RAF-Avia SF34 at Mariehamn on Feb 14th 2012, near collision with terrain
Last Update: September 30, 2013 / 13:57:43 GMT/Zulu time
Incident Facts
Date of incident
Feb 14, 2012
Classification
Report
Cause
Near collision
Airline
RAF-Avia
Departure
Helsinki, Finland
Destination
Mariehamn, Finland
Aircraft Registration
YL-RAG
Aircraft Type
SAAB 340
ICAO Type Designator
SF34
Finland's Onnettomuustutkintakeskus (Accident Investigation Board of Finland AIBF) released their final report concluding the probable causes of the serious incident were:
The serious incident was caused because the captain of NEF021 continued the approach in a situation which did not meet the requirements of a successful approach and landing. This degraded the flight crew’s situational awareness to the extent that the captain flew the aircraft into an unusual attitude and the crew lost control of the aircraft. This resulted in the risk of colliding with terrain.
As regards contributing factors Crew Resource Management was poorly handled, and the captain did not comply with the Company’s Operations Manual. Additionally, the crew did not follow the instrument approach procedure and ignored the warnings of the Ground Proximity Warning System.
The AIBF analyzed that the investigation could not establish with certainty why the aircraft turned off the Arc prematurely. The captain believed this was caused by a fault of the flight management computer, the first officer believed it was caused by the autopilot already have been armed for the approach and the side lobe of the localizer causing the autopilot to steer the aircraft off. The investigation ruled both scenarios out however, the APPR mode was armed only after the aircraft had turned left off the Arc. The investigation found a plausible scenario in which the VOR with the lead in course of 030 programmed would prompt the autopilot to begin intercepting the radial at a heading of 240 disengaging the NAV mode of the autopilot while following the programmed approach procedure. The crew did not monitor the continuation of the Arc to be followed until intercepting radial 030 but instead focussed on solving the perceived FMS problem.
The AIBF analyzed: "NEF021 continued to descend to 1800 FT MSL, below the Minimum Sector Altitude (MSA), with a heading which was approximately 40 degrees off the final approach track prescribed for the approach procedure. NEF021 should have maintained 1800 FT MSL. Since the aircraft was not stabilised on the approach track, they should have aborted the approach. NEF021 did not comply with the instrument approach procedure, nor did they have the runway or the approach lights in sight. The initial approach altitude prescribed for the approach is 1800 FT MSL; it is also the MSA. Descending below this altitude requires that the aircraft is established on the approach track and the glide path, or that the crew have the runway, its immediate surroundings or the approach lights in sight."
The AIBF continued:
The captain turned off the autopilot at 1600 FT MSL, turned right and manually continued to fly a heading which is at a 90 degree angle in relation to the final approach track, and descended to 1000 FT MSL. The pilots of NEF021 tried to get the runway in sight, but without success. While it might have been possible to see the runway in the prevailing conditions, their degraded situational awareness led them to look in the wrong direction for the runway.
The air traffic controller issued NEF021 a landing clearance which the co-pilot read back. The captain informed the co-pilot of the decision to continue the approach. The co-pilot replied that the runway is not in sight. This being the case, the captain did not have the grounds for making this decision. The co-pilot noticed that they had arrived on the final approach track at a 90 degree angle in relation to it and advised the captain to make a left turn. At this time they were 3.1 NM (approximately 5.7 km) from the threshold of RWY 21, flying at 1000 FT MSL.
The captain made a strong deflection with the aileron and the rudder to the left, in addition to which the captain deflected the elevator down. As a result of the flight control inputs the crew lost control of the aircraft and ended up in an unusual flight attitude in which the maximum bank angle was 50 degrees to the left and the maximum pitch angle was 19 degrees, nose down. The aircraft went into a sideslip with a rapidly accelerating sink rate. The Ground Proximity Warning System (GPWS) activated, warning the crew of an excessively steep bank angle, excessive deviation below the ILS glide slope and an excessive terrain closure rate. The sink rate of NEF021 peaked at approximately 5000 FT/min (25 m/s) at 300 FT AGL (90 M).
The captain managed to recover the aircraft at approximately 320 FT (98 m) MSL, i.e. approximately 150 FT (46 m) AGL. This happened about two seconds before they would have collided with the ground. They were 2.7 NM (5.0 km) from the threshold at this time.
The AIBF analyzed that evasive action (go-around) was required immediately upon the terrain GPWS alert. The captain stated that he did not hear the alert, and in the captain's perceiption the aircraft never was too low.
The AIBF characterized the crew cooperation between the two pilots with "cockpit authority gradient" and stated: "The investigation group believes that the cockpit authority gradient between the captain and the co-pilot of NEF021 was non-synergetic. The captain did not sufficiently communicate the autopilot mode selections to the co-pilot. The shortcomings in communication contributed to the inadequate airmanship, which materialised in degraded situational awareness and decision-making. Crew Resource Management was poorly handled and the captain did not comply with the Company’s Operations Manual." and summarized the first officer's actions: "The co-pilot actively attempted to comply with the Company’s standard operating procedures. The co-pilot, as per the interview, wanted to abort the approach but, according to previous experience, the co-pilot did not believe that the captain would agree to this. It is likely that the co-pilot’s limited flight experience also factored in. Moreover, the co-pilot believed that any attempts to actively interfere with the captain’s flying, such as taking over the controls, would have spelled trouble later on."
With respect to the air traffic controller the AIBF stated: "As per the air traffic controller’s statement, NEF021 appeared to be turning approximately 90 degrees to the left after it was cleared for approach, as seen on the ATS monitor. Since the air traffic controller assumed that NEF021 had deviated from the route given in the air traffic control clearance the controller requested the crew of NEF021 to confirm that they were tracking the initial approach route. However, the crew replied that they were on the initial approach route. Soon after this the symbol of the aircraft on the monitor became imprecise as regards azimuth information, and then it faded out below the radar horizon. At this time the controller could only assume that NEF021 was trying to follow the route given in the air traffic control clearance. The air traffic controller saw NEF021 crossing the final approach track at a 90 degree angle in relation to the final approach, following which it made a steep turn towards the left and disappeared behind the terrain and trees. At this time the controller believed that NEF021 would collide with the ground. Nonetheless, NEF021 re-appeared from behind the treeline. The air traffic controller did not want to distract the pilots by ordering a goaround."
Incident Facts
Date of incident
Feb 14, 2012
Classification
Report
Cause
Near collision
Airline
RAF-Avia
Departure
Helsinki, Finland
Destination
Mariehamn, Finland
Aircraft Registration
YL-RAG
Aircraft Type
SAAB 340
ICAO Type Designator
SF34
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
You can read 2 more free articles without a subscription.
Subscribe now and continue reading without any limits!
Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.
Send tip
Support AeroInside by sending a small tip amount.
Related articles
RAF AN26 at St. Petersburg on Apr 26th 2021, engine shut down in flight
A RAF Avia Antonov AN-26, registration YL-RAC performing freight flight MTL-9560 from Helsinki (Finland) to St. Petersburg (Russia) with 4 crew, was…
RAF AT72 at Trollhattan on Oct 9th 2018, runway excursion discovered 2 days later
A RAF Avia Avions de Transport ATR-72-200, registration YL-RAI performing freight flight MTL-425C from Szczecin (Poland) to Trollhattan (Sweden) with…
RAF-Avia SF34 at Helsinki on Dec 29th 2011, runway incursion
Finland's Onnettomuustutkintakeskus (Aircraft Accident Investigation Board, AIBF) released their final report concluding the probable causes of the…
Newest articles
THY A333 at Bucharest on Apr 17th 2024, lined up with right runway edge on departure
A THY Turkish Airlines Airbus A330-300, registration TC-LOC performing flight TK-1046 from Bucharest Otopeni (Romania) to Istanbul (Turkey) with 258…
Perimeter DH8C at Sandy Lake on Oct 19th 2022, tail strike on landing
A Perimeter Aviation de Havilland Dash 8-300, registration C-GJYZ performing a flight from Pikangikum, ON to Sandy Lake,ON (Canada) with 28…
Subscribe today
Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.
Pick your plan and subscribePartner
A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.
ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.
Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.
AeroInside Blog
Popular aircraft
Airbus A320Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American AirlinesUnited
Delta
Air Canada
Lufthansa
British Airways