B777 in Autoland Mode Left Runway When Another Aircraft Interfered With the Localiser Signal
B777 in Autoland Mode Left Runway When Another Aircraft Interfered With the Localiser Signal (9V-SWQ, SIA) Boeing 777-312ER 9V-SWQ of Singapore Airlines was flying from Manchester to Munich on 3 November 2011. Shortly after touch-down in Munich the aircraft veered to the left and went off the runway, before veering right and coming to a stop on the grass to the other side next to the runway. In their safety investigation report, published 85 months after the occurrence, German safety investigation body, the BFU, explain that: …the co-pilot was initially Pilot Flying (PF) during the flight Manchester – Munich. Based on the latest weather information at Munich, visibility 2,000 m, cloud base 300 ft, the Pilot in Command (PIC) decided to assume the role of PF, as the SOPs (FCOM/NORMAL PROCEDURES/OPERATION) of the operator required, and the co-pilot became Pilot Monitoring (PM). The PIC decided to conduct an automatic approach and autoland. A BAE 146-RJ85 taxied along taxiway B4 to runway 08R as the B 777 was about 2.9 NM ahead of the runway threshold 08R and 3.4 NM behind the BAE 146-RJ85 when it received take-off clearance. As the B 777 was about 50 ft above the runway in the flare phase the airplane began to slowly bank left up to 3.5°. As the B 777 flew above the runway threshold 08R, the BAE 146-RJ85 was in front of the localizer antenna and interfered with the localizer signal. The PIC called out: “Okay, flaps twenty.” At approximately 420 m beyond the runway threshold the airplane touched down with the left main landing gear and 132 kt (KIAS). At that time the Auto Flight System (AFS) switched to rollout mode. The autopilot was still engaged as the airplane moved toward the left runway edge and veered off the runway with a speed of 123 kt (KIAS) about 944 m beyond the threshold in the area of taxiway B4. For about 400 m the airplane rolled through the grass north of runway 08R in a slightly curved right hand turn. The largest lateral deviation from the runway was reached at about 1,242 m beyond the threshold; speed was 109 kt KIAS. Because of the system design the autopilot disengaged due to crew inputs via the rudder pedals. The airplane turned right by about 40°, re-entered the runway close to the intersection with taxiway B6, about 1,566 m beyond the threshold. The aircraft crossed the runway with a heading of about 120°. Speed was still 71 kt KIAS. The airplane veered off the runway again, turned left by about 40°, and came to a stop in the grass south of and parallel to runway 08R. There were no injuries or apparent aircraft damage. The crew stated that during the approach and the landing there were no indications as to malfunctions or system failures. The PIC stated he had tried to initiate a goaround procedure by pushing the TO/GA buttons on the thrust levers and thereby triggering the go-around mode once it had been noticed that the airplane banked to the left. But the airplane did not respond. At the same time he retracted the ground spoilers manually which had automatically been deployed at the time of the touchdown. The BFU say: The crew did not inform the approach controller of their intention to conduct an automatic...
