CRJ1, Kinshasa Democratic Republic of Congo, 2011
From SKYbrary Wiki
|On 4 April 2011, the crew of a Georgian Airways Bombardier CRJ100 operating a domestic flight for the United Nations lost control of their aircraft as they commenced a go around from below the MDA for the non precision approach flown due to an absence of visual reference with the runway. They were aware from their weather radar of severe convective weather in the vicinity of the airport although the METAR passed by ATC did not indicate this. The aircraft crashed alongside the runway and was destroyed. All occupants except one who was seriously injured were killed.|
|Actual or Potential
|Human Factors, Loss of Control, Weather|
|Aircraft||BOMBARDIER Regional Jet CRJ-100|
|Type of Flight||Public Transport (Passenger)|
|Origin||Kisangani/Bangoka International Airport|
|Intended Destination||Kinshasa/Ndjili International Airport|
|Take off Commenced||Yes|
|Flight Phase||Missed Approach|
|Location - Airport|
|Airport||Kinshasa/Ndjili International Airport|
|Tag(s)||Approach not stabilised,|
Non Precision Approach,
Inadequate Aircraft Operator Procedures,
Ineffective Regulatory Oversight
Plan Continuation Bias,
Procedural non compliance,
Ineffective Monitoring - PIC as PF
|Tag(s)||Flight Management Error,|
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.,
Strong Surface Winds,
Low Level Windshear
|Damage or injury||Yes|
|Aircraft damage||Hull loss|
|Fatalities||Most or all occupants (32)|
|Causal Factor Group(s)|
Air Traffic Management
On 4 April 2011, a Bombardier CRJ-100ER (4L-GAE) being operated by Georgian Airways on a charter flight for MONUSCO (the United Nations Stabilisation Mission in the DRC) from Kisingani to Kinshasa as UNO 834 crashed shortly after attempting to initiate a go around at destination whilst a severe thunderstorm was in progress. The aircraft was destroyed and all but one of the 33 occupants were killed. The sole survivor was seriously injured.
An Investigation was carried out by specially established Investigation Commission set up the Permanent Office for Investigation of Aviation Accidents and Incidents of the Ministry of Transport and Communication of the Democratic Republic of Congo (DRC).
The Flight Data Recorder (FDR) and 2 hour Cockpit Voice Recorder (CVR) were recovered and data was successfully downloaded despite damage being sustained by the former. The Canadian TSB then "took the lead in analysis of data in coordination with Bombardier". FDR data confirmed that "all aircraft systems were functioning normally" and that "no technical failures had been recorded during the flight".
It was established that the aircraft commander had been PF for the accident flight, which was the return leg of an earlier flight from Kinshasa to Kisangani. A ground engineer and one flight attendant were also on board. These flights were conducted under a long term charter agreement with MONUSCO which had been in place since 2008.
The 27 year old Captain had accumulated a total of 1622 hours on the CRJ100/200, just over 200 hours of this as a Captain. The 22 year old First Officer had under 500 hours total flying experience, the majority of it on the CRJ100.
After cruising at FL 300, the aircraft began its descent. The crew were able to see returns on their weather radar which indicated the presence of severe weather around Kinshasa.
When passing FL240 and 68 nm from Kinshasa, the crew established contact with Kinshasa APP and were asked to report reaching FL100. The crew acknowledged this and requested permission to intercept radial 061 for a Straight-In LOC approach to Runway 24. Establishing on the radial was approved and further descent was given to FL060. The latest weather was requested and passed as "wind 210 degrees, 8 knots, visibility 8 kilometres, thunderstorm over station, scattered 2500 feet, few CB 3000 feet, CB located north-east, south-west and west, broken 12000 feet, Temperature 38, correction 33, dew point 23, QNH 1008, NOSIG". The crew then "discussed options of avoiding the severe weather being displayed on their…..weather radar by skirting around (it)".
