News & Comment

Accident Report: Fatal Police Helicopter Double Engine Flameout Over City Centre

Posted by on 1:04 am in Accidents & Incidents, Helicopters, Human Factors / Performance, Safety Culture, Safety Management, Special Mission Aircraft

Accident Report: Fatal Police Helicopter Double Engine Flameout Over City Centre (A109K2 JA11PC) While returning from a routine patrol over a crowded city both engines flamed out on a police helicopter.  Due to the helicopter’s low altitude and the congested environment the aircraft crashed into buildings with multiple fatalities.  We examine at the accident investigator’s final report and highlight the value of studying accidents internationally. The Helicopter Accident You might have assumed was the tragic accident in Glasgow, UK, 29 November 2013 (UPDATE 23 October 2015: discussed here).  In fact it was an AgustaWestland A109K2 JA11PC of the Shizuoka Prefectural Police in Shizuoka City on 3 May 2005. During a routine traffic congestion patrol at around 16:28 Local Time on a National Holiday (Constitution Memorial Day), the helicopter, call sign ‘Fuji 1’, crashed into a residential area in Kusanagi, Shimizu-ku, Shizuoka City.  The aircraft was destroyed and a post-crash fire broke out.  All five police officers on board were fatally injured. The Japanese Aircraft and Railway Accidents Investigation Commission (ARAIC) issued their final report 28 March 2007.  Note that on 1 October 2008, ARAIC merged with the Japan Marine Accident Inquiry Agency (JMAIA) to form the Japan Transport Safety Board (JTSB). History of the Flight A routine afternoon road congestion survey flight was to be conducted using the ‘Fuji 2’, Eurocopter AS365N3 JA22PC, by the local Prefecture’s police aviation unit (one of many across Japan), which the investigators refer to as ‘the flying squad’.  The flight had been planned to cover the eastern area of the prefecture, but when the team of observers from the Traffic Regulation Division arrived, 40 minutes before the planned take-off, they asked to include a congestion survey on the Tomei Expressway in the west of the prefecture too and the Pilot In Command (PIC) agreed. Following a technical fault shortly after take-off at 14:00, Fuji 2 returned to base and five of the seven people on-board transferred to the slightly smaller Fuji 1, an AgustaWestland A109K2.  The flight was expected to last 2 hours and the pilot filed a flight plan that estimated 2 hours 20 minutes of fuel on-board.  The change to the smaller aircraft resulted in one other significant change, namely the PIC choose to leave the co-pilot behind. The replacement aircraft took off from Shizuhama Aerodrome at 14:42.  Investigators concluded the aircraft took off 58kg over maximum gross weight, perhaps symptomatic of the rushed change in plans. After taking off the aircraft flew an approximately 195nm route with a ground speed of about 110kt.  The early aerial photos recovered were taken from a 1,000 – 1,500ft above ground level, but those photos taken later were from 1,000ft or below.  The last photo was taken at 16:23:26, approximately five minutes before the crash.  At 16:25 the PIC made a radio call “Over Shimizu. Landing soon.”  It was usual to make a call to warn ground crew of their arrival and there was no indication of any abnormality.  In these final few minutes, witnesses remarked on the aircraft’s particularly low altitude. The accident investigators report that: a. At the point approximately 500m away from the crash site, flying altitude was approximately 300ft. b. In the area mentioned in a. above, sound of the aircraft changed and went silent. c. At the point approximately 150m away from the crash site, something fell away from the aircraft. d. In the area mentioned in c. above, the aircraft was silent with the MR blades almost stationary....

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Global 6000 Crosswind Landing Accident – UK AAIB Report

Posted by on 9:01 am in Accidents & Incidents, Airfields / Heliports / Helidecks, Business Aviation, Fixed Wing, Safety Management

