injuring all occupants. The Investigation found that the Captain knew that frozen deposits had accumulated on the airframe but appeared to have been unaware of the danger of not having the airframe de-iced. It was also found that the crew had not recognised the stall when it occurred and had overpowered the stick pusher and pitched up.  +
On 31 October 1994, an ATR 72 exited controlled flight after a flap retraction when descending through 9000 feet was followed by autopilot disconnect and rapid and very large un-commanded roll inputs from which recovery, not within the scope of received crew training, was not achieved. The investigation found this roll upset had been due to a sudden and unexpected aileron hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-icing boots during earlier holding in icing conditions which had been - unknown to the crew - outside the icing certification envelope.  +
On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.  +
On 28 July 2018, a right engine compressor stall on an ATR72-500 bound for Port Vila followed by smoke in the passenger cabin led to a MAYDAY declaration and shutdown of the malfunctioning engine. The subsequent single engine landing at destination ended in a veer-off and collision with two unoccupied parked aircraft. The Investigation noted the disorganised manner in which abnormal/emergency and normal checklists had been actioned and found that the ‘Before Landing’ Checklist had not been run which resulted in the rudder limiter being left in high speed mode making single engine directional control on the ground effectively impossible.  +
On 9 September 2017, an ATR 72-500 crew temporarily lost control of their aircraft when it stalled whilst climbing in light to moderate icing conditions after violation of applicable guidance. Recovery was then delayed because the correct stall recovery procedure was not followed. A MAYDAY declaration due to a perception of continuing ‘control problems’ was followed by a comprehensively unstabilised ILS approach to Madrid. The Investigation concluded that the stall and its sequel were attributable to deficient flight management and inappropriate use of automation. The operator involved was recommended to implement corrective actions to improve the competence of its crews.  +
On 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.  +
On 2 January 2014, the crew of an ATR 72-212A lost forward visibility due to the accumulation of a thick layer of salt deposits on the windshield whilst the aircraft was being radar positioned to an approach at Cork on a track which took it close to and at times over the sea in the presence of strong onshore winds. The Investigation concluded that the prevailing strong winds over and near to the sea in relatively dry air with little visible moisture present had been conducive to high concentrations of salt particles at low levels.  +
On 23 July 2014, a TransAsia Airways ATR 72-500 crashed into terrain shortly after commencing a go around from a VOR approach at its destination in day IMC in which the aircraft had been flown significantly below the MDA without visual reference. The aircraft was destroyed and48 of the 58 occupants were killed. The Investigation found that the accident was entirely attributable to the actions of the crew and that it had occurred in a context of a systemic absence of effective risk management at the Operator which had not been adequately addressed by the Safety Regulator.  +
On 4 March 2016, the flight crew of an ATR72-500 decided to depart from Manchester without prior ground de/anti icing treatment judging it unnecessary despite the presence of frozen deposits on the airframe and from rotation onwards found that manual forward control column input beyond trim capability was necessary to maintain controlled flight. The aircraft was subsequently diverted. The Investigation found that the problem had been attributable to ice contamination on the upper surface of the horizontal tailplane. It was considered that the awareness of both pilots of the risk of airframe icing had been inadequate.  +
On 9 April 2017, an ATR 72-500 crew were unable to obtain a right main landing gear locked down indication during their approach to Nelson and diverted to Palmerston North where the gear did not collapse on landing. The Investigation found the indication had been consequent on failure of both right main gear locking springs due to corrosion and that existing preventative maintenance procedures would not have detected this. It was also noted that contrary to the applicable procedures, the crew had cycled the gear several times which might, but in the event did not, have had significant effects.  +
On 18 February 2018, contact was lost with an ATR72-500 approaching Yasouj and two days later the wreckage of the aircraft was located in mountainous terrain with no sign of survivors. The flight recorders were eventually recovered and their data helped attribute the accident to descent below the designated minimum safe altitude followed by an encounter with severe mountain wave conditions which led to the crew losing control and a terrain impact which destroyed the aircraft and killed all its occupants. An apparently widespread failure to recognise the potential risk of severe mountain wave encounters was also found.  +
On 19 November 2017, an ATR 72-600 being operated by a flight crew who were simultaneously undertaking a routine Line Check during revenue flying made a hard landing at Canberra which caused significant damage to the aircraft. The Investigation noted that the low experience First Officer had mismanaged the final stages of the approach so that it was no longer stabilised and that although the opportunity was there, the Captain had failed to intervene promptly enough to prevent the resulting hard landing. The Check Captain had assessed the imminent landing as likely to be untidy rather than unsafe.  +
On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.  +
On 23 July 2015, an ATR72-600 crew suspected their aircraft was unduly tail heavy in flight. After the flight they found that all passenger baggage had been loaded in the aft hold whereas the loadsheet indicated that it was all in the forward hold. The Investigation found that the person responsible for hold loading as specified had failed do so and that this failure had not been detected by the supervising Dispatcher who had certified the loadsheet presented to the aircraft Captain. Similar loading errors, albeit all corrected prior to flight, were found by the Operator to be not uncommon.  +
On 6 July 2018, an ATR 72-600 followed an unstable approach at Fez with a multiple-bounce landing including a tail strike which caused rear fuselage deformation. The aircraft then continued in operation and the damage was not discovered until first flight preparations the following day. The Investigation found that the Captain supervising a trainee First Officer as handling pilot failed to intervene appropriately during the approach and thereafter had failed to act responsibly. The context for poor performance was assessed as systemic weakness in both the way the ATR fleet was being run and in regulatory oversight of the Operator.  +
On 22 October 2016, an ATR 72-600 Captain failed to complete a normal night landing in relatively benign weather conditions and after the aircraft had floated beyond the touchdown zone, it bounced three times before finally settling on the runway in a substantially damaged condition. The Investigation noted that touchdown followed an unstabilised approach and that there had been little intervention by the First Officer. However, it tentatively attributed the Captain’s poor performance to a combination of fatigue at the end of a repetitive six-sector day and failure of the operator to provide adequate bounced landing recognition and recovery training.  +
On 11 June 2014, an ATR 72-600 sustained substantial damage after hitting an object after touchdown at Surabaya but was able to taxi to post-flight parking. The Investigation found that several sizeable items of equipment had been left on the runway after it had been closed for overnight maintenance work and that no runway inspection had been carried out once the work was complete. It was concluded that departing aircraft had probably become airborne before reaching the reported location and that ATC had reacted with insufficient urgency after beginning to receive FOD reports from previous landing aircraft once daylight prevailed.  +
On 20 February 2014, the mishandling of an ATR 72-600 during descent to Sydney involving opposite control inputs caused an elevator disconnect and a serious cabin crew injury. After recovery of control, the flight was without further event. Post flight inspection did not discover serious structural damage caused to the aircraft and it remained in service for a further five days. The complex Investigation took over five years and examined both the seriously flawed flight crew performance and the serious continued airworthiness failures. Despite extensive safety action in the meantime, the concluding report still made five type airworthiness-related safety recommendations.  +
