Crash of a BAe 3201 Jetstream 32EP in Luleå

Date & Time: Sep 17, 2003 at 1828 LT
Type of aircraft:
Operator:
Registration:
SE-LNT
Flight Type:
Survivors:
Yes
Schedule:
Pajala – Luleå
MSN:
948
YOM:
1991
Flight number:
EXC403
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
31000
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
660
Copilot / Total hours on type:
237
Aircraft flight hours:
13494
Circumstances:
The pilots were scheduled to fly the aircraft, a BAe Jetstream 32, on scheduled flight EXC403 from Pajala Airport to Luleå/Kallax Airport. This was the third flight together for the day. Before takeoff they noted that the flight was planned without passengers. Since the co-pilot was shortly to undergo an Operator’s Proficiency Check and the commander had long flying experience, including as an instructor, the commander decided to take the opportunity to have the co-pilot train flying with simulated engine failure. The takeoff from Pajala was at 17.57 hrs with the co-pilot as Pilot Flying. During the climb the commander reduced thrust on the right engine to simulate engine failure. This was done by moving the engine control lever to its rear stop. The commander understood this to represent what is termed ”simulated feather” in which an engine generates no drag and causes the least possible resistance. The exercise passed off without problem and the co-pilot had no difficulties in handling the aircraft. It was decided to practise flying with simulated engine failure during the landing as well. During the approach to Luleå/Kallax Airport when the aircraft was at an altitude of about 3500 feet the commander accordingly reduced thrust on the right engine once again. The co-pilot understood that the whole landing, including touchdown, would be with one engine on reduced thrust. However, the commander’s intention was to restore normal thrust on the right engine before touchdown. Prior to landing the reference speed (Vref1) had been calculated at 107 knots IAS2 and the flaps lowered 20°, based on the calculated landing mass of 5 640 kg. During the approach when the aircraft was at about 3500 feet, the commander reduced right engine thrust. According to the FDR recording thrust was reduced initially to just over 19 % and subsequently, for six minutes, further to just under 11% at the same time as altitude decreased to 900 feet. The co-pilot flew the aircraft in a right turn to runway 32 and started his final 2 nautical miles from the runway threshold at a height of 900 feet. The final was entered with a somewhat higher glide angle than normal. As the aircraft approached the runway threshold the thrust on the right engine had decreased to approximately 7%. The approach took place with applied rudder and opposite banking to counteract the lateral forces generated by the asymmetrical thrust. During the approach the co-pilot experienced an inertia in the ailerons that he had never experienced previously. Shortly after the aircraft had crossed the runway threshold and was about 5 metres above the runway, both the co-pilot and the commander felt how the aircraft suddenly yawed and rolled to the right. Neither pilot remembers hearing the stall warning sounding. Despite application of full aileron and rudder the pilots were unable to stop the aircraft’s uncontrolled motion. This continued until the right wing tip hit the ground. The fuselage then struck the ground. The aircraft slid on its belly about 50 metres alongside the runway before stopping. The pilots hastily evacuated the aircraft. The accident was observed by the air traffic controller who immediately alarmed the airport rescue service, which arrived at the accident scene within a minute or so. After its arrival the commander boarded the aircraft and turned off the fuel supply and the main electricity, whereafter the rescue service covered the aircraft with foam. The accident occurred on 17 September 2003 at 18.28 hrs in position 6532N 02207E; 20 m above sea level in daylight.
Probable cause:
The accident was caused by shortcomings in the company’s quality assurance system, operational routines and regulations. These contributed to the facts that:
- the commander considered he was able to serve as a flying instructor on an aircraft type and in a flight situation for which he was neither qualified nor authorised,
- the pilot's lacked necessary familiarity with the aircraft type’s special flight characteristics during asymmetrical thrust, and
- the pilot's lacked familiarity with the regulations in force for flying training.
Final Report:

Crash of a BAe 3102 Jetstream 31 in Wick

Date & Time: Sep 17, 2003 at 1447 LT
Type of aircraft:
Operator:
Registration:
G-EEST
Survivors:
Yes
Schedule:
Aberdeen – Wick
MSN:
781
YOM:
1987
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7885
Captain / Total hours on type:
1195.00
Copilot / Total flying hours:
6800
Copilot / Total hours on type:
1000
Aircraft flight hours:
17845
Aircraft flight cycles:
20730
Circumstances:
The aircraft was landing on Runway 31 at Wick Airport. It crossed the threshold at 130 kt which was 21 kt faster than the correct threshold speed. After the co-pilot closed the power levers the aircraft floated about six feet above the runway surface. The aircraft touched down and bounced before touching down a second time more heavily, cracking a wing spar and flexing the aircraft structure sufficient to allow the right propeller to contact the runway. The aircraft bounced again before touching down for the third and final time. The investigation determined that just before the first touchdown, one or both power levers were moved aft of the flight idle position. It was concluded that both the commander and co-pilot were making inputs on the flying controls from that moment onwards until after the second, heavy touchdown. There was no evidence of any technical fault on the aircraft and the weather conditions were well within the limitations set for the aircraft. No safety recommendations were made.
Probable cause:
It is reasonable to conclude that the manoeuvres conducted by G-EEST during the landing were the result of combined control inputs made by the commander and co-pilot. The evidence indicates that this period of combined control started at least 0.28 seconds before the first touchdown and finished at some stage after the second and damaging touchdown. After the first touchdown the aircraft became airborne in a high-drag, low-lift configuration which was intended for ground operation only and a 5.6g impact ensued on the second touchdown. There was no evidence of any technical fault on the aircraft that could have been a factor and the meteorological conditions were within the limitations set for the aircraft. A more complete understanding of the accident might have been possible with additional flight data parameters such as engine performance, aircraft pitch, and power lever position.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Yacuiba

Date & Time: Jan 17, 2003 at 0900 LT
Type of aircraft:
Operator:
Registration:
CP-2404
Survivors:
Yes
Schedule:
Yacuiba - Santa Cruz
MSN:
680
YOM:
1985
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8194
Copilot / Total flying hours:
832
Circumstances:
During the takeoff roll at Yacuiba Airport, at V2 speed, the right engine lost power. The captain decided to continue the takeoff procedure. During initial climb, decision was taken to return for an emergency landing and the crew shut down the right engine and feathered its propeller. After touchdown on runway 20, the aircraft was unable to stop within the remaining distance, overran, lost its nose gear and collided with bushes and small trees, coming to rest about 50 metres past the runway end. All 21 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Excessive speed upon landing,
- Delayed application of the brake systems,
- The runway length available was limited according to the conditions in force,
- The total weight of the aircraft upon landing,
- The aircraft configuration,
- The direction and intensity of the wind,
- An inadequate crew training.
Additionally, the exact cause of the loss of power on the right engine was not clearly determined at the time the final report was published.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Skien

