Human factor

The instrument-rated pilot was executing a night instrument approach when the airplane impacted the water. The published approach minimums for the area navigation/global positioning system approach were 460-foot ceiling and one-mile visibility. Recorded air traffic control voice and radar data indicated that prior to the approach the pilot had turned to an approximately 180-degree heading and appeared to be heading in the direction of another airport. The controller reassigned the pilot a heading in order to intercept the final approach. The airplane was located in the water approximately 5,000 feet from the runway threshold. A postaccident examination of the airplane revealed that the left main landing gear was in the retracted position and the right main and nose landing gear were in the extended position. Examination of the left main landing gear actuator revealed no mechanical anomalies. The pilot had likely just commanded the landing gear to the down position and the landing gear was in transit. It is further possible that, as the gear was in transit, the airplane impacted the water in a left-wing and nose-down attitude and the left gear was forced to a gear-up position.

The flight crew reported for duty at Liverpool Airport at 0845 hrs. Their original task was to fly to Belfast City Airport, collect a transplant organ, and take it to Cambridge Airport. However, on their arrival at Belfast the transfer was no longer required, so they were given a new task to fly to Belfast Aldergrove Airport and collect an organ to carry to Birmingham Airport. The aircraft departed Belfast Aldergrove at 1450 hrs with the co-pilot as pilot flying. The flight was uneventful and the aircraft was given a radar vector to intercept the ILS for a straight-in approach to Runway 15 at Birmingham. The Runway 15 ILS course is 149°M. The autopilot was engaged and the aircraft was flying on a track of 135°M, 13 nm from the touchdown zone and at a groundspeed of 254 kt, when it crossed the localiser centreline. The aircraft then turned right onto a corrective track but once again passed through the localiser course. Further corrections were made and the aircraft passed through the localiser once more before becoming established at 5 nm. The co-pilot later reported that, because the autopilot was not capturing the localiser, he had disconnected it and flown the approach manually. When the aircraft was at 10 nm, the radar controller broadcast a message advising of the presence of a fog bank on final approach and giving RVRs of 1,400 m at touchdown and in excess of 1,500 m at both the mid-point and stop end. The airfield was sighted by the commander during the approach but not by the co-pilot. A handover to the tower frequency was made at around 8 nm. When the aircraft was at 6 nm, landing clearance was given and acknowledged. The tower controller then advised the aircraft that there was a fog bank over the airfield boundary, together with the information that the touchdown RVR was 1,400 m. The commander responded, saying: “WE’VE GOT ONE END OF THE RUNWAY”. The aircraft was correctly on the localiser and the glideslope at 4 nm. The Decision Altitude (DA) of 503 feet amsl (200 feet aal) for the approach was written on a bug card mounted centrally above the glare shield. Both pilots recollected that the Standard Operating Procedure (SOP) calls of “500 above” and “100 above” DA were made by the commander. However, neither pilot could recall a call of ‘decision’ or ‘go-around’ being made. At between 1.1 nm and 0.9 nm, and 400 feet to 300 feet aal, the aircraft turned slightly to the right, onto a track of 152°M. This track was maintained until the aircraft struck the glideslope antenna to the right of the runway some 30 seconds later (see Figure 3, page 11). The aircraft came to rest in an upright position on the grass with a fire on the left side. The co-pilot evacuated through the main cabin door, which is located on the left side of the fuselage, and suffered flash burns as he passed through the fire. The commander was trapped in the cockpit for a time.

