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Accident and Serious Incident Reports: WX

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Category: Weather Weather
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Definition

Reports relating to accidents and serious incidents which involved weather or related atmospheric conditions as a significant causal factor.

The reports are grouped together below in subcategories. Weather related events are mostly related to the occurrence or risk of a loss of control because of the effects of significant in flight icing or in flight turbulence. The turbulence case can involve en route or low level flight, the latter especially in respect of approach and landing. Many adverse weather events are associated with Cumulonimbus (Cb) cloud or phenomena associated with them such as the occurrence of Hail, Microbursts or Tornados.

In-Flight Airframe Icing

  • A346, en route, eastern Indian Ocean, 2013 (On 3 February 2013, an Airbus A340 crew in the cruise in equatorial latitudes at FL350 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL350 and reversion to Alternate Law. Excessive vibration on the left engine then began and a diversion was made. The engine remained in use and was subsequently found undamaged with the fault attributed to ice/water ingress due to seal failure.)
  • AT43, en-route, Folgefonna Norway, 2005 (On 14 September 2005, an ATR 42-320 operated by Coast Air AS experienced a continuous build up of ice in the climb, despite the activation of de-icing systems aircraft entered an uncontrolled roll and lost 1500ft in altitude. The crew initiated recovery actions, the aircraft was stabilised, and the flight continued without further event.)
  • AT72, vicinity Manchester UK, 2016 (On 4 March 2015, the flight crew of an ATR72-212 decided to depart from Manchester without prior ground de/anti icing treatment judging it unnecessary despite the presence of frozen deposits on the airframe and from rotation onwards found that manual forward control column input beyond trim capability was necessary to maintain controlled flight. The aircraft was subsequently diverted. The Investigation found that the problem had been attributable to ice contamination on the upper surface of the horizontal tailplane. It was considered that the awareness of both pilots of the risk of airframe icing had been inadequate.)
  • AT73, en-route, Roselawn IN USA, 1994 (On 31 October 1994, an ATR 72 exited controlled flight after a flap retraction when descending through 9000 feet was followed by autopilot disconnect and rapid and very large un-commanded roll inputs from which recovery, not within the scope of received crew training, was not achieved. The investigation found this roll upset had been due to a sudden and unexpected aileron hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-icing boots during earlier holding in icing conditions which had been - unknown to the crew - outside the icing certification envelope.)
  • ATP, en-route, Oxford UK, 1991 (On 11 August 1991, an British Aerospace ATP, during climb to flight level (FL) 160 in icing conditions, experienced a significant degradation of performance due to propeller icing accompanied by severe vibration that rendered the electronic flight instruments partially unreadable. As the aircraft descended below cloud, control was regained and the flight continued uneventfully.)
  • B738, Rostov-on-Don Russia, 2016 (On 19 March 2016, a Boeing 737-800 making a second night ILS approach to Rostov-on-Don commenced a go around from 720 feet aal but soon afterwards crashed at high speed onto the intended landing runway and was completely destroyed by the impact and an explosion. A Preliminary Report on the Investigation states that the descent preceding the crash appears to have been the consequence of an as yet unexplained nose down movement of the control column and a simultaneous and abnormally prolonged nose down stabiliser trim input using the control column switch. Cumulonimbus cloud was present overhead the airport.)

... further results

In-Flight Icing - Piston Engine

  • C172, Toronto Canada, 2003 (On 9th October 2003, a Cessna 172, suffered loss of power and made a forced landing after experiencing Carburettor Icing, over Toronto, Canada)
  • C404, Kulusuk Greenland, 2002 (On 1 August 2002, a Cessna 404, en-route at FL130 over Greenland, experienced sudden power loss on both engines, probably as a result of ice in the induction systems, leading to loss of control. The crew regained control at 3000 feet.)