On 24 August 2016, an ATR 72-600 experienced a static inverter failure which resulted in smoke and fumes which were identifiably electrical. Oxygen masks were donned, a MAYDAY declared and after the appropriate procedures had been followed, the smoke / fumes ceased. The Investigation noted a long history of capacitor failures affecting this unit which continued to be addressed by successive non-mandatory upgrades including another after this event. However, it was also found that there was no guidance on the re-instatement of systems disabled during the initial response to such events, in particular the total loss of AC electrical power.  +
On 14 November 2016, an ATR72-600 crew lost control at FL150 in severe icing conditions. Uncontrolled rolls and a 1,500 feet height loss followed during an apparent stall. After recovery, the Captain announced to the alarmed passengers that he had regained control and the flight was completed without further event. The Investigation found that the crew had been aware that they had encountered severe icing rather than the forecast moderate icing but had attempted to continue to climb which took the aircraft outside its performance limitations. The recovery from the stall was non-optimal and two key memory actions were overlooked.  +
On 9 July 2018, an ATR 72-600 continued a non-precision approach to Al Hoceima below the procedure MDA without obtaining visual reference and subsequently struck the sea surface twice, both times with a vertical acceleration exceeding structural limits before successfully climbing away and diverting to Nador having reported a bird strike. The Investigation attributed the accident to the Captain’s repeated violation of operating procedures which included another descent below MDA without visual reference the same day and the intentional deactivation of the EGPWS without valid cause. There was significant fuselage structure and landing gear damage but no occupant injuries.  +
On 2 September 2016, an ATR72-600 cleared to join the ILS for runway 28 at Dublin continued 800 feet below cleared altitude triggering an ATC safe altitude alert which then led to a go around from around 1000 feet when still over 5nm from the landing runway threshold. The Investigation attributed the event broadly to the Captain’s inadequate familiarity with this EFIS-equipped variant of the type after considerable experience on other older analogue-instrumented variants, noting that although the operator had provided simulator differences training, the -600 was not classified by the certification authority as a type variant.  +
On 15 May 2013, an ATR 72-600 on a visual approach to Moranbah descended sufficiently low in order to avoid entering cloud that a number of TAWS Warnings were activated. All were a consequence of the descent to below 500 feet agl at a high rate of descent which appeared not to have been appreciated by the flight crew. The Investigation found that the option of an available and suitable instrument approach procedure more appropriate for the prevailing low cloud base was ignored.  +
On 4 February 2015, a TransAsia Airways ATR 72-600 crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. They did not realise this until recovery from loss of control due to a stall was no longer possible. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off. Failure to follow SOPs and deficiencies in those procedures were identified as causal.  +
On 22 May 2020, a BAe ATP made a go around after the First Officer mishandled the landing flare at Birmingham and when the Captain took over for a second approach, his own mishandling of the touchdown led to a lateral runway excursion. The Investigation found that although the prevailing surface wind was well within the limiting crosswind component, that component was still beyond both their handling skill levels. It also found that they were both generally inexperienced on type, had not previously encountered more than modest crosswind landings and that their type training in this respect had been inadequate.  +
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.  +
On 9 May 1998, a British Regional Airlines ATP was being pushed back for departure at Jersey in daylight whilst the engines were being started when an excessive engine power setting applied by the flight crew led to the failure of the towbar connection and then to one of the aircraft's carbon fibre propellers striking the tug. A non standard emergency evacuation followed. All aircraft occupants and ground crew were uninjured.  +
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.  +
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.  +
On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.  +
On 29 March 2014, a Beech 1900D being taxied by maintenance personnel at Calgary entered the active runway without clearance in good visibility at night as a Boeing 737-700 was taking off. The 737 passed safely overhead. The Investigation found that the taxiing aircraft had taken a route completely contrary to the accepted clearance and that the engineer on control of the aircraft had not received any relevant training. Although the airport had ASDE in operation, a transponder code was not issued to the taxiing aircraft as required and stop bar crossing detection was not enabled at the time.  +
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.  +
On 12 December 2018, the flight crew of a Beechcraft 1900 landing at the uncontrolled airport at Trail after an into- sun offset visual approach failed to see a runway inspection vehicle coming towards them until after touchdown. Maximum reverse and braking and an increased vehicle speed to exit combined to prevent collision by 4 seconds. The Investigation found that the mandatory airport safety management system was dysfunctional with relevant driver procedures either not followed or nonexistent and noted that two other recent runway incursions had been deemed unrelated to airport operations so that no risk review was carried out.  +
On 17 March 2012, the Captain of a Beech 1900C operating a revenue passenger flight lost control of the aircraft during landing on the 18metre wide runway at destination after an unstabilised day visual approach and the aircraft veered off it into deep snow. The Investigation found that the Operator had not specified any stable approach criteria and was not required to do so. It was also noted that VFR minima had been violated and, noting a fatal accident at the same aerodrome five months previously, concluded that the Operators risk assessment and risk management processes were systemically deficient.  +
On 15 March 2008, a Beech 1900D on a non-revenue positioning flight to a private airstrip in mountainous terrain flown by an inadequately-briefed crew without sufficient guidance or previous relevant experience impacted terrain under power whilst trying to locate the destination visually after failing to respond to a series of GPWS Alerts and a final PULL UP Warning. Whilst attributing the accident to the crew, the Investigation also found a range of contributory deficiencies in respect of the Operator, official charting and ATS provision and additional deficiencies in the conduct of the unsuccessful SAR activity after the aircraft became overdue.  +
On 8 January 2003, a B190, operated by Air Midwest, crashed shortly after take off from Charlotte, NC, USA, following loss of pitch control during takeoff. The accident was attributed to incorrect rigging of the elevator control system compounded by the airplane being outside load and balance limitations.  +
On 14 January 2008, a single pilot Beech 1900C on a non scheduled mail flight which had departed from Honolulu disappeared during a visual dark night approach at its destination. The Investigation concluded that the pilot had become spatially disoriented and lost control of the aircraft.  +
On 18 January 2019, two aircraft taxiing for departure at Helsinki were cleared to cross the landing runway between two landing aircraft. Landing clearance for the second was given once the crossing traffic had cleared as it passed 400 feet in expectation that the previous landing aircraft would also shortly be clear. However, the first landing aircraft was slower than expected clearing the runway and so the second was instructed to go-around but did not then do so because this instruction was lost in the radar height countdown below 50 feet and the runway was seen clear before touchdown.  +
On 10 March 2019, the left angle of attack vane of a Boeing 737-MAX 8 began recording erroneous values shortly after takeoff from Addis Ababa which triggered left stick shaker activation which continued for the remainder of the flight. Immediately after flap retraction was complete, a series of automatic nose down stabiliser trim inputs began, which the pilots were eventually unable to counter after which a high speed dive led to terrain impact six minutes after takeoff. The Investigation is continuing.  +
On 29 October 2018, a Lion Air Boeing 737-MAX 8 crew had difficulty controlling the pitch of their aircraft after takeoff from Jakarta and after eventually losing control, a high speed sea impact followed. The Investigation found that similar problems had also affected the aircraft’s previous flight following installation of a faulty angle-of-attack sensor and after an incomplete post-flight defect entry, rectification had not occurred. Loss of control occurred because the faulty sensor was the only data feed to an undisclosed automatic pitch down system, MCAS, which had been installed on the 737-MAX variant without recognition of its potential implications.  +