Global 6000 Crosswind Landing Accident – UK AAIB Report (TAG Aviation, EC-LTF) The UK Air Accidents Investigation Branch (AAIB) have recently issued a 15 page report on a accident involving Bombardier Global 6000 EC-LTF of TAG Aviation España during a night crosswind landing. During the landing at Prestwick Airport on 6 March 2014, the right wing touched the runway.  The aircraft landed without injury to anyone on-board. Prior to glideslope capture for Runway 12 at Prestwick the wind calculated by the onboard systems was 90º from the right at 35 kt.  When cleared to land, the aircraft was notified by ATC that the wind was from 190º at 12 kt, a crosswind component of approximately 11 kt. Passing 1,000 ft agl, the indicated crosswind had reduced to 25 kt and the pilots then had visual contact with the runway. The AAIB comment in the summary of their report: The technique employed during the landing was different from that recommended in training material published by the manufacturer. Furthermore, the information in the training material about crosswind landings, and data on reduced wingtip clearance with increasing pitch attitude, had not been incorporated into the Airplane Flight Manual (AFM) or the Flight Crew Operating Manual (FCOM). The pilot flying (PF) was looking through a Head-Up Display (HUD) and his view of the runway may have been impeded because the symbols on the HUD screen were set too bright. On 17 April 2014 a similar event occurred to Global 6000 CS-GLB from another operator during a night crosswind landing at Luton Airport, resulting in left hand wing tip damage. That approach was made with a modest crosswind component from the right of about 9 kt and the aircraft was configured at flap 30 and flown at a target speed of VREF (112 kt). The AAIB report that following these two accidents several actions were taken. In particular Bombardier amended the Global 6000 FCOM to include their recommended crosswind technique (the wings level crab technique, where the aircraft is pointed into the wind to control direction) aligning with the Global Express and Global 500o FCOMs that already contained that material. Further Detail – HUD In relation to the HUD, Bombardier’s senior engineering test pilot commented, according to AAIB, that: …pilots who were new to HUDs must learn not to fixate on the screen but to “look through” it, otherwise their peripheral view of the outside world could be affected. He said that during this learning process, pilots must find the level of screen brightness with which they were most comfortable and it could take them a few landings to establish this. In his experience, new pilots initially tended to set the brightness level too high and this could cause the HUD symbology to become distracting. Consequently, during a landing with a significant crosswind, for example, a pilot who has set the brightness too high, may fixate on the screen and not discern all the relevant external cues. To reduce fixation on the screen, pilots should aim to use a HUD all the time when available. Further Detail – FDM EC-LTF was one of 30 aircraft monitored by the operator’s Flight Data Monitoring programme.  Downloads were nominally monthly and a base-specific report was produced that included an aggregate of the 20 most frequently triggered events for both the month and previous year, plus the...

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Psychology of Blame

Posted by on 5:29 pm in Accidents & Incidents, Crises / Emergency Response / SAR, Human Factors / Performance, Safety Culture, Safety Management

Psychology of Blame In their 2007 book Yes! 50 secrets from the Science of Persuasion, the authors Goldstein, Martin and Cialdini, discuss 2004 research by social scientists Charles Naquin and Terri Kurtzberg. Naquin and Kurtzberg tested the reaction when technical failures and human error were separately identified as the cause of an incident. The Research In one case they showed research subjects a fake newspaper article (based on a real incident).  It reported on a train collision that injured scores of people.  Some participants were told a technical failure was the cause and others a driver error.  They repeated this approach during a real internet outage at their university.  This time they used questionnaires about the university IT department that either stated the failure was believed to be due to a computer fault or a human error. In each case, the organisation involved (the train operator and the IT department) were considered more responsible if human error was thought to be the cause.  The researchers suggest that the perception of a human error provokes more thoughts of how a failure could be / should have been avoided than for technical fault, and so the failure seems worse. Discussion In one sense this is bad news for contentious safety professionals.  It suggests that human nature means we are more aggrieved and less forgiving when a human makes an error than when a technical failure occurs.  However, technical failures are mostly linked to the specification, design or maintenance of the system and the associated human decisions and actions.  So it also reinforces the perception that it is easier to blame frontline operators rather than the managers or designers.  Their interpretation also suggests it is difficult to expect society to accept the concept of a just culture after a major accident.  It may help explain, for example, the extreme charges and rapid trial in South Korea after the Sewol ferry disaster. However, one positive could be that it shows that swift public blaming of your own employees (as occurred after Costa Concordia or in a recent Spanish rail disaster) can only make things worse for the organisation (and not just because of the harm to your own safety culture).  A reason to avoid reliance on so called ‘just culpability tools’ and internal processes focused in judging frontline personnel rather than generating insight on necessary safety improvements. Safety Resources You may also find these Aerossurance articles of interest: How To Develop Your Organisation’s Safety Culture James Reason’s 12 Principles of Error Management What Lies Beneath: The Scope of Safety Investigations Airworthiness Matters: Next Generation Maintenance Human Factors Aircraft Maintenance: Going for Gold? B1900D Emergency Landing: Maintenance Standards & Practices Meeting Your Waterloo: Competence Assessment and Remembering the Lessons of Past Accidents Also: Safety Performance Listening and Learning – AEROSPACE March 2017 Learning from Adverse Events: Includes nine principles for incorporating human factors into learning investigations. Aerossurance has extensive air safety, operations, SAR, airworthiness, human factors, aviation regulation and safety analysis experience.  For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn for our latest...