In-Flight Icing - Turbine Engine

  • ATP, en-route, Oxford UK, 1991 (On 11 August 1991, an British Aerospace ATP, during climb to flight level (FL) 160 in icing conditions, experienced a significant degradation of performance due to propeller icing accompanied by severe vibration that rendered the electronic flight instruments partially unreadable. As the aircraft descended below cloud, control was regained and the flight continued uneventfully.)
  • B732, vicinity Washington National DC USA, 1982 (On 13 January 1982, an Air Florida Boeing 737-200 took off in daylight from runway 36 at Washington National in moderate snow but then stalled before hitting a bridge and vehicles and continuing into the river below after just one minute of flight killing most of the occupants and some people on the ground. The accident was attributed entirely to a combination of the actions and inactions of the crew in relation to the prevailing adverse weather conditions and, crucially, to the failure to select engine anti ice on which led to over reading of actual engine thrust.)
  • B752, en-route, Central Mauritania, 2010 (On 25 August 2010, a Boeing 757-200 being operated by UK airline Astraeus on a passenger flight from Freetown Sierra Leone to London Heathrow was in the cruise at night in IMC at FL370 when vibration levels on both engines increased. When the prescribed ice shedding drill was followed, one engine malfunctioned and vibration on the other remained abnormally high and so a MAYDAY was declared and a diversion to Nouakchott, Mauritania was made without further event. None of the 103 occupants were injured and there was no engine damage.)
  • F70, vicinity Munich Germany, 2004 (On 5 January 2004, a Fokker 70, operated by Austrian Airlines, carried out a forced landing in a field 2.5 nm short of Munich Runway 26L following loss of thrust from both engines due to icing.)
  • SH36, vicinity Marsa Brega Libya, 2000 (On 13 January 2000, a Shorts SD3-60 suffered a double engine failure on approach to Marsa Brega, Libya, attributed to failure to use engine anti-icing during flight in icing conditions. The aircraft ditched into the sea and was destroyed by impact forces.)

En Route In-Cloud Air Turbulence

  • A321, en-route, Vienna Austria, 2003 (On 26th May 2003, a British Midland A321 suffered severe damage from hail en route near Vienna.)
  • A332, en-route, near Dar es Salaam Tanzania, 2012 (On 27 February 2012, the crew of an Airbus A330 en route at night and crossing the East African coast at FL360 encountered sudden violent turbulence as they flew into a convective cell not seen on their weather radar and briefly lost control as their aircraft climbed 2000 feet with resultant minor injuries to two occupants. The Investigation concluded that the isolated and rapidly developing cell had not been detected because of crew failure to make proper use of their weather radar, but noted that activation of flight envelope protection and subsequent crew action to recover control had been appropriate.)
  • A333, en-route, Kota Kinabalu Malaysia, 2009 (On 22 June 2009, an Airbus A330-300 being operated by Qantas on a scheduled passenger flight from Hong Kong to Perth encountered an area of severe convective turbulence in night IMC in the cruise at FL380 and 10 of the 209 occupants sustained minor injuries and the aircraft suffered minor internal damage. The injuries were confined to passengers and crew who were not seated at the time of the incident. After consultations with ground medical experts, the aircraft commander determined that the best course of action was to complete the flight as planned, and this was uneventful.)
  • A343, en-route, mid North Atlantic Ocean, 2011 (On 22 July 2011 an Air France A340-300 en route over the North Atlantic at FL350 in night IMC encountered moderate turbulence following "inappropriate use of the weather radar" which led to an overspeed annunciation followed by the aircraft abruptly pitching up and gaining over 3000 feet in less than a minute before control was regained and it was returned to the cleared level. There Investigation concluded that "the incident was due to inadequate monitoring of the flight parameters, which led to the failure to notice AP disengagement and the level bust, following a reflex action on the controls.”)
  • A346, en route, eastern Indian Ocean, 2013 (On 3 February 2013, an Airbus A340 crew in the cruise in equatorial latitudes at FL350 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL350 and reversion to Alternate Law. Excessive vibration on the left engine then began and a diversion was made. The engine remained in use and was subsequently found undamaged with the fault attributed to ice/water ingress due to seal failure.)
  • B732, vicinity Islamabad Pakistan, 2012 (On 20 April 2012, the crew of a Boeing 737-200 encountered negative wind shear during an ILS final approach at night in lMC and failed to respond with the appropriate recovery actions. The aircraft impacted the ground approximately 4 nm from the threshold of the intended landing runway. The Investigation attributed the accident to the decision to continue to destination in the presence of adverse convective weather and generally ineffective flight deck management and noted that neither pilot had received training specific to the semi-automated variant of the 200 series 737 being flown and had no comparable prior experience.)