Date & Time: Nov 30, 2001 at 1828 LT
Type of aircraft:
Operator:
Registration:
SE-LGA
Survivors:
Yes
Schedule:
Bergen - Skien
MSN:
636
YOM:
1984
Flight number:
EXC204
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6590
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
390
Aircraft flight hours:
14074
Aircraft flight cycles:
16666
Circumstances:
The aircraft was on its way to Skien with a crew of two and 11 passengers. During the flight, ice was observed on the aircraft’s wings, but the ice was considered to be too thin to be removed. During descent towards runway 19 at Geiteryggen the aircraft’s ground proximity warning system (GPWS) sounded a total of three times. The aircraft was then in clouds and the crew did not have visual contact with the ground. The warnings, combined with somewhat poorly functioning crew coordination, resulted in the crew forgetting to actuate the system for removing ice from the wings. The subsequent landing at 1828 hrs was unusually hard, and several of the passengers thought that the aircraft fell the last few metres onto the runway. The hard landing caused permanent deformation of the left wing so that the left-hand landing gear was knocked out of position, and the left propeller grounded on the runway. The crew lost directional control and the aircraft skewed to the left and ran off the runway. The aircraft then hit a gravel bank 371 metres from the touchdown point. The collision with the gravel bank was so hard that the crew and several of the passengers were injured and the aircraft was a total loss. It was dark, light rain and 4 °C at Geiteryggen when the accident occurred. The wind was stated to be 120° 10 kt. The investigation shows that it is probable that ice on the wings was the initiating factor for the accident. The AIBN has not formed an opinion on whether the ice resulted in the high sink rate after the first officer reduced the power output of the engines, or whether the aircraft stalled before it hit the runway. Investigation has to a large extend focused on the crew composition and training. A systematic investigation of the organisation has also taken place. In the opinion of the AIBN, the company has principally based its operations on minimum standards, and this has resulted in a number of weaknesses in organisation, procedures and quality assurance. These conditions have indirectly led to the company operating the route Skien – Bergen with a crew that, at times, did not maintain the standard that is expected for scheduled passenger flights. The investigation has also revealed that procedures for de-icing of the aircraft wings could be improved.
Probable cause:
Significant investigation results:
a) The decision was made to wait to remove the ice from the wings because, according to the SOP, it should only be removed if it had been “typically half an inch on the leading edge”. This postponement was a contributory factor in the ice being forgotten.
b) At times, the relationship between the flight crew members was very tense during the approach to Skien. This led to a breakdown in crew coordination.
c) Among the consequences of the warnings from the GPWS was a very high workload for the crew. In combination with the defective crew coordination, this contributed to the ice on the wings being forgotten.
d) It is probable that the aircraft hit the runway with great force because the wings were contaminated with ice. The AIBN is not forming a final opinion on whether the wings stalled, whether the aircraft developed a high sink rate due to ice accretion or whether the hard landing was due to a combination of the two explanatory models.
e) The company could only provide documentary evidence to show that the Commander had attended an absolute minimum of training after being employed within the company. Parts of the mandatory training had taken place by means of self-study without any form of formal verification of achievement of results.
f) The company’s operation was largely based on minimum solutions. This reduced the safety margins within company operations.
g) The company’s quality system contributed little to ensuring ‘Safe Operational Practices’ in the company.
h) Authority inspection of the company was deficient.
Final Report:

Crash of a BAe 3201 Jetstream 32EP near Chulum Juárez: 19 killed

Date & Time: Jul 8, 2000 at 1950 LT
Type of aircraft:
Operator:
Registration:
N912FJ
Flight Phase:
Survivors:
No
Site:
Schedule:
Tuxtla Gutiérrez – Villahermosa – Veracruz – Mérida
MSN:
912
YOM:
1990
Flight number:
QA7831
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
5300
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
667
Copilot / Total hours on type:
40
Aircraft flight hours:
12041
Circumstances:
The aircraft departed Tuxtla Gutiérrez Airport on a regular schedule flight to Mérida with intermediate stops in Villahermosa and Veracruz, carrying 17 passengers and two pilots. En route to Villahermosa-Carlos Rovirosa Pérez Airport, at an altitude of 16,000 feet and about 50 miles from the destination, the crew encountered poor weather conditions and deviated from the V3 Airway to the right for about 24 km. After he initiated the descent, the crew was instructed by ATC to report 25 DME. Shortly later, while descending in clouds, the twin engine aircraft struck the slope of a mountain located near Chulum Juárez, about 80 km southeast of Villahermosa Airport. The wreckage was found at an altitude of 1,890 metres. The aircraft disintegrated on impact and all 19 occupants were killed.
Probable cause:
Controlled flight into terrain. Combining instrument flight (IFR), with visual flight (VFR), the crew lost situational awareness, deviating 29.8 miles to the right of the Victor 3 airway due to bad weather, when the weather conditions imposed the application of the instrument flight rules (IFR), causing collision of the aircraft with the mountain at 6200 feet of elevation without loss of control (CFIT).
The following contributing factors were identified:
- Severe weather conditions en route,
- Persistence of the pilot in command, to continue the instrument flight (IFR) on visual flight (VFR),
- Inconsistency in cockpit resource management (CRM),
- Loss of situational awareness of the flight crew and the controllers, due to numerous deviations from the route, due to severe weather conditions and poor communication between the parties.
- inadequate preparation of the flight plan, since in view of the very probable need to circumnavigate severe meteorological conditions, the flight altitudes that would continue outside of the controlled airspace (outside the v-3 airway) were not verified.
Final Report: