Sales & Services B190 at Karachi on Mar 18th 2016, engine failure before V1, continued takeoff leads to forced belly landing

Last Update: October 11, 2017 / 15:27:53 GMT/Zulu time

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Incident Facts

Date of incident
Mar 18, 2016

Classification
Report

Cause
Engine failure

Airline
Aircraft Sales and Services Ltd Pakistan

Departure
Karachi, Pakistan

Destination
Sui, Pakistan

Aircraft Registration
AP-BII

Aircraft Type
BEECH C-12J

ICAO Type Designator
B190

An Aircraft Sales and Services Ltd Pakistan Beech 1900D, registration AP-BII performed a charter flight from Karachi to Sui (Pakistan) with 18 passengers and 3 crew (two flight crew and one engineer in the passenger cabin), was accelerating for takeoff from Karachi's runway 25L, V1 had been computed at 104 and V2 at 106 KIAS. The captain (58, ATPL, 2,885 hours total, 717 hours on type) was pilot flying, the first officer (49, ATPL, 3,614 hours total, 245 hours on type) was pilot monitoring, the first officer was actually rated qualified captain on the Beech 1900D too. Both engines were set to maximum power and accelerated to 1691 respective 1699 rpm and developed 3401 ft/lbs respective 3211 ft/lbs torque. About 5 seconds after both engines had reached their maximum power the aircraft accelerated through 80 KIAS, the right hand engine at this time began to decrease its rpm while increasing its torque. Over the next 11 seconds the rpm fell to 709 rpm and the torque reached 3896 ft/lbs, then started to fluctuate. At the same time the torque of the left hand engine began to reduce to 2288 ft/lbs without any significant change in rpm which subsequently recovered to 3549 ft/lbs. The aircraft was now at 95 KIAS and not accelerating with the #2 rpm dropping, the first officer announced the aircraft was drifting to the right, the captain replied "continue ... continue". The speed increased to 96 KIAS, when the captain applied left rudder to turn left the airspeed fell to 94 KIAS. Both crew did not recognize that BOTH engines had developed problems and they were still below V1, so that takeoff should have been rejected. The first officer called the power on the left engine should be increased, the aircraft accelerated through 98 KIAS, the captain glanced onto the instruments and wanted to voice concern over the loss of power when the first officer called "V1, rotate" at 101.4 KIAS. The aircraft rotated and became airborne at 102 KIAS, the left engine was produced 1692 rpms and 3540 ft/lbs torque, the right hand engine was producing 800 rpms and 3422 ft/lbs torque. After becoming airborne the airspeed dropped to 101 KIAS, the aircraft continued to drift towards the right. The first officer took control of the aircraft. The airspeed continued to decrease, while decreasing through 98 KIAS the first officer called to select the landing gear up, the gear was selected up by the captain. At that time the right hand engine torque remained near the maximum, but the left hand engine was fluctuating. The aircraft reached 39 feet AGL when the captain called speed and the first officer lowered the nose, the airspeed settled at 100 KIAS. The first officer called to select the flaps up, the flaps were selected up. The aircraft began to immediately lose height but picked up speed. Engine #1 was producing 1692 rpm and 3409 ft/lbs torque, the right hand engine produced 933 rpm and 4699 ft/lbs torque. Descending through 10 feet AGL the aircraft increased through 105 KIAS. The first officer concluded the aircraft was unable to sustain flight and decided to put the aircraft back down on the remaining runway. The aircraft touched down very hard with its belly, the gear had already retracted, about 9000 feet past the runway threshold in the right half of the runway, skidded towards and past the right hand edge of the runway, after travelling around 600 feet past the right hand edge the aircraft returned onto the runway and came to a stop 1050 feet short of the runway end. The captain and a passenger sustained serious backbone injuries, the first officer shut the aircraft down and initiated an evacuation of the aircraft. The captain and the passenger as well as the first officer were taken to a hospital.

Pakistan's Safety Investigation Board (SIB) released their final report concluding the probable cause of the accident was:

Some internal malfunction of the Propeller Governor Part No. 8210-410 Serial No. 2490719 was the cause of experienced uncommanded auto feather. However, exact cause of the occurrence could not be determined.

Continuing take off below V1 speed (104kts) after encountering engine malfunction and after takeoff raising flaps below recommended height (400ft AGL) lead to decrease in lift and unsustainability of flight.

The SIB reported: "Due to the hard impact of the aircraft with ground, the captain and one passenger received serious injuries. Both seriously injured persons’ backbones were fractured necessitating prolonged hospitalization and lengthy treatment involving surgical procedures. Immediately after the accident, the Cockpit Crew (Captain and First Officer), were taken to hospital and necessary medical evaluations were conducted. The results of pertinent medical evaluation were within normal limits."

