Human factor

The pilot-in-command's failure to maintain proper airspeed and his failure to initiate a go-around, which resulted in the airplane touching down too fast on a short, wet runway and a subsequent runway overrun. Contributing to the accident was the copilot's failure to adequately monitor the approach and call for a go around and the flight crew's lack of proper crew resource management.

The event is classified as short landing accident and the cause is mainly due to human factors. The fact that the aircraft contacted the ground took place about 367 meters short of the runway threshold was due to the crew's decision to continue the instrument approach without a declared shared acquisition of the necessary visual references for the completion of the non-precision procedure and of the landing maneuver. The investigation revealed no elements to consider that the incident occurred due to technical factors inherent in the aircraft.
The following contributing factors were identified:
- The poor attitude of those present in the cockpit to use of basics of CRM, particularly with regard to interpersonal and cognitive abilities of each and, overwhelmingly, the commander.
- Deliberate failure to comply with SOP in place which provided, reaching the MDA, to apply the missed approach procedure where adequate visual reference of the runway in use had not been in sight of both pilots.
- Failure to apply, by those present in the cockpit, the operators rules, concerning in particular: the concept of "sterile cockpit"; to do the descent briefing; to make callouts on final approach.
- The routine with the crew, carrying out approaches to Palermo-Punta Raisi Airport, from which the complacency to favor the personalization of the standards set by operator, and by law. The complacency is one of the most insidious aspects in the context of the human factor, as it creeps in individual self-satisfaction of a condition, which generates a lowering of situational awareness, however bringing them to believe they had found the best formula to operate.
- The existence of adverse weather conditions, characterized by the presence of an extreme rainfall, which significantly reduced the overall visibility.
- The "black hole approach" phenomenon, due to adverse weather conditions together with an approach carried out at night, the sea, to a coast characterized by few dimly lit urban settlements.
This created the illusion in the PF of "feeling high" compared to what he saw and believed to be the threshold, with the result to get him to abandon the ideal descent profile, hitherto maintained, to make a correction and the subsequent short landing.
- The decrease of performance of the light beam produced by SLTH in extreme rain conditions; The only bright horizontal reference for the crew consisted of the crossbar of the SALS, probably mistaken for the threshold lights.

Double engine failure on final approach due to fuel exhaustion. It was determined that prior to takeoff from San Juan Airport, the fuel quantity in the tanks was sufficient for the flight to Santo Domingo. But the fuel cap was missing prior to takeoff and the crew applied some 'duct tape' in an attempt to replace the fuel cap. Despite the aircraft was unworthy, the crew decided to takeoff in such conditions. Because the fuel cap was missing, some fuel leaked in flight, causing both engines to stop on final approach to Santo Domingo Airport.

Findings:
- There were no technical defects identified that may have contributed to the accident and the aeroplane was considered controllable during the take-off roll, with the engine able to deliver power during the short flight.
- The aeroplane’s centre of gravity was at least 0.122m rear of the maximum permissible limit, which created a tendency for the nose to pitch up. The most likely reason for the crash was the aeroplane being excessively out of balance. In addition, the aeroplane probably became airborne early and at too low an airspeed to prevent uncontrollable nose-up pitch.
- The aeroplane reached a pitch angle that would have made it highly improbable for the unrestrained parachutists to prevent themselves sliding back towards the tail. Any shift in weight rearward would have made the aeroplane more unstable.
- The engineering company that modified ZK-EUF for parachuting operations did not follow proper processes required by civil aviation rules and guidance. Two of the modifications had been approved for a different aircraft type, one modification belonged to another design holder and a fourth was not referred to in the aircraft maintenance logbook.
- The flight manual for ZK-EUF had not been updated to reflect the new role of the aeroplane and was limited in its usefulness to the aeroplane owner for calculating weight and balance.
- Regardless of the procedural issues with the project to modify ZK-EUF, the engineering work conducted on ZK-EUF to convert it from agricultural to parachuting operations in the standard category was by all accounts appropriately carried out.
- The weight and balance of the aeroplane, with its centre of gravity at least 0.122m outside the maximum aft limit, would have caused serious handling issues for the pilot and was the most significant factor contributing to the accident.
- ZK-EUF was 17 kg over its maximum permissible weight on the accident flight, but was still 242 kg lighter than the maximum all-up weight for which the aeroplane was certified in its previous agricultural role. Had the aeroplane not been out of balance it is considered the excess weight in itself would have been unlikely to cause the accident. Nevertheless, the pilots should have made a full weight and balance calculation before each flight.
- The aeroplane owner and their pilots did not comply with civil aviation rules and did not follow good, sound aviation practice by failing to conduct weight and balance calculations on the aeroplane. This resulted in the aeroplane being routinely flown overweight and outside the aft centre of gravity allowable limit whenever it carried 8 parachutists.
- The empty weight and balance for ZK-EUF was properly recorded in the flight manual, but the stability information in that manual had not been appropriately amended to reflect its new role of a parachute aeroplane. Nevertheless, it was still possible for the aeroplane operator to initially have calculated the weight and balance of the aeroplane for the predicted operational loads before entering the aeroplane into service.
- The aeroplane owner did not comply with civil aviation rules and did not follow good, sound aviation practice when they: used the incorrect amount of fuel reserves; removed the flight manual from the aeroplane; and did not formulate their own standard operating procedures before using the aeroplane for commercial parachuting operations.
- The Director of Civil Aviation delegated the task of assessing and overseeing major modifications to Rule Part 146 design organisations and individual holders of “inspection authorisations”. The delegations did not absolve the Director of his responsibility to monitor compliance with civil aviation rules and guidance.
Page 38 | Report 10-009
- The delegations increased the risk that unless properly managed the CAA could lose control of 2 safety-critical functions: design and inspection. The Director had not appropriately managed that risk with the current oversight programme.
- The CAA had adhered strictly to its normal practice and was acting in accordance with civil aviation rules when approving the change in airworthiness category from special to standard. However, knowing the scope, size and complexity of the modifications required to change ZK-EUF from an agricultural to a parachuting aeroplane, it should have had greater participation in the process to help ensure there were no safety implications.
- There was a flaw in the regulatory system that allowed an engineering company undertaking major modification work on an aircraft to have little or no CAA involvement by using an internal or contracted design delegation holder and a person with the inspection authorisation to oversee and sign off the work.
- The level of parachuting activity in New Zealand warranted a stronger level of regulatory oversight than had been applied in recent years.
- The CAA’s oversight and surveillance of commercial parachuting were not adequate to ensure that operators were functioning in a safe manner.
- The CAA had mechanisms through the Director’s powers under the Civil Aviation Act and his designated powers under the HSE Act to effectively regulate the parachuting industry pending the introduction of Rule Part 115.
- An alcohol and drug testing regime needs to be initiated for persons performing activities critical to flight safety, to detect and deter the use of performance-impairing substances.
- In this case the impact was not survivable and the passengers wearing safety restraints would not have prevented their deaths, but in other circumstances the wearing of safety restraints might reduce injuries and save lives.
- Safety harnesses or restraints would help to prevent passengers sliding rearward and altering the centre of gravity of the aircraft. It could not be established if this was a factor in this accident.

