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.
Jets
Rapid Pitch-Up
Airbus A320-200. Substantial damage. No injuries.
The A320’s main landing gear contacted the runway at Japan’s Sendai Airport so softly on the morning of Feb. 5, 2012, that none of the usual sensory cues was clearly evident. Believing that the aircraft was floating too far down the runway, the captain decided that it would be safer to go around than to continue the landing.
The captain had progressively increased back-pressure on his sidestick to maintain the flare attitude, and he moved the stick fully aft while initiating the go-around. As a result, the A320 pitched up substantially and the tail struck the runway, said the Japan Transport Safety Board in its final report on the accident. Damage to the rear fuselage was substantial, but none of the 166 occupants was hurt. The crew subsequently landed the aircraft without further incident.
Visual meteorological conditions (VMC), with light surface winds from the southeast, prevailed at Sendai, and the flight crew had decided to conduct a visual approach, backed up by the instrument landing system (ILS), to Runway 27. Inbound from Osaka, the aircraft neared Sendai from the south, over the Pacific Ocean. The tower controller advised the crew that the winds were from 160 degrees at 2 kt.
The A320 was 1,000 ft above the ocean when the captain began a left turn onto final approach to Runway 27. The first officer subsequently called out a radio altitude of 500 ft as the aircraft descended on the ILS glideslope, and the captain replied “stabilized,” indicating that all performance parameters were within the limits for a stabilized approach and that the aircraft was configured properly for landing.
The aircraft crossed the runway threshold at 50 ft and at 138 kt — about 3 kt above the target airspeed. The captain initiated the flare at about 30 ft, as prescribed by standard operating procedures, and brought the throttles to idle.
Recorded flight data indicated that the aircraft “floated” about 10 ft above the runway before the main landing gear touched down about 2,297 ft (700 m) from the threshold of the 9,843-ft (3,000-m) runway. The touchdown was soft, with a change in vertical acceleration of 0.06 g, compared with an average of 0.19 g recorded for the last 13 landings. No sounds typical of touchdown were captured by the cockpit voice recorder. The first officer was looking out the windshield and did not notice the instrument panel indication of automatic spoiler deployment.
Believing that the aircraft was still airborne, the captain said “oh, no good” and then announced “go around.” With the application of go-around power, spoiler retraction and full-aft sidestick, the pitch angle increased rapidly from 1.8 to 12.7 degrees.
During the subsequent climb-out, a purser told the crew that a loud sound had been heard and that an unusual impact had been felt in the cabin. Suspecting a tail strike, the captain decided to enter a holding pattern while the runway was checked for debris. Airport personnel found a large white scrape mark about 3,740 ft (1,140 m) from the approach threshold.
During the brief hold, the crew detected “no particular body vibrations or other irregularities [and] decided to land at Sendai Airport as planned,” the report said. An examination of the A320 revealed a large abrasion on the lower rear fuselage and deformation of the rear pressure bulkhead.
Afterward, both pilots said that never before had they been unable to recognize when an airplane touched down on landing.
Smoke, Sparks Prompt Evacuation
Boeing 737-300. Minor damage. No injuries.
The six crewmembers were preparing the 737 for a ferry flight from London Gatwick Airport the morning of March 1, 2013, when the senior cabin crewmember saw smoke and sparks near a forward overhead locker.
“After ordering the cabin crew to leave the aircraft, the flight crew carried out the QRH [quick reference handbook] drills and declared a mayday before leaving the aircraft,” said the report by the U.K. Air Accidents Investigation Branch (AAIB).
Examination of the 737 revealed that the smoke and sparks had originated from electrical arcing across the pins of a spare galley connector that was receiving electrical power although its circuit breaker was pulled and collared. The report noted that the connector “was positioned close to damp sound-insulation material.”
A similar incident had occurred a year earlier to another aircraft in the operator’s fleet. Maintenance action was ordered, “but the operator’s maintenance systems allowed the task to be closed prior to completion of the rectification work” on the aircraft involved in the 2013 incident, the report said. Following that incident, “the connector was removed from the aircraft and the wires capped and stowed.”