... further results

Hail Damage

  • A321, en-route, Gimpo South Korea, 2006 (On 9 June 2006, an Airbus 321-100, operated by Asiana Airlines, encountered a thunderstorm accompanied by Hail around 20 miles southeast of Anyang VOR at an altitude of 11,500 ft, while descending for an approach to Gimpo Airport. The radome was detached and the cockpit windshield was cracked due to impact with Hail.)
  • A321, en-route, Vienna Austria, 2003 (On 26th May 2003, a British Midland A321 suffered severe damage from hail en route near Vienna.)

Volcanic Ash Effects

  • B742, en-route, Mount Galunggung Indonesia, 1982 (On 24 June 1982, a British Airways Boeing 747-200 lost power on all four engines while flying at night at FL370 en route from Kuala Lumpur to Perth. During the ensuing sixteen minutes, the aircraft descended without power from FL370 to FL120, at which point the flight crew were able to successfully restart engines one, two and four after which an en route diversion was made to Jakarta.)
  • B744, en-route, Alaska USA, 1989 (On 15th December 1989, a KLM Boeing 747 encountered a Volcanic Ash cloud over Alaska, USA. the ingestion of ash led to compressor stall of all engines; the engines were subsequently relighted successfully and the aircraft landed safely.)

Sand/Dust Storm

Fog

  • A320, Hiroshima Japan, 2015 (On 14 April 2015, a night RNAV(GNSS) approach to Hiroshima by an Airbus A320 was continued below minima without the prescribed visual reference and subsequently touched down 325 metres before the runway after failing to transition to a go around initiated from a very low height. The aircraft hit a permitted ground installation, then slid onto the runway before veering off it and stopping. The aircraft sustained extensive damage and an emergency evacuation followed with 28 of the 81 occupants sustaining minor injuries. The Investigation noted the unchallenged gross violation of minima by the Captain.)
  • A320, Jaipur India, 2014 (On 5 January 2014, an Airbus A320 was unable to land at Delhi due to visibility below crew minima and during subsequent diversion to Jaipur, visibility there began to deteriorate rapidly. A Cat I ILS approach was continued below minima without any visual reference because there were no other alternates within the then-prevailing fuel endurance. The landing which followed was made in almost zero visibility and the aircraft sustained substantial damage after touching down to the left of the runway. The Investigation found that the other possible alternate on departure from Delhi had materially better weather but had been ignored.)
  • A333, Kathmandu Nepal, 2015 (On 4 March 2015, the crew of a Turkish Airlines A333 continued an automatic non precision RNAV approach below the prescribed minimum descent altitude without having obtained any element of visual reference and when this was acquired a few seconds before the attempted landing, the aircraft was not aligned with the runway centreline and during a 2.7g low-pitch landing, the left main gear touched down on the grass. The aircraft then left the runway completely before stopping with a collapsed nose gear and sufficient damage to be assessed a hull loss. None of 235 occupants sustained serious injury.)
  • A343, Nairobi Kenya, 2008 (On 27 April 2008 an Airbus A340-300 crew lost previously-acquired visual reference in fog on a night auto ILS into Nairobi but continued to a touchdown which occurred with the aircraft heading towards the edge of the runway following an inappropriate rudder input. The left main gear departed the paved surface and a go around was initiated and a diversion made. The event was attributed to a delay in commencing the go around. No measured RVR from any source was passed by ATC although it was subsequently found to have been recorded as I excess of Cat 1 limits throughout.)
  • B737, Mildura VIC Australia, 2013 (On 18 June 2013, a Boeing 737-800 crew en route to Adelaide learned that un-forecast below-minima weather had developed there and decided to divert to their designated alternate, Mildura, approximately 220nm away where both the weather report and forecast were much better. However, on arrival at Mildura, an un-forecast rapid deterioration to thick fog had occurred with insufficient fuel to divert elsewhere. The only available approach was flown to a successful landing achieved after exceeding the minimum altitude by 240 feet to gain sight of the runway. An observation immediately afterwards gave visibility 900 metres in fog with cloudbase 100 feet.)
  • B738, Delhi India, 2014 (On 5 January 2014, a Boeing 737-800 operating a domestic flight into Dehli diverted to Jaipur due to destination visibility being below approach minima but had to break off the approach there when the aircraft ahead was "substantially damaged" during landing, blocking the only runway. There was just enough fuel to return to Dehli as a MAYDAY flight and successfully land below applicable minima and with minimal fuel remaining. The Investigation found that a different alternate with better weather conditions would have been more appropriate and that the aircraft operator had failed to provide sufficient ground-based support to the flight.)

... further results

Clear Air Turbulence

  • A332, en-route, near Bangka Island Indonesia, 2016 (On 4 May 2016, an Airbus A330-200 in the cruise in day VMC at FL390 in the vicinity of a highly active thunderstorm cell described by the crew afterwards as ‘cumulus cloud’ encountered a brief episode of severe clear air turbulence which injured 24 passengers and crew, seven of them seriously as well as causing some damage to cabin fittings and equipment. The Investigation was unable to determine how close to the cloud the aircraft had been but noted the absence of proactive risk management and that most of the injured occupants had not been secured in their seats.)
  • A388, en-route, southeast of Mumbai India, 2014 (On 18 October 2014, an Airbus A380 descending at night over north east India unexpectedly encountered what was subsequently concluded as likely to have been Clear Air Turbulence after diverting around convective weather. Although seat belt signs were already on, a flight deck instruction to cabin crew to be seated because of the onset of intermittent light to moderate turbulence was completed only seconds before the sudden occurrence of a short period of severe turbulence. Two unrestrained passengers and two of the cabin crew sustained serious injuries. There were other minor injuries and also some cabin trim impact damage.)
  • B741, en-route, Pacific Ocean, 1997 (On 28th December 1997, a Boeing 747-100 being operated by United Airlines, which had departed from Tokyo for Hawaii, encountered severe turbulence thought to have been associated with a Jet Stream over the Pacific Ocean.)
  • B772, en-route, Northern Kanto Japan, 2014 (On 16 December 2014, a US-operated Boeing 777-200 encountered a significant period of severe clear air turbulence (CAT) which was unexpected by the flight crew when travelling eastbound over northern Japan at night between FL 270 and FL290. The decision to turn back to Tokyo to allow the nine seriously injured passengers and crew to be treated was made 90 minutes later. The Investigation concluded that the CAT encountered had been correctly forecasted but the Operator's dispatcher-based system for ensuring crew weather awareness was flawed in respect of international operations out of 'non hub' airports.)
  • B773, en-route, east northeast of Anchorage AK USA, 2015 (On 30 December 2015, a Boeing 777-300 making an eastbound Pacific crossing en-route to Toronto encountered forecast moderate to severe clear air turbulence associated with a jet stream over mountainous terrain. Some passengers remained unsecured and were injured, one seriously and the flight diverted to Calgary. The Investigation found that crew action had mitigated the injury risk but that more could have been achieved. It was also found that the pilots had not been in possession of all relevant information and that failure of part of the air conditioning system during the turbulence was due to an improperly installed clamp.)

