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Munster

Crash of an ATR72-212 in Shannon

Date & Time: Jul 17, 2011 at 1021 LT
Type of aircraft:
Operator:
Registration:
EI-SLM
Survivors:
Yes
Schedule:
Manchester - Shannon
MSN:
413
YOM:
1994
Flight number:
EI3601
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2882
Captain / Total hours on type:
2444.00
Copilot / Total flying hours:
1678
Copilot / Total hours on type:
1351
Aircraft flight hours:
32617
Aircraft flight cycles:
37149
Circumstances:
The aircraft and crew commenced operations in EINN that morning, departing at 05.52 hrs and arriving at EGCC at 07.13 hrs. During the turnaround, fuel was uplifted and 21 passengers boarded. Using the flight number and call sign EI-3601 the scheduled passenger service departed EGCC at 07.47 hrs for EINN with an estimated flight time of one hour and nine minutes. En-route operations were normal and, in consultation with ATC, the aircraft descended and was cleared to self-position to DERAG2 for an Instrument Landing System (ILS) approach to RWY 24. At 09.08 hrs the aircraft commenced an approach to RWY 24 in strong and gusty crosswind conditions. Following a turbulent approach difficulty was experienced in landing the aircraft, which contacted the runway in a nose-down attitude and bounced. A go-around was performed and the aircraft was vectored for a second approach. During this second approach landing turbulence was again experienced. Following bounces the aircraft pitched nose down and contacted the runway heavily in a nose down attitude. The nose gear collapsed and the aircraft nose descended onto the runway. The aircraft sustained damage with directional control being lost. The aircraft came to rest at the junction of the runway and a taxiway. Following engine shutdown the forward Cabin Crew Member (CCM) advised the cockpit that there was no smoke and that the doors could be opened following which, an evacuation was commenced. Airport fire crews arrived on scene promptly and assisted passengers disembarking the aircraft. There were no injuries.
Probable cause:
Probable Cause:
1. Excessive approach speed and inadequate control of aircraft pitch during a crosswind landing in very blustery conditions.
Contributory Factors:
1. Confusing wording in the FCOM that led the crew to compute an excessive wind factor in the determination of Vapp.
2. Incorrect power handling technique while landing.
3. Inexperience of the pilot in command.
4. Inadequate information provided to flight crew regarding crosswind landing techniques.
Final Report:

Crash of a Swearingen SA227BC Metro III in Cork: 6 killed

Date & Time: Feb 10, 2011 at 0950 LT
Type of aircraft:
Operator:
Registration:
EC-ITP
Survivors:
Yes
Schedule:
Belfast – Cork
MSN:
BC-789B
YOM:
1992
Flight number:
NM7100
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1801
Captain / Total hours on type:
1600.00
Copilot / Total flying hours:
539
Copilot / Total hours on type:
289
Aircraft flight hours:
32653
Aircraft flight cycles:
34156
Circumstances:
The aircraft departed Belfast City Airport (EGAC) on an international scheduled passenger service to Cork Airport (EICK). Low Visibility Procedures (LVP) were in operation at the destination. The aircraft carried out two ILS1 approaches, each followed by a missed approach. The aircraft then entered a holding pattern following which a third ILS approach was made to Runway (RWY) 17. The approach was continued below Decision Height (200 ft) and a missed approach was initiated. Approaching the runway threshold, the aircraft rolled to the left followed by a rapid roll to the right during which the right wingtip contacted the runway surface. The aircraft continued to roll and impacted the runway in a fully inverted position. The aircraft departed the runway surface to the right and came to rest in soft ground. A significant quantity of mud entered the aircraft through a fracture in the roof, partially filling the cabin. Six persons (including the two Flight Crew members) were fatally injured, four were seriously injured and two received minor injuries. The propeller blades on both engines were severely damaged; three of the four propeller blades on the right-hand engine detached during the impact sequence. Fire occurred in both engines after impact. These fires were extinguished expeditiously by the Airport Fire Service.
Probable cause:
Loss of control during an attempted go-around initiated below Decision Height (200 feet) in Instrument Meteorological Conditions.
The following factors were considered as significant:
- The approach was continued in conditions of poor visibility below those required.
- The descent was continued below the Decision Height without adequate visual reference being acquired.
- Uncoordinated operation of the flight and engine controls when go-around was attempted
- The engine power-levers were retarded below the normal in-flight operational range, an action prohibited in flight.
- A power difference between the engines became significant when the engine power levers were retarded below the normal in-flight range.
- Tiredness and fatigue on the part of the Flight Crew members.
- Inadequate command training and checking.
- Inappropriate pairing of Flight Crew members, and
- Inadequate oversight of the remote Operation by the Operator and the State of the Operator.
Final Report:

