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Accident and Serious Incident Reports: CFIT

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Article Information
Category: Controlled Flight Into Terrain Controlled Flight Into Terrain
Content source: SKYbrary About SKYbrary
Content control: EUROCONTROL EUROCONTROL

Definition

Reports relating to accidents which resulted in Controlled Flight Into Terrain (CFIT) and serious incidents which could have resulted in CFIT.

The accident and serious incident reports are grouped together below in subcategories according to phase of flight.

En-route

  • A320, en-route Alpes-de-Haute-Provence France, 2015 (On 24 March 2015, after waiting for the Captain to leave the flight deck and preventing his return, a Germanwings A320 First Officer put his aircraft into a continuous descent from FL380 into terrain killing all 150 occupants. Investigation concluded the motive was suicide, noted a history of mental illness dating from before qualification as a pilot and found that prior to the crash he had been "experiencing mental disorder with psychotic symptoms" which had not been detected through the applicable "process for medical certification of pilots". Conflict between the principles of medical confidentiality and wider public interest was identified.)
  • C185, Smithers BC Canada, 2000 (On 27 September 2000, a Cessna 185, struck a snow covered hillside, probably while in controlled flight, en-route from Smithers BC, Canada.)
  • C30J, en-route, northern Sweden 2012 (On 15 March 2012, a Royal Norwegian Air Force C130J-30 Hercules en route on a positioning transport flight from northern Norway to northern Sweden crossed the border, descended into uncontrolled airspace below MSA and entered IMC. Shortly after levelling at FL 070, it flew into the side of a 6608 foot high mountain. The Investigation concluded that although the direct cause was the actions of the crew, Air Force procedures supporting the operation were deficient. It also found that the ATC service provided had been contrary to regulations and attributed this to inadequate controller training.)
  • DHC6, en-route, Mount Elizabeth Antarctica, 2013 (On 23 January 2013, a Canadian-operated DHC6 on day VFR positioning flight in Antarctica was found to have impacted terrain under power and whilst climbing at around the maximum rate possible. The evidence assembled by the Investigation indicated that this probably occurred following entry into IMC at an altitude below that of terrain in the vicinity having earlier set course en route direct to the intended destination. The aircraft was destroyed and there were no survivors.)
  • E190, en route, Bwabwata National Park Namibia, 2013 (On 29 November 2013, an Embraer 190 Captain intentionally initiated a high speed descent from the previously-established FL380 cruise altitude after the First Officer left the flight deck and thereafter prevented him from re-entering. The descent was maintained to ground impact with the AP engaged using a final selected altitude below ground level. The Investigation noted that the Captain had been through some “life experiences" capable of having an effect on his state of mind but in the absence of any other evidence was unable establish any motive for suicide.)
  • EC55, en-route, Hong Kong China, 2003 (On 26 August 2003, at night, a Eurocopter EC155, operated by Hong Kong Government Flight Service (GFS), performing a casualty evacuation mission (casevac), impacted the elevated terrain in Tung Chung Gap near Hong Kong International airport.)
  • P46T, vicinity Son Bonet Palma de Mallorca Spain, 2002 (On 19 December 2002, a Piper PA-46 Malibu, after takeoff from Son Bonet Aerodrome, penetrated the control zone (CTR) of Palma de Mallorca tower. The pilot was instructed to leave the CTR and the aircraft headed towards mountainous terrain to the north of the island where the flight conditions were below the VFR minimum. In level flight the aircraft impacted terrain at an altitude of 2000 ft killing all three occupants.)
  • SU95, manoeuvring near Jakarta Indonesia, 2012 (On 9 May 2012, a Sukhoi RRJ-95 on a manufacturer-operated demonstration flight out of Jakarta Halim descended below the promulgated safe altitude and, after TAWS alerts and warnings had been ignored, impacted terrain in level flight which resulted in the destruction of the aeroplane and death of all 45 occupants. The Investigation concluded that that the operating crew were unaware that their descent would take them below some of the terrain in the area until the alerts started and then assumed they had been triggered by an incorrect database and switched the equipment off.)


