The following information provides an awareness of problems that might be avoided in the future. The information is based on final reports by official investigative authorities on aircraft accidents and incidents.
CAT III Approach
Boeing 777-200. No damage. No injuries.
Inadequate crew coordination and monitoring of flight parameters were key factors in a serious incident that brought the 777 close to the ground during a go-around at Paris Charles de Gaulle Airport the morning of Nov. 16, 2011, according to the English translation of a report released in January by the French Bureau d’Enquêtes et d’Analyses (BEA).
At the onset of the incident, the captain had the airport in sight and was concentrating on completing a Category III (CAT III) autoland approach to a landing when a master caution activated, requiring a go-around in accordance with standard operating procedure. This resulted in a “conflict of plans of action between respecting the operator’s instruction and continuing the landing,” the report said.
The 777 was inbound to Paris from Caracas, Venezuela, and had been airborne for 10 hours. “After a long flight that arrived at 1100 in the morning (local time), this may have led to a certain loss of vigilance,” the report said. “However, the crew [later told investigators that they] did not feel tired.”
The English translation of the BEA report noted that the flight crew comprised the captain (the pilot flying), a copilot and a relief pilot but did not indicate whether there were passengers or cabin crew aboard the aircraft.
Low visibility procedures, which included increased spacing between arriving aircraft, had been in effect for several hours at de Gaulle. As the 777 neared the airport, the reported runway visual range for Runway 08R was 400 m (1/4 mi) in fog. Due to the low visibility, the captain decided to conduct an autoland approach. Accordingly, the crew requested and received radar vectors from air traffic control (ATC) for a CAT III approach to the runway.
The aircraft was on the glidepath and descending through a radio altitude of 320 ft when the master caution alarm sounded and an amber warning, “NO LAND 3,” was displayed on the engine indicating and crew alerting system. In addition, the green “LAND 3” indications on the primary flight displays changed to “LAND 2.”
The report explained that this indicated change to the aircraft’s autoland system performance would not, by itself, have prevented the crew from continuing the approach to CAT II minimums, typically a 50-ft decision height rather than the 20-ft decision height of a CAT III approach. During the investigation, the aircraft manufacturer determined that under the existing conditions, the landing could have been conducted safely. However, the aircraft operator required that a go-around be conducted if any alarm or mode change occurred below 1,000 ft during a CAT III approach.
The relief pilot, who was occupying the central observer’s seat, told investigators that neither the captain nor the copilot immediately reacted to the warnings, so he called out “warning.” The copilot subsequently called out “go around.”
By this time, however, the captain had acquired visual contact with the airport. “Having visual references and knowing that the landing was possible, his plan of action was to land,” the report said. “The ‘NO LAND 3’ warning, making mandatory a go-around, led to confusion and to a change in his plan of action.”
The captain initiated a go-around, but the procedure was only partially executed, with inadequate management of the autoflight systems, the report said. The captain inadvertently pressed the autothrottle-disconnect switch instead of the takeoff/go-around (TOGA) switch, which would have prompted an increase in thrust sufficient for a 2,000-fpm climb as well as the selection of the autopilot go-around pitch and roll modes. He then manually moved the thrust levers forward and pulled the control column back, but the control input was not sufficient to disconnect the autopilot, which was still in approach mode. The aircraft continued to descend on the glideslope.
The copilot told investigators that he was concentrating on changing the flap configuration and was not monitoring the flight parameters. The relief pilot called out “pitch attitude” twice before control inputs sufficient for a go-around were made. By this time, the captain also had disconnected the autopilot and moved the thrust levers full forward.
The 777 reached a radio height of 63 ft before beginning to climb. The crew retracted the landing gear and climbed straight out to 4,000 ft, as instructed by ATC. They subsequently set up for another CAT III approach and landed the aircraft on Runway 08R without further incident.