The aircraft continued at a speed above the maximum permitted 250 KIAS below FL100 and did not reduce below this until passing 4630 feet Altimeter Pressure Settings (Kinshasa airport elevation is 1014 feet amsl) The LOC frequency for the intended approach had been selected as the aircraft passed FL060 at a range of 20nm but it was not intercepted and the aircraft remained to the south (left) of the prescribed track. When the aircraft was about 10 nm out and still not on the LOC, the crew turned further to the left and then the First Officer announced that he had sighted the runway in his right one o'clock. The PF subsequently also saw it as the aircraft approached 6nm from the threshold. The aircraft speed was 210 KCAS, the altitude was 3250 feet - just over 1000 feet above the prescribed vertical profile for the LOC procedure - and the aircraft was still in clean configuration.
The crew decided to continue their approach. The PF disengaged the AP and turned towards the runway visually and instructed the First Officer to configure the aircraft for landing. The aircraft was positioned on the runway extended centreline by 2 nm from the runway threshold.
The Investigation established that at around this time, the aerodrome began to be affected by a squall line which was approaching from the north east and was of sufficient intensity to be clearly visible on recorded satellite images. This meant it was in an approximately 5 o'clock relative position to the aircraft track. Then, on short finals and below the MDA for the LOC approach (1470 feet QNH, equivalent to 472 feet aal), heavy rain was encountered. Although the wind shield wipers were switched on, as the aircraft approached 200 feet agl, the runway was no longer in sight and the PF called "go around, flaps 8". At this point, the aircraft was at 218 feet agl had a speed of 156 KCAS and about 80% engine rpm.
Initially, "a positive rate of climb was established with appropriate airspeed" but the landing gear was not raised. As the aircraft was climbing through an altitude of 1395 feet (equivalent to 397 feet agl) at 149 KCAS, sudden severe wind shear was encountered and a wind shear warning was annunciated 2 seconds later. FDR data showed that the aircraft had then pitched significantly nose down (from about 4-5 degrees nose up attitude to 7 degrees nose down attitude) over 5 seconds and had lost height so quickly that, although just before impact a "significant and instantaneous" up-elevator deflection was recorded, the crew did not recover control before the aircraft impacted the ground alongside the runway. The last FDR data prior to impact recorded a speed of 180 KCAS, a pitch attitude of 10° nose down and a magnetic heading of 220° degrees. The aircraft broke up on impact and the fuselage came to rest inverted about 400 metres beyond the initial impact point.
The aerodrome Emergency Crash and Rescue (ECR) Team attended immediately and nine of the occupants, badly injured but still alive, were removed from the fuselage. Some died en route to hospital and all but one of the others died after reaching it. MONUSCO's own ERC joined in the rescue effort after a short delay which occurred because their location on the aerodrome was further away from the crash site than the airport ERC and the emergency siren was not heard due to "the raging thunderstorm over the airfield at the time of the accident".
Based on analysis of the assembled evidence, the Investigation identified a number of concerns without stating or implying any relative importance by the order in which they were considered. In summary, these concerns were as follows:
- It was noted that Georgian Airways held a current IOSA certification from IATA but that there was an abnormally short pilot training requirement for promotion of First Officers to Captain and there was no OFDM programme for the accident aircraft type (although this was not a regulatory requirement).
- Although the Georgian CAA was responsible for nine AOCs, at the time of the accident, it did not employ any Operations Inspectors. Instead "surveillance of Georgian Airways crew was being carried out by co-opting senior crew from the same Operator, who temporarily performed the functions of a CAA Operations Inspector and carried out Standardization check rides."
- It was considered that meteorological information provided to the crew had been "inadequate". There had been clear evidence of the intensity and fast movement of the squall line encountered but not all of this had been available to ATC. It was also considered that there was some doubt over whether the crew had heard "thunderstorm over the station" as part of the weather report passed to them by ATC because of the effect of the "slight accent" with which it was spoken. The use of 'NOSIG' in the weather report passed to the crew (implying no significant change expected in conditions during the 30 minutes following the time of the report) was inappropriate since "the weather was indeed changing".