Crash of a Lockheed L-188AF Electra in Shannon

Date & Time: Mar 1, 1999 at 0846 LT
Type of aircraft:
Operator:
Registration:
N285F
Flight Type:
Survivors:
Yes
Schedule:
Cologne - Dublin - Shannon
MSN:
1107
YOM:
1959
Flight number:
EXS6526
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
3200.00
Copilot / Total flying hours:
3000
Copilot / Total hours on type:
760
Aircraft flight hours:
65000
Circumstances:
The aircraft (Flight 6526) departed Cologne at 0300 hours and routed directly to Dublin, where, after more than one hours delay due to the late arrival of a freight truck, the aircraft departed for Shannon Airport at 0816 hours. The crew consisted of the First Officer who was the handling pilot on both of these sectors, the Captain who was the non-handling pilot and the Flight Engineer. The take off gross weight was estimated at 83,701 lbs, well below the limiting 116,000 lbs take off weight (MTOW), and the centre of gravity was within limits. The landing weight was estimated at 80,345 lbs, again below the maximum landing weight of 98,102 lbs. The total freight on board was 14,000 lbs, less than half the 33,000 lbs maximum amount permissible. The aircraft reached it's designated altitude of FL120. The crew were handed over to Shannon Approach and given descent clearance. Shannon Approach instructed the crew to keep the speed up (due to an another aircraft behind them) and the aircraft was vectored on an approach to RWY 24. Due to the weather forecast for Shannon the crew decided to conduct the landing with 78% flaps set, rather than the standard 100% flap normally set for landing. During the approach the Captain called 1000 ft above the touchdown zone (TDZ), then 500 ft and every 100 ft thereafter to the Decision Altitude (DA). At an altitude of 700 ft the Ground Proximity Warning (GPWS) horn sounded. The Flight Engineer proceeded to inhibit the GPWS system. Slowing the aircraft to Vma (Maximum Manoeuvering Airspeed) the crew did not carry out the "before landing" checks. Whilst over the RWY threshold the gear warning horn sounded and five seconds later the crew heard a scraping sound and felt severe aircraft vibrations. Realising that the gear was not down the Captain called for a go-around. The First Officer continued to fly the aircraft and was cleared to 3000 ft by ATC. However, during the climb out the aircraft flew into cloud (Instrument Meteorological Conditions) at about 500/600 feet, and simultaneously the propeller assembly and part of No. 3 engine fell to the ground. Electrical power was lost and the only serviceable flight instruments available to the crew was the standby artificial horizon and wet compass. The First Officer relinquished control of the aircraft to the Captain who had great difficulty in maintaining directional control and it took the combined efforts of both pilots to control the excessive yaw through the rudder pedals. In addition, there was insufficient power available to climb to 3000 ft. In fact, less than 2000 ft was attained, as the aircraft commenced a slow difficult turn in a North Easterly direction and towards the high ground west of Limerick city. It was only by further manipulation of the throttles and feathering No. 4 engine that sufficient directional control was recovered, enough to respond to the instructions of the ATC Radar operator. The aircraft was now flying with only No.1 engine fully operative and No. 2 engine producing only half power and much vibration. The Radar operator vectored the aircraft to approach RWY 24 which became visible to the crew. They selected "gear down" and while only 2 of the 3 green landing lights illuminated, the Captain elected to proceed with the landing, with the flaps again set at 78%. This landing was successful, with all the landing gear deploying correctly. The aircraft was evacuated while the airport crash crews stood by.
Probable cause:
The primary responsibility for the safe conduct of a flight rests with the cockpit crew and, in this regard, they have the Aircraft Flight Manual (AFM), company Standard Operating Procedures (SOP's) and other technical manuals at their disposal in the cockpit. In particular, the company lays down the SOP's to be followed by each and every cockpit crew member in the interests of standardisation and flight safety. The implementation of these measures and procedures is carried out by the cockpit crew and they are aided in this process by artificial mechanical/electrical warning systems and audio alerts. In the L188 in question the two audio alert systems consist of a Ground Proximity Warning System (GPWS) and the landing gear warning horn. The GPWS system sounded at about 