Crash of a Cessna 501 Citation I in Birmingham

Date & Time: Nov 19, 2010 at 1535 LT
Type of aircraft:
Registration:
G-VUEM
Flight Type:
Survivors:
Yes
Schedule:
Belfast - Birmingham
MSN:
501-0178
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
1785
Copilot / Total hours on type:
735
Circumstances:
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.
Probable cause:
The co-pilot’s task of flying the approach would have become increasingly demanding as the aircraft descended and it is probable that his attention was fully absorbed by this. This was confirmed by his erroneous perception that the aircraft was in IMC from below 2,000 feet amsl. The co-pilot reported that during the final stages of the approach, when he noticed he had lost the localiser indication, he had asked the commander whether he should go around. The response he reported he heard of “no, go left” was not what he had expected, and may correspond to the time from which no further control inputs were made. The commander could not recall having given any instructions to the co-pilot after the ‘100 feet above’ call. It is likely that the crew commenced the approach with an expectation that it would be completed visually. However, the weather conditions were unusual and the aircraft entered IMC unexpectedly, late in the approach. As an aircraft gets closer to a runway the localiser and glideslope indications become increasingly sensitive and small corrections have a relatively large effect. The task for the flying pilot becomes more demanding and the role of the monitoring pilot has greater significance. A successful outcome relies on effective crew co-ordination, based on clear SOPs. The monitoring of this approach broke down in the latter stages and the crucial ‘decision’ call was missed, which led to the aircraft’s descent below minima.
Final Report:

Crash of a Beechcraft B90 King Air in Chattanooga

Date & Time: Sep 19, 2007 at 2015 LT
Type of aircraft:
Operator:
Registration:
N10TM
Survivors:
Yes
Schedule:
Birmingham - Chattanooga
MSN:
LJ-476
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11150
Captain / Total hours on type:
371.00
Aircraft flight hours:
9638
Circumstances:
Prior to departing, the pilot looked at the fuel quantity indicators, and believed that approximately 3 hours of fuel was available for the estimated 1 hour 20 minute flight. Upon reaching the cruise portion of the flight, the pilot realized that an insufficient quantity of fuel remained in order to complete the planned flight, and he elected to divert to a closer airport. While on final approach to the diversionary airport, both engines lost power, and the pilot made a forced landing to a parking lot. When asked about the performance and handling of the airplane during the flight, the pilot stated, "the airplane performed the way it was suppose to when it ran out of fuel."
Probable cause:
The pilot's inadequate preflight planning, which resulted in fuel exhaustion during the landing approach.
Final Report:

Crash of a Swearingen SA227AC Metro III in Rotterdam

Date & Time: Sep 19, 2005 at 0730 LT
Type of aircraft:
Operator:
Registration:
PH-DYM
Flight Phase:
Survivors:
Yes
Schedule:
Rotterdam – Birmingham
MSN:
AC-523
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 19 September 2005, the type F-Swearingen SA227-AC aircraft with registration PH-DYM was scheduled to make a charter flight from Rotterdam Airport to Birmingham Airport. Seventeen passengers and two cockpit crew members were on board. The planned departure time was 07.30 hours. The aircraft taxied to the beginning of runway 24 and lined up for take-off. During line-up, the speed levers for the engines were moved from taxi position to flight position. The nose wheel steering fault indicator lit up and the first officer, who was steering the aircraft, responded by saying that he had no nose wheel steering. The captain informed the first officer that he had forgotten to press the switch on the throttles, which activates the nose wheel steering system. The first officer then confirmed that he had nose wheel steering. With the engines in the low RPM range (taxi position, up to 70% of maximum RPM), the pilot can steer the aircraft using the rudder pedals while taxing. When the engines are operated in the high RPM selection (flight position, between 70% and 100% of the maximum RPM), the switch on the throttles, which activates the nose wheel steering system, must be pressed in during the first part of the take-off roll in order to be able to operate the nose wheel with the rudder pedal. At a speed around 50 knots, the switch which activates the nose wheel steering system is released. The aerodynamic forces of on the rudder are then sufficient to take over the steering from the nose wheel. Once take-off clearance was given by air traffic control, the first officer engaged power and started the take-off roll. He stated that once the nose wheel operating switch had been released, the aircraft almost immediately began moving towards the left hand side of the runway. He tried to use the brakes and the directional rudder, to return the aircraft to the centre of the runway. The aircraft had a speed of between 50 and 60 knots at that point. The crew rejected the take-off but could not prevent the aircraft ending up alongside the runway, on the left hand side. The captain stated that various forces influence the directional control of an aircraft during the take-off, such as wind, propeller wash, increasing air speed, etc. These forces necessitate steering corrections during the take-off. Only when the nose wheel steering system was disengaged the captain realized something was wrong. The grass area alongside the runway is lower than the runway and the ground was soft. The left landing gear sank in the soft ground first and, as a result, the aircraft decelerated heavily and the left landing gear broke off almost immediately. The tip of the left wing struck the ground. This caused a ground loop effect and turned the aircraft further left. As a consequence the right landing gear and the nose gear also broke off. Once the aircraft had come to a standstill, the captain switched off all onboard systems and cut off the fuel supply to the engines. Simultaneously, the first officer was given the task of evacuating the passengers. The passengers were calm and left the aircraft without problems via the left hand door at the front of the aircraft. A moment later, the airport fire service arrived at the location of the accident. One of the passengers was taken to hospital for a check-up; he was able to leave hospital the same morning. There was severe damage despite the relatively slow speed at which the aircraft left the runway.
Probable cause:
This accident was caused by an hydraulic leakage in the nose wheel steering system. The tyre tracks on the runway implied that the steering problem had occurred from the beginning of the take-off. The crew intervened as soon as after the nose wheel switch had been released and the nose wheel steering fault came on but were unable to prevent the aircraft leaving the runway.
Final Report: