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Crash of an Airbus A320-214 in Tallinn

Date & Time: Feb 28, 2018 at 1711 LT
Type of aircraft:
Operator:
Registration:
ES-SAN
Flight Type:
Survivors:
Yes
Schedule:
Tallinn - Tallinn
MSN:
1213
YOM:
2000
Flight number:
MYX9001
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
228
Captain / Total hours on type:
0.00
Copilot / Total flying hours:
24046
Copilot / Total hours on type:
40
Aircraft flight hours:
44997
Aircraft flight cycles:
21839
Circumstances:
On 28th February 2018 at 10:021, the Smartlynx Airlines Estonia Airbus A320-214 registered ES-SAN took off from Tallinn airport Estonia to perform training flights with 2 crew members (captain and safety pilot), 4 students and 1 ECAA inspector on board. Following several successful ILS approaches and touch-and-go cycles, at 15:04, after a successful touch down with the runway, the aircraft did not respond as expected to sidestick inputs when reaching rotation speed. After a brief lift-off, the aircraft lost altitude and hit the ground close to the end of the runway. In the impact, the aircraft engines impacted the runway and the landing gear doors were damaged. After the initial impact, the aircraft climbed to 1590 ft from ground level and pitched down again. The pilots were able to stabilize the flight path by using manual pitch trim and engine thrust and make a U-turn back towards the runway. The crew declared an emergency and the aircraft was cleared for an emergency landing. During the approach, the aircraft lost power in both engines. The aircraft landed 150 m before the threshold of runway at 15:11. On landing, aircraft tires burst, and the aircraft veered off the runway and finally came to a stop 15 m left to the runway. The safety pilot and one of the students suffered minor impact trauma in this accident. The aircraft landing gear doors, landing gears, both engine nacelles, engines and aircraft fuselage suffered severe damage in this accident resulting in aircraft hull loss.
Probable cause:
Causal factors:
This accident results from the combination of the following factors:
• The intermittent THSA override mechanism malfunction allowing to cause the loss of pitch control by both ELACs. The repetitive triggering of the ELAC PITCH faults was caused by the non or late activations of the PTA micro-switches, which were due to the OVM piston insufficient stroke. The insufficient OVM stroke was caused by the THSA OVM clutch unit non-standard friction. The oil in the THSA OVM casing appeared to be with a higher viscosity than defined in the CMM. The higher viscosity might have reduced the friction of the OVM clutch unit, causing the THSA OVM nonstandard friction.
• SEC design flaw allowing for a single event, the left landing gear temporary dedecompression, to cause the loss of pitch control by both SECs. The absence of ground spoilers arming for landing in the context of touch and go's training may have contributed to the temporary decompression of the left main landing gear.
• The training instructor`s decision for continuation of the flight despite repetitive ELAC PITCH FAULT ECAM caution messages. The lack of clear framework of operational rules for training flights, especially concerning the application of the MEL, and the specific nature of operations that caused pressure to complete the training program may have impacted the crew decision-making process.

