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  • A343 / RJ1H, Copenhagen Denmark, 2016 (Synopsis: On 26 December 2016, the wing of an Airbus A340-300 being repositioned by towing at Copenhagen as cleared hit an Avro RJ100 which had stopped short of its stand when taxiing due to the absence of the expected ground crew. The RJ100 had been there for twelve minutes at the time of the collision. The Investigation attributed the collision to differing expectations of the tug driver, the Apron controller and the RJ100 flight crew within an overall context of complacency on the part of the tug driver whilst carrying out what would have been regarded as a routine, non-stressful task.)
  • AN72, Sao Tome, Sao Tome & Principe, 2017 (Synopsis: On 29 July 2017, an Antonov AN-74 crew sighted several previously unseen large “eagles” rising from the long grass next to the runway as they accelerated for takeoff at Sao Tome and, concerned about the risk of ingestion, made a high speed rejected takeoff but were unable to stop on the runway and entered a deep ravine just beyond it which destroyed the aircraft. The Investigation found that the reject had been unnecessarily delayed until above V1, that the crew forgot to deploy the spoilers which would have significantly increased the stopping distance and that relevant crew training was inadequate.)
  • AS32 / B734, Aberdeen UK, 2000 (Synopsis: For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.)
  • AS3B, en-route, northern North Sea UK, 2008 (Synopsis: 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.)
  • AS3B, vicinity Den Helder Netherlands, 2006 (Synopsis: On 21 November 2006, the crew of a Bristow Eurocopter AS332 L2 making an unscheduled passenger flight from an offshore platform to Den Helder in night VMC decided to ditch their aircraft after apparent malfunction of an engine and the flight controls were perceived as rendering it unable to safely complete the flight. All 17 occupants survived but the evacuation was disorganised and both oversight of the operation by and the actions of the crew were considered to have been inappropriate in various respects. Despite extensive investigation, no technical fault which would have rendered it unflyable could be confirmed.)
  • AS55, vicinity Fairview Alberta Canada, 1999 (Synopsis: On 28th April 1999, an AS-355 helicopter suffered an in-flight fire attributed to an electrical fault which had originated from a prior maintenance error undetected during incomplete pre-flight inspections. The aircraft carried out an immediate landing allowing evacuation before the aircraft was destroyed by an intense fire.)
  • AT45, vicinity Prague Czech Republic, 2012 (Synopsis: On 31 October 2012, the crew of an ATR42 on a handover airworthiness function flight out of Prague briefly lost control in a full stall with significant wing drop after continuing a prescribed Stall Protection System (SPS) test below the appropriate speed and then failing to follow the correct stall recovery procedure. Failure of the attempted SPS test was subsequently attributed to both AOA vanes having become contaminated with water during earlier aircraft repainting at a specialist contractor and consequently being constrained in a constant position whilst the SPS test was being conducted at well above the prevailing freezing level.)
  • AT72, en-route, southern Scotland UK, 2011 (Synopsis: On 15 March 2011, an ATR 72-200 on a non revenue positioning flight from Edinburgh to Paris CDG in night VMC with just the two pilots on board began to experience roll and directional control difficulties as the aircraft accelerated upon reaching the planned cruise altitude of FL230. A ‘PAN’ call was made to ATC and a return to Edinburgh was made with successful containment of the malfunctioning flying controls.)
  • B190, vicinity Bebi south eastern Nigeria, 2008 (Synopsis: On 15 March 2008, a Beech 1900D on a non-revenue positioning flight to a private airstrip in mountainous terrain flown by an inadequately-briefed crew without sufficient guidance or previous relevant experience impacted terrain under power whilst trying to locate the destination visually after failing to respond to a series of GPWS Alerts and a final PULL UP Warning. Whilst attributing the accident to the crew, the Investigation also found a range of contributory deficiencies in respect of the Operator, official charting and ATS provision and additional deficiencies in the conduct of the unsuccessful SAR activity after the aircraft became overdue.)
  • B722 / BE10, Atlanta GA USA, 1990 (Synopsis: On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.)
  • B733, vicinity Montpelier, France 2011 (Synopsis: On 10 January 2011, a Europe Airpost Boeing 737-300 taking off from Montpelier after repainting had just rotated for take off when the leading edge slats extended from the Intermediate position to the Fully Extended position and the left stick shaker was activated as a consequence of the reduced stalling angle of attack. Initial climb was sustained and soon afterwards, the slats returned to their previous position and the stick shaker activation stopped. The unexpected configuration change was attributed to paint contamination of the left angle of attack sensor, the context for which was inadequate task guidance.)
  • B734 / C172, vicinity Girona Spain, 2016 (Synopsis: On 28 September 2016, a Boeing 737-400 and a Cessna 172 both on IFR Flight Plans came into close proximity when about to turn final on the same non-precision approach at Girona from different initial joining routes. The Investigation found that two ACC sector controllers had issued conflicting approach clearances after losing situational awareness following a routine sector split due to an area ATC flow configuration change. The detection of the consequences of their error had then been hindered by a temporary area low level radar outage but helped by timely visual acquisition by both aircraft and a TCAS RA.)
  • B737 / B737, vicinity Geneva Switzerland, 2006 (Synopsis: On 11 May 2006, B737-700 taking off from Geneva came into close proximity with a Boeing Business Jet (BBJ) on a non revenue positioning flight which had commenced a go around from the same runway following an unstabilised approach. The Investigation attributed the conflict to the decision of ATC to give take off clearance to the departing aircraft when the approach of the inbound aircraft could have been seen as highly likely to result is a go around which would lead to proximity with the slower departing aircraft.)
  • B737, Singapore Seletar, 2017 (Synopsis: On 16 November 2017, a Boeing 737-700 departing Singapore Seletar was observed by ATC to only become airborne very near the end of the runway and to then climb only very slowly. Ten approach lights were subsequently found to have been impact-damaged by contact with the aircraft. The Investigation found that after the crew had failed to follow procedures requiring them to validate the FMC recalculation of modified takeoff performance data against independent calculations made on their EFBs, takeoff was made with reduced thrust instead of the full thrust required. The modification made was also found not to have been required.)
  • B737, Southend UK, 2010 (Synopsis: On 21 Nov 2010, a Boeing 737-700 being operated by Arik Air on a non revenue positioning flight from Southend to Lagos with only the two pilots on board carried out a successful take off in daylight and normal ground visibility from runway 06 but became airborne only just before the end of the runway.)
  • B737, manoeuvring, west of Norwich UK 2009 (Synopsis: On 12 January 2009, the flight crew of an Easyjet Boeing 737-700 on an airworthiness function flight out of Southend lost control of the aircraft during a planned system test. Controlled flight was only regained after an altitude loss of over 9000 ft, during which various exceedences of the AFM Flight Envelope occurred. The subsequent investigation found that the Aircraft Operators procedures for such flights were systemically flawed.)
  • B738 / DV20, vicinity Reus Spain, 2019 (Synopsis: On 12 May 2019, a Boeing 737-800 making its second procedural ILS approach to runway 25 at Reus came into conflict with an opposite direction light aircraft as the latter approached one of the designated VFR entry points having been instructed to remain well above the altitude which normally ensures separation of IFR and VFR traffic. The collision risk was resolved by TCAS RA promptly followed by the 737. The Investigation concluded that limiting the TWR radar display to the ATZ for controller training purposes had resulted in neither the trainee controller nor their supervisor being aware of the risk.)
  • B738 / E135, en-route, Mato Grosso Brazil, 2006 (Synopsis: On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer Legacy at the same level. Control of the 737 was lost and it crashed, killing all 154 occupants. The Legacy's crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the Legacy to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently switched off their transponder. After the consequent disappearance of altitude from all radar displays, ATC assumed but did not confirm the aircraft had descended.)
  • B738, Dubai UAE, 2013 (Synopsis: On 6 December 2013, a Boeing 737-800 passenger aircraft was flown from Amman to Dubai out of revenue service with a quantity of 'live' boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance. As a result of the investigation, a previously unreported flight by the same operator in revenue service which had also carried live oxygen generators was disclosed.)
  • B743, vicinity Jeddah Saudia Arabia, 2008 (Synopsis: On 5 May 2008, a Saudi Arabian Boeing 747-300 being positioned for maintenance to include investigation of degraded power output from the no 1 GE CF6-50 engine experienced an uncontained failure of the same engine shortly after take off from Jeddah followed by an uneventful air turn back. The failure was attributed to the vulnerability of the engine design to high pressure turbine blade loss.)
  • B789 / C172, en-route, northwest of Madrid Spain, 2017 (Synopsis: On 8 August 2017, a Boeing 787-9 climbing through FL109 after departing Madrid received and promptly followed a TCAS RA ‘DESCEND’ against crossing traffic at FL110 and this action quickly resolved the conflict. The Investigation found that both aircraft involved were following their IFR clearances and attributed the conflict to the controller involved who forgot to resolve a previously-identified potential conflict whilst resolving another potential conflict elsewhere in the sector. It was also found that the corresponding STCA activation had not been noticed and in any event had occurred too late to be of use.)
  • BE20, vicinity Gillam Canada, 2019 (Synopsis: On 24 April 2019, the engine of a Beech B200 en-route from Winnipeg to Churchill at FL 250 failed due to fuel exhaustion and the crew realised that they had forgotten to refuel before departure. An emergency was declared and a diversion to the nearest available airport was commenced but the right engine later failed for the same reason leaving them with no option but to land on a frozen lake surface. The Investigation concluded that confusion as to relative responsibility between the trainee Captain and the supervising pilot-in-command were central to the failure to refuel prior to departure as intended.)
  • C172, McKinney TX USA, 2003 (Synopsis: On 8 July 2003, a Cessna 172S on an instructional flight hit a vulture which caused significant structural damage to the left wing. During the attempted forced landing which followed, control of the aircraft was lost and the aircraft crashed into terrain near McKinney TX USA.)
  • C310, vicinity Wolf Point MT USA, 2000 (Synopsis: On 25 May 2000, a commercially operated Cessna 310R on a positioning flight encountered a flock of geese in VMC at about 600 feet agl after a daylight take off from Wolf Point MT and one of the geese impacted and broke through the windscreen causing the pilot to loose control and the aircraft to crash.)
  • 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.)
  • C550, en-route, north of Savannah GA USA, 2019 (Synopsis: On 9 May 2019, a Cessna 550 level at FL 350 experienced an unexplained left engine rundown to idle and the crew began descent and a diversion to Savannah. When the right engine also began to run down passing 8000 feet, an emergency was declared and the already-planned straight-in approach was successfully accomplished without any engine thrust. The ongoing Investigation has already established that the likely cause was fuel contamination resulting from the inadvertent mixing of a required fuel additive with an unapproved substance known to form deposits which impede fuel flow when they accumulate on critical fuel system components.)
  • C560, vicinity Oslo Norway, 2017 (Synopsis: On 11 January 2017, control of a Cessna Citation 560 departing Oslo on a short positioning flight was lost during flap retraction when a violent nose-down manoeuvre occurred. The First Officer took control when the Captain did not react and recovered with a 6 g pullout which left only 170 feet of ground clearance. A MAYDAY - subsequently cancelled when control was regained - was declared and the intended flight was then completed without further event. The Investigation concluded that tailplane stall after the aircraft was not de-iced prior to departure was the probable cause of the upset.)
  • CRJ2, Dubai UAE, 2011 (Synopsis: On 9 May 2011, a Bombardier Challenger 850 began a positioning flight night take off from Dubai aligned with the right hand edge of runway 30 for which take off clearance had been given. The error was not detected until a collision with a lighting installation after which a high speed rejected take off was made. The Investigation noted that the Captain had lined up the aircraft on the runway edge in good visibility before passing control for the take off to the low-experience First Officer. It was concluded that the crew failed to sufficiently prioritise their external situational awareness.)
  • CRJ2, en-route, Jefferson City USA, 2004 (Synopsis: On October 14, 2004, a Bombardier CRJ-200 being operated by Pinnacle Airlines on a non revenue positioning flight crashed into a residential area in the vicinity of Jefferson City Memorial Airport, Missouri after the flight crew attempted to fly the aircraft beyond its performance limits and a high altitude stall, to which their response was inappropriate, then followed.)
  • DC86, en-route, Narrows VA USA, 1996 (Synopsis: On 22 December 1996, during a post-maintenance airworthiness function flight at night in IMC, a Douglas DC8 operated by Airborne Express failed to recover from an intentional approach to the stall and loss of control without recovery followed leading to impact into mountainous terrain in the vicinity of Narrows, Virginia.)
  • DH8A, en-route, near Bristol UK, 2010 (Synopsis: On 24 April 2010, a Bombardier DHC8-100 operated by Olympic Airways which had, some weeks earlier, been flown to the UK for heavy maintenance at Exeter was positioning from East Midlands to Exeter in day VMC with just the two flight crew on board when it experienced a significant oil loss from one engine en route and responded by shutting it down and declaring a ‘PAN’ to ATC for radar vectors direct to destination. The remaining engine was then found to be losing oil, and the declared status was upgraded to a MAYDAY and a successful diversion to the nearest suitable airfield, Bristol, was made.)