- The approach was characterised by multiple violations of SOPs and was clearly unstabilised. The instrument approach procedure for which the aircraft was cleared was not flown in accordance with that clearance and neither the initiation of the go around nor the prescribed wind shear escape procedure were flown correctly.
- The assessment by the crew of weather information displayed on their weather radar was considered "inappropriate".
- The decision of the aircraft commander to attempt a landing was also considered "inappropriate".
- Given that flight crew assigned to the Georgian Airways MONUSCO contract were based locally for continuous periods of 3 to 6 months, the need for some form of effective operational standards oversight was clear but in the absence of this, it was considered that an OFDM programme could have been effective in this respect.
The Investigation determined that the Probable Cause of the accident was "the encounter of the aircraft with a severe microburst-like weather phenomenon at a very low altitude during the process of Go Around. The severe vertical gust/downdraft caused a significant and sudden pitch change to the aircraft which resulted in a considerable loss of height. Being at very low altitude, recovery from such a disturbance was not possible".
Six Contributory Factors were also identified as follows:
- The inappropriate decision of the crew to continue the approach, in the face of extremely inclement weather being displayed on their weather radar.
- Lack of adequate supervision by the Operator to ensure that its crew complied with established procedures including weather avoidance procedures and Stabilized Approach criteria.
- Inadequacy of Georgian Airways' training program for upgrade to Captain.
- Lack of effective oversight of Georgian Airways by the Georgian CAA.
- Lack of appropriate equipment at Kinshasa airport for identification and tracking of adverse weather phenomena, resulting in failure by ATC to provide appropriate early warning to the aircraft.
- ATC not declaring the airfield closed when visibility dropped below (approach) minima.
Thirteen Safety Recommendations were made as a result of the Investigation as follows:
- that the DRC Ministry of Transport should provide appropriate meteorological equipment to the Meteorological Service in DRC so that the expected level of meteorological services can be provided.
- that the DRC Civil Aviation Authority should exercise effective safety oversight over all operators in the Democratic Republic of Congo, including aircraft chartered by MONUSCO.
- that the DRC Airports Authority (RVA) should procure appropriate weather radars for important airfields in the DRC or alternatively, provide suitable web connections to important Meteorological stations so that they can log on to relevant web sites like EUMETSAT, in order to monitor the weather conditions in real time;
- that the DRC Airports Authority (RVA) should provide appropriate training to the staff of the Meteorological Services as well as to the ATC, in order to improve their performance standards.
- that MONUSCO should consider doing away with a separate Meteorological Service provider for its use and instead rely only on DRC Government provided meteorological service.
- that MONUSCO should demand that all Operators chartered by it should have a FOQA program in place, whose results should be shared with MONUSCO.
- that Georgian Airways should consider revision of its training program including the increased use of simulator flights for initial upgrade on type.
- that Georgian Airways should ensure that a system is put in place to retain a copy of the Load and Balance Sheet on ground for each flight.
- that Georgian Airways should consider implementation of a FOQA Program for its CRJ aircraft.
- that Georgian Airways should consider laying greater emphasis in its Ground Training program on the following:
- Recognition and management of threats and errors; (ICAO Annex 1, Chapter 2, Para. 126.96.36.199.1.2 a)
- Exercise of good judgment and airmanship, to include structured decision making and the maintenance of situational awareness; (ICAO Annex 1, Chapter 2, Para. 188.8.131.52.1.2 e)
- that the Georgian Civil Aviation Authority should exercise effective safety oversight over operations being conducted for extended periods of time by its Operators outside the main operational bases.
- that the Georgian Civil Aviation Authority should review the training program of Georgian Airways.
- that the International Civil Aviation Organization should consider stipulating Flight Operations Quality Assurance (or Flight Data Monitoring (FDM)) program as a mandatory requirement (i.e. a 'Standard') for all aircraft above 20,000kg MTOW which are engaged in commercial operations.