On 25 March 2003, the crew of a Bell 412 lost control of the aircraft as a result of pilot mishandling associated with the development of a Vortex Ring State.  +
On 19 March 2009 a BAe 146-200 being operated by South African Airlink on a scheduled passenger flight from George to Cape Town in day VMC experienced a flameout of all four engines during the landing roll at Cape Town. The aircraft had enough momentum to roll forward on the runway and vacate onto a taxiway and the APU continued to provide electrical power to the hydraulic system, which facilitated braking and directional control. It was then towed from the taxiway to the apron and the passengers disembarked normally.  +
On 10 October 2006, a BAE Systems 146-200 being operated by Danish airline Atlantic Airways on a passenger flight from Sola to Stord overran the end of runway 33 at destination at a slow speed in normal visibility at dawn (but just prior to the accepted definition of daylight) before plunging down a steep slope sustaining severe damage and catching fire immediately it had come to rest. The rapid spread of the fire and difficulties in evacuation resulted in the death of four of the 16 occupants and serious injury to six others. The aircraft was completely destroyed.  +
On 28 April 1999, a BAe 146-300 departing Birmingham began its daylight take off from Runway 33 without ATC clearance just prior to the touchdown of a PA38 on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off, just missing the PA38 which had stopped just off the runway 33 centreline. The Investigation noted the 146 pilots belief that a take off clearance had been issued but also that no attempt appeared to have been made to read it back or confirm it with the First Officer.  +
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.  +
On 12 March 2005, the crew of a BAe 146-300 climbing out of Frankfurt lost elevator control authority and an un-commanded descent at up to 4500 fpm in a nose high pitch attitude occurred before descent was arrested and control regained. After landing using elevator trim to control pitch, significant amounts of de/anti-icing fluid residues were found frozen in the elevator/stabilizer and aileron/rudder gaps. The Investigation confirmed that an accumulation of hygroscopic polymer residues from successive applications of thickened de/anti ice fluid had expanded by re-hydration and then expanded further by freezing thus obstructing the flight controls.  +
On 1 December 1969, a Boeing 707-320 being operated by Pan Am and making a daylight take off from Sydney, Australia ran into a flock of gulls just after V1 and prior to rotation and after a compressor stall and observed partial loss of thrust on engine 2 (only), the aircraft commander elected to reject the take off. Despite rapid action to initiate maximum braking and the achievement of full reverse thrust on all engines including No 2, this resulted in an overrun of the end of the runway by 170m and substantial aircraft damage. A full emergency evacuation was carried out with no injuries to any of the occupants. There was no fire.  +
On 12 April 2019, a Boeing 717-200 commenced a go around at Strasbourg because the runway ahead was occupied by a departing Bombardier CRJ700 which subsequently, despite co-ordinated TCAS RAs, then came to within 50 feet vertically when only 740 metres apart laterally as the CRJ, whose crew did not see the 717, passed right to left in front of it. The Investigation attributed the conflict primarily to a series of flawed judgements by the TWR controller involved whilst also noting one absent and one inappropriate ATC procedure which respectively may have provided a context for the resultant risk.  +
On 7 February 2008, a Boeing 717-200 being operated by Australian airline National Jet on a scheduled passenger service from Nhulunbuy (Gove) to Darwin flew an unstabilised night visual approach at the destination and made a very hard landing. The landing roll was completed and the aircraft taxied to the terminal. None of the 94 occupants were injured but the aircraft was suffered substantial structural damage and damage to the left hand main landing gear.  +
On 12 May 2005, a Boeing 717 crew climbed in night IMC without selecting the appropriate anti-icing systems on and as a result lost control. The non-standard crew response led to an eight minute period of pitch excursions which occurred over a 13,000 feet height band at recorded ground speeds between 290 and 552 knots prior to eventual recovery and included a split in control columns some two minutes into the upset. The Investigation concluded that the aircraft had been fully serviceable with all deviations from normal flight initiated or exacerbated by the control inputs of the flight crew.  +
On 28 February 2006, a Boeing 717-200 being operated by National Jet for Qantas Link on a domestic scheduled passenger flight from Paraburdoo to Perth, Western Australia in day IMC experienced an activation of the stall protection system just after the aircraft had levelled at a cruise altitude of FL340. The response of the flight crew was to initiate an immediate descent without either declaring an emergency or obtaining ATC clearance and, as a result, procedural separation against opposite direction traffic at FL320 was lost. The 72 occupants were uninjured and the aircraft was undamaged.  +
On 13 October 2010, a Boeing 717-200 being operated by Cobham Aviation Services Australia for QantasLink on a scheduled passenger flight from Perth to Kalgoorlie Western Australia carried out two consecutive approaches at destination in day VMC which resulted in stick shaker activations and subsequent go arounds. A third approach at a higher indicated airspeed was uneventful and continued to a landing. There were no abrupt manoeuvres and none of the 102 occupants were injured.  +
On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.  +
On 25 December 2003, a Boeing 727-200 being operated by UTA (Guinea) on a scheduled passenger flight from Cotonou to Beirut with a planned stopover at Kufra, Libya, failed to get properly airborne in day VMC from the 2400 metre departure runway and hit a small building 2.45 metres high situated on the extended centreline 118 metres beyond the end of the runway. The right main landing gear broke off and ripped off a part of the trailing edge flaps on the right wing. The airplane then banked slightly to the right and crashed onto the beach where it broke into several pieces and ended up in the sea where the depth of water varied between three and ten metres. Of the estimated 163 occupants, 141 were killed and the remainder seriously injured.  +
On 22 July 2008, a Kelowna Flightcraft Air Charter Ltd. Boeing 727-200 was operating a cargo flight from Moncton NB, to Hamilton, OT. After radar vectoring for an approach to Runway 06 at Hamilton, the aircraft touched down hard and bounced before touching down hard a second time. Immediately after the second touchdown, a go-around was initiated. During rotation, the tailskid made contact with the runway. The thrust reverser actuator fairing and the number 2 engine tailpipe made contact with the ground off the departure end of the runway. The aircraft climbed away and then returned for a normal landing on Runway 12. There were no injuries; the aircraft sustained only minor damage.  +
On 7 September 2006, a DHL Boeing 727-200 overran the runway at Lagos by 400 metres after the First Officer was permitted to attempt a landing in challenging weather conditions on a wet runway off an unstable ILS approach. Following a long and fast touchdown at maximum landing weight, a go around was then called after prior selection of thrust reversers but was not actioned and a 400 metre overrun onto soft wet ground followed. The accident was attributed to poor tactical decision making by the aircraft commander.  +
On 24 March 2010, a Boeing 727-200 being operated by Canadian company Cargojet AW on a scheduled cargo flight from Hamilton Ontario to Moncton New Brunswick failed to stop after a night landing on 1875 metre long runway 06 at destination in normal ground visibility and eventually stopped in deep mud approximately 100 metres beyond the runway end and approximately 40 metres past the end of the paved runway end strip. The three operating flight crew, who were the only occupants, were uninjured and the aircraft received only minor damage.  +
On 29 February 2004, a Boeing 737-200 crossed an active runway in normal daylight visibility ahead of a departing Airbus A321, the crew of which made a high speed rejected take off upon sighting the other aircraft after hearing its crossing clearance being confirmed. Both aircraft were found to have been operating in accordance with their acknowledged ATC clearances issued by the same controller. An alert was generated by the TWR conflict detection system but it was only visually annunciated and had not been noticed. Related ATC procedures were subsequently reviewed and improved.  +