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Disasters and Crises – 10 Lessons on Early Warning

Posted by on 8:36 am in Accidents & Incidents, Crises / Emergency Response / SAR, Safety Culture, Safety Management

Disasters and Crises – 10 Lessons on Early Warning Aerossurance has recently looked at how conventional responses can fail in the face of a crisis. Dr Ian Mitroff, Professor Emeritus at the USC Marshall School of Business at the University of Southern California, has identified 10 lessons on early warning, which are also highly relevant to how accidents evolve: All disasters and crises are preceded by early warning signs of impeding failure: Barry Turner’s ground breaking research Man Made Disasters, published in 1978, highlights the prevalence of such warnings and how they are often overlooked during the ‘incubation period’.  UPDATE 16 January 2017: see this review of Man Made Disasters. Signals are not self-amplifying or self-blocking: Mitroff observes that it is organisations that can either amplify or block these early warning signs, the very reason for a culture that seeks out potential early warning signs.  Margaret Heffernan has written about Wilful Blindness, and how organisations can block out these warnings, which Mitroff comes to in his third lesson: Signals are part of the organisation:  Signals don’t exist on their own.  Organisations get the news they encourage.  An organisation that discourages or downplays certain types news will discourage that news from being reported in future. Signal detection is a reflection of our priorities: Organisations are swamped with information, so unless we give priority to the warning signs for crises or accidents, they are unlikely to be noticed.  In turn, if we only search for certain types of crises or for certain threats we may well miss the signs for other types. Signal detection needs detectors:  It is important to have mechanisms that detect early warning signals. Within an organisation, free and open safety reporting, a vigorous audit programme that looks at the effectiveness of controls not just compliance and a robust, even paranoid, process of management review that seeks out indications of problems (and sees early warning as ‘good news’ not ‘bad news’) can all help. Different signals require different detectors: So while the mechanisms mentioned above are relevant to safety threats, other mechanisms are required to detect the early warning signs of financial fraud, civil disturbances or industrial unrest. Not all signals are alike: Mitroff proposes that signals are differentiated by their source (internal or external to the organisation) and type (technical or human). Signal detectors need to be monitored: Mitroff uses the example of a 1991 power outage in New York.  The AT&T back-up generator failed and the tertiary battery system came into operation.  Activating the 6 hour battery system triggered an alarm, but the alarm was not spotted and when the battery expired air traffic controllers lost essential communications.  The reason the alarm was not heard: both operators on the same shift had been rostered onto a training course.  Ironically the course was on alarm systems! Signals have to be transmitted to the right people: As sadly illustrated in Hawaii in 1941. Individual signal detection is not enough: Often multiple weak signals from multiple sources need to be collated an analysed. See also: How to Lead During a Crisis: Lessons From the Rescue of the Chilean Miners Aerossurance has extensive safety management, emergency response, safety leadership, organisational culture, operations, and safety analysis experience.  For practical safety advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...

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BAe 146 & Avro RJ85 Fire Bombers

Posted by on 6:16 pm in Design & Certification, Fixed Wing, Maintenance / Continuing Airworthiness / CAMOs, Special Mission Aircraft