Precipitation-limited In Flight Vision

  • A320, Brunei, 2014 (On 7 July 2014, an Airbus A320 landing at Brunei departed the side of the runway almost immediately after touchdown and continued to gradually diverge from the runway axis until stopping after a ground run of approximately 1,050 metres. The Investigation concluded that the aircraft commander, having taken over control from the First Officer when the latter lost their previously-acquired prescribed visual reference below Decision Altitude due to a sudden-onset intense rain shower ahead, had then continued the approach without recognising that the only lights still visible to him were those at the right hand edge of the runway.)
  • A320, Halifax NS Canada, 2015 (On 29 March 2015, an Airbus A320 crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.)
  • A320, Toronto ON Canada, 2017 (On 25 February 2017, an Airbus A320 left the side of the landing runway at Toronto when, for undetermined reasons, the Captain, as Pilot Flying, set up a drift to the right just before touchdown. This was then followed by a lateral runway excursion into wet grass in rain-reduced visibility which continued for 1,650 metres before the aircraft regained the runway and stopped. The Investigation noted that both the absence of runway centreline lighting and the aircraft operator’s policy of not activating the aircraft rain repellent system or applying the alternative hydrophobic windshield coating may have increased the excursion risk.)
  • A332, Jakarta Indonesia, 2013 (On 13 December 2013, an Airbus A330 encountered very heavy rain below 100 feet agl just after the autopilot had been disconnected for landing off an ILS approach at Jakarta. The aircraft Commander, as pilot flying, lost visual reference but the monitoring First Officer did not. A go around was neither called nor flown and after drifting in the flare, the aircraft touched down with the right main landing gear on the grass and continued like this for 500 metres before regaining the runway. The Investigation noted that prevailing SOPs clearly required that a go around should have been flown.)
  • A333, Montréal QC Canada, 2014 (On 7 October 2014, an Airbus A330-300 failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.)
  • A343, Toronto Canada, 2005 (On 2 August 2005, an Air France Airbus A340 attempted a daylight landing at destination on a rain-soaked runway during an active thunderstorm and overran for 300 metres ending up in a ravine from where, despite its destruction by fire, all occupants escaped. The Investigation recommendations focussed mainly on crew decision making in adverse weather conditions and issues related to the consequences of such an overrun on survivability.)

... further results

Strong Surface Winds

  • A319, vicinity Wuxi China, 2010 (On 14 September 2010, the crew of a Sichuan Airlines Airbus A319 continued an ILS approach into Wuxi despite awareness of adverse convective weather conditions at the airport. Their inattention to automation management then led to a low energy warning and the inappropriate response to this led to the activation of flight envelope protection quickly followed by a stall warning. Inappropriate response to this was followed by loss of control and a full stall and high rate of descent from which recovery was finally achieved less than 900 feet agl.)
  • A320, Hamburg Germany, 2008 (On 1 March 2008 an Airbus A320 being operated by Lufthansa on a scheduled passenger flight from Munich to Hamburg experienced high and variable wind velocity on short finals in good daylight visibility and during the attempt at landing on runway 23 with a strong crosswind component from the right, a bounced contact of the left main landing gear with the runway was followed by a left wing down attitude which resulted in the left wing tip touching the ground. A rejected landing was then flown and after radar vectoring, a second approach to runway 33 was made to a successful landing. No aircraft occupants were injured but the aircraft left wing tip was found to have been damaged by the runway contact. The track of the aircraft and spot wind velocities given by ATC at key points are shown on the illustration below.)
  • A321, Hakodate Japan, 2002 (On 21 January 2002, an Airbus A321-100 being operated by All Nippon Airways on a scheduled passenger flight from Nagoya to Hakodate encountered sudden negative windshear just prior to planned touchdown and the pitch up which followed resulted in the aft fuselage being damaged prior to the initiation of a climb away to position for a further approach which led to a normal landing. Three of the cabin crew sustained minor injuries but the remaining 90 occupants were uninjured.)
  • A343, Toronto Canada, 2005 (On 2 August 2005, an Air France Airbus A340 attempted a daylight landing at destination on a rain-soaked runway during an active thunderstorm and overran for 300 metres ending up in a ravine from where, despite its destruction by fire, all occupants escaped. The Investigation recommendations focussed mainly on crew decision making in adverse weather conditions and issues related to the consequences of such an overrun on survivability.)
  • AT75, vicinity Cork Ireland, 2014 (On 2 January 2014, the crew of an ATR 72-212A lost forward visibility due to the accumulation of a thick layer of salt deposits on the windshield whilst the aircraft was being radar positioned to an approach at Cork on a track which took it close to and at times over the sea in the presence of strong onshore winds. The Investigation concluded that the prevailing strong winds over and near to the sea in relatively dry air with little visible moisture present had been conducive to high concentrations of salt particles at low levels.)
  • B732, vicinity Abuja Nigeria, 2006 (On 29 October 2006, an ADC Airlines’ Boeing 737-200 encountered wind shear almost immediately taking off from Abuja into adverse weather associated with a very rapidly developing convective storm. Unseen from the apron or ATC TWR it stalled, crashed and burned after just over one minute airborne killing 96 of the 105 occupants. The Investigation concluded that loss of control during the wind shear encounter was not inevitable but was a consequence of inappropriate crew response. Concerns about the quality of crew training and competency validation were also raised.)

