Starbow AT72 at Accra on Nov 25th 2017, runway excursion during takeoff due to sliding pilot seat

Last Update: April 14, 2020 / 11:30:16 GMT/Zulu time

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Incident Facts

Date of incident
Nov 25, 2017

Classification
Accident

Flight number
S9-104

Departure
Accra, Ghana

Destination
Kumasi, Ghana

Aircraft Registration
9G-SBF

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A Starbow Airlines Avions de Transport Regional ATR-72-212A, registration 9G-SBF performing flight S9-104 from Accra to Kumasi (Ghana) with 63 passengers and 5 crew, was accelerating for takeoff from Accra's runway 21 at 12:20L (12:20Z) when the aircraft veered left off the runway and entangled with the perimeter fence. One passenger received serious, four passengers received minor injuries, the aircraft sustained substantial damage.

The airport reported flight S9-104 from Accra's Kokota Airport to Kumasi carrying 63 passengers and 5 crew skidded off the runway during takeoff. One passenger received minor injuries and was taken to a hospital.

On Nov 26th 2017 the airline reported the aircraft carrying 63 passengers and 5 crew skidded off the runway. Five occupants including Ghana's Deputy Minister of Energy sustained minor injuries. The airline suspended all operations with immediate effect.

First investigation results suggest the aircraft skidded off the runway and impacted a fence wall after an engine (PW127) shut suddenly down.

On Nov 30th 2017 Ghana's Civil Aviation Authority reported the aircraft was accelerating for takeoff from Accra when at about 70 KIAS the captain's seat moved fully backwards violently and shifted to the left. As the captain was still controlling nose wheel steering via the steering tiller, this caused the aircraft to veer left and off the runway. The captain did not regain control of the aircraft prior of it coming to a stop close to the perimeter fence following efforts by the first officer to retard the power levers. The crew secured the aircraft, the passengers disembarked. There were five injuries. The occurrence was rated an accident, an investigation is underway.

The occurrence aircraft had joined Starbow's fleet only on Nov 22nd 2017.

Although the document is marked "confidential", Ghana's Ministry of Aviation published their Accident Investigation Board'ss (AIB) final report concluding the probable causes of the accident were:

Contributory Factors

Factors that contributed to the accident include the following;

- The rain storm that affected the airfield during the takeoff.

- Loss of situational awareness in the takeoff process.

- Inadvertent movement of the captain’s seat.

- Improper procedure in aborting the takeoff.

- Poor crew resource management.

Causal Factors

It is the opinion of the committee that the causal factors which led to the accident include;

- Loss of situational awareness on the part of the cockpit crew, leading to runway excursion.

- Failure by the crew to execute correct procedure in aborting the takeoff.

The AIB assigned by the Ministry reported one passenger received serious injuries requiring surgery, four passengers received minor injuries. The aircraft sustained substantial damage, when it veered left of runway 21 during the takeoff run. In addition, the aircraft ran over the inner PAPI light and destroyed it, 30 meters of the airport's inner perimeter fence were also damaged.

The captain (36, ATPL, 6,500 hours total, 5,400 hours on type) was pilot flying, the first officer (39, ATPL, 2,700 hours total, 1,450 hours on type) was pilot monitoring.

The AIB annotated: "Currently, the captain holds the positions of Director of Flight Operations, Chief Pilot and Training Captain. The FO was previously employed by FLY 540 as a FO on the ATR 72. His last flight with FLY 540 was in January 2014. He flew the Piper Seminole in March 2014 to obtain his ATPL and did not fly again until he was employed by Aero Surveys Ltd in July of 2017. The accident occurred during his first day on the job as a FO having flown only one hour twelve minutes the morning before the leg that resulted in the accident."

The AIB stated:

The aircraft had just come out of a 4-year major check and was airworthy prior to the flight. It had one outstanding Airworthiness Directive (AD) which was due on 30 December 2018 affecting both pilot and co-pilot seats. The AD was issued by EASA on 16 December 2016 to address the inadvertent movement of the cockpit seat. The AD was effective on 30 December 2016 and due on 30 December 2018. During the 4-year check, a works order was raised during the check for the implementation of the AD but it was not carried out Prior to the AD.