read moreSeason’s Greetings from Aerossurance
Aerossurance sends its Season’s Greetings to all its customers, partners, suppliers, colleagues and friends. We also wish you all a safe and prosperous 2019! For aviation advice you can trust, contact Aerossurance at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreUSAF Engine Shop in “Disarray” with a “Method of the Madness”: F-16CM Engine Fire
USAF Engine Shop in “Disarray” with a “Method of the Madness”: F-16CM Engine Fire USAF Lockheed Martin F-16CM 92-3883 suffered a General Electric F110-129 engine fire on departure from Misawa Air Base, Japan on 20 February 2018. The resulting USAF Accident Investigation Board (AIB) investigation report describes organisational weaknesses in a USAF engine maintenance facility and the latent defect of an obsolete part incorrectly fitted 6 years earlier. History of the Flight The AIB explain that: The mishap flight (MF) consisted of two F-16CM aircraft. The mishap pilot (MP) departed runway (RWY) 28, fifteen seconds after the mishap lead pilot (MLP). Shortly after the afterburner takeoff, Misawa air traffic controllers informed the MP and the mishap lead pilot (MLP) that the MP had a large flame coming from the aft section of the MP’s aircraft. The MLP also contacted the MP regarding the fire. During the MP’s ascent, he noticed an unexpected decay in his airspeed and climb rate. The MP took a right turn back towards RWY 28, and when unable to maintain airspeed or altitude, the MP jettisoned his stores (external fuel tanks) in accordance with F-16CM critical actions procedures. The two jettisoned fuel tanks landed off-base in Lake Ogawara… The tanks contained approximately 300 gallons each at the time they were jettisoned. The Crash Survivable Flight Data Recorder (CSFDR) indicated the total weight of two tanks with JP-8 was 896 pounds. Following the jettison, the MA regained some airspeed and achieved a better climb rate to get into a position to land. The MP landed on RWY 28, and accomplished the emergency engine shutdown and emergency ground egress critical action procedures. There were no injuries resulting from the mishap. The engine damage and loss of external fuel tanks resulted in a loss (calculated with absurd precision) of $987,545.57. The Investigation The investigation concluded that the cause of the accident was an obsolete turbine frame forward fairing that fractured, causing the engine to ‘overheat’, and resulting in significant damage to parts of the engine. This fairing is made up of three titanium segments that line the forward outer section of the turbine frame. In 2007 an order had been issued that “dictated replacement across the fleet by August 2010 of this susceptible fairing, along with its attaching hardware” after operators “began experiencing excessive wear, cracking and, in a few cases, failure of the turbine frame forward fairing”. This engine had been fitted with the later standard in 2010, however during a subsequent engine shop visit in 2012: …maintenance personnel ordered and installed an obsolete part, a turbine frame forward fairing, years after it was replaced by a forward fairing made of stronger material and design. The logistics system then delivered the obsolete forward fairing. Maintenance personnel installed the obsolete forward fairing on the mishap engine (ME) using the updated version of the bracket hardware. The obsolete forward fairing’s weaker material, along with wear from the mismatched [bracket] hardware, ultimately caused the forward fairing to fracture during takeoff. Once fractured, a piece of the forward fairing lifted and blocked the cooling flow of air around the engine, causing the area near the blockage to overheat and catch fire. Since the obsolete titanium fairings were new at the time of installation, they would have accumulated 760 flying hours on the day of the mishap. The AIB President further found by a preponderance of the evidence that maintenance...
read moreBFU Investigate S-76B Descending to 20ft at 40 kts En Route in Poor Visibility
BFU Investigate S-76B D-HHNH Descending to 20ft at 40 kts En Route in Poor Visibility The German safety investigation body, the BFU, is investigating a serious incident that occurred to Sikorsky S-76B D-HHNH of Heli Service International on 23 October 2017. UPDATED 22 November 2019 after issue of the final report. History of the Flight In an interim report they describe that the flight was on a return to Emden from the DolWin Alpha High Voltade Direct Current (HVDC) platform in the North Sea, which helps transit power from offshore wind farms ashore. At 0842 hrs the helicopter took off now with four persons on board [2 crew. 2 passengers] for the return flight…[and]…climbed to 2,000 ft AMSL which remained the same up until right abeam of Borkum Island. At 0854 hrs the flight crew established radio contact with the Flugleiter at [the uncontrolled] Emden Airfield and requested information regarding the prevailing weather conditions. They were told: “Right now it is raining, cloud base few one thousand, overcast thousand five hundred and wind south-west 10 to 15 gusts 20 kt, QNH 1,010 and visibility here visual reference point 2.5 to 3 km.” At 0857 hrs the crew informed Bremen Radar of passing way-point JUIST. However: Before reaching way-point JUIST the helicopter began to descend. The descent ended in low altitude with reduced speed near the coast line. Then the helicopter climbed again to about 500 ft AMSL and continued the flight to Emden. At 0901 hrs the crew again requested information regarding the prevailing weather at Emden Airfield. They were told: “Right now it has decreased a little