... further results

Lightning Damage

  • A332, Perth WA Australia, 2014 (On 26 November 2014, an Airbus A330-200 was struck by lightning just after arriving at its allocated stand following a one hour post-landing delay after suspension of ramp operations due to an overhead thunderstorm. Adjacent ground services operatives were subject to electrical discharge from the strike and one who was connected to the aircraft flight deck intercom was rendered unconscious. The Investigation found that the equipment and procedures for mitigation of risk from lightning strikes were not wholly effective and also that perceived operational pressure had contributed to a resumption of ground operations which hindsight indicated had been premature.)
  • AS3B, en-route, northern North Sea UK, 2008 (On 22 February 2008, a Eurocopter AS332 L2 Super Puma flying from an offshore oil platform to Aberdeen was struck by lightning. There was no apparent consequence and so, although this event required a landing as soon as possible, the commander decided to continue the remaining 165nm to the planned destination which was achieved uneventfully. Main rotor blade damage including some beyond repairable limits was subsequently discovered. The Investigation noted evidence indicating that this helicopter type had a relatively high propensity to sustain lightning strikes but noted that, despite the risk of damage, there was currently no adverse safety trend.)
  • B752, Girona Spain, 1999 (On 14th September 1999, a Britannia Airways Boeing 757 crash landed and departed the runway after a continued unstabilised approach in bad weather to Girona airport, Spain.)
  • D228, vicinity Bodø Norway, 2003 (On 4 December 2003, the crew of a Dornier 228 approaching Bodø lost control of their aircraft after a lightning strike which temporarily blinded both pilots and damaged the aircraft such that the elevator was uncontrollable. After regaining partial pitch control using pitch trim, a second attempt at a landing resulted in a semi-controlled crash which seriously injured both pilots and damaged the aircraft beyond repair. The Investigation concluded that the energy in the lightning had probably exceeded certification resilience requirements and that up to 30% of the bonding wiring in the tail may have been defective before lightning struck.)
  • E145, vicinity Manchester UK, 2001 (On 25 September 2001, an Embraer 145 in descent to Manchester sustained a low power lightning strike which was followed, within a few seconds, by the left engine stopping without failure annunciation. A successful single engine landing followed. The Investigation concluded that the cause of failure of the FADEC-controlled AE3007 engine (which has no surge recovery logic) was the aero-thermal effects of the strike to which all aircraft with relatively small diameter fuselages and close mounted engines are vulnerable. It was considered that there was a risk of simultaneous double engine flameout in such circumstances which was impossible to quantify.)
  • SB20, vicinity Sumburgh, UK 2014 (On 15 December 2014, the Captain of a Saab 2000 lost control of his serviceable aircraft after a lightning strike when he attempted to control the aircraft manually without first disconnecting the autopilot and despite the annunciation of a series of related alerts. The aircraft descended from 4,000 feet to 1,100 feet at up to 9,500 fpm and 80 knots above Vmo. A fortuitous transient data transmission fault caused autopilot disconnection making it possible to respond to EGPWS 'SINK RATE' and 'PULL UP' Warnings. The Investigation concluded that limitations on autopilot disconnection by pilot override were contrary to the type certification of most other transport aircraft.)