  • DH8A/DH8C, en-route, northern Canada, 2011 (Synopsis: On 7 February 2011 two Air Inuit DHC8s came into head-to-head conflict en route over the eastern shoreline of Hudson Bay in non radar Class ‘A airspace when one of them deviated from its cleared level towards the other which had been assigned the level 1000 feet below. The subsequent investigation found that an inappropriate FD mode had been used to maintain the assigned level of the deviating aircraft and noted deficiencies at the Operator in both TCAS pilot training and aircraft defect reporting as well as a variation in altitude alerting systems fitted to aircraft in the DHC8 fleet.)
  • DH8D / B735, Exeter UK, 2009 (Synopsis: On 30 October 2009, a Bombardier DHC8-400 departing Exeter at night failed to stop as cleared at the runway 08 holding point and continued onto the runway on which a Boeing 737-500 had just touched down on in the opposite direction. The Investigation attributed the DHC8-400 crew error to distraction arising from failure to follows SOPs and poor monitoring of the Captain taxiing the aircraft by the First Officer. The failure of the DHC8 crew to immediately report the occurrence to Flybe, which had resulted in non-availability of relevant CVR data to the Investigation was also noted.)
  • DHC6, en-route, Mount Elizabeth Antarctica, 2013 (Synopsis: 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, manoeuvring, northeast of Lisbon Portugal 2018 (Synopsis: On 11 November 2018, an Embraer 190-100LR just airborne on a post maintenance non revenue positioning flight became extremely difficult to control as it entered cloud despite the complete absence of any flight control warnings. After reversion to Direct Law, partial normal control was regained and, once visual, the flight was guided to an eventually successful landing. The Investigation found that the aircraft had been released from heavy maintenance with the aileron system incorrectly configured and attributed this primarily to the comprehensively dysfunctional working processes at the maintenance facility involved. Extensive airframe deformation meant the aircraft was a hull loss.)
  • EC25, en-route, 20nm east of Aberdeen UK, 2012 (Synopsis: On 10 May 2012, the crew of a Eurocopter EC225 LP on a flight from Aberdeen to an offshore platform received an indication that the main gearbox (MGB) lubrication system had failed. Shortly after selecting the emergency lubrication system, that also indicated failure and the crew responded in accordance with the QRH drill to “land immediately” by carrying out a successful controlled ditching. The ongoing investigation has found that there had been a mechanical failure of the MGB but that the emergency lubrication system had, contrary to indications, been functioning normally.)
  • EC25, en-route, 32nm southwest of Sumburgh UK, 2012 (Synopsis: On 22 October 2012, the crew of a Eurocopter EC225 LP on a flight from Aberdeen to an offshore platform received an indication that the main gearbox (MGB) lubrication system had failed. Shortly after selecting the emergency lubrication system, that system also indicated failure and the crew responded in accordance with the QRH drill to “land immediately” by carrying out a successful controlled ditching. The ongoing investigation has found that there had been a mechanical failure within the MGB but that the emergency lubrication system had, contrary to indications, been functioning normally.)
  • EC35, Sollihøgda Norway, 2014 (Synopsis: On 14 January 2014, the experienced pilot of an EC 135 HEMS aircraft lost control as a result of a collision with unseen and difficult to visually detect power lines as it neared the site of a road accident at Sollihøgda to which it was responding which damaged the main rotor and led to it falling rapidly from about 80 feet agl. The helicopter was destroyed by the impact which killed two of the three occupants and seriously injured the third. The Investigation identified opportunities to improve both obstacle documentation / pilot proactive obstacle awareness and on site emergency communications.)
  • F27, vicinity Jersey Channel Islands, 2001 (Synopsis: Shortly after take-off from Jersey Airport, Channel Islands, a F27 experienced an uncontained engine failure and a major fire external to the engine nacelle. The fire was extinguished and the aircraft landed uneventfully back at Jersey.)
  • F2TH / GLID, vicinity St Gallen-Altenrhein Switzerland, 2017 (Synopsis: On 15 October 2017, a Falcon 2000EX on base leg for an easterly ILS approach at St Gallen-Altenrhein came into close proximity with a reciprocal track glider at 5000 feet QNH in Class ‘E’ airspace in day VMC with neither aircraft seeing the other until just before their minimum separation - 0.35 nm horizontally and 131 feet vertically - occurred. The Investigation attributed the conflict to the lack of relevant traffic separation requirements in Class E airspace and to the glider not having its transponder switched on and not listening out with the relevant ATC Unit.)
  • FA50 / Vehicle, Moscow Vnukovo Russia, 2014 (Synopsis: On 20 October 2014 a Dassault Falcon 50 taking off at night from Moscow Vnukovo collided with a snow plough which had entered the same runway without clearance shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol. The Investigation found that the A-SMGCS effective for over a year prior to the collision had not been properly configured nor had controllers been adequately trained on its use, especially its conflict alerting functions.)
  • FA50, vicinity London City UK, 2010 (Synopsis: On 21 January 2010, a Mystere Falcon 50 being operated by TAG Aviation on a positioning flight from Biggin Hill to London City in day VMC began a descent at a high rate below its cleared altitude of 2000 ft amsl because the aircraft commander believed, on the basis of external visual cues, that the aircraft was on a final approach track for Runway 27 at destination when in fact it was downwind for Runway 09. After an alert from ATC as the aircraft passed 900 ft agl at a rate of descent of approximately 2200 fpm, recovery to a normal landing on Runway 09 was achieved.)
  • GALX, en-route, North East of Newfoundland, Canada, 2007 (Synopsis: On 8 February 2007, A Gulfstream G-200 on an eastbound transatlantic delivery flight being undertaken by its operator entered a high altitude stall resulting from crew flight planning errors after which flight at an altitude incompatible with the performance limits of the aircraft as loaded was attempted. The crew response to this situation was confused but eventually, recovery to controlled flight was achieved. The Investigation attributed the event to lack of flight crew understanding of the core principles of flight at high altitude.)
  • GLF4, Abuja Nigeria, 2018 (Synopsis: On 12 September 2018, a Gulfstream G-IV overran the runway at Abuja after the air/ground status system failed to transition to ground on touchdown and the crew were slow to recognise that as a result neither spoilers nor thrust reversers had deployed. In the absence of recorded flight data, it was not possible to establish why the air/ground sensing system did not transition normally but no fault was found. The aircraft operator’s procedures in the event of such circumstances were found to be inadequate and regulatory oversight of the operator to have been comprehensively deficient over an extended period.)
  • JS41, vicinity Durban South Africa, 2009 (Synopsis: On 24 September 2009 a BAe Jetstream 41 being operated by SA Airlink on a positioning flight from Durban to Pietermaritzburg with only three crew members on board experienced an engine fire during take off and after reaching a height of about 500 feet agl then entered a semi controlled descent to a high impact forced landing in a residential area about 1400 metres beyond the runway end. The three occupants were all seriously injured and the aircraft commander subsequently died as a result of his injuries. A fourth person on the ground was also injured.)
  • LJ35, vicinity Masset BC Canada, 1995 (Synopsis: On 11 January 1995, a Learjet 35 on a medical positioning flight and carrying a medical team crashed into the sea while conducting an NDB approach to Masset, British Columbia, Canada. The most probable cause was considered to be a miss-set altimeter.)
  • MD82 / C441, Lambert-St Louis MI USA, 1994 (Synopsis: On 22 November 1994 a McDonnell Douglas MD 82 flight crew taking off from Lambert- St. Louis at night in excellent visibility suddenly became aware of a stationary Cessna 441 on the runway ahead and was unable to avoid a high speed collision. The collision destroyed the Cessna but allowed the MD82 to be brought to a controlled stop without occupant injury. The Investigation found that the Cessna 441 pilot had mistakenly believed his departure would be from the runway he had recently landed on and had entered that runway without clearance whilst still on GND frequency.)
  • MD83, en-route, near Nancy France, 2009 (Synopsis: On 20 December 2009 a Blue Line McDonnell Douglas MD-83 almost stalled at high altitude after the crew attempted to continue climbing beyond the maximum available altitude at the prevailing aircraft weight. The Investigation found that failure to cross check data input to the Performance Management System prior to take off had allowed a gross data entry error made prior to departure - use of the Zero Fuel Weight in place of Gross Weight - to go undetected.)
  • NIM / AS32, vicinity RAF Kinloss UK, 2006 (Synopsis: On 17 October 2006, at night, in low cloud and poor visibility conditions in the vicinity of Kinloss Airfield UK, a loss of separation event occurred between an RAF Nimrod MR2 aircraft and a civilian AS332L Puma helicopter.)
  • PC12 /A318, en-route north east of Toulouse France, 2010 (Synopsis: On 2 June 2010, an A318 crew en route from over southern France as cleared at FL290 just managed to avoid collision with a Pilatus PC12 making a non revenue positioning flight on the same track and in the same direction after detection of slight and unexpected turbulence had prompted a visual scan ahead. Earlier, the PC12 pilot cleared at FL270 had observed a difference between his available two altimeters but after getting confirmation from ATC that the altimeter on the side which also had an invalid airspeed reading was correct had assumed that one was the correctly reading one.)