The airplane was flying a VOR/DME-C approach that was on an oblique course about 40 degrees to the runway 30 centerline; the wind conditions produced an 8-knot tailwind for landing on runway 30. Despite the tailwind, the captain elected to land on the 6,600-foot-long runway instead of circling to land with a headwind. Moderate to heavy rain had been falling for the past hour, and the runway was wet. The crew said that the airplane was flown at the prescribed airspeed (Vref) for its weight with the wing flaps fully extended on final approach, and that they touched down just beyond the touchdown zone. The captain said that he extended the wings' spoilers immediately after touchdown. He tested the brakes and noted normal brake pedal pressure. However, during rollout, he noted a lack of deceleration and applied more brake pressure, with no discernible deceleration. The airplane's optional thrust reversers had been previously rendered non-operational by company maintenance personnel and were therefore not functional. The captain stated that he thought about performing a go-around but believed that insufficient runway remained to ensure a safe takeoff. While trying to stop, he did not activate the emergency brakes (which would have bypassed the anti-skid system) because he thought that there was insufficient time, and he was preoccupied with maintaining control of the airplane. He asked the first officer to apply braking with him, and together the crew continued applying brake pedal pressure; however, when the airplane was about 2,000 feet from the runway's end, it was still traveling about 100 knots. As the airplane rolled off the departure end on runway 30, which was wet, both pilots estimated that the airplane was still travelling between 85 and 90 knots. The airplane traveled 618 feet through a rain-soaked grassy runway safety area before encountering a drainage swale that collapsed the nose gear. As the airplane was traversing the soft, wet field, its wheels partially sank into the ground. While decelerating, soil impacted the landing gear wheels and struts where wiring to the antiskid brake system was located. The crew said that there were no indications on any cockpit annunciator light of a system failure or malfunction; however, after the airplane came to a stop they observed that the annunciator light associated with the antiskid system for the No. 2 wheel was illuminated (indicating a system failure). The other three annunciator lights (one for each wheel) were not illuminated. During the approach, the first officer had completed the landing data card by using a company-developed quick reference card. The quick reference card’s chart, which contained some data consistent with the landing charts in the Airplane Flight Manual (AFM), did not have correction factors for tailwind conditions, whereas the charts in the AFM do contain corrective factors for tailwind conditions. The landing data prepared by the first officer indicated that 3,240 feet was required to stop the airplane on a dry runway in zero wind conditions, with a wet correction factor increasing stopping distance to 4,538 feet. The Vref speed was listed as 127 knots for their landing weight of 11,000 pounds, and the first officer’s verbal and written statements noted that they crossed the runway threshold at 125 knots. During the investigation, Bombardier Lear calculated the wet stopping distances with an 8-knot tailwind as 5,110 feet. The touchdown zone for runway 30 is 1,000 feet from the approach end. The crew’s estimate of their touchdown location on the runway is about 1,200 feet from the approach end, yielding a remaining runway of 5,400 feet. On-duty controllers in the tower watched the landing and said that the airplane touched down in front of the tower at a taxiway intersection that is 1,881 feet from the approach end, which would leave about 4,520 feet of runway to stop the airplane. The controllers observed water spraying off the airplane’s main landing gear just after touchdown. Post accident testing indicated that the brake system, including the brake wear, was within limits, with no anomalies found. No evidence of tire failure was noted. The antiskid system was removed from the airplane for functional tests. The control box and the left and right control valves tested within specifications. The four wheel speed sensors met the electrical resistance specification. For units 1, 2 and 3, the output voltages exceeded the minimum specified voltages for each of the listed frequencies. Unit 4 was frozen and could not be rotated and thus could not be tested. Sensors 1 and 2 exceeded the specified 15% maximum to minimum voltage variation limit. Sensor 3 was within the limit and 4 could not be tested. Based on all the evidence, it is likely that the airplane touched down on the water-contaminated runway beyond the touchdown zone, at a point with about 600 feet less remaining runway than the performance charts indicated that the airplane required for the wet conditions. Since a reverted rubber hydroplaning condition typically follows an encounter with dynamic hydroplaning, the reverted rubber signatures on the No. 2 tire indicate that the airplane encountered dynamic hydroplaning shortly after touchdown, and the left main gear wheel speed sensor anomalies allowed the left tires to progress to reverted rubber hydroplaning. This, along with postaccident testing, indicates that the anti-skid system was not performing optimally and, in concert with the hydroplaning conditions, significantly contributed to the lack of deceleration during the braking attempts.

The crew started the approach to Zaligei Airport runway 03 in good weather conditions. The aircraft landed hard 200 metres past the runway threshold, causing both propeller blades to struck the ground on a distance of 33 metres. The aircraft bounced and landed a second time 263 metres further then a third time after 15 metres. Upon impact, both engines were torn off and the aircraft rolled for about 400 metres before coming to rest, bursting into flames. Two passengers were killed while five others were injured. All 37 other occupants escaped unhurt. The aircraft was totally destroyed by a post crash fire.

Following an uneventful flight from Lima, the crew continued the approached while the aircraft was unstabilized. Upon touchdown on runway 07, the aircraft landed relatively hard then bounced three times when the crew retracted the landing gear. The aircraft slid on its belly for about 600 metres before coming to rest. All nine occupants escaped uninjured while the aircraft was damaged beyond repair.

The twin engine aircraft departed Aix-les-Milles Airport at 1520LT on a local training flight. The crew was cleared to fly between 5,000 and 6,000 feet. The aircraft overflew successively Marseille and Toulon then passed over Le Castellet. While cruising at an altitude of 6,000 feet and at a speed of 110 knots, the airplane entered an uncontrolled descent, dove into the ground with a rate of descent of 6,000 feet per minute and crashed in a near vertical position in a rocky zone located in the Sainte-Victoire Mountain Range, near Saint-Antonin-sur-Bayon. The aircraft was destroyed by impact forces and a post crash fire and both occupants were killed, one instructor and one pilot under supervision.

