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  • B772, San Francisco CA USA, 2013 (Synopsis: On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.)
  • A319, London Heathrow UK, 2013 (Synopsis: On 24 May 2013 the fan cowl doors on both engines of an Airbus A319 detached as it took off from London Heathrow. Their un-latched status after a routine maintenance input had gone undetected. Extensive structural and system damage resulted and a fire which could not be extinguished until the aircraft was back on the ground began in one engine. Many previously-recorded cases of fan cowl door loss were noted but none involving such significant collateral damage. Safety Recommendations were made on aircraft type certification in general, A320-family aircraft modification, maintenance fatigue risk management and aircrew procedures and training.)
  • A319, Mumbai India, 2013 (Synopsis: On 12 April 2013, an Airbus A319 landed without clearance on a runway temporarily closed for routine inspection after failing to check in with TWR following acceptance of the corresponding frequency change. Two vehicles on the runway saw the aircraft approaching on short final and successfully vacated. The Investigation concluded that the communication failure was attributable entirely to the Check Captain who was in command of the flight involved and was acting as 'Pilot Monitoring'. It was considered that the error was probably attributable to the effects of operating through the early hours during which human alertness is usually reduced.)
  • Vehicles / B722, Hamilton ON Canada, 2013 (Synopsis: On 19 March 2013 a Boeing 727 freighter was cleared to take off on a runway occupied by two snow clearance vehicles. The subsequent cancellation of the take off clearance was not received but a successful high speed rejected take off was accomplished on sight of the vehicles before their position was reached. The Investigation attributed the occurrence to the controller's failure to 'notice' the runway blocked indicator on his display and to his non-standard use of R/T communications. The late sighting of the vehicles by the aircraft crew was due to the elevated runway mid section.)
  • A321, Hurghada Egypt, 2013 (Synopsis: On 28 February 2013, the initial night landing attempt of a Ural Airlines Airbus A321 at Hurghada was mishandled in benign conditions resulting in a tail strike due to over-rotation. The Investigation noted that a stabilised approach had been flown by the First Officer but found that the prescribed recovery from the effects of a misjudged touchdown had not then been followed. It was also concluded that communication between the two pilots had been poor and that the aircraft commander's monitoring role had been ineffective. The possibility of the effects of fatigue was noted.)
  • B738, en-route, south south west of Brisbane Australia, 2013 (Synopsis: On 25 February 2013, a Boeing 737-800 about to commence descent from FL390 began to climb. By the time the crew recognised the cause and began to correct the deviation - their unintended selection of a inappropriate mode - the cleared level had been exceeded by 900 feet. During the recovery, a deviation from track occurred because the crew believed the autopilot had been re-engaged when it had not. The Investigation noted the failure to detect either error until flight path deviation occurred and attributed this to non-compliance with various operator procedures related to checking and confirmation of crew actions.)
  • SW4, Sanikiluaq Nunavut Canada, 2012 (Synopsis: On 22 December 2012, the crew of a Swearingen SA227 attempting a landing, following an unstabilised non-precision approach at Sanikiluaq at night with questionable alternate availability in marginal weather conditions, ignored GPWS PULL UP Warnings, then failed in their attempt to transition into a low go around and the aircraft crashed into terrain beyond the runway. One occupant – an unrestrained infant – was killed and the aircraft was destroyed. The Investigation faulted crew performance, the operator and the regulator and reiterated that lap-held infants were vulnerable in crash impacts.)
  • SF34, vicinity Newcastle New South Wales Australia, 2012 (Synopsis: On 8 November 2012, the crew of a Saab 340 advised destination ATC at Newcastle in daylight hours that they were 'visual' and were so cleared. The aircraft was then observed to turn towards the lights of an industrial complex 6nm from the airport and descend and ATC intervened to provide guidance to final approach. Investigation found that the experienced Captain was guiding the First Officer, who had gained his professional licence 10 months earlier, towards what he had mistaken for the runway. Descent, perceived by the Captain as on 'finals', continued to 680 feet agl before a climb commenced.)
  • CRJ7, Lorient France, 2012 (Synopsis: On 16 October 2012, a Brit Air Bombardier CRJ 700 landed long on a wet runway at Lorient and overran the runway. The aircraft sustained significant damage but none of the occupants were injured. The Investigation attributed the accident to poor decision making by the crew whilst showing signs of complacency and fatigue and failing to maintain a sterile flight deck or go around when the approach became unstable. A context of deficiencies at the airport and at the Operator was also detailed and it was concluded that aquaplaning had occurred.)
  • DH8C, vicinity Abu Dhabi UAE, 2012 (Synopsis: On 9 September 2012, the crew of a DHC8-300 climbing out of Abu Dhabi declared a PAN and returned after visual evidence of the right engine overheating were seen from the passenger cabin. The Investigation found that the observed signs of engine distress were due to hot gas exiting through the cavity left by non-replacement of one of the two sets of igniters on the engine after a pressure wash carried out overnight prior to the flight and that the left engine was similarly affected. The context for the error was identified as a dysfunctional maintenance organisation at the Operator.)
  • C500, vicinity Santiago Spain, 2012 (Synopsis: On 2 August 2012, a Cessna 500 positioning back to base after completing an emergency medical team transfer operation earlier in the night crashed one mile short of the runway at Santiago in landing configuration after being cleared to make an ILS approach. The Investigation concluded that the approach was unstabilised, had been flown without following the ILS GS and that the crew had used DME distance from the VOR near the crash position rather than the ILS DME. Fog was present in and around the airport.)
  • AT72, vicinity Tyumen Russian Federation, 2012 (Synopsis: On 2 April 2012, the crew of an ATR72-200 which had just taken off from Tyumen lost control of their aircraft when it stalled after the flaps were retracted and did not recover before it crashed and caught fire killing or seriously injuring all occupants. The Investigation found that the Captain knew that frozen deposits had accumulated on the airframe but appeared to have been unaware of the danger of not having the airframe de-iced. It was also found that the crew had not recognised the stall when it occurred and had overpowered the stick pusher and pitched up.)