On 20 October 1993, a Boeing 737-200 being operated by Air Malta on a scheduled passenger flight from Malta to London Gatwick landed at destination on the taxiway parallel to the runway for which landing clearance had been given in good visibility at night after a Surveillance Radar Approach (SRA) terminating at 2 miles from touchdown had been conducted in VMC. There was no damage to the aircraft or injury to the occupants and the aircraft taxied to the allocated gate after the landing.  +
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.  +
On 5 September 2005, a Boeing 737-200 being operated by Mandala Airlines on a scheduled domestic passenger flight from Medan, Indonesia to Jakarta failed to become properly airborne during the attempted take off from from runway 23 in day VMC and, after failing to remain airborne, overran the end of the runway at speed finally coming to a stop outside the airport perimeter. The aircraft was destroyed by impact forces and a subsequent fire and 100 of the 117 occupants were killed and 15 seriously injured. The aircraft collided with residential property, vehicles and various other obstructions and as a result a further 49 people on the ground were killed and a further 26 seriously injured.  +
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.  +
On 30 October 2006, at Seattle-Tacoma International Airport, Seattle, Washington a Boeing 737-200 operated by Alaska Airlines, took off in daylight from a runway parallel to that which had been cleared with no actual adverse consequences.  +
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.  +
On 29 October 2006, an ADC Airlines’ Boeing 737-200 encountered wind shear almost immediately taking off from Abuja into adverse weather associated with a very rapidly developing convective storm. Unseen from the apron or ATC TWR it stalled, crashed and burned after just over one minute airborne killing 96 of the 105 occupants. The Investigation concluded that loss of control during the wind shear encounter was not inevitable but was a consequence of inappropriate crew response. Concerns about the quality of crew training and competency validation were also raised.  +
On 20 April 2012, the crew of a Boeing 737-200 encountered negative wind shear during an ILS final approach at night in lMC and failed to respond with the appropriate recovery actions. The aircraft impacted the ground approximately 4 nm from the threshold of the intended landing runway. The Investigation attributed the accident to the decision to continue to destination in the presence of adverse convective weather and generally ineffective flight deck management and noted that neither pilot had received training specific to the semi-automated variant of the 200 series 737 being flown and had no comparable prior experience.  +
On 20 August 2011, a First Air Boeing 737-200 making an ILS approach to Resolute Bay struck a hill east of the designated landing runway in IMC and was destroyed. An off-track approach was attributed to the aircraft commander’s failure to recognise the effects of his inadvertent interference with the AP ILS capture mode and the subsequent loss of shared situational awareness on the flight deck. The approach was also continued when unstabilised and the Investigation concluded that the poor CRM and SOP compliance demonstrated on the accident flight were representative of a wider problem at the operator.  +
On 6 March 2003, a Boeing 737-200 being operated by Air Algerie had just become airborne during a daylight departure when the left hand engine suddenly failed just after the PF had called for “gear up”. Shortly afterwards, the aircraft commander, who had been PNF for the departure, took control but the normal pitch attitude was not reduced to ensure that a minimum airspeed of V2 was maintained and landing gear was not retracted. The aircraft lost airspeed, stalled and impacted the ground approximately 1nm from the point at which it had become airborne. A severe post crash fire occurred and the aircraft was destroyed and all on board except one passenger, were killed.  +
On 13 January 1982, an Air Florida Boeing 737-200 took off in daylight from runway 36 at Washington National in moderate snow but then stalled before hitting a bridge and vehicles and continuing into the river below after just one minute of flight killing most of the occupants and some people on the ground. The accident was attributed entirely to a combination of the actions and inactions of the crew in relation to the prevailing adverse weather conditions and, crucially, to the failure to select engine anti ice on which led to over reading of actual engine thrust.  +
On 23 July 2006, a Boeing B737-300 operated by United Airlines executed an early rotation during a night take off when a Boeing 747 operated by Atlas Air was observed on a landing roll on an intersecting runway at Chicago O’Hare Airport. The occurrence is attributed to ATC error.  +
On 4 August 2014, a Boeing 737-300 making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown by the crew of a DHC8-400 which was taxiing along the same taxiway in the opposite direction. This resulted in a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.  +
On 1 February 1991, a Boeing 737-300 had just made a normal visibility night touchdown on Los Angeles runway 24L in accordance with its clearance when its crew saw another aircraft stationary ahead of them on the same runway. Avoidance was impossible in the time available and a high speed collision and post-impact fire destroyed both aircraft and killed 34 of their 101 occupants and injured 30 others. The other aircraft was subsequently found to have been a Fairchild Metroliner cleared to line up and wait by the same controller who had then cleared the 737 to land.  +
On 18 December 2010, the ATC Runway Controller responsible for runway 24 at Amsterdam gave a daylight take off clearance in normal visibility to a Norwegian Boeing 737-300 whilst a bird control vehicle which they had earlier given clearance to enter the runway was still on it. The departing aircraft overflew the vehicle without noticing it. The subsequent investigation highlighted significant differences between the procedures for active runway access at Amsterdam and corresponding international practice as well as finding that integrated safety investigation and overall safety management at the airport were systemically ineffective.  +
On 10 February 2010 a KLM Boeing 737-300 unintentionally made a night take off from Amsterdam in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation noted the familiarity of the crew with the airport and identified apparent complacency.  +
On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.  +
On 6 February 2009, the crew of a Boeing 737-300 departing Birmingham successfully rejected take off from well above V1 when it became clear to the First Officer as handling pilot, that it was impossible to rotate. The Investigation found that cause of the rotation difficulty was that the crew had failed to set the stabiliser trim to the appropriate position for take off after delaying this action beyond the normal point in pre flight preparations because ground de icing was in progress and not subsequently noticing.  +
On 21 September 2012, an Aurela Boeing 737-300 lost directional control and left the paved surface when attempting to turn off the landing runway at Birmingham expeditiously to avoid the following aircraft having to go around. The Investigation noted that the range of the approaching aircraft - still 2.5nm as the incident aircraft began to clear the runway - had not been communicated and concluded that the speed of the aircraft had been inappropriate for the prevailing wet surface conditions as well as unnecessary to prevent a go around by the following aircraft.  +
On 5 March 2000, a Boeing 737-300 being operated by Southwest Airlines on a scheduled passenger flight from Las Vegas to Burbank overran the landing destination runway in normal day visibility after a steep visual approach had been flown at an abnormally high speed. The aircraft exited the airport perimeter and came to a stop on a city street near a gas station. An emergency evacuation of the 142 occupants led to 2 serious injuries and 42 minor injuries and the aircraft was extensively damaged.  +
On 14 April 2012, a Titan Airways Boeing 737-300 attempted to take off from Chambery with incorrect reference speeds taken from the EFB used for performance calculations. As a consequence, the pressure hull was damaged by a tail strike during take off, although not sufficiently to affect cabin pressure during the subsequent flight. The Investigation concluded that the accident raised regulatory issues in respect of the general design and use of EFB computers to calculate performance data.  +
On 15 December 2015, a Boeing 737-300 crew inadvertently taxied their aircraft off the side of the taxiway into a ditch whilst en route to the gate after landing at Nashville in normal night visibility. Substantial damage was caused to the aircraft after collapse of the nose landing gear and some passengers sustained minor injuries during a subsequent cabin crew-initiated evacuation. The Investigation found that taxiing had continued when it became difficult to see the taxiway ahead in the presence of apron lighting glare after all centreline and edge lighting in that area had been inadvertently switched off by ATC.  +