Contributory factors
• Smartlynx Estonia ATO TM does not clearly define the need for arming spoilers when performing touch-and-go training (ATO procedures not in accordance with Airbus SOP). The fact that there is no clear reference in the Smartlynx Estonia ATO TM Touch-And-Go air exercise section to additional procedures that should be used, in combination with lack of understanding of the importance for arming the spoilers during this type of flights contributed to TRI making a decision to disarm the spoilers during touch and go training enabling landing gear bounce on touch down.
• At the time of the event Airbus QRH did not define the maximum allowed number of resets for the flight control computers.
• At the time of the event Airbus FCTM did not require to consider MEL on touch-and-go and stop-and-go training.
• The oil in the THS OVM casing was with higher viscosity than defined in the CMM. The higher viscosity might have reduced the friction of the OVM clutch unit.
• The aircraft maintenance documentation does not require any test of the OVM during aircraft regular maintenance checks.
• Smartlynx Estonia ATO OM does not clearly specify the role in the cockpit for the Safety Pilot. The lack of task sharing during the event caused the ECAM warnings to be left unnoticed and unannounced for a long period.
• The crew not resetting the ELAC 1. The fact that ELAC 1 PITCH FAULT was left unreset lead to the degradation of the redundancy of the system. Considering the remoteness of the loss control of both elevators, there is no specific crew training for MECHANICAL BACKUP in pitch during approach, landing and take-off. This condition of the aircraft occurred for the crew in a sudden manner on rotation and during training flight, where the experienced TRI is not in PF role and cannot get immediate feedback of the aircraft behaviour and condition. Despite these difficult conditions the crew managed to stabilize and land the aircraft with no major damage to the persons on board. The crew performance factors that contributed to the safe landing of the aircraft are the following:
• The TRI followed the golden rule of airmanship (fly, navigate, communicate), by stabilizing the aircraft pitch by using the trim wheel and by keeping the aircraft engine power as long as possible;
• The Safety Pilot started to play a role in the cockpit by assisting the TRI and student by informing them about the status of the aircraft and later on taking the role of the PM.
Final Report:

Crash of an Antonovv AN-26B in Tallinn

Date & Time: Aug 25, 2010 at 1747 LT
Type of aircraft:
Operator:
Registration:
SP-FDP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
EXN3788
MSN:
119 03
YOM:
1982
Flight number:
Tallinn - Helsinki
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5569
Captain / Total hours on type:
4432.00
Copilot / Total flying hours:
738
Copilot / Total hours on type:
485
Aircraft flight hours:
21510
Circumstances:
On 25th August 2010 cargo aircraft An-26B, registration SP-FDP started from Tallinn-Lennart Meri-Ülemiste Airport to Helsinki. After uneventful flight preparations, the aircraft started its take-off roll on runway 08. Based on pilots statements and FDR/CVR recordings the aircraft entered runway 08 from taxiway B on the West end of the runway and lined up for takeoff. On 16:47:22 the aircraft started its takeoff roll. The calculated V1 was 182 and Vr was 201 km/h. 10 seconds later PF started rotation without Vr callout at 123 km/h. The aircraft pitch angle increased to 4.6˚ 2 seconds later. At 16:47:38 the navigator made V1 call-out at 160.5 km/h. 1 second later flight engineer called “Retracting” in Polish. The aircraft started to pitch down and 3 seconds later it contacted the runway and continued on its belly for 1,228 m before coming to its rest position 3 m right from the runway centerline. No persons were injured and no fire broke up. The occurrence was classified as an accident due to the substantial damage to the aircraft structures.
Probable cause:
The investigation determined the inadequate action of the flight engineer, consisting in early and uncommanded landing gear retraction, as a cause of the accident.
Contributing factors to the accident were:
1. Inadequate crew recourse management and insufficient experience in cooperation and coordination between crewmembers.
2. Start of aircraft rotation at low speed and with fast elevator movement to 17˚, which resulted in:
Lifting the aircraft sufficiently to close the WOW switch and allow the retraction of the landing gear at the speed not sufficient for the climb.
Providing misleading information to FE about the aerodynamic status of the aircraft.
3. Inadequate adjustment of the WOW switch, which allowed the gear retraction to be activated before the aircraft was airborne. The position of the landing gear selector on the central console is not considered as a contributing factor to the accident. However, investigation finds necessary to point it out as a safety concern, specifically in situations, where crewmembers are trained and/or used to operate the aircrafts with gear selector location according to the EASA Certification Standards CS-25. Positioning of the gear lever to the location which is compliant to EASA document CS-25, would create additional safety barrier to avoid similar occurrences, specifically in aircrafts where landing gear is operated by FE.
Final Report:

Crash of an Antonov AN-26B in Tallinn

Date & Time: Mar 18, 2010 at 1018 LT
Type of aircraft:
Operator:
Registration:
SP-FDO
Flight Type:
Survivors:
Yes
Schedule:
Helsinki – Tallinn
MSN:
105 03
YOM:
1980
Flight number:
EXN3589
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4695
Captain / Total hours on type:
2295.00
Copilot / Total flying hours:
990
Copilot / Total hours on type:
495
Aircraft flight hours:
25941
Circumstances:
Exin Co was operating An-26B for regular cargo flight between Tallinn and Helsinki. The crew performed last maintenance check in Tallinn on previous day and made uneventful flight to Helsinki on 17th March afternoon. Next morning the aircraft took off from Helsinki for regular flight EXN3589 to Tallinn at 09:46 local time. The takeoff weight was 23,954 kg, 46 kg below the MTOW. Four crewmembers, company mechanic and one cargo attendant were on board. During takeoff crew used RU 19-300 APU for additional thrust as prescribed in AFM. The RU 19-300 was shot down after takeoff. The flight was uneventful until 08:14:50, 9.5 nm from the runway 26. When power levers were retarded to flight idle crew noticed engine vibration and smelled a smoke in the cockpit. The engine chip detector indicator in the cockpit was lit. After short discussion about which engine should be shot down the flight engineer shot down the left engine and the captain tried to start the RU19A-300 (APU) to gain more thrust. During the approach the air traffic controller noticed the aircraft deviation from the approach path to the left and notified the crew. According to the FDR and CVR data the crew was unable to maintain a proper approach path both in lateral and vertical dimensions. The attempts to start RU19A-300 engine failed. Visual contact with the RWY was established 0.5 nm from the threshold. The aircraft crossed the airport boundary being not configured for landing and with IAS 295-300 km/h. The flaps were extended for 10˚ over the threshold; the landing gear was lowered after passing the RWY threshold and retracted again. The aircraft made a high speed low path over the runway on ca 10-15 feet altitude with the landing gear traveling down and up again. Flaps were extended over runway, and then retracted again seconds before impact. At the end of the RWY the full power on right engine was selected, aircraft climbed 15-20 feet and started turning left. Crew started retracting flaps and lowered landing gear. Aircraft crossed the highway at the end of the RWY on altitude ca 30 feet, then descended again, collided with the treetops at the lake shore and made crash-landing on the snow and ice-covered lake waterline. Due to the thick ice the aircraft remained on the ice and glided 151 m on the ice with heading 238˚ before coming to full stop. After the impact the flight engineer shoot down the RH engine and power and released all engine fire extinguishers. All persons onboard escaped immediately through the main door. No emergency was declares and despite suggestions from FO go-around was not commanded.
Probable cause:
Causes of the accident:
1. The failure of the left engine lubrication oil system, leading to the failure of the rear compressor bearing and inflight engine failure.
2. The failure of the crew to maintain the approach path and adhere to single engine landing procedures.
Factors contributing to the accident:
1. Improper and insufficient crew training, inter alia complete absence of simulator training.
2. The lack of effective coordination between crewmembers.
3. The failure of the crew to start RU19A-300 (APU).
4. Adverse weather conditions.
5. Inadequate company supervision by Polish CAA, consisting in not noticing the lack.
of flight crew training and companies generally pour safety culture.
6. Inadequate company maintenance practices, leaving preexisting breather duct failure unnoticed.
Final Report:

Crash of a PZL-Mielec AN-28PD in Tallinn: 2 killed

Date & Time: Feb 10, 2003 at 1942 LT
Type of aircraft:
Operator:
Registration:
ES-NOY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tallinn - Helsinki
MSN:
1AJ006-04
YOM:
1989
Flight number:
ENI827
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10856
Captain / Total hours on type:
510.00
Copilot / Total flying hours:
2827
Copilot / Total hours on type:
475
Aircraft flight hours:
1428
Aircraft flight cycles:
2141
Circumstances:
The twin engine aircraft departed Tallinn-Ülemiste Airport on a mail flight to Helsinki, carrying three crew members (two pilots and one mechanic) and a load consisting of 514 kilos of mail. Four seconds after lift off from runway 08, while climbing to a height of 12 metres and at a speed of 170 km/h, the left engine suffered vibrations. The power lever for the left engine was brought back to idle then in a full forward position. Nevertheless, the aircraft lost height, nosed down and crashed in a wooded area located one km past the runway end. Both pilots were killed and the mechanic was seriously injured.
Probable cause:
It was determined that the right engine failed during initial climb following the rupture of a turbine ball bearing due to poor lubrication.
Final Report:

