Divided Responsibility

The flight crew of the Fairchild SA227-BC Metro III had descended below decision height in fog at Cork Airport in Ireland before initiating their third missed approach. They lost control, and the airplane rolled right and struck the ground inverted, killing both pilots and four of the 10 passengers.

In its final report on the Feb. 10, 2011, crash, the Irish Air Accident Investigation Unit (AAIU) cited as the probable cause the “loss of control during an attempted go-around below decision height in instrument meteorological conditions [IMC].”

The report also cited contributory causes, including not only the pilots’ flight techniques but also their fatigue, the “inadequate command training and checking” during the commander’s upgrade, the inappropriate pairing of two relatively inexperienced pilots and the “inadequate oversight of the remote operation by the operator and the state of the operator.”

After reviewing the complex relationships among three organizations — the accident airplane’s operator, which held a Spanish air operator certificate (AOC); the ticket seller, which was based in the Isle of Man; and the Spanish company that provided the airplanes and pilots under an agreement with the ticket seller — accident investigators identified “systemic deficiencies at the operational, organisational and regulatory levels … [that] provided the conditions for poor operational decisions to be made on the day of the accident.”

The business model, in which the ticket seller provided air service even though neither it nor the owner held an operating license or an AOC, was “not in the best interests of passenger safety,” the report said.

Below Minimums

The morning of the accident, the flight crew reported for work at 0615 local time at Belfast (Northern Ireland) International Airport and flew the accident airplane on a brief positioning flight to Belfast City Airport, where the airplane took on enough fuel for a roundtrip flight to Cork. After 10 passengers boarded, the copilot delivered the required safety briefing and the airplane took off at 0810 with the copilot at the controls.

As the airplane approached Cork at 0848, the automated terminal information service reported that low-visibility procedures were in effect. Air traffic control (ATC) provided information on runway visual range (RVR) for Runway 17, which was below required minimums for Category I operations, and said that a Category II instrument landing system approach, with lower visibility minimums, was available.

Neither pilot was approved to conduct Category II operations, and the airplane, which was not equipped with an autopilot or flight director system, was therefore not authorized for those approaches, the report said.

Nevertheless, the crew began the approach and continued the descent below the 200 ft decision height (DH) to 101 ft before beginning a missed approach. The second approach — to Runway 35, because the crew believed that the position of the sun behind the airplane might make it easier for them to see the runway — was continued to 91 ft. At 0915, after the second missed approach, they asked to spend 15 to 20 minutes in a holding pattern, waiting for visibility to improve. While in the holding pattern, the pilots discussed weather information for several nearby airports, including Kerry, where conditions were reported as good, with visibility of more than 10 km (6 mi).

However, at 0939, after ATC said that visibility was improving but still below required minimums, they began another approach to Runway 17, again continuing the descent below the DH, with the commander, the pilot not flying (PNF), operating the power levers.

“This was followed by a reduction in power and a significant roll to the left,” the report said. “Just below 100 ft radio altitude, a go-around was called by the PNF, which was acknowledged by the PF [pilot flying]. Coincident with the application of go-around power by the PNF, control of the aircraft was lost. The aircraft rolled rapidly to the right beyond the vertical, which brought the right wingtip into contact with the runway surface.”

The airplane was inverted when it struck the runway about 0950 and came to a stop in soft ground to the right of the runway; fires broke out in both engine nacelles and were extinguished by the airport fire service. In addition to the six fatalities, four passengers were seriously injured, and the other two received minor injuries. The airplane was destroyed.

Organizational Complexities

The airplane was owned by a Spanish bank, leased to a Spanish firm doing business as Air Lada and subleased to the Spanish operator, Flightline, which held an AOC. Flightline, along with three other operators, worked with the ticket seller, Manx2, which acted as the operators’ agent and provided a single brand name and livery. The ticket seller told accident investigators that “it did not wish to have the regulatory complexity and crewing problems associated with holding an AOC,” the report said. “Accordingly, aircraft were leased from EU [European Union] AOC holders.”

The report said that this business model “allowed specialisation, with the ticket seller concentrating on the commercial side of the operation and subcontractors used for most other requirements; the operational requirements of crewing, maintenance, provision and operation of the aircraft being addressed by the AOC holders.”