bit few seven hundred, broken one thousand, overcast one thousand eight hundred, the rain is gradually slowing down”. The aircraft landed safely at 0911 hrs. The Aircraft Commander (PIC) had a total flying experience of 11,461 hours, of which 3,025 hours were on type. The First Officer (co-pilot) had 910 hours flying experience, of which 359 hours were on type. Investigation (Interim Report) The BFU examined the events leading to the period between 0957 and 0901 when the aircraft lost speed and altitude over the Wadden Sea, the tidal mud flats between the outer island and the mainland. …during the two legs (outbound and return) the co-pilot in the left-hand seat acted as Pilot Flying (PF) and the Pilot in Command (PIC) in the right-hand seat as Pilot Non Flying (PNF). After take-off from the converter station DOLWIN ALPHA the helicopter had been operated using the Flight Director (FD) coupled in the Upper Modes ALT and NAV. Between the way-points UTIRA and HW751 the FD had decoupled without reason. The two autopilots had changed from Attitude Retention (ATT) Mode to Stability Augmentation System (SAS) Mode. This resulted in the PF having to actively control the helicopter manually. Subsequently, the PNF tried to find and eliminate the cause for the FD failure. Both in vain. After they had enquired about the prevailing weather conditions at Emden Airfield they decided to reduce the flight altitude before reaching the coast line. During descent the helicopter had suddenly encountered heavy rain and significantly reduced visibility. At about 500 ft AMSL the co-pilot had handed over controls to the PIC. Notably: He had instructed the co-pilot to extend the landing gear because he wanted to be prepared for a possible off-field landing due to the unexpected bad weather. According to the Cockpit Voice...
read moreCRJ900 Skids Sideways Down Finnish Runway
CRJ900 Skids Sideways Down Finnish Runway On 25 October 2017, Bombardier CRJ900 EI-FPD of Cityjet was operating as Scandinavian Airlines (SAS) flight SK4236 from Stockholm, Sweden, to Turku, Finland, where it landed at 2024 local time. The Landing of Cityjet Bombardier CRJ900 EI-FPD at Turku After touchdown the aircraft did not decelerate as anticipated and entered a skid, drifting towards the right hand edge of the runway but with the nose pointing to the left of track. In their safety investigation report the Finnish Safety Investigation Authority (SIAF or Onnettomuustutkintakeskus) describe how: Approximately 1,200 m from touchdown, the skidding airplane began to veer to the right towards the edge of the paved area. It impacted and broke five runway edge lights. The minimum distance between the right mainwheel tires and the unpaved area was less than 0.5 m. The airplane then started to rotate to the left. When it was at right angles to the runway heading it was moving at 42 kt (78 km/h) groundspeed. It came to a halt next to the runway centerline 2,050 m from the initial touchdown point, having rotated 196° counter-clockwise from the initial direction of travel. The distance from the final position to the runway end was approximately 160 m. Analysis SIAF developed an AcciMap that summarises their analysis: SIAF Conclusions SIAF present 11 conclusions, each paired first with an observation: 1. Aerodrome maintenance decided to clear the runway after an arriving flight had landed and a departing flight had taken off. The decision was not reviewed even though weather was changing rapidly and continuous snowfall increased the thickness of the slush layer on the runway. Conclusion: Long-term runway maintenance planning is not possible under rapidly changing weather conditions. 2. The flight crew did not question the weather and runway condition data on which they based their decisions. The flight crew monitored wind data closely. Conclusion: Some time had passed from the preparation of the previous SNOWTAM. Personnel at the aerodrome knew that snowfall was intensifying. SNOWTAM reliability degrades fast under rapidly changing weather conditions. 3. The airplane was above the maximum performance limited landing weight on landing. Conclusion: The multi-step procedure required to determine the permitted landing weight using the tables provided for the purpose contributed to an error in weight calculations. 4. At Turku, only runway 26 is ILS-equipped. Conclusion: The flight crew elected to conduct a tailwind landing on runway 26 because they considered a runway 08 approach impossible due to the lack of ILS. Finland’s airports, with the exception of Helsinki-Vantaa, have ILS at one end of the runway only. 5. Landing was firm; therefore, weight on the right main landing gear lightened as the oleo leg extended after touchdown, the extension reaching a point where the airplane systems sensed an airborne condition. The thrust reverser system, although armed, was unavailable after touchdown. Conclusion: The flight crew was not familiar with reselecting the thrust reverser system in case of it being inhibited. 6. The airplane entered a hydroplaning condition at the moment of touchdown due to the high groundspeed and a slush deposit on the runway. Conclusion: Anticipating the possibility of hydroplaning enhances situational awareness and prepares for a necessary action if the airplane enters a hydroplaning condition. 7. Hydroplaning prevented the wheels from spinning up to a required speed and therefore the anti-skid system did not activate. The captain’s brake application, which was later augmented by simultaneous brake application by the first officer, resulted in the wheels remaining locked until the airplane came to a halt. Conclusion: The...