700' AGL and this should have been sufficient to warn the crew that the landing gear handle was not down and consequently that the undercarriage was not in the landing configuration. The Flight Engineer, however, reached up and inhibited the GPWS. He said he did this because he understood the aircraft to have 78% flap set for landing and that this was why the GPWS warning sounded. He obviously confused this warning with a warning which he would have got below 200 feet radio height when the flaps are set at less than 100% for landing. The fact that this particular aircraft had no FLAP OVERRIDE switch, as the other two similar aircraft in the fleet had, would probably have added to this confusion. Whether the engineer was instructed to inhibit the GPWS by other crew members is not clear from the CVR. In the debrief following the accident the other crew members agreed that the engineer would have been correct in inhibiting the GPWS as they were landing with 78% flaps configuration. They, therefore, also misinterpreted the GPWS warning. Having failed to carry out the landing checks and with the undercarriage not down, the normal undercarriage warning horn should have sounded when the throttles were retarded for landing. However, it is possible to silence this warning in the 78% flap configuration, which would not have been possible if the flaps were set in the normal (100%) configuration for landing. It appears that as the throttles were being retarded the Flight Engineer pressed the warning horn button to prevent the alarm from sounding. Whether he was so instructed is not clear as parts of the CVR tape were difficult to interpret due to its poor quality. During the final stage of landing the throttles were advanced again thus negating the warning cancellation. As the aircraft rounded out for landing the warning horn was again free to sound, and it did, as the throttles were retarded. However, at this stage, there was too little time to lower the undercarriage and five seconds later the propellers stuck the runway surface.
The following findings were identified:
- The aircraft had a valid standard Airworthiness Certificate issued by the United States Department of Transportation, Federal Aviation Administration and had been maintained in accordance with an approved schedule.
- No evidence was found of any technical problems on the aircraft, or its systems, that could have had any bearing on the accident. In addition, the aircraft records show that the aircraft was dispatched on the accident flight with no deferred maintenance items.
- The crew were properly licensed, in accordance with US Federal Aviation Administration Regulations, to undertake this flight.
- The Captain stated that he had slight flu symptoms over the two days prior to the flight but that did not disbar him from undertaking the flight.
- The flight crew consisted of the Captain, First Officer and Flight Engineer. The First Officer was the handling pilot on this flight.
- No emergency call was made to ATC by the Captain or First Officer. The Shannon Radar controller provided invaluable voice and directional assistance to the crew as they struggled to maintain control of their seriously damaged aircraft and this was subsequently acknowledged by the crew.
- The subsequent actions of the crew in landing the aircraft safely from the second approach were commendable.
- The ILS for RWY 24 was fully serviceable.
- Crew fatigue is not considered a factor in this accident as they had sufficient time off duty in the days immediately prior to the flight and their overall flying duties are of average industry standards.
- Debris from the disintegrating No. 3 engine fell to earth on the western side of RWY 24, within the boundaries of Shannon Airport. Fortunately, there was no damage to property or people.
- The selection of 78% flap setting for the landing was in accord with the Operators SOP's for the prevailing landing conditions. However in selecting 78% flap setting the crew were of the mistaken opinion that the GPWS warning horn should be silenced even though the aircraft was not in the landing configuration.
- The Flight Engineer silenced the landing gear warning horn during the approach phase while the engine power levers were being retarded. It is only when these levers were slightly advanced, just before the round-out stage, that the landing warning horn system was again primed and subsequently sounded.
- The normal landing checks were not carried out by the flight crew. Not one crew member realised that the undercarriage gear was not down and locked.
- The crew stated that this was an inexplicable oversight on their part.
Final Report:

Crash of a Bristol 175 Britannia 253 in Shannon

Date & Time: Sep 30, 1977
Type of aircraft:
Registration:
EI-BBY
Flight Type:
Survivors:
Yes
MSN:
13455
YOM:
1959
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Shannon Airport runway 24, at an altitude of 300 feet, the crew encountered severe vibrations. The captain decided to initiate a go-around but the aircraft continued to descent until it struck the ground short of runway threshold. Upon impact, the right wing and the undercarriage were torn off and the aircraft came to rest in flames in a pasture. All six occupants escaped with minor injuries while the aircraft was damaged beyond repair.

Crash of a Piper PA-31T Cheyenne II in Shannon: 5 killed

Date & Time: Nov 12, 1976 at 1722 LT
Type of aircraft:
Operator:
Registration:
HB-LHT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Shannon - London - Geneva
MSN:
31-7520003
YOM:
1975
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1456
Captain / Total hours on type:
30.00
Aircraft flight hours:
877
Circumstances:
The twin engine airplane was completing an on-demand taxi flight from Shannon to Geneva with an intermediate stop in London, carrying four employees of the Digital Company and one pilot. The takeoff roll was initiated from runway 06 at Shannon Airport in poor weather conditions with a limited visibility due to fog. After liftoff, the airplane failed to maintain a positive vario and failed to gain sufficient height. At a speed of 160 knots, it nosed down to an angle of 5° and struck the runway surface about 1,600 metres from the runway threshold (point of departure). It bounced then struck successively a fence and a stone wall before crashing in flames in a prairie. The aircraft was totally destroyed by impact forces and a post crash fire and all five occupants have been killed.
Probable cause:
At the time of the accident, the runway visual range for runway 06 was 250 metres, which was considered as below the published procedures of the company and the airport which stipulated a minimum of 300 metres. No technical anomalies were found on the aircraft, its engines or instruments. The pilot took the decision to takeoff in below weather minimums and his experience was considered as insufficient with only 30 flying hours on type.

Crash of a Douglas DC-6B in Shannon: 83 killed

Date & Time: Sep 10, 1961 at 0355 LT
Type of aircraft:
Registration:
N90773
Flight Phase:
Survivors:
No
Schedule:
Düsseldorf – Shannon – Gander – Chicago
MSN:
44058
YOM:
1953
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
77
Pax fatalities:
Other fatalities:
Total fatalities:
83
Circumstances:
After takeoff by night from runway 24 at Shannon Airport, while climbing, the airplane turn to the left then banked left to an angle of 90° and eventually crashed inverted in the Shannon estuary, about two miles from the airfield. The aircraft was totally destroyed and all 83 occupants were killed. At the time of the accident, the visibility was poor due to the night and mist.
Probable cause:
Failure of the captain to maintain control of the aircraft after becoming airborne due to either:
- A defective artificial horizon and/or
- A fault in the right-hand aileron tabs.
Contributory causes could have been unsuitable weather conditions and possible crew fatigue.
Final Report:

Crash of a Douglas DC-6A in Shannon

Date & Time: Mar 26, 1961
Type of aircraft:
Operator:
Registration:
G-APOM
Flight Type:
Survivors:
Yes
Schedule:
Shannon - Shannon
MSN:
45519
YOM:
1958
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training mission at Shannon Airport. Following several touch-and-go maneuvers, the pilot performed a normal landing and prepared for takeoff again when one of the crew member inadvertently raised the undercarriage. The airplane sank on its belly and slid for several yards before coming to rest in flames on the left edge of the runway. All six crew members were evacuated safely while the aircraft was destroyed.
Probable cause:
The accident was the consequence of the following factors:
- Poor crew coordination,
- Poor flight preparation,
- Lack of pilot experience.

Crash of a De Havilland DH.104 Dove 5 in Shannon: 4 killed

Date & Time: Jan 27, 1961
Type of aircraft:
Operator:
Registration:
188
Flight Type:
Survivors:
Yes
Schedule:
Shannon - Shannon
MSN:
04503
YOM:
1959
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was performing a local training mission at Shannon Airport. On approach in high winds, the twin engine airplane went out of control and crashed in a field located few km from the runway threshold. A crew member was injured while four other occupants were killed.
Crew:
Cpt Jim Liddy, pilot,
Lt D. J. Brady, pilot, †
Lt P. B. Corr, ATC, †
Mr. P. B. Wall, Dpt Transport & Power, †
Mr. J. C. O'Donoghue, Dpt Transport & Power. †

Crash of a Douglas DC-7C in Shannon: 34 killed

Date & Time: Feb 26, 1960
Type of aircraft:
Operator:
Registration:
I-DUVO
Flight Phase:
Survivors:
Yes
Schedule:
Rome – Shannon – Gander – New York
MSN:
45231
YOM:
1958
Flight number:
AZ618
Location:
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
34
Circumstances:
Shortly after takeoff from runway 05, while climbing to a height of 165 feet, the pilote started a turn to the left according to departure procedures. While turning, the airplane lost height, causing the left wing tip to struck a stone wall located near the Clonloghan church. Out of control, the aircraft crashed in flames in an open field and was completely destroyed upon impact. Eleven of the 12 crew members were killed as well as 23 passengers. Eighteen people were seriously wounded.
Probable cause:
No definite evidence leading to a particular reason for this accident was revealed by the investigation. It can only be concluded that the airplane lost height in a turn shortly after takeoff and struck the ground.