On 15 June 2006 a TNT Belgium-operated Boeing 737-300 on diversion to East Midlands because of poor destination weather made an unintended ground contact 90 metres to one side of the intended landing runway whilst attempting to initiate a go around after a mis-flown daylight Cat 3A ILS approach. The RH MLG assembly broke off before the aircraft left the ground again and climbed away after which it was then flown to nearby Birmingham for a successful emergency landing. The subsequent investigation attributed the poor aircraft management which led to the accident to pilot distraction.  +
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.  +
On 13 October 2012, the crew of a Boeing 737-300 destined for the new Padang airport at Minangkabau inadvertently landed their aircraft on runway 34 at the old Padang Airport at Tabing which has a similarly-aligned runway. The Investigation found that the Captain disregarded ILS indications for the correct approach after visually acquiring the similarly aligned runway when the correct runway was not also in sight. Since the chosen runway was some 6 miles ahead of the intended one, a high descent rate achieved through sideslip, followed with this unstable approach, continued to an otherwise uneventful landing.  +
On 13 September 2016, a Boeing 737-300 made an unstabilised approach to Wamena and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in collapse of the main landing gear, loss of directional control and a lateral runway excursion. The Investigation found that the approach had been carried out with both the cloudbase and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.  +
On 20 December 2011, the experienced Captain of a Sriwijaya Air Boeing 737-300 flew an unstabilised non-precision approach to a touchdown at Yogyakarta at excessive speed whilst accompanied by a very inexperienced First Officer. The aircraft overran the end of the 2200 metre-long wet runway by 75 metres . During the approach, the Captain 'noticed' several GPWS PULL UP Warnings but no action was taken. The Investigation attributed the accident entirely to the actions of the flight crew and found that there had been no alert calls from the First Officer in respect of the way the approach was flown.  +
On 2 September 1999, a United Airlines Boeing Boeing 737-300 in the cruise at FL240, experienced severe turbulence due to an encounter with the wake vortex from a preceding MD11 on a similar track which had climbed through the level of the B737 with minimum lateral separation, 1.5 minutes earlier.  +
On 2 May 2009, a Boeing 737-300 being operated by French airline Europe Airpost on a passenger charter flight from Marseille to Antalya, Turkey was descending in day VMC towards destination when a sudden and severe turbulence encounter led to a temporary loss of control and stall. Recovery was achieved and none of the 115 occupants was injured and the aircraft was undamaged.  +
On 1 April 2011, a Southwest Boeing 737-300 climbing through FL340 experienced a sudden loss of pressurisation as a section of fuselage crown skin ruptured. A successful emergency descent was made with a diversion to Yuma, where the aircraft landed half an hour later. Investigation found that the cause of the failure was an undetected manufacturing fault in the 15 year-old aircraft. One member of the cabin crew and an off duty staff member who tried to assist him became temporarily unconscious after disregarding training predicated on the time of useful consciousness after sudden depressurisation.  +
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.  +
On 18 July 2006, a Boeing 737-300 being operated by a Spanish Airline commenced a daylight non precision approach with a 12 degree offset FAT towards Belfast Aldergrove but then made an unstable descent to 200 feet agl towards an unlicensed runway at a different airport before being told by ATC radar to go around. A further also unstable approach to the correct airport/runway followed. The Investigation noted that there were multiple cues indicating that an approach to the wrong airport was being made and was not able to establish any reason why two successive unstable approaches were not discontinued  +
On 23 September 2007, the pilots of a Thomsonfly Boeing 737-300 almost lost control of their aircraft after initiating a go around from an unstable low airspeed and low thrust condition reached progressively but unnoticed during an approach to Bournemouth at night. Mismanagement of the aircraft during the go around was attributed to a lack of adequate understanding of the aircraft pitch control system and led to extreme pitch and an aerodynamic stall but the crew subsequently recovered control of the aircraft and an uneventful second approach and normal landing followed.  +
On 7 February 2010, a Boeing 737-300 being operated by Jet2 on a scheduled passenger flight from Leeds/Bradford UK to Chambery France was making an ILS approach to runway 18 at destination in day IMC when a Mode 2 EGPWS ‘Terrain, Pull Up’ Warning occurred. A climb was immediately initiated to VMC on top and a second ILS approach was then made uneventfully. Despite extreme pitch during the early stages of the pull up climb, none if the 109 occupants, all secured for landing, were injured.  +
On 26 March 2008, a Ukraine International Airlines’ Boeing 737-300 being vectored by ATC to the ILS at destination Helsinki in IMC descended below its cleared altitude and came close to a telecommunications mast. ATC noticed the deviation and instructed a climb. The investigation attributed the non-compliance with the accepted descent clearance to the failure of the flight crew to operate in accordance with SOPs. It was also noted that the way in which ATC safety systems were installed and configured at the time of the occurrence had precluded earlier ATC awareness of the hazard caused by the altitude deviation.  +
On 12 June 2015, a Boeing 737-300 crew forgot to set QNH before commencing a night non-precision approach to Kosrae which was then flown using an over-reading altimeter. EGPWS Alerts occurred due to this mis-setting but were initially assessed as false. The third of these occurred when the eventual go-around was initially misflown and descent to within 200 feet of the sea occurred before climbing. The Investigation noted failure to action the approach checklist, the absence of ATC support and the step-down profile promulgated for the NDB/DME procedure flown as well as the potential effect of fatigue on the Captain.  +
On 1 August 1997, an Air Malta B737, descending for an approach into Manchester UK in poor weather, descended significantly below the cleared and correctly acknowledged altitude, below MSA.  +
On 10 January 2011, a Europe Airpost Boeing 737-300 taking off from Montpelier after repainting had just rotated for take off when the leading edge slats extended from the Intermediate position to the Fully Extended position and the left stick shaker was activated as a consequence of the reduced stalling angle of attack. Initial climb was sustained and soon afterwards, the slats returned to their previous position and the stick shaker activation stopped. The unexpected configuration change was attributed to paint contamination of the left angle of attack sensor, the context for which was inadequate task guidance.  +
On 8 September 1994, a US Air Boeing 737-300 crashed near Pittsburg USA following loss of control attributed to a rudder malfunction.  +
On 3 January 3 2004, a Boeing 737-300 being operated by Flash Airlines on a passenger charter flight from Sharm el-Sheikh Egypt to Cairo for a refuelling stop en route to Paris CDG crashed into the sea 2½ minutes after a night take off into VMC and was destroyed and all 148 occupants killed. The Investigation was unable to establish a Probable Cause but found evidence of AP status confusion and the possibility of distraction leading to insufficient attention being paid to flight path control.  +
On 28 September 2016, a Boeing 737-400 and a Cessna 172 both on IFR Flight Plans came into close proximity when about to turn final on the same non-precision approach at Girona from different initial joining routes. The Investigation found that two ACC sector controllers had issued conflicting approach clearances after losing situational awareness following a routine sector split due to an area ATC flow configuration change. The detection of the consequences of their error had then been hindered by a temporary area low level radar outage but helped by timely visual acquisition by both aircraft and a TCAS RA.  +
On 12 November 1996, a B737-400 descended below its assigned level in one of the holding patterns at London Heathrow in day IMC to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level, 1000 feet below. STCA prompted ATC to intervene and the 737 climbed back to its cleared level. Neither aircraft was fitted with TCAS 2 or saw the other visually.  +
Significant damage was caused to the tailplane and elevator of a Boeing 737-400 after the pavement beneath them broke up when take off thrust was applied for a standing start from the full length of the runway at Aberdeen. Although in this case neither outcome applied, the Investigation noted that control difficulties consequent upon such damage could lead to an overrun following a high speed rejected takeoff or to compromised flight path control airborne. Safety Recommendations on appropriate regulatory guidance for marking and construction of blast pads and on aircraft performance, rolling take offs and lead-on line marking were made.  +