Crash of a PZL-Mielec AN-28 in Kärdla: 2 killed

Date & Time: Nov 23, 2001 at 1835 LT
Type of aircraft:
Operator:
Registration:
ES-NOV
Survivors:
Yes
Schedule:
Tallinn - Kärdla
MSN:
1AJ003-03
YOM:
1986
Flight number:
ENI1007
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9840
Captain / Total hours on type:
192.00
Copilot / Total flying hours:
472
Copilot / Total hours on type:
106
Aircraft flight hours:
1690
Circumstances:
En route from Tallinn to Kärdla, at an altitude of 6,000 feet, the crew obtained the last weather bulletin for Kärdla Airport. The actual conditions were as follow: wind 020° at 24 knots, visibility 8,000 metres, snow, overcast 1,200 feet, broken 600 feet, temperature 0°, dewpoint 0°, QNH 1001, braking action is good, runway in use 32. One minute later, the crew was cleared to descend to 1,400 feet and reported this altitude at a distance of 11 km from the airport. The airplane continued on a heading of 240° towards the OZ NDB beacon, which was the Final Approach Fix (FAF) located about 4 km from the runway threshold. The crew continued the descent and initiated a slow turn towards the runway some 2,5 km short of the FAF. The aircraft descended into trees some 1,500 metres short of runway threshold and crashed in a wooded area. Two passengers were killed and 15 other occupants were injured, some seriously. The aircraft was totally destroyed.
Probable cause:
The accident was the consequence of an incorrect assessment of the situation by the commander of the aircraft during the approach, which resulted in errors in the piloting techniques, expressed in:
- Transition from intense icing conditions to active descent with a transition from the originally planned instrument approach to a visual approach;
- Failure to take into account the possibility of complex meteorological conditions in preparation for the approach and during the approach - the crew did not consider the possibility of going around or returning to the point of departure;
- Maintaining an unjustified low airspeed and high vertical descent speed during an approach with poor altitude control;
Associated factors were:
- Difficult weather conditions due to severe icing conditions;
- Reassessment by the aircraft commander of his knowledge and experience in controlling the An-28 aircraft in adverse weather conditions;
- Failure to comply with the requirements of the Airplane Flight Manual of the An-28 aircraft for the operation of aircraft systems and crew resource management;
- Failure to comply with the Airplane Flight Manual in terms of timely termination of the approach and transition to climb;
- The copilot, taking into account the large flying experience of the aircraft commander and overestimating his flight and navigation skills, behaved passively and did not provide him with adequate assistance in difficult conditions during the approach;
- Transition from an instrument approach to a visual approach without ATC clearance;
- The lack of 32 visual assessment of the angle of the descent trajectory (PAPI system) on the runway.
Final Report:

Crash of a Junkers JU.52/3mge off Keri Island: 9 killed

Date & Time: Jun 14, 1940 at 1500 LT
Type of aircraft:
Operator:
Registration:
OH-ALL
Flight Phase:
Survivors:
No
Schedule:
Tallinn – Helsinki
MSN:
5494
YOM:
1936
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Few minutes after take off from Tallinn-Ülemiste Airport, while overflying the Gulf of Finland, the three engine aircraft named 'Kaleva' was shot down by the pilots of two Soviet Air Force Tupolev SB-2. Out of control, the aircraft crashed into the sea off the Keri Island. All nine occupants were killed.
Probable cause:
Shot down by two Soviet fighters.