‘Surreal’ Approach
Airbus A319-132. No damage. Two minor injuries.
Inbound from Vienna, Austria, with 152 passengers and five crewmembers the night of Dec. 19, 2010, the flight crew was turning base for a landing at Köln/Bonn (Germany) Airport when they detected a “strange, strong and unpleasant” odor. They queried the purser, who reported that there was no abnormal odor in the cabin.
“A short time later, during intercept of the extended centre line, both pilots noticed an adverse effect on their physical and cognitive performance,” said the report on the serious incident published by the German Federal Bureau of Aircraft Accident Investigation (BFU) in December 2013.
The pilot-in-command (PIC), 35, said that his first sensation was an “intense prickling in his hands and feet.” He then experienced tunnel vision and severe dizziness. The copilot, 26, said that nausea “hit him like a punch to his stomach.” His arms and legs began to feel numb, and he could not think clearly.
After donning oxygen masks, the PIC’s condition improved somewhat. “He felt physically ill [and] was at the upper limit of what he thought he could do while manually flying the airplane with the assistance of the flight director,” the report said. The copilot’s condition worsened. “He did not feel capable to actively influence the course of events and just hoped it would be a successful landing,” the report said. “Both pilots described their condition shortly before touchdown as surreal and like a dream.”
The landing was successful, and the pilots subsequently were taken by ambulance to a hospital for medical treatment. “In the hospital, both pilots were examined and released after about two hours,” the report said. “Blood and urine tests were not made.”
The PIC resumed flying duties four days after the incident; the copilot said that he remained unfit to fly for seven months due to illness and post-traumatic stress disorder. The pilots’ symptoms were analyzed by the German Airforce Institute of Aerospace Medicine. Possible causes included inhalation of carbon monoxide, insecticide or deicing fluid; ingestion of contaminated food or drink; lack of oxygen; and cardiological disease. Further analysis of possible factors such as oil, hydraulic fluid and rain repellent leaks, and electrical system malfunctions was performed by the BFU. However, no definitive conclusion was reached about the cause of the pilots’ illness.
Maintenance technicians who examined the airplane shortly after it was parked detected a “strange odor” although the cockpit windows had been opened. “The technicians estimated it was highly likely caused by deicing fluid,” the report said. “The technicians definitely ruled out oil, fuel and electrical smell.” (The A319 had been deiced prior to its departure from Vienna.)
However, further inspections of the airplane and a functional check flight did not reveal the source of the odor that had partially incapacitated the flight crew.
Turboprops
Attention Lapse on Landing
Fairchild Metro III. Substantial damage. No injuries.
The flight crew was conducting a cargo flight the morning of March 7, 2013, to Dublin (Ireland) Airport, which had about 1,200 m (3/4 mi) visibility in fog and an overcast at 300 ft. The pilots said that the Metro broke out of the clouds at about 650 ft during the ILS approach to Runway 10.
“As per normal procedure after landing, the first officer, who was the pilot flying, gave the controls to the captain … so that he [the first officer] could complete the ‘Leaving the Runway’ checklist,” said the report by the Irish Air Accident Investigation Unit (AAIU). “This checklist is completed from memory and included booster pump and flap-to-zero selections.”
The captain was applying wheel braking and the indicated airspeed was below 90 kt when the nose landing gear suddenly collapsed. Both propellers struck the runway, and the aircraft came to an abrupt stop resting on its nose. Neither pilot was injured.
The AAIU determined that the first officer likely had inadvertently retracted the landing gear, rather than the flaps, during the landing roll. “Whilst it is not possible to be definitive as to why the landing gear selector was moved to the ‘UP’ position, the [first officer] described feelings of tension and stress associated with the limits approach he flew into [Dublin] due to the poor weather conditions,” the report said.
“It is possible that following the successful landing, and the associated relief of tension and stress, the [first officer] may have relaxed, leading to a reduced level of task attention as he went through his checks prior to leaving the runway. This reduced level of task attention probably facilitated the lapse whereby the landing gear selector was incorrectly moved to the ‘UP’ position.”