The pilot's delayed application of full power during a soft/wet field takeoff, resulting in a collision with trees during takeoff.

Contributing safety factors:
• The operator’s processes for determining the aircraft’s required landing distance did not appropriately consider all of the relevant performance factors.
• The operator’s processes for learning and implementing change from the previous runway overrun incident were ineffective.
• The flight crew did not use effective crew resource management techniques to manage the approach and landing.
• The crew landed long on a runway that was too short, affected by a tailwind, had a degraded surface and was water contaminated.
• The crew did not carry out a go-around during the approach when the visibility was less than the minimum requirements for a visual approach.
• The baulked landing that was initiated too late to assure a safe takeoff.
Other safety factors:
• The aircraft aquaplaned during the landing roll, limiting its deceleration.
• The runway surface was described as gravel, but had degraded over time.
• The weather station anemometer was giving an incorrect wind indication.

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.

The following factors were identified:
- During the approach, the flight crew's attention was focused on the characteristics of the geographical relief and presence of birds, reducing their awareness as to the maintenance of the approach slope.
- The group culture of maintaining a low angle of approach led the crew to choose the runway aspect instead of the VASIS as a reference for the approach, making them susceptible to various types of spatial illusion.
- Taking into account copilot's report that he was not succeeding in correcting the aircraft glide path relative to the runway, one may suppose that he was not applying the appropriate amplitude for such correction.
- The physical characteristics of the runway 15 (the active one) contributed to a wrong perception of the ideal glide path. The pronounced acclivity of the runway, its width (narrower than the runways on which the crew was accustomed to operate), and the low terrain near the threshold, caused in the pilots a perception that they were above the ideal approach slope, leading them to seek correction, which resulted in an angle of approach below the ideal one.
- For the flight in question, the company chose two pilots who had never operated in SBQV. A crewmember with previous experience in the locality would have a higher level of awareness in relation to the specific characteristics of the aerodrome.
- No company publications were found that could provide the pilots with guidance on the specifics of SBQV, capable of helping with the management of the risks associated with the operation in that aerodrome.

Loss of control on final approach due to the movement of several passengers in the cabin, panicked by the presence of a crocodile.

- In violation of the airline's flight operation manual the captain attempted the approach to Yichun below required visibility. The airport reported 2800 meters of visibility while the manual required 3600 meters of visibility to begin the approach
- In violation of regulations by the Civil Aviation Authority the crew descended below minimum descent altitude although the aircraft was operating in fog and visual contact with the runway had not been established
- Despite the aural height announcements and despite not seeing the runway the crew continued the landing in the blind without initiating a go-around resulting in impact with terrain
Contributing factors were:
- The airline's safety management is insufficient:
* part of the flight crew arbitrarily implement the company's operations manual as the company does not follow up outstanding problems. Records suggest frequent deviations from approach profiles, i.e. deviation above or below glide slopes, excessive rates of descents and unstable approaches
* crew rostering and crew cooperation: Each of the crew was flying into Yichun for the first time despite the known safety risks at the airport, the communication and cooperation within the crew was insufficient, the crew members did not monitor each other in order to reduce human errors
* the airline's emergency training did not meet requirements, in particular the cabin crew training did not provide for hands on training on E190 cabin doors and overwing exits. Alternate means by the airline did prove ineffective and did not provide the quality China's Civil Aviation Authority requires thus leaving cabin crew unprepared to meet required cabin crew emergency response capabilities
- Parent company's Shenzhen Airlines oversight insufficient
* Shenzhen Airlines, after having taken over Henan Airlines in 2006, did not provide sufficient funding and technical support affecting the stability and safety of staff and quality management
* Air China, holding stock into Shenzhen Airlines, installed a safety supervisor but failed to address the safety management issues with Shenzhen and Henan Airlines
- No supervision by China's Civil Aviation Authority
* the license to operate the flight from Harbin to Yichun was granted without route validation and without safety management in violation of regulations
* to solve the lack of cabin crew flight attendants were certified although not meeting the relevant requirements for air transport operations
* the regional office of the Civil Aviation Authority did not communicate to their superiors that they had approved the domestic operation of the route from Harbin to Yichun permitting non-standard procedures
- China's Civil Aviation Authority safety management loopholes.