Today in Aviation Accident History

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DerAdlerIstGelandet

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I have always been interested in the "What", "When", "When" and "Why" aircraft accidents happen. Even more so now that I work in aviation safety, and am involved in investigations. Thought I would I would start a thread, and I will try and update it daily with an event that happened on that particular day.

Here is the first entry...

June 18, 1972

Operator: British European Airways
Flight: 548
Aircraft Type: Hawker Siddeley HS-121 Trident 1C
SN: G-ARPI
Location: Staines, England

Crew: 9
Passengers: 109
Fatalities: 118

Accident Overview: This was a regularly scheduled passenger flight from London to Brussels. The aircraft took off at 16:08, and per BEA standard practice, the take off was conducted with 20 degrees flap, leading edge slats extended, and the engine thrust set to below full power. After take off the pilot should increase speed to VNA which was 177 knots IAS. Shortly thereafter at approximately 90 seconds after take off, flaps should be brought fully up, and the thrust reduced to noise abatement standards. Once the aircraft reached 3000 ft, the power was to be set, and the leading edge slats retracted, and climb established at 225 knots IAS.

The takeoff started normal, but while passing through 1,750 ft, approximately 114 seconds after take off), and at an airspeed of 162 knots IAS, the co-pilot not on the controls mistakenly retracted the leading edge slats, which put the aircraft near stall speed. Two seconds later the stick shaker stall warning/recovery operated. This caused the auto-pilot to automatically disengage, and the nose to pitch down, increasing airspeed. The elevator trim however stayed at the same setting as they were with the auto-pilot engaged, which was with the leading edge slats extended. This caused the aircraft nose to pitch up rapidly 128 seconds into the flight, and entering a true aerodynamic stall, and then a deep stall. Recovery was not possible at that altitude. The aircraft impacted a field, killing all souls on board.

Probable Cause/Cause:
1. Failure of the PIC to achieve proper altitude and speed during noise abatement procedures.

2. Leading edge slat retraction 60 knots below minimum speed.

3. Failure to monitor speed error, and leading edge slat lever movement.

BE548 before the accident.
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Picture Source: UNK

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Source: Talk:British European Airways Flight 548 - Wikipedia

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Source: Row over pilot medical centre closure

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Source: Crash of a BAe Trident in London, UK: 118 killed | Bureau of Aircraft Accidents Archives

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Source: Crash of a BAe Trident in London, UK: 118 killed | Bureau of Aircraft Accidents Archives

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Source: Crash of a BAe Trident in London, UK: 118 killed | Bureau of Aircraft Accidents Archives
 
June 19, 1947

Operator: Pan Am
Flight: 121
Aircraft Type: Lockheed L-049 Constellation
Registration: NC8845
Location: Mayadine, Syria

Crew:
10
Passengers: 26
Fatalities: 14

Accident Overview: The aircraft was en route from Karachi, Pakistan to Istanbul, Turkey. While cruising at 18,500 ft., the No. 1 propeller had to be feathered due to problems with the engine. Subsequently, the remaining 3 engines overheated. The crew then reduced power, and began an descent. The crew elected to attempt a landing in Istanbul, Turkey. While descending through 10,000 ft. the No. 2 engine caught fire, and a rapid descent was begun. The No. 2 engine would then separate from the aircraft, and the crew attempted to conduct an emergency landing into the desert. On of the engines ended up digging into the ground, causing a ground loop and ripping the aircraft in two. 14 of the crew and passengers on board were killed.

The Third Officer on this aircraft was Gene Roddenberry, who survived the accident and would go on to create the original Star Trek series.

Probable Cause: The cause was found to be mechanical failure. The accident investigation found that the failure of the No. 1 engine was caused by a broken exhaust rocker in the No. 18 cylinder. The No. 2 engine fire was caused by a failed thrust bearing which caused a blockage of oil from the feathering motor to the propeller dome.

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Source: Petr Popelar Collection
 
Probable Cause/Cause:
1. Failure of the PIC to achieve proper altitude and speed during noise abatement procedures.
2. Leading edge slat retraction 60 knots below minimum speed.
3. Failure to monitor speed error, and leading edge slat lever movement.

Wouldn't be accepted as probable cause nowadays...
 
Why not. It would just be called "Failure to Follow Procedures", or even "Failure to use proper CRM". I see examples of this in investigations I have participated in.
 
at an airspeed of 162 knots IAS, the co-pilot not on the controls mistakenly retracted the leading edge slats, which put the aircraft near stall speed. Two seconds later the stick shaker stall warning/recovery operated. This caused the auto-pilot to automatically disengage, and the nose to pitch down, increasing airspeed. The elevator trim however stayed at the same setting as they were with the auto-pilot engaged, which was with the leading edge slats extended.
Tons of questions. Were there legible CVR/FDR tapes? Did the PF realize the slats were in? Why weren't they re-extended? Even with trim set too nose high, both crew members together should have been able to overcome it. Crew coordination?? Full power?? Is everybody so afraid of Captain Bligh they'll go to their deaths rather than take action?? The cause of this accident wasn't "failure to gain altitude" or "premature slat retraction", it was ACRMD; Agravated Crew Resource Management Deficiency.
Cheers,
Wes
 
Tons of questions. Were there legible CVR/FDR tapes? Did the PF realize the slats were in? Why weren't they re-extended? Even with trim set too nose high, both crew members together should have been able to overcome it. Crew coordination?? Full power?? Is everybody so afraid of Captain Bligh they'll go to their deaths rather than take action?? The cause of this accident wasn't "failure to gain altitude" or "premature slat retraction", it was ACRMD; Agravated Crew Resource Management Deficiency.
Cheers,
Wes

I am sure if the full report was read, those questions would be answered. As for the probable cause listed, that comes straight from the report. It's not my finding.

I'll start linking the report when available.

From the small synopsis what I read the SIC retracted the slats without the PIC telling him to, and the PIC did not not notice. Poor communication as well.

All in all this is a prime example of poor CRM (not as good as some of the Asian accidents though). That however would be the "root cause" and not the "probable cause".

Also notice my post above yours, where I states that today it would be called "lack of CRM" or improper use of CRM.
 
June 20, 2011

Operator: RusAir
Flight: 9605
Aircraft Type: Tupolev Tu-134A-3
SN: RA-65691
Location: Petrozavodsk, Russia

Crew: 9
Passengers: 43
Fatalities: 47

Accident Overview:
Flight 9605 had departed Moscow on a regular scheduled flight to Petrozavodsk. The aircraft was attempting to land in heavy fog, when it started its descent early, and approximately 200 meters off course. ATC recommended to the PIC that he conduct a go-around, and attempt another stabilized approach. The PIC informed the tower that he would not do a go-around, and that he could land the aircraft on the 1st attempt.

The aircraft struck a 15 meter tree, 1,300 meters from the runway, and crashed onto the A-133 Highway, killing 47 passengers and crew.

Probably Cause/Cause/Contributing Factors:
1. The investigation into the accident found that probably cause was poor use of CRM. The PIC excluded the SIC from all decisions.

2. Landing the aircraft in conditions below weather minimums for the airport.

3. Failure to go-around, and allowing the aircraft to descend below minimum safe altitude in the absence of visual contact with approach lighting and landmarks.

4. The aircraft's navigator was under the influence of alcohol (0.08).

5. The use of satellite navigation equipment to determine the aircraft's position, which was in violation of flight manual supplement for the Tu-134.

Investigation Report:
https://mak-iac.org/upload/iblock/186/report_ra-65691.pdf (In Russian Only)

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Photographer: Alexey Reznichenko. Source: Tu 134 crashed in Russia - PPRuNe Forums

All below pictures found at: ASN. Photographer listed on picture.

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Regarding BEA 548 the problems were basically set in motion by health & personality issues

Captain Key had coronary artery disease, something he probably didn't even know he had. Sure, he was a bit pudgy, but he passed every physical, he served in the RAF, and had a clean bill of health: At the time, BEA's pilots wanted to go on strike, and Key was opposed to this. He had the attitude that as long as you work for an organization, you come into work on time, do your job, and come what may. Not everybody agreed with it, and many decided to strike: An argument ensued, and Key blew his stack. This might very well have spiked his blood pressure and triggered a coronary artery event, possibly a dissection in the arteries (unsure).

The two pilots who were to fly with him that day Keighley (22 y/o & F/O), and Ticehurst (24 & S/O) were there when it occurred, and Key was known to be highly critical, somewhat perfectionistic, and a bit of a dick to be honest -- and after they saw him blow his stack, they figured laying low might very well be the smartest move. Turns out it wasn't.
 
July 1, 2002
Uberlingen Crash

2002 Überlingen mid-air collision - Wikipedia

This one was particularly senseless as it not only involved a crash but a murder resulted as well.

The causes seemed to basically be the following
  • Privatization: Certain things might very well be best off handled by private agencies, but this is not an absolute. The best way I describe the matter is that anything taken to an extreme is dangerous.
  • Air-Traffic Center: The regulations were overly lax and the centers were undermanned with rules that normally required two people, but sometimes allowed one person to be in the room while the other was taking an extended break.
  • Telecommunications Problems: It prevented quick contact being made to the airports informing of an approaching airliner, which ultimately preoccupied the controllers attention from the fact that two aircraft were getting dangerously close.
  • Radar Technical Issues: The radar was in standby mode and certain warning functions didn't activate, so the overworked controller dealing with communications issues was unaware of the proximity of the accident aircraft until they were nearly on top of each other
  • TCAS: They worked on both aircraft so were not a problem per se giving correct instructions for evasive action
  • Culture: Us westerners tend to operate under the policy that the TCAS alert overrides even the ATC and should be followed without hesitation or question; the Russians however tended to trust ground control more so, and had regulations that allowed them to decide which to follow. The 757 did the exact thing they were supposed to and initiated a descent, the Tu-154 followed the controller instead of the TCAS.
  • Controller Error: He gave orders to the Tu-154 to descend when the TCAS told them to climb, he also told the Tu-154 that the 757 was coming from the wrong side (I'm not sure if it'd make a difference, but...)
As if all this wasn't bad enough, the father of two children on the Tu-154, hunted down Peter Nielsen (the ATC) and killed him. They said he was experiencing diminished capacity, but the fact that...
  • He had a knife on him raises questions as to what he had it for
    • Was it to simply assert control over the situation?
    • Was it to murder Nielsen if he didn't apologize and talk with him?
    • Was it to murder Nielsen with or without regard to what he said?
The criminal justice major part of me seems to indicate the whole thing was premeditated and he planed to stick Nielsen off the bat.
 
I don't know about Russians, but in the USA a large part of blue collar working men have a knife on them all the time.
It's necessary part of our working uniform, I use mine about every day.
 
Controller Error: He gave orders to the Tu-154 to descend when the TCAS told them to climb,
You can't call this an error. He didn't have a TCAS readout. That came later. He was busy dealing with a communications issue and was unaware that his conflict alarm system was inop, so became aware of the conflict at the last second without time to assess the situation. He had the odds stacked against him, which explains what happened, but doesn't absolve him of responsibility for the outcome. Karma caught up with him in the end.
If the Russians complied with the international concensus that was developing about the precedence of TCAS alerts over ATC instructions, it would have saved Peter Neilsen's bacon. Unfortunately this is contrary to their aeronautical culture, which is all about control from the ground. Autonomy is a scary concept to them.
"If it happens on your watch, even if you have no control over it, the responsibility is yours and so are the consequences." First thing you learn in boot camp. It's the breaks of the game, and what you sign up for when you get involved.
Cheers,
Wes
 
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You can't call this an error.
Good point
He had the odds stacked against him, which explains what happened, but doesn't absolve him of responsibility for the outcome.
Frankly, I place the blame on the fact that one guy was doing a job two or three should have been doing.
Karma caught up with him in the end.
I'm not sure if I constitute vigilante justice as karma
 

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