ATR had previously issued two AOMs on 2 April 2014 and 27 July 2016 advising operators on how to address the inadvertent seat movement, pending the final fix of the defect. A third AOM was also issued on 19 December 2016 on the same subject. The three AOMs were based on the SBs issued by the seat manufacture, IPECO. ... ATR OEB is requesting the flight crew to ensure their seat is locked properly. In fact, even without AD embodied, as soon as the seat is locked, it will not move. The Purpose of the AD is to limit the backward travel movement due to improper seat locking.

The weight and balance sheet for the flight was checked and found to be okay.

With respect to the history of the operator and aircraft the AIB stated:

Aero Survey Limited was certified in 2007 to perform domestic air shuttle services. They operated two Embraer EMB 110 Bandeirante. In 2011, the airline changed ownership and modified its operations to include domestic scheduled flights with the brand name Starbow. It began operations on 26 September 2011 providing domestic transport services with the BAE 146 – 300 aircraft.

In June 2015 Starbow supplemented its operations with a wet leased ATR 72 aircraft operated by SwiftAir S.A. In December 2017 the company ceased operating the BAE 146 – 300 and deregistered the last aircraft on 13 December 2017. Starbow entered into an agreement with NAC Aviation, Ireland, to dry lease two ATR 72 – 212A. The first aircraft, 9G-SBF was received on 22 November 2017 and the second was to arrive at a later date.

The AIB analysed:

The weather was VFR, however conditions changed rapidly to IMC due to heavy rain. No weather warning was issued by ATC.

IKM 104 was cleared for taxi via A and A2 to backtrack on the displaced threshold to make way for Emirates to exit the runway at A1 which the crew complied.

The crew were not heard performing any checks except, “gustlock” before takeoff.

At about 63 knots, a sound is heard on the CVR indicative of a seat movement which is consistent with the captain’s report that his seat moved backwards inadvertently to the aft stop position and failed to lock. The captain handed over controls to the co-pilot which was acknowledged.

Crew was not aware that the aircraft was going off the runway during the takeoff until the aircraft was almost at the edge of the runway. At this point the storm had hit the airfield, it had started raining heavily and the windshield wipers were operating at maximum speed.

On realising that the aircraft was going off the runway, the crew initiated action to abort the takeoff by bringing the power levers to ground idle and tried to maintain directional control with the rudder. However, reverse thrust was not selected.

The aircraft reached 94 knots before decelerating gradually and thereafter impacted the inner perimeter fence with both engines running.

The takeoff run was initiated just as the airport was being engulfed in thundery rain.

The wind information from ATC was 100° at 17knots.

The crew was in a hurry to takeoff ahead of the incoming storm.

The captain handed over controls to the co-pilot after the inadvertent movement of his seat, which appeared to have occurred around 63 knots. The same crew had experienced a similar inadvertent seat movement on their morning flight from Kumasi to Accra in which the captain handed over control to the co-pilot and the co-pilot continued the takeoff without any incident.

On this Flight IKM 104, at the time the captain handed over controls to the co-pilot, the aircraft was left off centreline and heading approximately 6° off.

The entire takeoff run up to the point of runway exit was done on one half of the runway.

The crew appeared to have lost situational awareness during the takeoff run.

Before initiating the takeoff, the crew should have anticipated the effect of the rain and winds from the storm and their priority should have been to ensure that the aircraft was properly aligned on the centreline and taken the necessary corrective measures to ensure that the aircraft remained on the centreline during the roll.

There was poor crew resource management in the entire flight. The captain performed most of the activities in the cockpit and the crew did not follow the company SOPs. For instance;
a. Radio communications with ATC was handled solely by the captain.
b. The taxi was done by the captain and followed the track shown in figure 14. The aircraft barely stayed on the centre line throughout the taxi.
c. No reading of checklist or pre-departure brief was heard prior to the take off.
d. Aircraft positioned for takeoff on the left side of runway centreline.
e. No call outs were heard during the takeoff run.

In addition to normal braking, selection of emergency brakes and use of reverse thrust could have decelerated the aircraft faster and prevented the collision of the aircraft with the inner perimeter fence.