Low Level Windshear

  • A319, vicinity Wuxi China, 2010 (On 14 September 2010, the crew of a Sichuan Airlines Airbus A319 continued an ILS approach into Wuxi despite awareness of adverse convective weather conditions at the airport. Their inattention to automation management then led to a low energy warning and the inappropriate response to this led to the activation of flight envelope protection quickly followed by a stall warning. Inappropriate response to this was followed by loss of control and a full stall and high rate of descent from which recovery was finally achieved less than 900 feet agl.)
  • A320, Bilbao Spain, 2001 (On 7th February 2001, an Iberia A320 was about to make a night touch down at Bilbao in light winds when it experienced unexpected windshear. The attempt to counter the effect of this by initiation of a go around failed because the automatic activation of AOA protection in accordance with design criteria which opposed the crew pitch input. The aircraft then hit the runway so hard that a go around was no longer possible. Severe airframe structural damage and evacuation injuries to some of the occupants followed. A mandatory modification to the software involved was subsequently introduced.)
  • A321, Hakodate Japan, 2002 (On 21 January 2002, an Airbus A321-100 being operated by All Nippon Airways on a scheduled passenger flight from Nagoya to Hakodate encountered sudden negative windshear just prior to planned touchdown and the pitch up which followed resulted in the aft fuselage being damaged prior to the initiation of a climb away to position for a further approach which led to a normal landing. Three of the cabin crew sustained minor injuries but the remaining 90 occupants were uninjured.)
  • A321, Manchester UK, 2011 (2) (On 23 December 2011, an Austrian Airlines Airbus A321 sustained a tail strike at Manchester as the main landing gear contacted the runway during a night go around initiated at a very low height after handling difficulties in the prevailing wind shear. The remainder of the go around and subsequent approach in similar conditions was uneventful and the earlier tail strike was considered to have been the inevitable consequence of initiating a go around so close to the ground after first reducing thrust to idle. Damage to the aircraft rendered it unfit for further flight until repaired but was relatively minor.)
  • A333, Montréal QC Canada, 2014 (On 7 October 2014, an Airbus A330-300 failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.)
  • AS32, en-route, North Sea UK, 2002 (On 28th February 2002, an Aerospatiale AS332L Super Puma helicopter en route approximately 70 nm northeast of Scatsa, Shetland Islands was in the vicinity of a storm cell when a waterspout was observed about a mile abeam. Soon afterwards, violent pitch, roll and yaw with significant negative and positive ‘g’ occurred. Recovery to normal flight was achieved after 15 seconds and after a control check, the flight was completed. After flight, all five tail rotor blades and tail pylon damage were discovered. It was established that this serious damage was the result of contact between the blades and the pylon.)
  • AS50, en-route, Hawaii USA, 2005 (On 23 September 2005, an AS350 helicopter, operated by Heli USA Airways, crashed into the sea off Hawaii following loss of control associated with flight into adverse weather conditions.)
  • AT75, vicinity Cork Ireland, 2014 (On 2 January 2014, the crew of an ATR 72-212A lost forward visibility due to the accumulation of a thick layer of salt deposits on the windshield whilst the aircraft was being radar positioned to an approach at Cork on a track which took it close to and at times over the sea in the presence of strong onshore winds. The Investigation concluded that the prevailing strong winds over and near to the sea in relatively dry air with little visible moisture present had been conducive to high concentrations of salt particles at low levels.)
  • B732, vicinity Abuja Nigeria, 2006 (On 29 October 2006, an ADC Airlines’ Boeing 737-200 encountered wind shear almost immediately taking off from Abuja into adverse weather associated with a very rapidly developing convective storm. Unseen from the apron or ATC TWR it stalled, crashed and burned after just over one minute airborne killing 96 of the 105 occupants. The Investigation concluded that loss of control during the wind shear encounter was not inevitable but was a consequence of inappropriate crew response. Concerns about the quality of crew training and competency validation were also raised.)
  • B732, vicinity Islamabad Pakistan, 2012 (On 20 April 2012, the crew of a Boeing 737-200 encountered negative wind shear during an ILS final approach at night in lMC and failed to respond with the appropriate recovery actions. The aircraft impacted the ground approximately 4 nm from the threshold of the intended landing runway. The Investigation attributed the accident to the decision to continue to destination in the presence of adverse convective weather and generally ineffective flight deck management and noted that neither pilot had received training specific to the semi-automated variant of the 200 series 737 being flown and had no comparable prior experience.)
  • B734, Brisbane Australia, 2001 (On 18th January 2001, a Qantas Boeing 737-400 encountered a Microburst while conducting a go-around at Brisbane Australia.)
  • B735, Denver USA, 2008 (Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.)