read moreHelicopter Tail Rotor Strike from Firefighting Bucket
Helicopter Tail Rotor Strike from Firefighting Bucket On 2 May 2017 Bell 206B3 N911GE, operated by the Marion County Sheriff’s Office as a public-use aircraft, sustained substantial damage during firefighting operations near Orange Springs, Florida. The pilot was seriously injured. The pilot was using an under slung Bambi Bucket and had completed between 25 and 30 drops on the fire. According to the US National Transportation Safety Board (NTSB) safety investigation report: After refueling, he completed three or four additional drops and then filled and pulled the bucket from the water and immediately felt “a severely out of CG [center of gravity] condition to the right.” He assumed that the bucket cables were entangled in the right landing skid, so he released the water from the bucket. The condition persisted, so he rocked the helicopter to attempt to free the cable without success. He then released the cable with the cargo release button and heard the “clunk” sound typically heard when the bucket was released, but then he heard another “clunk.” The helicopter then began to spin violently and after 4-6 rotations crashed into the water. After the aircraft submerged, rolled right and came to rest the pilot “egressed through the left cockpit door and swam to the surface”. On reaching the surface he inflated his life jacket, swam to the water’s edge and used his personal mobile phone to call for help. The NTSB investigation revealed: …6-inch long cable marks on the right rear landing skid tube and a torsional fracture of the tail rotor short shaft. Based on the pilot’s statement, the cable marks likely occurred initially when a cable became entangled on the skid tube… After releasing the bucket the tail rotor shaft fractured when the cable or bucket contacted the tail rotor. Safety Resources Just today, 1 December 2018, a firefighting Kamov Ka-32T crashed in Korea with the loss of one life while uplifting water, though as seen in the library footage below, that was likely by a suction system. Other Ka-32s do use an under-slung bucket: A Flight Safety Foundation (FSF) report ‘External Loads, Powerplant Problems And Obstacles Challenge Pilots During Aerial Fire Fighting Operations’ reviewed US accident reports from 1974 to 1998. UPDATE 28 January 2019: The Bureau d’Enquêtes et d’Analyses (BEA) are investigating an accident in Reunion on 24 January where a Airbus Helicopters AS350B3e/H125 F-OFML appears to have suffered a tail rotor strike on its own under slung firefighting bucket. Also see our articles: Wayward Window: Fatal Loss of a Fire-Fighting Helicopter in NZ Firefighting Helicopter Wire Strike Keep Your Eyes on the Hook! Underslung External Load Safety EC120 Underslung Load Accident 26 September 2013 – Report Unexpected Load: AS350B3 USL / External Cargo Accident in Norway Unexpected Load: B407 USL / External Cargo Accident in PNG Load Lost Due to Misrigged Under Slung Load Control Cable Fatal Wire Strike on Take Off from Communications Site UPDATE 21 October 2018: Fallacy of ‘Training Out’ Error: Japanese AS332L1 Dropped Load UPDATE 20 December 2019: Helicopter External Sling Load Operation Occurrences in New Zealand UPDATE 30 May 2020: Fatal Wisonsin Wire Strike When Robinson R44 Repositions to Refuel UPDATE 28 June 2020: Maintenance Issues in Fire-Fighting S-61A Accident UPDATE 27 December 2020: Fire-Fighting AS350 Hydraulics Accident: Dormant Miswiring UPDATE 9 January 2021: Korean Kamov Ka-32T Fire-Fighting Water Impact and Underwater Egress Fatal Accident UPDATE 21 May 2021: Firefighting AW139 Loss of Control and Tree Impact UPDATE 16 October 2021: South Korean Fire-Fighting Helicopter Tail Rotor...