The captain’s seat inadvertently moved during the takeoff because it was not properly locked. It was the captain’s responsibility to ensure that his seat was properly locked prior to take off as recommended by ATR in its AOMs. Starbow should have incorporated the recommendations in theAOMs into their SOPs and ensured compliance by their pilots.

During the 4-year check, a job card was raised for the implementation of EASA AD No 2016-0256 in respect of the captain and co-pilot’s seats. However, the work was deferred and the status remained open with due date 30 December 2018. The AD highlighted the need to secure and lock the seat in its required position. Even though the due date of the AD was 30 December 2018, given that this was a new aircraft type inclusion, the operator had the opportunity for the modification to be implemented prior to taking delivery of the aircraft from NAC.

The GCAA certification team became aware of the non-implementation of the AD during their inspection. Since this was a new aircraft type inclusion the CAA should have advised the operator to take the opportunity to implement the AD prior to the issuance of the certificate of airworthiness.

An initial examination of the seats after the accident revealed the following;
a. A broken spring on the right horizontal track locks system of the captain’s seat.
b. Both alignment washers (packers) were not in place on the captain’s seat.

In the case of the co-pilot’s seat, all springs and washers were intact. Also, while all other springs looked black (refer to figure 19), that on the captain’s seat looked ash in colour (refer to figure 18), an indication that the broken spring may have been replaced during maintenance.

Further examination and rotational test on the seat by IPECO revealed the following;
a. Roll back of the seat is impossible when the pins are correctly locked into the rails. Thus the seat was unlocked during take-off roll.
b. A substantial rotational play is present on this seat. This play seems to be the cause of the difficulties of stopping a roll back from an unlocked position.
c. The cause of the rotational play could not be identified.
d. The failure of the right spring may have contributed to the fact that the roll back was not stopped during take-off roll.
e. The incorrect fitting assembly of the spring (missing washers) may have contributed to the failure of the right spring. “

The Duty Air Traffic Controller activated emergency rescue actions. Three fire trucks were dispatched to the scene from the RFFS plus another fire truck from the Air Force Base. The RFFS arrived at the scene after four minutes. An ambulance and a pickup vehicle were also dispatched by the RFFS to the scene. Another ambulance from the Airport Clinic with a medical team was dispatched to the scene. Efforts were made to rescue passengers in the rain using the fire tender.

Passengers disembarked through the rear service door with the assistance of the RFFS who provided a ladder. The disembarkation and movement of passengers to the holding area at the RFFS lasted over 40 minutes. Passengers should have been evacuated quickly out of the aircraft instead of holding them in the aircraft and disembarking them as and when vehicles became available.

The operator failed to provide transport and other services to the passengers at the accident scene and thereafter. The operator appeared unfamiliar with their responsibilities in respect of post-accident passenger handling.

Vehicular movement to and from the accident scene was extremely difficult due to the soggy nature of the terrain. A fire tender got stuck at some point during the evacuation.

Preliminary investigation of aircraft accidents in Ghana, handled by the GCAA, is on an adhoc basis under the direction of the Director Safety Regulations and the GCAA accident investigations Coordinator. There was no toxicology test and no post-accident physical medical examination was conducted on the crew because this was not requested by the preliminary investigation team (PIT). The PIT did not provide a list of possible witnesses and their contact details. This caused delays in locating witnesses to appear before the committee. GCAA should develop adequate procedure for handling preliminary investigations.

Metars:
DGAA 251400Z 28005KT 240V300 9999 FEW020 FEW030CB 25/20 Q1011 NOSIG=
DGAA 251300Z 22012KT 1300 TSRA OVC013 FEW030CB 23/22 Q1012 NOSIG=
DGAA 251200Z 27007KT 230V300 9999 FEW028 30/23 Q1012 NOSIG=
DGAA 251100Z 26008KT 230V290 9999 FEW024 SCT028 30/24 Q1013 NOSIG=
DGAA 251000Z 27009KT 240V300 9999 FEW020 29/24 Q1013 NOSIG
Incident Facts

Date of incident
Nov 25, 2017

Classification
Accident

Flight number
S9-104

Departure
Accra, Ghana

Destination
Kumasi, Ghana

Aircraft Registration
9G-SBF

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

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