High Speed Leads to Excursion
Cessna 425. Substantial damage. Three minor injuries.
The pilot conducted a global positioning system (GPS) approach the morning of March 28, 2011, to Runway 22 at Hemphill County Airport in Canadian, Texas, U.S., which had surface winds from 140 degrees at 5 kt, 5 mi (8 km) visibility and an overcast at 600 ft.
“The airplane broke out of the clouds directly over the end of the runway,” said the report by the U.S. National Transportation Safety Board (NTSB). “The pilot then remained clear of clouds and executed a no-flap circling approach to the opposite-direction runway.”
Investigators determined that the approach airspeed was excessive and that the tire on the right main landing gear burst during the hard touchdown. The airplane then bounced and veered off the runway after the left main gear collapsed. Four passengers sustained minor injuries; the pilot and two other passengers were not hurt.
‘Complacency’ Cited in CFIT
Rockwell 690A. Destroyed. Six fatalities.
Night VMC prevailed when the Commander departed from Falcon Field in Mesa, Arizona, U.S., for a visual flight rules (VFR) flight to Safford, Arizona, on Nov. 23, 2011. “There was no moon, and the direction of flight was toward sparsely lit terrain,” the NTSB report said. “The pilot did not request VFR flight-following or minimum safe altitude warning (MSAW) services” for the 110-nm (204-km) flight.
Due to inbound traffic, the tower controller kept the airplane on the northeasterly runway heading for about two minutes before clearing the pilot for his requested right turn-out. There was no further radio communication with the Commander.
Radar data showed that the airplane turned directly toward Safford and climbed to 4,500 ft. About four minutes later, it struck a 5,057-ft mountain about 15 nm (28 km) southeast of the airport, killing all six occupants.
“This controlled flight into terrain (CFIT) accident was likely due to the pilot’s complacency (because of his familiarity with the flight route and because he selected a direct route, as he had previously done, even though he turned toward the destination later than he normally did) and lack of situational awareness,” the report said.
The cruise altitude likely had been chosen to keep the airplane below the 5,000-ft floor of Phoenix Class B airspace. The direct track between the Mesa and Safford airports passed about 3 nm (6 km) south of the mountain, but “the delayed right turn from [Mesa] put the airplane on a track that intersected the mountain,” the report said. “The pilot did not adjust his flight track to compensate for the delayed right turn to ensure clearance from the mountain.”
The report noted that six years before the crash, passenger seating had been reduced from six to five by removing a seat belt from the aft divan; the modification rendered the Commander exempt from the requirement to be equipped with a terrain awareness and warning system (TAWS).
Piston Airplanes
Engine Fire on Takeoff
Convair 340. Substantial damage. No injuries.
The captain suspected that the spark plugs were fouled when the left engine backfired during the run-up for a cargo flight from San Juan, Puerto Rico, to Saint Thomas, Virgin Islands, the morning of Jan. 17, 2011. “An additional engine run resulted in no further backfiring, and the captain decided to depart,” the NTSB report said.
Nearing the destination, the left engine backfired again, but the freighter was landed without further incident. No maintenance was requested or performed before the subsequent departure for the return flight to San Juan.
“During the takeoff, the local controller noted black smoke trailing the left engine and advised the flight crew,” the report said. “However, the captain attributed the smoke to normal operation for the airplane type and decided to continue the flight.”
After the flight crew switched radio frequencies to San Juan Approach, the local controller at Saint Thomas saw bright orange and red flames emerge from the Convair’s left engine. The information was relayed by the approach controller to the crew. “They immediately executed the fire checklist and shut down the left engine,” the report said. “However, the fire continued because it was located in an area where fire-suppression bottles could not reach.”
The crew turned back to Saint Thomas. The fire had damaged the left brake line, and after touching down, the airplane veered off the right side of the runway, crossed a taxiway and a perimeter road, went through the perimeter fence and came to a stop with the nose section over a public road.