read moreIced C208 Loses Airspeed During Circling Approach and Strikes Ground
Iced C208 Loses Airspeed During Circling Approach and Strikes Ground On the morning of 30 December 2014, Cessna 208B Grand Caravan N950FE, operated by Baron Aviation Services for Federal Express (FedEx), impacted the ground short of the Roswell International Air Center Airport, New Mexico. Instrument meteorological conditions (IMC) prevailed at the time of the accident and an instrument flight rules (IFR) flight plan had been filed for a Part 135 scheduled cargo flight from Lubbock, Texas. Baron Aviation Services, of Vichy, Missouri, was founded in 1973 and has been a FedEx feeder carrier since 1975. This was originally with DC-3s. The company has grown to a current C208 fleet size of 34 aircraft. N950FE is owned by FedEx. History of the Flight According to the US National Transportation Safety Board (NTSB) safety investigation report (released 3 years and 10 months after the accident in November 2018): The pilot reported that he encountered inflight icing and solid IMC conditions for most of the flight and due to airplane performance was unable to climb above 8,500 feet mean sea level. In the post-accident interview, the pilot thought the altitude limitation was due to ice forming on the unprotected portions of the wings. During the approach the pilot received vectors and altitude changes by the controller; the controller issued a clearance to 4,900 feet; the pilot acknowledged and stated that he didn’t have much elevator control and thought that his controls were “almost frozen”. In the post-accident interview the pilot added that he controlled his descent by adjusting power. He added that based on losing altitude, by using flaps during a climb, he elected not to use flaps on the approach; stating he never went below 100 knots on the approach. About three miles from the runway the controller cleared the pilot down to 4,580 ft, and the pilot acknowledged the transmission. Two miles from the runway the controller reported he was “on course”, and 4,280 ft was the recommended altitude. The pilot was unable to identify the runway until too late for a normal descent to land. Rather than perform the missed approach procedures, he elected to turn left, for a circling [no flpap] approach to runway 35. During the maneuver, an intermittent stall warning horn was heard in the background of radio communications between the controller and the pilot, indicating that the airplane was below the manufacturer’s recommended approach speed. The pilot stated that he “never went below 100 knots” during the approach. On the second landing attempt, before crossing the runway threshold, the airplane suddenly experienced an un-commanded roll to the left and the left wing and left aileron impacted terrain. The pilot was uninjured and the aircraft received substantial to the left wing. Frost and ice was evident on the aircraft. NTSB Analysis …the manufacturer’s minimum recommended no-flaps airspeed in icing conditions is 120 knots. Additionally, the manufacturer recommended using 10° of flap extension for landing when airframe ice was suspected. It is likely that, during the approach for landing, the pilot did not compensate for the airframe icing by increasing the approach airspeed as recommended. The accident is consistent with the pilot not maintaining adequate airspeed during a circling approach to the runway, and the uncommanded roll is consistent with an aerodynamic stall. The situation was likely exacerbated by the presence of ice on the wings and control...
read moreAAIB Highlight Electronic Conspicuity and the Limitations of See and Avoid after Mid Air Collision
AAIB Highlight Electronic Conspicuity and the Limitations of See and Avoid after MAC (Cessna 152 G-WACG and Guimbal Cabri G2 G-JAMM) Cessna 152, G-WACG and Guimbal Cabri G2 helicopter G-JAMM collided in mid-air when both were engaged on training flights near Waddesdon, Buckinghamshire on 17 November 2017. History of the Flight The UK Air Accidents Investigation Branch (AAIB) safety investigation report explains that both aircraft were operating under Visual Flight Rules (VFR) in uncontrolled Class G airspace and neither aircraft was receiving an ATC service. The AAIB comment that: Both aircraft were based at Wycombe Air Park/Booker(WAP). WAP is a busy general aviation airfield with fixed wing, rotary and gliding activity. The weather conditions were clear with good visibility. [However], the opportunity for the occupants of either aircraft to see the other was limited because, although they were in proximity for some time, they were both following a similar track and were not in each other’s field of view. At 1159:10 hrs, G-WACG, with a higher groundspeed, was approximately 0.5 nm behind G-JAMM and 1,950 ft above. A minute later, G-WACG was 750 ft above and approximately 1,000 ft behind. The vertical and horizontal separation progressively reduced to the point of the collision. The damage sustained by G-WACG indicated that the initial contact with G-JAMM was between the right wing of the aircraft and the main rotor blades of the helicopter. The collision occurred in an area called the Brize Norton-Heathrow-Luton Gap, that the Future Airspace Strategy VFR Implementation Group (FASVIG), now Airspace4All, described as an: Intensive private and commercial licence training area for Oxford, Wycombe, White Waltham and other airfields/airstrips in the area, plus helicopter training from RAF Benson.’ Conspicuity and Look-Out Radar data indicated that, when G-WACG was 1,950 ft above G-JAMM, it was only 0.5 nm behind it. A simple assessment indicates that, if G-WACG was straight and level with zero pitch angle at 2,000 ft above G-JAMM, it would have to have been at least 1.9 nm behind for the pilot to have had any opportunity of detecting a possible conflict without additional manoeuvring. In the absence of a turn, the pilot would need to have pitched the aircraft at least 24° nose-down to have had any chance of observing the helicopter. The situation, whereby additional manoeuvring would have been required by G-WACG to bring the helicopter into view, would have persisted up to the point of collision. The cockpit field of view from the Guimbal Cabri G2 is predominantly forwards and sideways. Rearward visibility is severely restricted by the engine and transmission, making rearward searching for an overtaking aircraft impractical. G-JAMM was painted predominantly metallic red with the upper section and tail painted white. The main rotor blades were light grey with yellow tips. The AAIB note that: The European Aviation Safety Agency (EASA) Part-FCL – Subpart C provides a syllabus of flight instruction for a Private Pilot’s Licence (PPL) and includes the note: ‘Each of the exercises involves the need for the applicant to be aware of the needs of good airmanship and look-out, which should be emphasised at all times.’ Specific details concerning the use and interpretation of the syllabus is the responsibility of the National Licensing Authority, in the UK this is the Civil Aviation Authority (CAA). CAA Safety Sense Leaflet 13, ‘Collision Avoidance’ provides comprehensive guidance on the importance of lookout for pilots operating under Visual Flight Rules (VFR)....
read moreSAR Crew With High Workload Land Wheels Up on Beach
SAR Crew With High Workload Land Wheels Up on Beach On 9 August 2016, a Search and Rescue (SAR) Leonardo AW139 of the Japan Coast Guard (JCG), JA968A, made a wheels-up landing on a beach in Miyagi Prefecture, Japan. The aircraft had been called out on a rescue mission in a small cove in the wake of a passing tropical storm. History of the Flight According to the Japan Transport Safety Board (JTSB) safety investigation report, as the aircraft was descending through 150ft on approach to enter a hover in the cove, the aural warning that the landing gear was still up sounded. The aircraft commander requested that the co-pilot cancel the alert. At the same time the aircraft was experiencing considerable turbulence and the Aircraft Commander was cautious to avoid an over torque. The crew successfully winched two survivors aboard and it was decided to land on the adjacent beach to pass the casualties to a shore party. The beach was sloping and their was a risk of debris and so the crew were attentive to those hazards, however the pre-landing checklist does not appear to have been followed according to the JTSB. On landing…well you may have guessed…the pilot realised that his eye line was lower than usual… Having landed wheel up, the Aircraft Commander, then lifted the helicopter, lowered the gear and landed again. The aircraft, which did have a mechanic onboard, was subsequently flow back to Sendai Airport. The aircraft had suffered damage to the lower fuselage, namely: Deformed outer skin panel, deformed frame at the fuselage bottom and the damaged Heli-Tele antenna VHF 2 antenna damaged upper cover of the hoist light collapsed and deformed Search light glass cracked JTSB make no comment on why the JCG unusually do hoisting wheels up. JTSB Probable Cause …the Rotorcraft suffered damages because it had landed without extending the landing gear. Regarding why it had landed without extending the landing gear, it is probable that various tasks were occurred in short time span and at same time other crews on board were also focusing on their own various tasks, so that they could not carry out necessary corporation or support, and because the workload of the captain continued to be high, there were not enough time for the captain to shift his mind from the rescue operation to the landing procedure, as the result, he forgot the check prior to the landing prescribed in the flight manual and did not check the landing gear condition. Safety Actions JCG actions included: Re-educating, re-training and examining flight for captains and co-pilots; Re-education of Sendai Air Base personnel on the implementation of Crew Resource Management (CRM) Emphasising the application of checklists and briefings Continuations of periodic CRM training and sharing the contents of each flight debriefing systematically to utilize those for practical CRM education Emphasising compliance with Operating Manual and the division of crew roles Continuation of safety audits Dynamic risk assessment of landing sites Safety Resources You may also be interested in these Aerossurance articles: James Reason’s 12 Principles of Error Management Back to the Future: Error Management Complacency: A Useful Concept in Safety Investigations? HROs and Safety Mindfulness Business Aviation Compliance With Pre Take-off Flight Control Checks Investigation into F-22A Take Off Accident Highlights a Cultural Issue C-130J Control Restriction Accident, Jalalabad HF Lessons from an AS365N3+ Gear Up Landing Korean T-50 Accident at Singapore...