“This serious incident was due to the inadequate monitoring of flight parameters by the flight crew,” the report concluded. “After the incident, prevention information relating to go-arounds with no TOGA selection was distributed among 777 sector pilots.”
‘Sorry About That’
Airbus A319-112, Transall C-160. No damage. No injuries.
Visual meteorological conditions (VMC) with light winds prevailed at Zweibrücken Airport in Germany the afternoon of May 14, 2008, when the A319 flight crew requested clearance to taxi from the gate. A controller who was handling ground, departure and arrival operations told the crew to taxi to Runway 03 and to line up and wait on the runway, said a report published in January by the German Federal Bureau of Aircraft Accident Investigation.
While the Airbus was taxiing out, the crew of a Transall C-160, a twin-turboprop military transport, called for taxi clearance. The crew was conducting a series of parachute drops and was using Runway 21 for takeoff because the runway was much closer to its parking area. The controller told the crew to “taxi holding point runway … correction, taxi holding point Alpha, Runway 21.”
The report said that this instruction was not in strict accordance with proper ATC phraseology, but the C-160 crew correctly read back “taxi runway holding point Runway 21 via Alpha.”
The Airbus was lined up and waiting on the runway about one minute later when the controller said, “A319, wind variable 1 knot, Runway 03, cleared for takeoff.”
The report noted that the elevation of the 2,950-m (9,679-ft) runway is higher at the mid-point than at the thresholds; consequently, the crew of an aircraft positioned at one end of the runway has little, or no, ability to see the other end of the runway. Moreover, the tower controllers do not have an unobstructed view of the approach end of Runway 03.
As the A319 crew began the takeoff run, the controller realized that the C-160 crew was not holding on Taxiway Alpha, as instructed, but had taxied onto the runway. The controller told the C-160 crew to “hold position” and the A319 crew to “break up.”
Noting that “break up” is not a phrase used in ATC communications, the report said that the controller likely meant to tell the A319 crew to “stop immediately” — that is, to reject their takeoff. The crew did not understand the “break up” instruction and asked the controller to “say again.”
However, by this time, the Airbus had accelerated through V1, the maximum speed at which the crew could take action to safely reject the takeoff. The crew continued the takeoff, and the A319 passed 400 ft above the C-160. There were 137 people aboard the Airbus; the C-160 had a crew of four and an unspecified number of passengers.
After seeing the Airbus pass overhead, the C-160 crew told the controller that they had been instructed to line up and wait on the runway. The controller said, “You were cleared to holding point Alpha.” The crew replied, “OK, sorry about that.”
Ditching Follows Fuel Exhaustion
Beech King Air C90GTX. Substantial damage. No injuries.
The pilot-in-command (PIC), who had logged 2,600 of his 11,500 flight hours in 90-series King Airs, had been contracted by an air taxi operator to ferry the newly purchased airplane from Wichita, Kansas, U.S., to Willemstad, Curaçao, in the Netherlands Antilles. He was accompanied by an employee of the operator, a 3,650-hour pilot who had recently completed initial training in the airplane.
The first stop was planned for Fort Lauderdale, Florida, but strong headwinds prompted a landing in Marianna, Florida, where the King Air was refueled, said the report by the U.S. National Transportation Safety Board (NTSB).
After continuing the flight to Fort Lauderdale, the pilot requested that the nacelle fuel tanks be topped off. The PIC told investigators that he monitored the refueling, but surveillance cameras showed that the line service agent was alone when the nacelle tanks were filled.
The pilots stayed overnight in Fort Lauderdale and returned to the airport early in the morning of April 3, 2012. The PIC reviewed the fueling ticket and concluded that 134 gal (507 L) had been pumped into the nacelle tanks, bringing the total fuel load to 366 gal (1,385 L).
However, investigators found that only 25 gal (95 L) of fuel had been required to top off the nacelle tanks. The number “134” on the fueling ticket was the line service agent’s employee number.