The U.K. Civil Aviation Authority said that it reviewed the ticket seller’s website “periodically” and expressed concern that the seller “was allowing the impression to be created that it was a licensed airline.” The website subsequently was changed to identify the ticket seller as the “agent for the four AOC holders within the marketing group,” the report said.

The ticket seller told investigators that it depended on local regulatory authorities and their Safety Assessment of Foreign Aircraft (SAFA) ramp checks, as well as the U.K. Department for Transport, to ensure that their airplanes met safety requirements.

Under a 2010 contract, the operator subleased the accident airplane and a second Metro III from the owner and “was responsible for the whole operation,” including training and checking the pilots and auditing the operation, the report said. A separate contract with the maintenance provider specified that the owner was to pay all maintenance costs.

The Agencia Estatal de Seguridad Aérea (AESA), Spain’s aviation safety and security agency, was responsible for regulatory oversight, but it told accident investigators that it “had no knowledge of the owner, which was a commercial company and therefore not within its regulatory remit, nor were they aware of the connection between the ticket seller and the owner.”

When the airplane was being used by a previous operator, AESA had sent inspectors to the Isle of Man for a ramp inspection, but, because the operator was not required to inform the agency of its remote activities, AESA was unaware that the airplane was being used in the area under a new AOC.

AESA told accident investigators that “to have better tools/procedures for proper oversight of a remote operation, EU regulation should require the operators to provide the certifying authority with a formal declaration stating which are the organizations that ultimately decide the flight’s schedule, routes, crew roster, etc.”

Four Days as Commander

The commander of the accident flight began flying in 2007 and held a European Joint Aviation Authorities (JAA) commercial pilot license issued in Spain. He had accumulated 1,801 flight hours, including 1,600 hours in type. He was hired as a Metro III copilot for three Spanish operators, and he flew concurrently for all three in early 2009, before being hired as a copilot by the operator of the accident airplane. His first flight as a commander was Feb. 6, 2011 — four days before the accident — and he had accumulated 25 hours in type as pilot-in-command. Records showed that, before the accident flight, he had flown into Cork 61 times as a copilot and seven times as a commander. There were no records of a diversion on any of those flights and no record that the commander had ever flown to Kerry.

The copilot held a JAA commercial pilot license issued in the United Kingdom and an SA227 type rating. He had 539 total flight hours, including 289 in type, and began flying for the operator on Jan. 8, 2011. When the accident occurred, he had flown 19 hours for the operator; a required line check had not been completed.

Reconfigurations

The accident airplane was manufactured in 1992 for an operator in Mexico. It was registered in Spain in 2004, and its most recent airworthiness review certificate was issued in 2010. At the time of the accident, it had been flown about 32,653 hours and 34,156 cycles.

The airplane had been configured to allow removal of the passenger seats for nighttime mail/cargo flights and reinstallation of the seats for daytime passenger flights. The operator told accident investigators that two commanders had been “trained and authorized” to remove and reinstall the seats, but according to regulations, this task was “restricted to holders of a valid [Joint Aviation Requirements] … flight engineers licence.”¹

For the accident flight, the airplane had 18 passenger seats — the maximum capacity approved by the AESA.

Maintenance was performed by an approved maintenance organization based in Barcelona, Spain. Technical logs showed no defects between Nov. 9, 2010, when the airplane was returned to service after repairs for a hard landing, and the day of the accident.

An analysis of the airplane’s flight data recorder showed that, throughout the 106 hours of available data, there had been a “mismatch between the recorded torques being delivered by the two engines,” the report said, tracing the problem to a faulty sensor. The flight crews consistently adjusted the power levers manually to compensate, but in the final seconds of the accident flight, when the pilots reduced power below the normal in-flight range, the power difference was significant, the report said. The difference was among the contributory causes cited in the report.

Fog and Low Visibility

Flight documentation emailed to the crew the night before the flight by a service provider in Spain included initial weather information, which had been obtained at 1622 on Feb. 9. At 0625 the morning of the accident, the pilots downloaded current weather information, which said the RVR at Cork was above the required minimums, although there was fog nearby; the terminal area forecast called for visibility of 300 m (984 ft) and broken clouds at 100 ft, with visibility improving to more than 10 km (6 mi) between 0900 and 1100.

The airport had been operating under low visibility procedures since 1550 on Feb. 8, 2011, and the Irish Meteorological Service told investigators that weather conditions at the time of the accident had included fog, broken clouds at 100 ft and visibility around 350 m (1,148 ft); RVR on Runway 17 was 600 m (1,969 ft), and RVR on Runway 35 was 450 m (1,476 ft).