Approach and Landing

  • A306, East Midlands UK, 2011 (On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.)
  • A306, vicinity Birmingham AL USA, 2013 (On 14 August 2013, a UPS Airbus A300-600 crashed short of the runway at Birmingham Alabama on a night IMC non-precision approach after the crew failed to go around at 1000ft aal when unstabilised and then continued descent below MDA until terrain impact. The Investigation attributed the accident to the individually poor performance of both pilots, to performance deficiencies previously-exhibited in recurrent training by the Captain and to the First Officer's failure to call in fatigued and unfit to fly after mis-managing her off duty time. A Video was produced by NTSB to further highlight human factors aspects.)
  • 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 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, 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.)
  • A320, Khartoum Sudan, 2005 (On 11 March 2005, an Airbus A321-200 operated by British Mediterranean Airways, executed two unstable approaches below applicable minima in a dust storm to land in Khartoum Airport, Sudan. The crew were attempting a third approach when they received information from ATC that visibility was below the minimum required for the approach and they decided to divert to Port Sudan where the A320 landed without further incident.)
  • A320, vicinity Addis Ababa Ethiopia, 2003 (On 31 March 2003, an A320, operated by British Mediterranean AW, narrowly missed colliding with terrain during a non-precision approach to Addis Ababa, Ethiopia.)
  • A320, vicinity Bahrain Airport, Kingdom of Bahrain, 2000 (On 23 August 2000, a Gulf Air Airbus A320 flew at speed into the sea during an intended dark night go around at Bahrain and all 143 occupants were killed. It was subsequently concluded that, although a number of factors created the scenario in which the accident could occur, the most plausible explanation for both the descent and the failure to recover from it was the focus on the airspeed indication at the expense of the ADI and the effect of somatogravic illusion on the recently promoted Captain which went unchallenged by his low-experience First Officer.)
  • A320, vicinity Glasgow UK, 2008 (An Airbus A322 being operated by British Airways on a scheduled passenger flight from London Heathrow to Glasgow was being radar vectored in day IMC towards an ILS approach to runway 23 at destination when an EGPWS Mode 2 Hard Warning was received and the prescribed response promptly initiated by the flight crew with a climb to MSA.)
  • A320, vicinity Naha Okinawa Japan, 2014 (On 28 April 2014, an Airbus A320 making a precision radar approach at Naha in IMC began descent from 1,000 feet QNH at 6nm from touchdown with the autopilot engaged and continued it until successive EGPWS 'PULL UP' Warnings occurred soon after the radar controller had advised four miles from touchdown. Minimum recorded radio height was 242 feet with neither the sea nor the runway in sight. The Investigation noted ineffective alerting by the First Officer, the radar controller's failure to notice the error until just before the EGPWS Warnings and the absence of MSAW annunciations at the controller's position.)
  • A320, vicinity Oslo Norway, 2008 (On 19 December 2008, an Aeroflot Airbus A320 descended significantly below its cleared and acknowledged altitude after the crew lost situational awareness at night whilst attempting to establish on the ILS at Oslo from an extreme intercept track after a late runway change and an unchallenged incorrect readback. The Investigation concluded that the response to the EGPWS warning which resulted had been “late and slow” but that the risk of CFIT was “present but not imminent”. The context for the event was considered to have been poor communications between ATC and the aircraft in respect of changes of landing runway.)
  • A320, vicinity Sochi Russia, 2006 (On 3 May 2006, an Airbus 320 crew failed to correctly fly a night IMC go around at Sochi and the aircraft crashed into the sea and was destroyed. The Investigation found that the crew failed to reconfigure the aircraft for the go around and, after having difficulties with the performance of an auto go-around, had disconnected the autopilot. Inappropriate control inputs, including simultaneous (summed) sidestick inputs by both pilots were followed by an EGPWS PULL UP Warning. There was no recovery and about a minute into the go around, a steep descent into the sea at 285 knots occurred.)
  • … further results


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For all accident reports held on SKYbrary, see Accident and Serious Incident Reports.