“Utilizing the information contained on the fuel ticket, it was determined that the airplane had departed with only 261 gallons [988 L] of fuel on board,” the report said. “Review of performance data in the [airplane flight manual] revealed that, in order to complete the flight, the airplane would have needed to depart with 328 gallons [1,241 L] on board.”
The King Air was cruising over Haiti at 27,000 ft about two hours after departure when the PIC noticed that the indicated fuel quantity was lower than expected. “However, the pilot decided to continue despite his proximity to airports on Hispaniola that were suitable for diversion,” the report said. “By the time he began to be concerned about a possible fuel leak or indication failure, he was once again over open water.”
The airplane was about 90 nm (49 km) from Willemstad when the PIC decided to divert to Oranjestad, Aruba, because of “very low indications” on the fuel gauges. Both engines flamed out due to fuel exhaustion shortly after the descent was begun.
Realizing that he could not reach Oranjestad, the PIC ditched the airplane in the Caribbean Sea. The pilots boarded a life raft and were rescued about 20 minutes later by the crew of a Royal Netherlands helicopter. The King Air subsequently sank.
Pyrotechnic Paper Clip
ATR 72-212A. Minor damage. No injuries.
Shortly after the aircraft reached cruise altitude, 25,000 ft, during a flight from Vaasa, Finland, to Tallinn, Estonia, the morning of Nov. 28, 2011, dark blue smoke began to emerge from the aircraft communications addressing and reporting system thermal printer. The flight crew saw a red glow inside the printer.
“The pilots donned their oxygen masks, started an immediate descent and made the decision to land at Pori Airport,” said the English translation of the report on the serious incident by the Safety Investigation Authority of Finland. The crew declared an emergency, reported a cockpit fire and requested and received radar vectors to Pori.
The pilots initially had difficulty donning and using their oxygen masks. “The oxygen masks hampered communication between the pilots and between the captain and the cabin crew,” the report said.
The captain instructed the cabin crew to prepare the cabin and passengers for an emergency landing. The smoke was thick at first but dissipated during the approach to Pori, leaving a strong odor in the cockpit and in the front of the cabin. No portable fire extinguishers or passenger oxygen masks were used during the approach. The pilots landed the aircraft without further incident, and the seven passengers deplaned normally.
“A paper clip which showed signs of having been heated was found inside the printer,” the report said. “The paper clip caused a short circuit in the printer. The smoke generation ended when the printer’s circuit breaker tripped. There was no actual fire inside the printer. … Immediately after the occurrence, [the operator] banned the use of paper clips on its entire fleet.”
Fire Erupts Near Oil Gauges
Beech 58 Baron. Destroyed. Four fatalities.
The Baron was cruising at 9,000 ft in VMC about 30 minutes after departing from Atlanta for a charter flight to Hazard, Kentucky, the afternoon of May 25, 2011, when the pilot told ATC, “We gotta declare an emergency. Got a fire.”
The controller asked him to state his intentions, but there were no further radio transmissions from the pilot. The airplane rapidly descended below radar contact. “The time interval between the pilot’s declaration of an emergency and the last radar return from the airplane was a little less than one minute, suggesting that the fire grew quickly, without much of an incipient stage,” the NTSB report said. “These characteristics are consistent with a fuel-fed fire.”
A witness saw a two-engine airplane flying about 1,500 ft above mountainous terrain before it abruptly banked right and pitched nose-down. The witness then heard an explosion.
The Baron had crashed in a wooded area near Murphy, North Carolina, killing the pilot and the three passengers. “The cockpit, cabin, instrument panel, nose compartment, empennage and inboard sections of both wings were nearly consumed by the post-crash fire,” the report said.
Investigators determined that the fire most likely began underneath the instrument panel, near the direct-read oil gauges. Because of the extensive fire damage, however, NTSB was unable to form a conclusion about what caused the fire.
Piper Navajo C. No damage. No injuries.