On 6 June 2010, a Boeing 737-400 being operated by Atlas Blue, a wholly owned subsidiary of Royal Air Maroc, on a passenger flight from Amsterdam to Nador, Morocco encountered a flock of geese just after becoming airborne from runway 18L in day VMC close to sunset and lost most of the thrust on the left engine following bird ingestion. A MAYDAY was declared and a minimal single engine climb out was followed by very low level visual manoeuvring not consistently in accordance with ATC radar headings before the aircraft landed back on runway 18R just over 9 minutes later.  +
On 2 October 2010 a Boeing 737-400 being operated by Turkish operator Corendon Airlines on a passenger flight from Dalaman to Amsterdam made a late touchdown on landing runway 22 at destination in normal daylight visibility conditions and failed to stop before the end of the runway. The overrun occurred at low speed and there were no injuries to the 173 occupants and only minor damage to the aircraft.  +
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.  +
On 18th January 2001, a Qantas Boeing 737-400 encountered a Microburst while conducting a go-around at Brisbane Australia.  +
On 10 December 2016, a Boeing 737-400 main gear leg collapsed on landing after an approach at excessive speed was followed by a prolonged float prior to touchdown on the high-altitude Kabul runway. The Investigation found that the collapse had followed a severe but very brief wheel shimmy episode in the presence of a number of factors conducive to this risk which the aircraft operator’s pilots had not been trained to avoid. It was also found that although the aircraft operator regularly undertook wet lease contract flying, their pilot training policy did not include any route or aerodrome competency training.  +
On 3 November 2015, a Boeing 737-400 continued an unstabilised day approach to Lahore. When only the First Officer could see the runway at MDA, he took over from the Captain but the Captain took it back when subsequently sighting it. Finally, the First Officer took over again and landed after recognising that the aircraft was inappropriately positioned. Both main gear assemblies collapsed as the aircraft veered off the runway. The Investigation attributed the first collapse to the likely effect of excessive shimmy damper play and the second collapse to the effects of the first aggravated by leaving the runway.  +
On 2 October 2008, a Boeing 737-400 being used for flight crew command upgrade line training unintentionally landed off a non precision approach at Palembang in daylight on a taxiway parallel to the landing runway. Neither pilot realised their error until the aircraft was already on the ground when they saw a barrier ahead and were able to brake hard to stop only 700 metres from touchdown. It was found that the taxiway involved had served as a temporary runway five years earlier and that previously obliterated markings from that use had become visible.  +
On 24 September 2015, a Boeing 737-400 cleared for a night take-off from Sharjah took off from the parallel taxiway. The controller decided that since the taxiway was sterile and the aircraft speed was unknown, the safest option was to allow the take-off to continue. The Investigation noted that the taxiway used had until a year previously been the runway, becoming a parallel taxiway only when a new runway had been opened alongside it. It was noted that the controller had "lost visual watch" on the aircraft and regained it only once the aircraft was already at speed.  +
On 5 May 2017, a Boeing 737-400 made a visual approach to Timbuktu and slightly overran the end of the 2,170 metre-long runway into soft ground causing one of the engines to ingest significant quantities of damaging debris. The Investigation found that the landing had been made with a significantly greater than permitted tailwind component but that nevertheless had the maximum braking briefed been used, the unfactored landing distance required would have been well within that available. The preceding approach was found to have been comprehensively unstable throughout with no call for or intent to make a go around.  +
On 7 March 2007, a Boeing 737-400 being operated by Garuda landed on a scheduled passenger flight from Jakarta to Yogyakarta overran the end of the destination runway at speed in normal daylight visibility after a late and high speed landing attempt ending up 252 metres beyond the end of the runway surface in a rice paddy field. There was a severe and prolonged fire which destroyed the aircraft (see the illustration below taken from the Investigation Report) and 21 of the 140 occupants were killed, 12 seriously injured, 100 suffered minor injuries and 7 were uninjured.  +
On 11 October 2013, the commander of a Boeing 737-400 taxiing on wet taxiways at night after landing at Zurich became uncertain of his position in relation to the clearance received and when he attempted to manoeuvre the aircraft off the taxiway centreline onto what was believed to be adjacent paved surface, it became bogged down in soft ground. The Investigation considered the direct cause of the taxiway excursion was not following the green centreline lights but it recommended improvements in the provision of clear and consistent taxi instructions and in taxiway designations in the area of the event.  +
On 23 February 1995, a British Midland Boeing 737-400 made an emergency landing at Luton airport UK after losing most of the oil from both engines during initial climb out from East Midlands airport UK, attributed to failures in the quality of maintenance work and procedures during routine inspections of both engines prior to the flight.  +
On 11 August 2007, a Qantas Boeing 737-400 on a scheduled passenger service from Perth, WA to Sydney, NSW was about three quarters of the way there in day VMC when the master caution light illuminated associated with low output pressure of both main tank fuel pumps. The flight crew then observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position and he immediately selected them to the ON position. The flight was completed without further event.  +
On 1 January 2007, a B737-400 crashed into the sea off Sulawesi, Indonesia, after the crew lost control of the aircraft having become distracted by a minor technical problem.  +
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.  +
On 12 October 2018, the crew of a Boeing 737-400 already released to service under MEL conditions with an inoperative No 1 engine generator encountered a loss of services from the No 2 electrical system en-route to East Midlands which created a situation not addressed by QRH procedures. The flight was completed and both the new and existing defects were subsequently rectified relatively easily. The Investigation concluded that the operator involved appeared to be prioritising operational requirements over aircraft serviceability issues and made a range of Safety Recommendations aimed at improving company safety culture and the effectiveness of regulatory oversight.  +
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.  +
On 7 September 2010, a Turkish operated Boeing 737-400 flew a non precision approach at Lyon Saint-Exupéry in IMC significantly below the procedure vertical profile throughout and only made a go around when instructed to do so by ATC following an MSAW activation. The minimum recorded radio height was 250 feet at 1.4nm from the runway threshold.  +
Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.  +
On 24 August 2010, a Boeing 737-500 made an uncontrolled touchdown on a wet runway at Jos in daylight after the approach was continued despite not being stabilised. A lateral runway excursion onto the grass occurred before the aircraft regained the runway centreline and stopped two-thirds of the way along the 3000 metre-long runway. Substantial damage was caused to the aircraft but none of the occupants were injured. The aircraft commander was the Operator's 737 Fleet Captain and the Investigation concluded that the length of time he had been on duty had led to fatigue which had impaired his performance.  +
On 21 August 2006, a Boeing 737-500 suffered a nose landing gear collapse during towing at the Newark Liberty International Airport. A technical crew was repositioning the aircraft in visual meteorological conditions during the occurrence. No persons were injured and minor aircraft damage occurred.  +
On 5 September 1996, a Boeing 737-500 operated by British Midland, encountered severe wake turbulence whilst in the hold over London. The wake was attributed to a B767 some 6 nm ahead.  +
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.  +
On 9 January 2021, contact was lost with a Boeing 737-500 as it approached 11,000 feet less than five minutes after departing Jakarta in daylight. It was subsequently found to have entered a rapid descent whilst in unexceptional weather conditions and been destroyed by sea surface impact which killed all 62 occupants. The Investigation is ongoing but is currently focusing on finding an explanation for the apparently uncommanded but progressive asymmetric thrust reduction which culminated in a wing drop and a consequent loss of control. An initial recommendation has been made requiring effective Upset Prevention and Recovery Training.  +