Examination of the left engine revealed that two of the 18 pistons did not move in their cylinders when the propeller was rotated. “This discrepancy could result in unburned fuel or oil entering the exhaust system and igniting in the exhaust or augmentor tubes,” the report said.
Inadvertent Gear Retraction
Beech Duchess. Substantial damage. No injuries.
The Duchess was taking off from Bournemouth (England) Airport for an instrument instructional flight the afternoon of Feb. 6, 2013, when the landing gear partially retracted. “The aircraft was brought to a rest on the runway with a collapsed nose gear and partially collapsed main gear,” the AAIB report said. The pilot, the flight instructor and the passenger were not injured.
Investigators determined that while making rudder inputs to maintain directional control in a brisk crosswind, the pilot’s knee likely had struck and dislodged the gear selector knob, which is at the bottom right side of the panel. “A detent system designed to prevent inadvertent operation of the gear lever was not effective,” the report said.
Fuel Leak Causes Fire
Cessna 310K. Substantial damage. No injuries.
Shortly after starting the left engine in preparation for a flight from Olive Branch, Mississippi, U.S., the morning of March 7, 2012, the pilot saw smoke emerge from the nacelle and from below the panel. He shut down both engines and exited the airplane.
“Local personnel responded and extinguished the fire,” the NTSB report said. Subsequent examination of the left engine revealed that the fire likely was caused by the ignition of fuel that had leaked from the fuel strainer onto electrical connections for the battery and starter solenoid.
Helicopters
‘Fast-Changing Weather’
Eurocopter AS350-B3. Destroyed. Four fatalities.
The pilot had conducted three charter flights in Papua, New Guinea, the morning of March 16, 2012, and was en route with three passengers from Wanagon to the company’s base in Timika when he received a radio call from the company asking him to pick up another passenger in West Gully.
“The pilot flew to West Gully and attempted to land twice but was unsuccessful due to poor visibility,” said the report by the Indonesian National Transportation Safety Committee (NTSC).
The pilot resumed the flight to Timika but found that the weather conditions there also precluded a landing. He radioed the company that he was diverting to Landville. The report noted that the remote, mountainous area is subject to fast-changing weather and that Landville was an oft-used alternate because it generally has better visibility than the heliports at higher elevations.
There was no further radio communication with the pilot. An emergency locator transmitter (ELT) signal was detected, but the search was delayed by a false report that the helicopter had landed at Landville and was subsequently hampered by adverse weather conditions.
The wreckage of the helicopter was found the next morning at 8,000 ft. The NTSC determined that the helicopter was in level cruise flight when it struck the steep mountain slope. The accident was categorized as CFIT.
Unapproved Fuel
Hughes 500D. Substantial damage. No injuries.
The pilot was conducting a positioning flight to Aiken, South Carolina, U.S., the afternoon of March 20, 2012, when the tailwind changed to a headwind. The pilot realized that the reduced groundspeed would prevent him from reaching the destination, so he diverted to McCormick, South Carolina.
Finding that no fuel was available at the airport, the pilot repositioned to a nearby automobile station, where the helicopter was refueled with 25 gal (95 L) of 87-octane gasoline. “The pilot did not know what the approved alternate fuel was for the turbine engine,” the NTSB report said. “According to the engine manufacturer, automotive fuel is not an approved fuel on the list.”
Shortly after departing from the station, the helicopter was about 200 ft above the ground and at 70 kt when the engine lost power. “The pilot lowered the collective pitch as much as possible to clear a power line and reach an open field,” the report said. “Once clear of the power line, he lowered the collective pitch to the full-down position.”
The helicopter touched down hard in a tail-low attitude. The tail boom separated, and the helicopter rolled over on its right side.
The 500D flight manual lists several types of jet fuels as “primary” fuels for the helicopter and notes that aviation gasoline can be used in an emergency. The report said that the probable cause of the accident was “the pilot’s decision to use automotive fuel instead of [an] approved alternate fuel.”