At the day of the accident, the pilot, accompanied by his wife, planned to fly from Karlsruhe/Baden-Baden Airport to the Cottbus-Drewitz Special Airfield under Instrument Flight Rules (IFR) with a Piper PA 46-350P. Prior to the flight he refueled 400 liters and submitted a flight plan. According to the radar recording of the responsible air traffic control center, the airplane started at 0923 hrs1 and flew the planned route at Flight Level (FL) 190 to Cottbus-Drewitz, following the flight plan. The airplane started to descend at approx. 1044 hrs. The Initial Approach Fix (IAF) Cottbus-Drewitz NDB (DRW) was overflown in an altitude of approx. 3,900 ft AMSL with a Ground Speed (GS) of approx. 170 kt, at approx. 1104 hrs, and the descent was continued for the approach NDB-RWY-25. After flying over the intermediate approach fix in approx. 2,800 ft AMSL with a GS of approx. 190 kt, the airplane flew a turn to the left in order to intercept the final approach. The radar recording ended at 1107:34 hrs. At that time the airplane was turning into the final approach in an altitude of 2,400 ft AMSL with a GS of approx. 200 kt. According to radar recordings of the German Federal Armed Forces, the airplane was captured several more times within the turn radius: at 1107:50 hrs in an altitude of 1,200 ft AMSL, at 1108:01 hrs in an altitude of 2,700 ft AMSL, and finally in 1,700 ft AMSL and 1,000 ft AMSL. The recording ended at 1108:21 hrs in an altitude of 600 ft AMSL. The airplane crashed into a field south of the Polish city of Gubin and caught fire. Both occupants lost their lives.

The pilot was landing at a private strip at Wentworth. The runway was oriented 110/290° and had several level changes along its length which required all landings to be made in the 110° direction and all takeoffs in the 290° direction. Touchdown was required to take place on a level portion before the ground rose relatively steeply and levelled out again. The final part of the runway sloped gently down towards the end, which was bordered by a dry stone wall. The surface, from police photographs taken soon after the accident, showed it to be closely mown grass and firm, despite the indications of recent rain. The wind at the time was 220°/10 kt and the pilot reported that the approach was made directly into the setting sun, making it difficult to monitor the airspeed indicator. Touchdown was achieved on the first level portion of the runway and the brakes were applied very soon afterwards; however the pilot stated that there was no discernible braking action, despite applying firmer pressure on the brake pedals. Seeing that the stone wall at the end of the runway was approaching, he steered the aircraft to the right and towards a hedge, however he was unable to prevent the left wing striking the walland causing severe damage outboard of the engine. The pilot was uninjured and evacuated the aircraft normally. The police photographs indicate that the mainwheels were skidding on the wet grass almost throughout the landing roll of about 630 metres. Whilst the pilot acknowledged that his airspeed might have been somewhat high, he did not feel at the time of touchdown that his ground speed was unusual and he attributes the lack of braking action to the slippery runway surface.

The aircraft was on an instrument flight rules flight from the Edmonton City Centre Airport to Kirby Lake, Alberta. At approximately 1114 Mountain Daylight Time, during the approach to Runway 08 at the Kirby Lake Airport, the aircraft struck the ground, 174 feet short of the threshold. The aircraft bounced and came to rest off the edge of the runway. There were 2 flight crew members and 8 passengers on board. The captain sustained fatal injuries. Four occupants, including the co-pilot, sustained serious injuries. The 5 remaining passengers received minor injuries. The aircraft was substantially damaged. A small, post-impact, electrical fire in the cockpit was extinguished by survivors and first responders. The emergency locator transmitter was activated on impact. All passengers were BP employees.

The pilot was conducting a charter flight from Lady Barron, Flinders Island to Bridport, Tasmania with six passengers on board. The aircraft departed Lady Barron Aerodrome at about 1700 Australian Eastern Daylight-saving Time and entered instrument meteorological conditions (IMC) several minutes afterwards while climbing to the intended cruising altitude of about 1,500 ft. The pilot did not hold a command instrument rating and the aircraft was not equipped for flight in IMC. He attempted to turn the aircraft to return to Lady Barron Aerodrome but became lost, steering instead towards high ground in the Strzelecki National Park in the south-east of Flinders Island. At about 1715, the aircraft exited cloud in the Strzelecki National Park, very close to the ground. The pilot turned to the left, entering a small valley in which he could neither turn the aircraft nor out climb the terrain. He elected to slow the aircraft to its stalling speed for a forced landing and, moments later, it impacted the tree tops and then the ground. The first passenger to exit the aircraft used the aircraft fire extinguisher to put out a small fire that had begun beneath the engine. The other passengers and the pilot then exited the aircraft safely. One passenger was slightly injured during the impact; the pilot and other passengers were uninjured. During the night, all of the occupants of the aircraft were rescued by helicopter and taken to the hospital in Whitemark, Flinders Island.