... further results

In Flight Icing - Turboprop Engine

  • MD82, en route, west of Wichita KA USA, 2002 (On 4 June 2002, the crew of an MD82 in the cruise at FL330 with AP and A/T engaged failed to notice progressive loss of airspeed and concurrent increase in pitch attitude as both engines rolled back to thrust levels which could not sustain level flight. The aircraft stalled and a recovery was accomplished with significant altitude necessary before engine thrust was restored and a diversion made. The Investigation attributed the engine rollback to ice crystal icing obstructing the engine inlet pressure sensors following crew failure to use the engine anti-icing as prescribed. Two Safety Recommendations were made.)

In Flight Icing - Jet Engine

Mountain Wave/Rotor Conditions

  • B773, en-route, east northeast of Anchorage AK USA, 2015 (On 30 December 2015, a Boeing 777-300 making an eastbound Pacific crossing en-route to Toronto encountered forecast moderate to severe clear air turbulence associated with a jet stream over mountainous terrain. Some passengers remained unsecured and were injured, one seriously and the flight diverted to Calgary. The Investigation found that crew action had mitigated the injury risk but that more could have been achieved. It was also found that the pilots had not been in possession of all relevant information and that failure of part of the air conditioning system during the turbulence was due to an improperly installed clamp.)

Triggered Lightning Strike

Layer Cloud Airframe Icing

  • A319, vicinity Wuxi China, 2010 (On 14 September 2010, the crew of a Sichuan Airlines Airbus A319 continued an ILS approach into Wuxi despite awareness of adverse convective weather conditions at the airport. Their inattention to automation management then led to a low energy warning and the inappropriate response to this led to the activation of flight envelope protection quickly followed by a stall warning. Inappropriate response to this was followed by loss of control and a full stall and high rate of descent from which recovery was finally achieved less than 900 feet agl.)
  • A320, Bilbao Spain, 2001 (On 7th February 2001, an Iberia A320 was about to make a night touch down at Bilbao in light winds when it experienced unexpected windshear. The attempt to counter the effect of this by initiation of a go around failed because the automatic activation of AOA protection in accordance with design criteria which opposed the crew pitch input. The aircraft then hit the runway so hard that a go around was no longer possible. Severe airframe structural damage and evacuation injuries to some of the occupants followed. A mandatory modification to the software involved was subsequently introduced.)
  • A321, Hakodate Japan, 2002 (On 21 January 2002, an Airbus A321-100 being operated by All Nippon Airways on a scheduled passenger flight from Nagoya to Hakodate encountered sudden negative windshear just prior to planned touchdown and the pitch up which followed resulted in the aft fuselage being damaged prior to the initiation of a climb away to position for a further approach which led to a normal landing. Three of the cabin crew sustained minor injuries but the remaining 90 occupants were uninjured.)
  • A321, Manchester UK, 2011 (2) (On 23 December 2011, an Austrian Airlines Airbus A321 sustained a tail strike at Manchester as the main landing gear contacted the runway during a night go around initiated at a very low height after handling difficulties in the prevailing wind shear. The remainder of the go around and subsequent approach in similar conditions was uneventful and the earlier tail strike was considered to have been the inevitable consequence of initiating a go around so close to the ground after first reducing thrust to idle. Damage to the aircraft rendered it unfit for further flight until repaired but was relatively minor.)
  • A333, Montréal QC Canada, 2014 (On 7 October 2014, an Airbus A330-300 failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.)
  • AS32, en-route, North Sea UK, 2002 (On 28th February 2002, an Aerospatiale AS332L Super Puma helicopter en route approximately 70 nm northeast of Scatsa, Shetland Islands was in the vicinity of a storm cell when a waterspout was observed about a mile abeam. Soon afterwards, violent pitch, roll and yaw with significant negative and positive ‘g’ occurred. Recovery to normal flight was achieved after 15 seconds and after a control check, the flight was completed. After flight, all five tail rotor blades and tail pylon damage were discovered. It was established that this serious damage was the result of contact between the blades and the pylon.)

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