The Navajo pilot used the common traffic advisory frequency (CTAF) to broadcast his intention to taxi to Runway 32 for takeoff from Port Hedland Airport in Western Australia the afternoon of May 27, 2013.
About five minutes later, the crew of an aviation rescue and fire fighting (ARFF) vehicle used a portable radio to announce on the CTAF frequency that they were crossing the runway to return to the fire station.
The ARFF vehicle then entered the 2,500-m (8,203-ft) runway from a taxiway about halfway down the runway, said the report by the Australian Transport Safety Bureau.
The Navajo pilot told investigators that he made the required CTAF broadcasts as he taxied onto the approach end of the runway and began the takeoff. “The crew of the fire vehicle had not heard any CTAF broadcasts [from the Navajo pilot], nor did they see the aircraft when they scanned the runway prior to crossing, possibly due to heat haze,” the report said.
The pilot had not heard the CTAF broadcasts from the ARFF vehicle. During the investigation, “Airservices Australia determined that the transmission power of the portable radios was lower than the radios mounted in the vehicle,” which had not been programmed with the CTAF frequency, the report said. “The investigation also noted that a radio dead zone — an area within the range of a radio transmitter in which the signal is not received — may exist in the vicinity of the Runway 32 threshold.”
After the Navajo lifted off, the pilot saw the ARFF vehicle crossing the runway. “As the aircraft was airborne, the pilot assessed the safest action was to continue the takeoff,” the report said. “By the time [the aircraft] crossed the intersection [at 300 to 400 ft], the fire vehicle was clear of the runway.”
Helipad Known as Flight Hazard
Bell 206-L4. Substantial damage. One fatality.
The pilot was attempting to land the JetRanger on an oil-drilling platform in the Gulf of Mexico to pick up a passenger the afternoon of May 28, 2012, when the main rotor blades struck the corner of an oil derrick that was partially positioned over the helipad. The tail boom separated as the helicopter spun into the water.
The pilot — who was wearing a seat belt, shoulder harness and life vest — sustained multiple blunt-force injuries on impact and drowned when the JetRanger sank rapidly. The NTSB report said that the helicopter’s emergency external floats had not inflated.
At the time, the fixed oil-drilling platform was mated to a jack-up rig, a mobile platform used for maintenance and exploratory drilling. Although a notice to airmen (NOTAM) had not been issued and there were no markings on the fixed platform’s helipad, the pilot knew that this helipad was closed due to the proximity of the jack-up rig’s derrick and that aviation operations were being conducted on the larger and unobstructed helipad on the jack-up rig.
“There was also nothing in the operator’s flight operations manual that would have restricted the pilot from landing under an obstruction,” the report said. “Other company pilots were aware that [the fixed platform] helipad was a flight hazard due to the encroachment of the [jack-up rig’s] oil derrick, but it was never reported to management or via the company’s internal safety notification system.”
Company records showed that the pilot had flown to the platform several times and had landed on the jack-up rig two days before the accident. “It could not be determined why the pilot decided to land on the smaller and obstructed helipad rather than the jack-up rig’s larger helipad,” the report said, noting that several workers had tried to signal the pilot not to attempt the landing on the fixed platform.
Rotor Snags a Power Line
Robinson R44. Destroyed. Two fatalities.
A search was begun when the R44 did not return at the expected time from an aerial tour launched from Wheatland, Missouri, U.S., the afternoon of May 24, 2013. The wreckage of the helicopter was found the next day in a densely wooded area near Cross Timbers, Missouri. The pilot and his passenger had been killed.
“A power line was found wrapped around the main rotor driveshaft, and a section of the power line was found resting on the ground leading from the power line pole to the main wreckage,” the NTSB report said.
Investigators determined that the power line had been suspended about 65 ft (20 m) above the ground and was perpendicular to the helicopter’s flight path. After striking the power line, the R44 had descended into trees. The helicopter was destroyed by the impact and subsequent fire.