BAe 146 & Avro RJ85 Fire Bombers Fire bombing, as show in this video of training, was unlikely to have been something envisaged in the early 1970s as the then HS146, was on the drawing board. Neptune Aviation Services, whose name neatly indicates their initial operation of ex-US Navy Lockheed P-2 Neptunes, is one of four companies in North America that have selected the BAe 146/Avro RJ for conversion. BAE, who are providing design support, described the four companies as follows in 2013: Conair Group Inc of Abbotsford, British Columbia, Canada, the largest air tanker operator in the world with a fleet of around 50 fixed-wing special mission aircraft, including Convair 580 Conair Firecats, Douglas DC-6 and Lockheed Electra Airtankers. Operating for over 40 years, Conair has selected the Avro RJ85 for its conversion programme and a number of aircraft have been delivered so far from regional aircraft lessor, Falko Regional Aircraft. Tronos Plc/Neptune Aviation Services – Tronos Plc, a UK-based BAe 146 aircraft lessor with a MRO facility in Prince Edward Island, Canada, has developed a BAe 146 Airtanker and the first two have been delivered to Neptune Aviation Services of Missoula, Montana, with a further two under conversion in Canada. Apart from the BAe 146 Airtankers Neptune operates a fleet of eight Neptunes in this role. Minden Air of Minden, Nevada which has recently completed the conversion of its first BAe 146 Fireliner and which is now undergoing extensive flight testing. A second aircraft is under conversion and eventually these aircraft will replace the venerable Neptunes currently in service with Minden Air. Air Spray who operate from Red Deer Regional Airport, Alberta, Canada and Chico Airport, California, has been flying as an airtanker operator for over 45 years and currently has a fleet 35 aircraft including Lockheed L188 Electras, AT802s and the largest fleet of Twin Commander 690 aircraft in the world. It has two BAe 146-200 that will be available for the 2015 fire season. They are 3,000 gallon US Forest Service Type 1 Airtankers, which forms the bulk of the fire-fighting fleet in North America. Mark Taylor, Business Director Engineering for BAE Systems Regional Aircraft commented: We estimate that the extreme nature of this wildfire flying means that for every BAe 146/Avro RJ flight cycle on a typical mission, the impact for structural and fatigue life is estimated to be the equivalent of between four and seven flight cycles of normal flight. This figure will be validated during the initial years of operation and might vary due to the nature of the Airtanker design. This type of specialist service is one which we can provide to these operators and the authorities are pleased that we, as the Original Equipment Manufacturer, are taking such a close interest in these programmes. The specialist design and engineering services provided by BAE Systems Regional Aircraft to these operators/conversions in support of their individual tanker designs include aerodynamic/computational fluid dynamics analysis; dynamic loads assessment; structural analysis; technical data packs; flight test planning and analysis; and flight test engineers and pilots. UPDATE 28 December 2014 In December 2013 Aero Flite’s Avro RJ85 Tanker 160 undertook a retardant drop demonstration at Fox Field, California. Typically 20 to 25 drops are conducted over a two or three day period. The process involves dropping retardant over a test grid of thousands of cups, to measure the dispersion pattern. Further Reading...

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EU Offshore Safety Directive – Oil & Gas UK Briefing

Posted by on 11:06 am in Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Management

EU Offshore Safety Directive – Oil & Gas UK Briefing The consultation period on the Department of Energy & Climate Change (DECC) / Health and Safety Executive (HSE) consultation document on draft UK regulations to implement the new EU Offshore Safety Directive has ended.  Trade body Oil & Gas UK say: These changes are some of the most significant for safety and environmental regulation for many years. While there is much in the new regulatory framework that is familiar, there are also a number of important amendments. Oil & Gas UK held an evening briefing on the topic in London on October 21 which included presentations from: Sam Boileau, Partner Environment & Safety at Dentons: The Legal Perspective Liz Hoskin, HSE Regulatory Liaison at Shell UK Limited: An Operator’s Perspective There is more on the timeline on the HSE website. The papers from a February 2014 Oil & Gas UK seminar can be found here. For advice on aviation safety & contracting for the oil and gas industry, contact: enquiries@aerossurance.com Follow us on LinkedIn for our latest...

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OGP is now IOGP

Posted by on 11:00 pm in Fixed Wing, Helicopters, News, Offshore, Oil & Gas / IOGP / Energy, Safety Management

OGP is now IOGP The International Association of Oil & Gas Producers (known across the industry as OGP) has rebranded as IOGP to coincide with their 40th anniversary. They say: Over the past year we have been developing an updated brand for the International Association of Oil & Gas Producers.  Our aim from the start: to have an identity that better reflects our global role and the industry we serve.  While the organization’s formal name remains unchanged, the look is very different.  Moreover our new abbreviation – which features an ‘I’ for ‘international’ – provides a fresh emphasis on our global remit as a trusted source of fact-based information and a credible advocate of the industry we serve. While the colour scheme is more garish this clearly isn’t one of the most fundamental rebranding exercises.  Perhaps a little bizarrely the launch involved projecting the old and new logos on to the Tower of London (home of the crown jewels and historically a site of execution for traitors). Aerossurance is an Aberdeen based aviation consultancy with an international customer base.  For independent advice you can trust on aviation safety & contracting for the oil and gas industry and first-hand knowledge of IOGP Aviation Management Guidelines (Report 590), IOGP Offshore Helicopter Recommended Practices (OHRP – Report 690) and the FSF BARSOHO Standard contact: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates.  ...