The SIB analysed:

At 0323:44 UTC when the aircraft was crossing 96.75 kts of speed during takeoff roll, the PM asked PF to turn left and apply left rudder. From this moment onwards the aircraft speed started to decrease gradually for next six seconds i.e. till 0323:50 UTC and reached 94.82 kts.

The cockpit crew could not realize at this stage that there was a problem with both engines and they were still below V1 which, as per pre flight calculation / planning, was 104 kts. The applicable procedure given in Pilot Checklist (B1900 Emergency Procedures) for ‘Engine Failure During Takeoff’ at or below V1 was not followed which mentions to abort takeoff. Their decision to continue take off with one engine not providing sufficient power at aircraft speed below V1 was not correct.

The SIB further analysed with respect to landing the aircraft back:

According to First Officer’s statement, at this time he observed the aircraft not climbing (losing height) and sluggish controls response (due low airspeed) and there was no option other than to make the aircraft land on the remaining runway. So, he attempted to land the aircraft and in that bargain hit the runway surface hard approximately 9000 ft from runway 25L beginning in right half. The aircraft continued to drag on the runway while continuously drifting right for 800 ft before departing towards right side on fair weather strip.

After travelling approximately 600 ft on fair weather strip, the aircraft veered towards left and came to final stop on the runway 1050 ft short from end of runway.

As the Captain was seriously injured, the First Officer brought Fuel Control Levers, Propeller Levers and Power Levers back; put Battery and Generators Off after the aircraft came to halt. An immediate evacuation of the passengers was carried out.

The SIB reported that "The fuel samples from aircraft and oil samples from both engines were drawn and submitted to Perac Research and Development Foundation (PRD) Karachi for analysis. The PRD reports did not reveal any abnormality with fuel and oil of the mishap aircraft."

The SIB further reported that although pitot leak tests could not be carried out as the pitot static lines had been damaged in the crash landing it could be determined that both ASIs were generally underreading by 3 knots around takeoff speeds.

The SIB analysed:

The NTSB FDR report and FDR tabular data file was shared with Pratt & Whitney (PWC) Canada. The PWC report concluded that :

FDR data was characteristic of an un-commanded propeller feathering event of No. 2 engine as shown by the sharp propeller speed reduction being concurrent with the torque increase.

The SIB analysed:

Study of the Propeller Pitch Change Mechanism showed that uncommanded feathering may take place because of Loss of oil pressure, Auto-feather system malfunction or Malfunction of propeller governor.

The No. 2 engine was examined by Vector Aerospace Australia. The examination report concluded that there was no anomaly with the engine which could ontribute to the experienced un-commanded auto-feather. The over torque sustained was within limits and no maintenance action was required as per Maintenance Manual. No apparent damage to the engine was found as consequent to the crash landing.

The Primary Propeller Governor and Overspeed Governor of No. 2 engine were examined by Woodward Inc, USA. This examination report ascertained that there was no anomaly found which could cause the reported event of un-commanded auto feathering. Although few anomalies were observed at the IDLE settings, however, same can’t cause the auto feathering as it had occurred at Max Power Settings of Take Off.

Components of Auto Feathering System comprising of two switches (Pressure Switch High and Pressure Switch Low) were subjected to Shop check at M/s PIAC Component Overhaul Shop and found with no discrepancy or anomaly which could contribute towards the reported incidence.

The operator was operating the aircraft since November, 2008. The authorized Release Certificate FAA form 8130-3 showed that Propeller Governor Part No. 8210-410 Serial No. 2490719 was overhauled and recalibrated in accordance with Woodward Manual 61-20-35 Rev (10/98) and Woodward SB 33531 was complied with. The Overhaul was performed by International Governor Services, Broomfield, USA on 14th July, 2008.

The Woodward finding that Propeller Governor Serial No. 2490719 was serviced by a facility other than Woodward and its several operating parameters were found away from the Woodward specifications indicated that the last servicing of the governor was improper but had no contribution towards the reported event of auto feathering.

The investigation therefore concluded that some internal malfunction of the Governor of No. 2 engine propeller may have caused uncommanded auto feather. However, exact cause of the occurrence could not be determined.
Incident Facts

Date of incident
Mar 18, 2016

Classification
Report

Cause
Engine failure

Airline
Aircraft Sales and Services Ltd Pakistan

Departure
Karachi, Pakistan

Destination
Sui, Pakistan

Aircraft Registration
AP-BII

Aircraft Type
BEECH C-12J

ICAO Type Designator
B190

This article is published under license from Avherald.com. © of text by Avherald.com.
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