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B752, Puerto Plata Dominican Republic, 1998

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Summary
On 1 January 1998, a Boeing 757-200 being operated by Airtours International on a passenger charter flight from Bangor MA USA to Puerto Plata Dominican Republic struck the ground to the right of the intended landing runway shortly after the aircraft commander, flying manually as PF for a third approach, had initiated a late go around after failing to retain effective control of the aircraft. Despite sustaining substantial damage to the landing gear and airframe not appreciated by the flight crew, the aircraft was then successfully flown pressurised to the nominated diversion, Santo Domingo where an uneventful landing was accomplished. A fuel leak from the APU was observed once parked but the decision was taken to shut it down using the normal switch and not to expedite passenger disembarkation and no fire occurred. None of the occupants were injured during the landing attempt at Puerto Plata but the aircraft was found to have suffered extensive damage and had to be repaired before further flight by a team from the aircraft manufacturer.
Event Details
When January 1998
Actual or Potential
Event Type
Human Factors, Loss of Control
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOEING 757-200
Operator Airtours International
Domicile United Kingdom
Type of Flight Public Transport (Passenger)
Origin Bangor International
Intended Destination Puerto Plata/Gregorio Luperon International Airport
Actual Destination Las Americas International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Missed Approach
APR
Location - Airport
Airport Puerto Plata/Gregorio Luperon International Airport
General
Tag(s) Approach not stabilised,
Non Precision Approach,
Inadequate Aircraft Operator Procedures
HF
Tag(s) Inappropriate crew response - skills deficiency,
Ineffective Monitoring,
Manual Handling,
Procedural non compliance
LOC
Tag(s) Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,
Environmental Factors,
Temporary Control Loss,
Unintended transitory terrain contact
Outcome
Damage or injury Yes
Aircraft damage Major
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Airport Management
Investigation Type
Type Independent

Description

On 1 January 1998, a Boeing 757-200 being operated by Airtours International on a passenger charter flight from Bangor MA USA to Puerto Plata Dominican Republic stuck the ground to the right of the intended landing runway shortly after the aircraft commander, flying manually as PF for a third approach, had initiated a late go around after failing to retain effective control of the aircraft. Despite sustaining substantial damage to the landing gear and airframe not appreciated by the flight crew, the aircraft was then successfully flown pressurised to the nominated diversion, Santo Domingo where an uneventful landing was accomplished. A fuel leak from the APU was observed once parked but the decision was taken to shut it down using the normal switch and not to expedite passenger disembarkation and no fire occurred. None of the occupants were injured during the landing attempt at Puerto Plata but the aircraft was found to have suffered extensive damage and had to be repaired before further flight by a team from the aircraft manufacturer.

Investigation

An Investigation in accordance with the provisions of Annex 13 was carried out by the Dominican Republic Authorities with assistance from the National Transportation Safety Board (USA) (NTSB) and the UK AAIB. Prevailing weather conditions at Puerto Plata during the arrival were overcast with a cloud base similar to the MDA for the available NPA and at times lower. It was established that the aircraft had previously made two unsuccessful NPAs, both using the promulgated VOR/DME procedure to approach the same runway with a short period holding in between. After reaching the MDA on the second of these, the aircraft commander had decided to continue descent without having the required visual reference and when, at low level, it became apparent that the aircraft was too high to complete a landing, he had then decided to fly a low level circuit to a third landing attempt. This circuit was unstable and culminated in ground impact during the initiation of a very late go around. It was noted that throughout the approach, there had been extensive breaches of Operator SOPs by the aircraft commander with no evidence of any effective monitoring or intervention by the First Officer. It was concluded that Crew Resource Management had been poor.

The Final Report of the Investigation was published on 6 April 1999 and may be seen in full at (bookshelf reference after upload, see below fir source files). Three Safety Recommendations were made:

  1. The Operator should ensure that a programme to review, on a regular basis, disidentified DFDR records in order to assess adherence to Standard Operating Procedures (SOPs) by its crews is introduced as soon s possible
  2. The Operator should review, in general terms, the operating procedures to ensure that they are providing the most effective guidance to pilots in order to ensure safe and efficient approach procedures.
  3. The Airfield Authority should provide an effective form of approach lighting for Runway 26 at Puerto Plata.

The Final Report was released on 6 April 1999 and may be seen at SKYbrary bookshelf: AAIB - Aircraft Accident Report 3/99

Further Reading