Immediate Cause

Although accident investigators concluded that the “immediate cause of the accident was a loss of control of the aircraft at a low height, from which recovery was not possible,” the report also cited contributing operational, organizational and regulatory issues.

Both pilots reported for duty “without the prescribed rest,” the report said, “and it is likely that [both] were suffering from tiredness and fatigue at the time of the accident.”

The commander had received inadequate training for his role, the report said.

“Poor evaluation of the weather conditions, lack of CRM [crew resource management] and inappropriate decision making are largely attributable to the inadequate command training. … In addition, the copilot, who had only recently joined the operation, had not been line-checked, yet was paired with the newly appointed commander. This inappropriate pairing resulted in a flat cockpit authority gradient with little formal command in evidence.”

The copilot had not initially been scheduled for the flight but was added after the originally scheduled copilot asked the aircraft owner’s operations manager — described by that copilot as “the person responsible” — for a duty change. The operator was not told of the change, “although the preparation of rosters and availability of adequately rested flight crew was wholly the responsibility of the operator,” the report said.

“Such a crew pairing is not conducive to flight safety and came about due to the operator not exercising appropriate control over its crew rosters and its lack of operational control and effective oversight,” the report said.

Missing Link

The investigation found “no evidence of a direct link between [the ticket seller] and the operator, the holder of the operating licence providing the air services,” the report said.

The accident flight was considered an “intra-Community air service” — one that operated within the EU under regulatory requirements calling for “a high and uniform level of protection of the European citizen through the adoption of common safety rules.” This intra-Community air service represented a departure from the operator’s previous core activity of cargo flights.

“Sufficient scrutiny of this proposed remote operation by the operator should have identified and managed the additional resources and challenges while mitigating any risks identified,” the report said. “The lack of a contract, or contact, between the operator and the ticket seller illustrated that this did not take place.”

Because the operator’s AOC was issued by Spain, that meant that Spain was the only EU member state with responsibility for oversight of the operation. Regulatory authorities in Ireland and the United Kingdom had no role in oversight, and EU regulations did not permit their involvement except through a ramp check under the SAFA program, but “SAFA inspections cannot substitute for the continuing safety oversight responsibility of a national aviation authority,” the report said.

The report added that “the investigation is concerned that the lack of adequate oversight and control … by the regulatory authority of the state of the operator did not identify the operator’s shortcomings, thereby contributing to the cause of the accident.”

The report also criticized “the commercial model of an intra-­Community air service provided by a ticket seller [as] not in the best interests of passenger safety, as it can facilitate utilisation of resource-constrained undertakings [firms] to provide air services, thus allowing a ticket seller to exercise an inappropriate and disproportionate role with no accountability regarding air safety.”

The report contained 11 recommendations, including one calling on the European Commission’s director-general for mobility and transport to “review the role of the ticket seller when engaged in providing air passenger services and restrict ticket sellers from exercising operational control of air carriers providing such services, thus ensuring that a high and uniform level of safety is achieved for the traveling public.”

Other recommendations said the director-general should:

• Improve “the efficacy and scope of SAFA inspections, and … provide for the extension of oversight responsibilities, particularly in cases where effective oversight may be limited due to resource issues, remote operation or otherwise”; and,
• Review the obligations of EU member states to order penalties for violations of flight time limitations.

Several recommendations called on the European Aviation Safety Agency to provide guidance to operators on the handling of successive instrument approaches in IMC or at night when landings cannot be made, to ensure that existing regulations prescribe an appropriate level of command training and checking, and to review the process for issuing AOCs.

A recommendation to the AESA said the agency should review its policies on oversight of air carriers, especially those engaged in remote operations, and recommendations to the operator called for a review of its policy on diversions following a missed approach resulting from weather and the implementation of “appropriate training for personnel responsible for flight safety and accident prevention.” 

This article is based on AAIU Report 2014-001, “Formal Report: Accident, Fairchild Aircraft Corporation, SA 227-BC Metro III, EC-ITP; Cork Airport, Ireland; 10 February 2011.” The 240-page report was published Jan. 28, 2014.

Note

1. The report said that seat removal and reinstallation procedures also were required to be “specified in the maintenance organisation exposition and be accepted by the competent authority.” Accident investigators received no evidence that this had been done, the report said.