read moreInvestigation into F-22A Take Off Accident Highlights a Cultural Issue
Investigation into F-22A Take Off Accident Highlights a Cultural Issue: 07-4146 at NAS Fallon, 13 April 2018 On 15 November 2018 the US Air Force (USAF) released the Accident Investigation Board (AIB) report into a Lockheed Martin F-22A Raptor 07-4146 accident at NAS Fallon, NV on 13 April 2018. The Accident Flight The F-22A of the 90th Fighter Squadron, based at Elmendorf-Richardson, Alaska, was taking off from Fallon for a Top Gun graduation exercise, operating against US Navy F-18s. The aircraft was rotated at 120 knots calibrated airspeed (KCAS) and the pilot subsequently raised the landing gear handle (LGH) to retract the landing gear (LG) on sensing the aircraft becoming airborne. However, just after the main landing gear (MLG) retracted, the aircraft settled back on the runway. The MLG doors were shut but the nose landing gear (NLG) doors were still in transit. The aircraft slid over 6,500 ft (1985m), stopping 9,400 ft (2,865m) from the runway threshold. The pilot was uninjured. Early reports of an engine malfunction, possibly based on engine nozzle positions, proved false (the nozzles free float in an in-flight shut down and in this case when weight on wheels was not activated). The Investigation The investigators make much of the fact that Takeoff and Landing Data (TOLD) was not calculated for the conditions that day at NAS Fallon as required. Consequently, the TOLD on the pilot’s lineup card was based on a… …a military power (MIL) takeoff at 80 degrees Fahrenheit (F) using a 10,000 ft runway at sea level. The elevation of NAS Fallon is 3,934 ft, runway 31L is 13,961 ft long, and the temperature on the morning of the mishap was 46 degrees F. The rotation and takeoff speeds listed on the lineup card were 136 KCAS and 163 KCAS respectively. The calculated rotation and takeoff speeds for the conditions at NAS Fallon on the day of the mishap are 143 KCAS and 164 KCAS respectively. The pilot based his decision on whether the aircraft was airborne on peripheral vision only. without verifying the climb dive marker (CDM) was above the horizon or the vertical velocity indicator (VVI) was positive. In fact, the pilot had initiated rotation at just 120 KCAS. This was 16 knots below the line up card and 23 knots below a correctly calculated rotation speed. Weight off wheels occurred at at 135 KCAS. This was 28 knots below the line up card and 29 knots below a correctly calculated take off speed. The F-22A momentarily became airborne, but there was insufficient lift to sustain flight. Data from five past sorties showed that this pilot initiated rotation at 120±5 KCAS. The pliot stated: There is a technique that I heard from somewhere (I don’t know where, whether it was at the B-Course [the type conversion course] or [at his squadron,] the 90th) to initiate [rotation] – if you have a 136 [rotation speed], kind of standard below 2,000 feet – that you initiate aft stick pressure at 120 so that the nose is up at that rotation speed, and that has been my habit pattern. This technique was not limited to one pilot. In 64.3% of 56 sorties sampled, rotation was initiated greater than 5 knots prior to the calculated rotation speed and in 52.1%, rotation occurs at 120±5 KCAS (as per the accident pilot). All pilots who were interviewed noted that they check their TOLD before takeoff. After the mishap, at a pilot meeting attended by 20 to 30 F-22 pilots, about...
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