On 3rd December 1999, a Boeing 737-500 being operated by Maersk Air on a scheduled passenger flight from Birmingham to Copenhagen made a successful diversion to Billund in conditions of poor weather across the whole of the destination area after a go around at the intended destination but but landed with less than Final Reserve Fuel.  +
On 17 November 2013, the crew of a Boeing 737-500 failed to establish on the ILS at Kazan after not following the promulgated intermediate approach track due to late awareness of LNAV map shift. A go around was eventually initiated from the unstabilised approach but the crew appeared not to recognise that the autopilot used to fly the approach would automatically disconnect. Non-control followed by inappropriate control led to a high speed descent into terrain less than a minute after go around commencement. The Investigation found that the pilots had not received appropriate training for all-engine go arounds or upset recovery.  +
On 7 June 2007, a Boeing 737-500 operated by LOT Polish Airlines, after daylight takeoff from London Heathrow Airport lost most of the information displayed on Electronic Flight Instrument System (EFIS). The information in both Electronic Attitude Director Indicator (EADI) and Electronic Horizontal Situation Indicators (EHSI) disappeared because the flight crew inadvertently mismanaged the Flight Management System (FMS). Subsequently the crew had difficulties both in maintaining the aircraft control manually using the mechanical standby instruments and communicating adequately with ATC due to insufficient language proficiency. Although an emergency situation was not declared, the ATC realized the seriousness of the circumstances and provided discrete frequency and a safe return after 27 minutes of flight was achieved.  +
On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase. The Investigation found that a malfunction which probably prevented use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for inability to control the aircraft manually given that dispatch without either autopilot working is permitted.  +
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.  +
On 16 August 2001, a Continental Boeing 737-500 which had just landed on runway 18R at Dallas-Fort-Worth crossed runway 18L in daylight in front of a Delta Boeing 737-300 which had originally been believed to be holding position but was then seen to be taking off from the same runway. The Delta aircraft rotated early and sharply to overfly the crossing aircraft and suffered a tail strike in doing so. Clearance was estimated to have been about 100 feet. Both aircraft were being operated in accordance with valid ATC clearances issued by the same controller.  +
On 5 June 2015, a Boeing 737-600 landed long on a wet runway at Montréal and the crew then misjudged their intentionally-delayed deceleration because of an instruction to clear the relatively long runway at its far end and were then unable to avoid an overrun. The Investigation concluded that use of available deceleration devices had been inappropriate and that deceleration as quickly as possible to normal taxi speed before maintaining this to the intended runway exit was a universally preferable strategy. It was concluded that viscous hydroplaning had probably reduced the effectiveness of maximum braking as the runway end approached.  +
On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.  +
On 2 July 2008, an Air Tran Airways B737-700 which had just landed at night on runway 34C at Sea-Tac failed to hold clear of runway 34R during taxi as instructed and passed almost directly underneath a North West Airlines A330-200 which had just become airborne from Runway 32R. The Investigation found that the 737 crew had been unaware of their incursion and that the alert provided by ASDE-X had not provided an opportunity for ATC to usefully intervene to stop prevent the potential conflict  +
On 11 May 2006, B737-700 taking off from Geneva came into close proximity with a Boeing Business Jet (BBJ) on a non revenue positioning flight which had commenced a go around from the same runway following an unstabilised approach. The Investigation attributed the conflict to the decision of ATC to give take off clearance to the departing aircraft when the approach of the inbound aircraft could have been seen as highly likely to result is a go around which would lead to proximity with the slower departing aircraft.  +
On 29 March 2018, a Boeing 737-700 commenced a late go-around from landing at Amsterdam on a runway with an extended centreline which passed over another runway from which a Boeing 737-800 had already been cleared for takeoff. An attempt by the controller responsible for both aircraft to stop the departing aircraft failed because the wrong callsign was used, so low level divergent turns were given to both aircraft and 0.5nm lateral and 300 feet vertical separation was achieved. The Investigation concluded that the ATC procedure involved was potentially hazardous and made a safety recommendation that it should be withdrawn.  +
On 29 December 2006, Geneva ATC saw the potential for runway 23 conflict between a departing 737 and an inbound F100 and instructed them to respectively reject take off and go around respectively. Although still at a relatively slow speed, the 737 continued its take off and subsequently lost separation in night IMC against the F100. The Investigation noted that take off clearance for the 737 had been delayed by a slow post-landing runway clearance by a business jet and that the 737 had not begun take off after clearance to do so until instructed to do so immediately.  +
On 17 November 2007 a Boeing 737-700 made an emergency descent after the air conditioning and pressurisation system failed in the climb out of Coolangatta at FL318 due to loss of all bleed air. A diversion to Brisbane followed. The Investigation found that the first bleed supply had failed at low speed on take off but that continued take off had been continued contrary to SOP. It was also found that the actions taken by the crew in response to the fault after completing the take off had also been also contrary to those prescribed.  +
n 22 December 2003, a Boeing 737-700 being operated by UK Operator Easyjet on a scheduled passenger flight from Amsterdam to London Gatwick was taxiing for departure at night in normal visibility and took a different route to that instructed by ATC. The alternative route was, unknown to the flight crew, covered with ice and as a consequence, an attempt to maintain directional control during a turn was unsuccessful and the aircraft left wing collided with a lamp-post. The collision seriously damaged the aircraft and the lamp post. One passenger sustained slight injuries because of the impact. The diagram below taken from the official investigation report shows the area where the collision occurred.  +
On 26 April 2011 a Southwest Boeing 737-700 was assessed as likely not to stop before the end of landing runway 13C at alternate Chicago Midway in daylight and was intentionally steered to the grass to the left of the runway near the end, despite the presence of a EMAS. The subsequent investigation determined that the poor deceleration was a direct consequence of a delay in the deployment of both speed brakes and thrust reverser. It was noted that the crew had failed to execute the ‘Before Landing’ Checklist which includes verification of speed brake arming.  +
On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots’ lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.  +
On 9 January 2012, an Enerjet Boeing 737-700 overran the landing runway 03 at Fort Nelson by approximately 70 metres after the newly promoted Captain continued an unstabilised approach to a mis-managed late-touchdown landing. The subsequent Investigation attributed the accident to poor crew performance in the presence of a fatigued aircraft commander.  +
On 7 January 2016, a Boeing 737-700 was inadvertently cleared by ATC to take off on a closed runway. The take-off was commenced with a vehicle visible ahead at the runway edge. When ATC realised the situation, a 'stop' instruction was issued and the aircraft did so after travelling approximately 740 metres. Investigation attributed the controller error to "lost situational awareness". It also noted prior pilot and controller awareness that the runway used was closed and that the pilots had, on the basis of the take-off clearance crossed a lit red stop bar to enter the runway without explicit permission.  +
On 18 June 2013, a Boeing 737-800 crew en route to Adelaide learned that un-forecast below-minima weather had developed there and decided to divert to their designated alternate, Mildura, approximately 220nm away where both the weather report and forecast were much better. However, on arrival at Mildura, an un-forecast rapid deterioration to thick fog had occurred with insufficient fuel to divert elsewhere. The only available approach was flown to a successful landing achieved after exceeding the minimum altitude by 240 feet to gain sight of the runway. An observation immediately afterwards gave visibility 900 metres in fog with cloudbase 100 feet.  +