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UK CAA Release CRM Videos

Posted by on 10:01 pm in Business Aviation, Fixed Wing, Helicopters, Human Factors / Performance, Safety Management

UK CAA Release Crew Resource Management Videos In an initiative to improve Crew Resource Management (CRM) in the industry the UK Civil Aviation Authority (CAA) has released a series of open-access training videos.  The CAA comment that: The three case-study videos have been developed to highlight some of the main human factors concerns currently facing the aviation industry, such as ‘automation complacency’ and ineffective monitoring – both phenomena being the result of an over reliance on technology to the detriment of ‘hand flying’ skills. The momentum behind the production of the videos, and the need for a new approach to CRM training in the commercial air transport sector in general, came from research carried out by a panel of senior CAA and airline flight instructors and examiners. Analysis of 250 accidents involving large public transport aircraft, for example, shows that 28% of fatal accidents worldwide include flight handling issues and 24% include inappropriate action by crew (see CAP1036, Global Fatal Accident Review). An airline’s CRM training is now therefore a vital part of its overall safety strategy. The CRM panel’s full recommendations can be found at www.caa.co.uk/cap737 The Videos 1) Getting Out of Trouble: Multi Pilot CRM A reconstruction of an actual incident where a malfunction forced the crew of a large helicopter to divert to an unfamiliar airfield. Autopilot mode confusion during the glidescope capture results in loss of control a breakdown in collective situation awareness. 2) Getting Behind the Aircraft: Single Pilot CRM In a fictional incident poor pre flight planning results in missing a NOTAM regarding unserviceable glideslope. Distracted the business jet pilot then misses cues from ATIS, other aircraft and ATC and finds himself getting behind the aircraft. Committed to make a meeting a rushed steep descent almost ends in catastrophe. 3) Getting Down to Root Causes: Assessment of CRM Based on the reconstruction of an actual Line Orientated Evaulation (LOE) this video shows how human behaviour can be identified. The first briefing reveals knowledge differences between the FO and Captain while poor monitoring by the crew almost causes a stall. Bristow Group, FlightSafety International and Thomas Cook Airlines supported the production of these videos. Versions without captions or interviews (suitable for use in training discussions) can be found on the CAA YouTube channel. UPDATE 9 January 2017: HeliOffshore have released a HeliOffshore Automation Guidance document and six videos to demonstrate the offshore helicopter industry’s recommended practice for the use of automation. Aerossurance has extensive air safety, design, human factors and safety analysis experience.  For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...

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NTSB Update on SpaceShip Two Accident

Posted by on 4:59 pm in Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Safety Management, Special Mission Aircraft

NTSB Update on SpaceShip Two Accident Today the National Transportation Safety Board (NTSB) issued a press release on progress with the investigation into the Virgin Galactic Scaled Composites Model 339 SpaceShip Two N339SS accident on 31 Oct 2014: November 12, 2014 WASHINGTON — The National Transportation Safety Board issued an investigative update today into the crash of SpaceShip Two on Oct. 31, 2014, in Mojave, Calif. • The on-scene portion of the investigation into the crash of Virgin Galactic/Scaled Composites SpaceShipTwo, a test flight conducted by Scaled Composites, has concluded and all NTSB investigators have returned to Washington, DC. • The SpaceShipTwo wreckage has been recovered and is being stored in a secure location for follow-on examination. • The NTSB operations and human performance investigators interviewed the surviving pilot on Friday. According to the pilot, he was unaware that the feather system had been unlocked early by the copilot. His description of the vehicle motion was consistent with other data sources in the investigation. He stated that he was extracted from the vehicle as a result of the break-up sequence and unbuckled from his seat at some point before the parachute deployed automatically. • Recorded information from telemetry, non-volatile memory, and videos are being processed and validated to assist the investigative groups. • An investigative group to further evaluate the vehicle and ground-based videos will convene next week at the NTSB Recorders Laboratory in Washington, D.C. • The systems group continues to review available data for the vehicle’s systems (flight controls, displays, environmental control, etc.) The group is also reviewing design data for the feather system components and the systems safety documentation. • The vehicle performance group continues to examine the aerodynamic and inertial forces that acted on the vehicle during the launch. The press release will again raise questions about the manner in which data about on-going investigations, particularly over the attributions of apparent actions of individual crew, is released early in the investigation.  Professor Graham Braithwaite of Cranfield University recently presented to the International Society of Air Safety Investigators (ISASI) on the perils of working with the media in the aftermath of an accident, Previous briefings are available online: Additionally footage at the accident site is available: UPDATE 28 July 2015: Board Meeting : Commercial Space Launch Accident – SpaceShipTwo NTSB Final Report Executive Summary: On October 31, 2014, at 1007:32 Pacific daylight time, the SpaceShipTwo (SS2) reusable suborbital rocket, N339SS, operated by Scaled Composites LLC (Scaled), broke up into multiple pieces during a rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. The pilot received serious injuries, and the copilot received fatal injuries. SS2 was destroyed, and no one on the ground was injured as a result of the falling debris. SS2 had been released from its launch vehicle, WhiteKnightTwo (WK2), N348MS, about 13 seconds before the structural breakup. Scaled was operating SS2 under an experimental permit issued by the Federal Aviation Administration’s (FAA) Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations (CFR) Part 437. Scaled had developed WK2 and was developing SS2 for Virgin Galactic, which planned to use the vehicles to conduct future commercial space suborbital operations. SS2 was equipped with a feather system that rotated a feather flap assembly with twin tailbooms upward from the...

