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The human operator, the least reliable element of an aerodyne, but the most essential...!
Frank Caron (1991)


Last update:
26 September 2016

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Events analysis
 
 
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2006: A320, Iljuk (A320 Asiana Pilots Suspended for Hailstorm Incident)
2006: A320, Iljuk

The Ministry of Construction and Transportation suspended two Asiana Airlines pilots whose aircraft was severely damaged after they flew into a hailstorm over Gyeonggi Province last year.

Asiana Airlines Flight 8942 made an emergency landing after hailstones and lightning caused the aircraft's nose cone to shear off and windshield to shatter over Iljuk, Gyeonggi Province on 9 June 2006. The Ministry's Civil Aviation Safety Authority said Thursday that Asiana was fined W100 million (US$1=W936) and the pilot and co-pilot were suspended for three months and one and a half months, respectively, for the incident.

The airplane was flying from Jeju Island to Kimpo airport with about 200 passengers on board when it entered the storm. Hailstones smashed the windshield, severely limiting visibility, but the pilots were able to land the plane safely. Asiana Airlines initially said it would award both pilots a "Well Done" award, its highest citation. But it reversed that decision when it was found that the pilots flew into the storm in violation of safety rules.

"Other planes detected the storm in advance and returned to the airport to avoid the hailstones," a ministry official said.

"The accident was completely avoidable. It was clearly negligent of the pilots to overlook the danger signs."

2006: B737-800, Knok (Ryanair error blamed after passenger jet nearly crashed into Knok airport)

A Ryanair aircraft “marginally avoided” crashing after the airline failed to inform its pilots of changes to the approach to an airport, according to the official report on the incident.

The aircraft emerged from low cloud only 400ft from the ground, triggering an alarm and forcing the captain to make an emergency ascent.

The Irish airline also failed to report the incident to Ireland’s Air Accident Investigation Unit for almost two weeks, by which time some of the evidence had been deleted.

The Boeing 737, carrying 144 passengers and crew, was flying from Gatwick to Knock, in the west of Ireland, on March 23.

Several navigational aids, which help pilots land in poor visibility, had been switched off at Knock (UK) while the airport was upgraded. Ryanair had been informed of the changes six weeks earlier but, despite being one of the main operators at Knock, it did not pass on the information to its pilots.

This led the pilots to programme the wrong approach information into the aircraft’s flight computer, which manages the autopilot. An air traffic controller told the pilots, as they approached Knock, that they had to alter their approach. They became “so engrossed” by the need to update the computer that they did not realise they were descending at a fast rate and becoming dangerously close to the ground.

The report said: “The work overload meant normal routine checks were not carried out and there was no questioning of the developing situation by either pilot. When they finally broke clear of cloud at about 400ft, the spatial reality finally dawned on both pilots as the pilot flying disengaged the autopilot and executed a non-procedural go-around.

The investigators found the pilots failed to respond quickly enough to the changing circumstances and the captain allowed himself to become distracted from the task of flying the plane. But the report concluded that the root of the problem lay in the failure to give the pilots the correct information to plot a safe course.

A cockpit manual, supplied by an outside company, had also not been updated with the new information about Knock.

Both pilots had long experience of flying older 737s but had only recently switched to the modern, highly automated version of the aircraft operated by Ryanair.

This cognitive deficit led to their difficulties in managing and interacting with the Boeing 737-800 automations,” the report said. It concluded: “This serious incident is defined as controlled flight into terrain only marginally avoided.”

The investigators also criticised the “unacceptable delay” by Ryanair in notifying them of the incident. Information about the flight had been recorded on devices in the cockpit but these had been overwritten during subsequent flights.

In March a Ryanair flight bound for Londonderry in Northern Ireland landed at Ballykelly five miles away after the pilot mistook the old military runway for the city’s airport.

In September last year a co-pilot had to take emergency control of a Ryanair plane approaching Rome because the captain suffered a breakdown.

In July 2004 a captain on his last day with the airline descended at twice the recommended rate towards Stockholm’s Skavsta airport. He continued to descend too steeply, despite warnings from the co-pilot.


2006: CRJ100, Lexington (Comair Crash)

The taxiway for commercial jets using Lexington Blue Grass Airport's (Kentucky, USA) main runway was altered a week before Comair Flight 5191 took the wrong runway and crashed here, killing all but the co-pilot of the 50 people aboard.
 
Both the old and new taxiways cross over the shorter general aviation runway where the commuter jet tried to take off Sunday.
 
Conversations between pilots and the person on duty in the control tower before dawn Sunday mentioned only the airport's main commercial strip, runway 22.
 
Somehow, the commuter jet ended up on the airport's other much shorter runway, runway 26, which has a cracked surface and used for small planes.

The pilots tried to lift off, but the plane clipped trees, then quickly crashed in a field and burst into flames,

An initial examination of the flight data recorders indicated that the pilots of the jet opted for a 1,066 meters runway, instead of a runway of more than twice that length that is perpendicular to the shorter runway and is used most by commercial jets at Blue Grass Airport.
 
Bombardier, the Canadian company that built the airplane, mentionned a fully loaded CRJ-100 depending on wind and other conditions, typically requires a runway at least 1500 meters to take off.
 
The aircraft took off in hazy weather only moments before the crash. It was headed to Hartsfield-Jackson International Airport in Atlanta on a flight that was scheduled for just over an hour.


2006: C5 Galaxy, Dover (Pilots error and bad CRM blamed for USAF Galaxy Crash)
2006: C5 Galaxy, Dover 2006: C5 Galaxy, Dover 2006: C5 Galaxy, Dover 2006: C5 Galaxy, Dover 2006: C5 Galaxy, Dover
US military investigators have determined that pilot error led to the 3 April 2006 loss of a US Air Force Lockheed C-5 Galaxy at Dover AFB, Delaware.
The pilots and flight engineers “did not properly configure, manoeuvre and power the aircraft during approach and landing”, says the accident investigation board appointed by Air Mobility Command. All 17 people on board the C-5 survived, but three sustained serious injuries.

Following a normal take-off and initial climb, the crew observed a No 2 engine “Thrust Reverser Not Locked” indication light. They shut down the engine as a precaution and returned to Dover AFB. The AIB determined that during the return to the base:

The aircraft stalled, hit a tele­graph pole and crashed into a field “about a mile” short of the runway. It was supposed to fly to Ramstein Air Base in Germany, and was loaded with 47,700kg of supplies.


2005: AN-12B, Entebe (Crashed An-12B was overloaded)

The Antonov An-12B cargo aircraft crash at Entebe on 8 january 2005 killed the six Russian crew. The inquiry has identified overloading and engine failure as the cause of the accident, but also cites a culture of poor maintenance and inattention to safety oversight as contributory factors.

The aircraft (9Q-CIH) was registered in the Democratic Republic of Congo and operated by Uganda's Service Air. It crashed 5 Nm north of Entebe as it tried to turn back to the airport after an engine failure.

Some 2 minutes later after take off, the crew reported to ATC that one of the starboard engine has failed and feathered. The aircraft contacted tall trees, stalled, crashed, desintegrated and was totaly destroyed with its cargo in the intense fire that ensued.

The report recommends that all operators in Uganda airspace, even if licensed abroad, should meet the minimum safety requirements for Uganda permits.


2004: CRJ200, Jefferson City (NTSB concluded 'Poor Airmanship' The Root Cause Behind 2004 Pinnacle Airlines Crash)

Two pilots who took their commuter jet on a high-altitude joyride, then failed to follow proper procedures after both engines failed, were to blame for the October 2004 crash of the plane in Jefferson City, Missouri.

2006: C5 Galaxy, Dover 2006: C5 Galaxy, Dover 2006: C5 Galaxy, Dover
Federal investigator says pilots committed a number of errors and airline failed to properly train them.

"This accident was caused by the pilots' inappropriate and unprofessional behavior" said the NTSB. This accident shows a need for regional air carriers to adopt more stringent professional standards for pilots - as major airlines have done - and improve training procedures for pilots flying at high altitudes.

Pilots were ferrying the 50-seat Pinnacle Airlines regional jet from Little Rock to Minneapolis without passengers when they decided "to have a little fun" according to the cockpit voice recorder transcript. Subsequently pilots:

  • took the plane to an unusually high altitude of FL410 (max certified altitude), the flight plan was FL330, and the company maximum authorised altitude is FL380.
  • performed aggressive flight maneuvers,
  • switched seats during the flight
  • and ignored repeated cockpit warnings that the plane was about to stall.

First one, then the second engine stalled. The crew declared an emergency with the tower, informing them of an engine failure. However, they failed to inform the tower that both engines had failed while they made four unsuccessful attempts to restart the engines, without following the proper procedures to restart.

The crew also continued to try to restart the engines after the controller asked if they wanted to land.

The flight crew attempted to make an emergency landing at the Jefferson City airport but crashed in a residential area about 3 miles south of the airport. The airplane was destroyed by impact forces and a post crash fire.

"Overall, the pilots' behavior during this flight was not consistent with the degree of discipline, maturity and responsibility required of professional pilots," said the NTSB's acting deputy director of aviation safety.

According to the NTSB, the probable causes of the crash -- which killed the two pilots ferrying the aircraft -- were as follows:

  1. the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots' inadequate training (regarding how to fly at high altitudes and how to handle emergencies...).
  2. the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites.
  3. and the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition.

Contributing to the cause of the accident a problem with the GE jet engines were the engine core lock condition (engine froze), which prevented at least one engine from being restarted, with a history of locking up at high altitudes during test flights.

At least the airplane flight manuals did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.


quick links

5 steps to convince about safety

Why air safety improvement is too slow (organisation)?

Why air safety improvement is too slow (culture)?

Why training is the main solution to human factors issues

Human factors still the current challenge of the industry

No limits for the understanding of human factors

Suggestions for a discipline committee

Too long briefings

Current CRM have reach its limits

Aviation safety international legal definitions

Two statements about fatigue every manager must know