On 22 July 2013 the Captain of a Boeing 737-700 failed to go around when the aircraft was not stabilised on final approach at La Guardia and then took control from the First Officer three seconds before touchdown and made a very hard nose first touchdown which substantially damaged the aircraft. The Investigation concluded that the accident had been a consequence of the continued approach and the attempt to recover with a very late transfer of control instead of a go around as prescribed by the Operator. The aircraft was "substantially damaged".  +
On 27 October 2016, a Boeing 737-700 crew made a late touchdown on the runway at La Guardia and did not then stop before reaching the end of the runway and entered - and exited the side of - the EMAS before stopping. The Investigation concluded that the overrun was the consequence of a failure to go around when this was clearly necessary after a mishandled touchdown and that the Captain's lack of command authority and a lack of appropriate crew training provided by the Operator to support flight crew decision making had contributed to the failure to go around.  +
On 16 November 2017, a Boeing 737-700 departing Singapore Seletar was observed by ATC to only become airborne very near the end of the runway and to then climb only very slowly. Ten approach lights were subsequently found to have been impact-damaged by contact with the aircraft. The Investigation found that after the crew had failed to follow procedures requiring them to validate the FMC recalculation of modified takeoff performance data against independent calculations made on their EFBs, takeoff was made with reduced thrust instead of the full thrust required. The modification made was also found not to have been required.  +
On 21 Nov 2010, a Boeing 737-700 being operated by Arik Air on a non revenue positioning flight from Southend to Lagos with only the two pilots on board carried out a successful take off in daylight and normal ground visibility from runway 06 but became airborne only just before the end of the runway.  +
On 17 April 2018, sudden uncontained left engine failure occurred to a CFM56-7B powered Boeing 737-700 when climbing through approximately FL320. Consequent damage included a broken cabin window causing rapid decompression and a passenger fatality. Diversion to Philadelphia without further significant event then followed. A single fan blade was found to have failed due to undetected fatigue. The Investigation noted that the full consequences of blade failure had not been identified during engine / airframe type certification nor fully recognised during investigation of an identical blade failure event in 2016 which had occurred to another of the same operator’s 737-700s.  +
On 27 August 2016, debris from sudden uncontained failure of the left CFM56-7B engine of a Boeing 737-700 climbing through approximately FL 310 west southwest of Pensacola in day VMC penetrated the fuselage barrel and caused a rapid depressurisation. An emergency descent and a diversion to Pensacola followed without further event. The Investigation found that collateral damage had followed low-cycle fatigue cracking of a single fan blade due to a previously unrecognised weakness in the design of this on-condition component which, because it had not been detected during the engine certification process, meant its consequences “could not have been predicted”.  +
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.  +
On 12 January 2014, a Boeing 737-700 making a night visual approach to Branson advised 'field in sight' approximately 20 miles out and was transferred to TWR and given landing clearance at approximately 6,000 feet. However, the crew had misidentified the airport and subsequently landed on a similarly-orientated runway at a different airport. The Investigation found that required flight crew procedures for such an approach had not been followed and also that applicable ATC procedures for approval of visual approaches by IFR flights were conducive to pilot error in the event that airports were located in close proximity.  +
On 5 November 2011, ATC cleared a Virgin Australia Boeing 737-700 to climb without speed restriction through an active parachute Drop Zone contrary to prevailing ATC procedures. As a result, prescribed separation from the drop zone was not maintained, but an avoiding action turn initiated by the 737 crew in VMC upon recognising the conflict eliminated any actual risk of collision with either the drop aircraft or its already-departed free-fall parachutists. The incident was attributed to a combination of inadequate controller training and inadequate ATC operational procedures.  +
On 1 December 2011 a Southwest Boeing 737-700 was cleared to taxi in after landing on a route which included crossing another active runway before contacting GND and the controller who had issued that clearance then inadvertently issued a take off clearance to a Gama Charters Learjet 45 for the runway to be crossed. One of the 737 pilots saw the approaching Learjet and warned the PF to stop as the runway crossing was about to begin. The departing aircraft then overflew the stationary 737 by 62 feet after rotating shortly before the crossing point without seeing it.  +
On 16 October 2010, in day VMC, a Boeing 737-800 being operated by Turkish Airlines on a passenger flight from Dublin to Istanbul entered runway 28 at Dublin whilst an Airbus A319 being operated by Germanwings on a scheduled passenger flight from Koln to Dublin was about 0.5nm from touchdown on the same runway. The Airbus immediately initiated a missed approach from approximately 200 ft aal simultaneously with an ATC call to do so.  +
On 13 August 2018, a Boeing 737-800 arriving at Edinburgh came to within 875 metres of an Airbus A320 departing from the same runway. Landing clearance was given one minute prior to touchdown which occurred when the departing aircraft was passing 60 feet aal and both aircraft were over the runway surface at the same time which constituted a runway incursion under local procedures. The Investigation found that the TWR position had been occupied by a trainee controller who had not received sufficient support from their supervisor after failing to act appropriately to ensure that the prescribed separation was maintained.  +
On 25 April 2013, the experienced pilot of an en-route motor glider which was not under power at the time and therefore not transponding observed a potentially conflicting aircraft in Class 'E' airspace near Frankfurt Hahn and commenced avoiding action. Although the glider was within their field of view, neither of the pilots of the other aircraft, a Boeing 737 in a descent, was aware of the proximity of the glider until it passed them on an almost parallel opposite-direction track 161 feet below them at a range of 350 metres as their aircraft was passing approximately 6,500 feet QNH.  +
On 4 April 2016, a Boeing 737-800 crew taking off in normal night visibility from Jakarta Halim were unable to avoid an ATR 42-600 under tow which had entered their runway after ambiguity in its clearance. Both aircraft sustained substantial damage and caught fire but all those involved escaped uninjured. The Investigation concluded that contributory to the accident had been failure to use a single runway occupancy frequency, towing of a poorly lit aircraft, the potential effect on pilot detection of an obstruction of embedded approach lighting ahead of the displaced landing threshold and issues affecting controller traffic monitoring effectiveness.  +
On 8 September 2020, an airport maintenance team driving at night on the centreline of the active runway at Birmingham were unaware that an inadequately secured 2 metre-long ladder had fallen from their pickup truck. Three aircraft then landed in the following half hour narrowly missing the ladder before it was discovered and the runway closed. The Investigation found that a more suitable alternative vehicle was available and that the completely inadequate method used to secure the ladder in their vehicle had failed to restrain it when the vehicle accelerated after passing the aiming point markings in the touchdown zone.  +
On 7 October 2014, a locally-based Boeing 737-800 taxiing for departure from runway 34 at Dublin as cleared in normal night visibility collided with another 737-800 stationary in a queue awaiting departure from runway 28. Whilst accepting that pilots have sole responsible for collision avoidance, the Investigation found that relevant restrictions on taxi clearances were being routinely ignored by ATC. It also noted that visual judgement of wingtip clearance beyond 10 metres was problematic and that a subsequent very similar event at Dublin involving two 737-800s of the same Operator was the subject of a separate investigation.  +
On 28 April 2018, a Boeing 737-800 exited the landing runway at Perth and without clearance crossed a lit red stop bar protecting the other active runway as another 737 was accelerating for takeoff. This aircraft was instructed to stop due to a runway incursion ahead and passed 15 metres clear of the incursion aircraft which by then had also stopped. The Investigation concluded that, after failing to refer to the aerodrome chart, the Captain had mixed up two landing runway exits of which only one involved subsequently crossing the other active runway and decided the stop bar was inapplicable.  +