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Dash 8 Runway Excursion after Unstable Crosswind Approach – Danish AIB Report

Posted by on 7:13 am in Accidents & Incidents, Airfields / Heliports / Helidecks, Fixed Wing, Human Factors / Performance, Safety Management

Dash 8 Runway Excursion after Unstable Crosswind Approach – Danish AIB Report The Danish Accident Investigation Board (DAIB), the Havarikommissionen, has recently issued their report into an accident to Bombardier Dash 8-200  OY-GRI, operated by Air Greenland, at Greenland’s third largest town, Ilulissat (BGJN), on 29 January 2014. The DAIB summary states: Adverse crosswind conditions at BGJN led to flight crew target fixation, a flight crew divergence from the operator’s stabilized approach parameters and a mental blocking of an appropriate decision on going around. The flight crew divergence from the operator’s stabilized approach parameters induced a non-stabilized approach, which in combination with power levers retarded below flight idle in flight resulted in an accelerated rate of descent leading to a hard landing, with side load on the left main landing gear at touchdown. The left main landing gear structural fuse pin sheared as a result of lateral and vertical overload stress. Cycling the power levers between ground and flight range prevented an appropriate deceleration of the aircraft and prolonged the landing roll. The prolonged landing roll combined with the application of full left rudder and no decisive use of reverse thrust on the side with the unaffected main landing gear made it impossible for the flight crew to maintain directional control. The lack of directional control resulted in the aircraft running off the side of the runway and the safety zone, respectively. The aircraft was destroyed as it skidded off the and down an embankment.  Fortunately only two minor injuries were sustained among the 15 occupants. The DAIB found the crew had agreed to a visual steep approach of 5.1° and a reference airspeed of 99kt.  They also agreed a crosswind limitation of 31kt, above the operator’s limit of 25kt. The wind conditions given to the crew during short final approach warned of speeds up to 39kt.  Though the DAIB comment about a possible confirmation bias: The combination of the ATS phraseology (“maximum to…… three niner knots) and at that time an increasing flight crew work load might have triggered the first officer’s perception of an ATS wind speed reporting of “maximum two niner knots”, which was below the flight crew agreed cross wind limitation of 31 knots. As the aircraft passed below 1,000ft airspeed was still 144kt, exceeding the operator’s stable-approach maximum of 119kt for that aircraft’s configuration. The airspeed was still 138kt shortly after descending below 500ft.  The crosswind and a low flap setting of 15°, affected the crew’s ability to handle the aircraft.  While still airborne, the crew retarded the throttle below the flight-idle setting – into the ‘beta range’ normally used on the ground.  Use of this setting in flight presents risks propeller overspeed and engine damage, but a warning horn to alert the crew does not activate if the aircraft is below 20ft. The European Aviation Safety Agency (EASA) published a Safety Information Bulletin on crosswind landings earlier in the year. UPDATE 19 May 2016: The Japanese Transport Safety Board (JTSB) release their report into a heavy landing incident during training in crosswinds on Bombardier Dash 8-200 JA801B of Oriental Air Bridge in Nagasaki in February 2014. UPDATE 10 March 2017: Unstable Approach Dash 8 Touches Down 450ft Before Threshold UPDATE 24 April 2017:  Unstabilised CL-600 Approach Accident at Aspen UPDATE 13 July 2020: ATR72 Survives Water Impact During Unstabilised Approach UPDATE 4 October 2020: Investigators Suggest Cultural Indifference to Checklist Use...

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