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Difference between revisions of "SW4, Cork Ireland, 2011"

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[[File:SW4 TDZ ict1.jpg|thumb|none|500px|The location of the wreckage with the yellow cross marking indicating the first point of aircraft contact with the runway (reproduced from the Official Report)]]
 
[[File:SW4 TDZ ict1.jpg|thumb|none|500px|The location of the wreckage with the yellow cross marking indicating the first point of aircraft contact with the runway (reproduced from the Official Report)]]
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==Investigation==
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The event was Investigated by the Irish AAIU with the aid of some technical assistance provided by the UK [[AAIB]]. The Investigation established that the aircraft involved had been leased to another company which was not the holder of an Air Operator Certificate but termed by the Investigation as the ‘Owner’, who in turn sub-leased it to a small Spanish AOC holder called Flightline S.L. - the ‘Operator’ - which sold the provision of “passenger air transport service” to a ‘Ticket Seller’ based on the Isle of Man called “Manx2” which was not the holder of Air Operators Certificate. The aircraft was maintained by another (Spanish) Company termed by the Investigation the ‘Maintenance Provider’ which neither directly provided nor contracted line maintenance provision in respect of the remote operation being carried out from a base in the Isle of Man, a non-EU Territory.
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The Investigation was materially assisted by the successful recovery and replay of the [[FDR]] and [[CVR]], although the Operator was unable to provide on request and as required by regulation the FDR data frame layout. The lack of this ability was found not to have been discovered during Operator quality audits or to have been made a requirement by the applicable National Regulations. Data from the [[NVM]] of the recovered [[TAWS]] equipment fitted to the aircraft and ATC radar recording were also available.
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It was found that after an initial wingtip contact with the intended landing runway as marked on the diagram above, the aircraft had ended up inverted some 189 metres from the initial contact point some 72 metres to the right of the runway centreline. The Investigation noted that, having first extinguished the two engine fires and taken action to eliminate any further fire risk, the Airport [[RFFS]] had initially forced open the rear cargo door (see the close-up picture of the wreckage below) as the main means to facilitate extrication of the surviving occupants after first removing the baggage and the divider separating the hold from the passenger cabin.
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It was established that the aircraft had been engaged in night mail cargo flights for the UK Royal Mail under the terms of a contract between the aircraft ‘Owner’ and an agency working on behalf of the UK Royal Mail. The accident flight crew of two pilots had commenced duty at 0615 at Belfast Aldergrove and positioned the aircraft empty to Belfast City, where they arrived at 0715 for the scheduled 0750 departure to Cork.
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An ATC [[Flight Plan|FPL]] for the accident flight was found to have been filed three hours earlier by a Fixed Base Operator (FBO) in Billund, Denmark showing just one alternate, Waterford. The pilots had obtained TAF and [[METAR]] information when beginning duty which had indicated that fog at Cork may well prevent a landing but had not obtained any other weather at that time except that for Dublin. The evidence available indicated that they had been unaware of the weather at Waterford, the single nominated alternate on the filed FPL, or that at other potential diversions - Shannon and Kerry. Given the poor weather at Cork, they were required to (re) file a FPL with two viable alternates but did not do so. Boarding of the passengers was delayed because both pilots were still securing some of the passenger seats which the off-going flight crew from the night cargo flights were supposed to have completed. It was found that none of the Operator’s pilots were trained or authorised to refit seats and that there were discrepancies between the actual and documented seating configuration on the accident flight. The required pre-fight safety briefing was given to the 10 passengers by the Co Pilot, since no cabin crew was present or required.

Revision as of 10:58, 29 January 2014

Description

On 10 February 2011, a Fairchild SA 227-BC Metro III being operated by Spanish Company Flightline exclusively for an Isle of Man based “Ticket Seller” called Manx2 (which was not also an aircraft operator) on a scheduled passenger flight from Belfast City, UK to Cork, Ireland crashed when the crew lost control whilst attempting to commence a daylight go around at destination after failing, on the third attempt, to transition to visual reference for landing due to fog. The aircraft was destroyed on impact and concurrent fires in parts of the wreckage were quickly extinguished by the airport fire service. Six of the 12 occupants were killed, four were seriously injured and two sustained minor injuries.

The location of the wreckage with the yellow cross marking indicating the first point of aircraft contact with the runway (reproduced from the Official Report)

Investigation

The event was Investigated by the Irish AAIU with the aid of some technical assistance provided by the UK Aircraft Accident Investigation Branch (UK) (AAIB). The Investigation established that the aircraft involved had been leased to another company which was not the holder of an Air Operator Certificate but termed by the Investigation as the ‘Owner’, who in turn sub-leased it to a small Spanish AOC holder called Flightline S.L. - the ‘Operator’ - which sold the provision of “passenger air transport service” to a ‘Ticket Seller’ based on the Isle of Man called “Manx2” which was not the holder of Air Operators Certificate. The aircraft was maintained by another (Spanish) Company termed by the Investigation the ‘Maintenance Provider’ which neither directly provided nor contracted line maintenance provision in respect of the remote operation being carried out from a base in the Isle of Man, a non-EU Territory.

The Investigation was materially assisted by the successful recovery and replay of the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR), although the Operator was unable to provide on request and as required by regulation the FDR data frame layout. The lack of this ability was found not to have been discovered during Operator quality audits or to have been made a requirement by the applicable National Regulations. Data from the Non Volatile Memory of the recovered GPWS/TAWS equipment fitted to the aircraft and ATC radar recording were also available.

It was found that after an initial wingtip contact with the intended landing runway as marked on the diagram above, the aircraft had ended up inverted some 189 metres from the initial contact point some 72 metres to the right of the runway centreline. The Investigation noted that, having first extinguished the two engine fires and taken action to eliminate any further fire risk, the Airport Rescue and Fire Fighting Services had initially forced open the rear cargo door (see the close-up picture of the wreckage below) as the main means to facilitate extrication of the surviving occupants after first removing the baggage and the divider separating the hold from the passenger cabin.

It was established that the aircraft had been engaged in night mail cargo flights for the UK Royal Mail under the terms of a contract between the aircraft ‘Owner’ and an agency working on behalf of the UK Royal Mail. The accident flight crew of two pilots had commenced duty at 0615 at Belfast Aldergrove and positioned the aircraft empty to Belfast City, where they arrived at 0715 for the scheduled 0750 departure to Cork.

An ATC FPL for the accident flight was found to have been filed three hours earlier by a Fixed Base Operator (FBO) in Billund, Denmark showing just one alternate, Waterford. The pilots had obtained TAF and Meteorological Terminal Air Report (METAR) information when beginning duty which had indicated that fog at Cork may well prevent a landing but had not obtained any other weather at that time except that for Dublin. The evidence available indicated that they had been unaware of the weather at Waterford, the single nominated alternate on the filed FPL, or that at other potential diversions - Shannon and Kerry. Given the poor weather at Cork, they were required to (re) file a FPL with two viable alternates but did not do so. Boarding of the passengers was delayed because both pilots were still securing some of the passenger seats which the off-going flight crew from the night cargo flights were supposed to have completed. It was found that none of the Operator’s pilots were trained or authorised to refit seats and that there were discrepancies between the actual and documented seating configuration on the accident flight. The required pre-fight safety briefing was given to the 10 passengers by the Co Pilot, since no cabin crew was present or required.