Cirrus D328 at Mannheim on Mar 19th 2008, overran runway, gear collapse

Last Update: September 13, 2012 / 07:25:44 GMT/Zulu time

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Incident Facts

Date of incident
Mar 19, 2008

Classification
Report

Flight number
C9-1567

Aircraft Registration
D-CTOB

Aircraft Type
DORNIER 328

ICAO Type Designator
D328

A Cirrus Airlines Dornier Do-328-100, registration D-CTOB performing flight C9-1567 from Berlin Tempelhof to Mannheim (Germany) with 24 passengers and 3 crew, had performed a LOC/DME approach and landed on Mannheim's runway 27 past the touch down zone, bounced and settled on the runway about 150 meters short of the runway end. The aircraft overran the end of the runway and impacted an earthwall about 50 meters past the runway end. 5 passengers received minor injuries, the aircraft received substantial damage.

Germany's Bundesstelle für Flugunfalluntersuchung (BFU) released their final report in German (later released English version) concluding the probable causes of the accident were:

- the aircraft rolled past the end of the runway and impacted with an earthwall
- no balked landing was initiated
- thrust levers were not moved to ground idle/reverse after touch down
- the landing was still continued after the touch down zone had been overflown
- the power levers were not pulled back to flight idle during the flare which was missed by both pilots
- the flight crew deviated from standard operating procedures during the approach and reached and exceeded their performance capabilities

Contributing factors were:

- the non-precision approaches to as well as landings in Mannheim were conducted not according to operations manual with significant frequency within the airline
- Temporary Revisions and Flight Ops Information released by the aircraft manufacturer had not been incorporated into the operations manual of the airline
- Practical training of the the flight crew was inadequate with respect to avoiding erroneous power lever handling according to documentation released by the aircraft manufacturer
- the crew conducted a non-precision approach that was not in compliance with the operations manual and aeronautical information publication (AIP)
- the design of the power levers was not sufficient fault tolerant
- the existing risks of erroneous handling of power levers was not properly recognized and corrected by regulatory oversight and manufacturer despite numerous events and repeated safety recommendations
- the touch down zone in Mannheim was not marked
- the runway end safety area past runway 27 was insufficient to warrant a safety level recommended by ICAO and required by the regulator.

The BFU reported the first officer (28, CPL, 321 hours total, 121 hours on type) was pilot flying for the sector, the captain (47, ATPL, 4,921 hours total, 1,661 hours on type) was pilot monitoring for the sector.

The BFU reported that the captain had failed his theoretical exams to acquire the ATPL due to not scoring 75% of points in 6 of 8 parts of the exams, but passed the examination in a second attempt 4 months later. He failed his practical test to acquire the ATPL due to entering the control zone of Hahn without clearance. He also failed the flight test in the second attempt, the examiner noted "loss of orientation" as reason. Following additional training the captain passed the third flight test.

After joining Cirrus Airlines in 2004 the captain was retrained to qualify for the Dornier Do-328. During the training, although passing the relevant lessons, the instructors noted repeatedly: "General overview and basic flying skills within limits." The final check, although passed, was commented by the examiner with "Improve general overview, system knowledge! General airmanship at lower limit only".

After receiving the type rating for the Dornier 328 the captain received line training by the airline, the supervising pilots noting unsteady performance, partly satisfactory performance and partly lacking performance, for example "-Ldg MHG – touchdown behind first half of rwy!!! no reverse + brake action - some times missing general overview".

The BFU reported further, that no final line check was conducted. The performance shown during supervision was insufficient to qualify to work as a captain for the company. The supervision was instead continued for a right hand seat as first officer and was successfully completed.

The captain subsequently flew 2 years and 896 hours as first officer. The company reported during this time he works intensively on his basic flying skills and improved significantly, became well above average of first officers and increasingly showed captain skills. In 2007 the company therefore decided to start a second supervision as a captain, which resulted in mostly "good performance" notes, however, there were also remarks like "More leaderwork" and "Don‘t forget you are the leader". After a landing in Mannheim the supervisor noted "8.1 On short fields choose a touchdown point and land the a/c there (PWR-lever in FI to avoid excessive flare); 8.4 Use reverse AND brakes to decelerate a/c". The supervision was successfully completed and resulted in "Good performance, counted as line check". Subsequently he flew as captain.

Other than with the captain the first officer completed his exams, training and supervision without problems, his performance was assessed as generally good.

The aircraft was on approach to Mannheim cleared to descend to FL080 and advised to expect LOC/DME approach to runway 27 when the first officer remarked his landings in Mannheim needed improvement. The captain, who had acknowledged and mentioned good handling on takeoff and departure, showed no concern but attempted to encourage the first officer. The crew had briefed an approach speed of 110 knots, but the approach briefing remained incomplete following several interruptions. The aircraft was cleared to descend to 5000 feet and to intercept the localizer, the captain went onto a company frequency to talk to dispatch while the first officer intercepted the localizer but did not arrest the descent to level off at 5000 feet. After the captain had finished his communication with dispatch, the first officer recognized his error when the aircraft was already at 3800 feet (sector MSA 3900 feet), the captain recommended to correct a little, the first officer climbed the aircraft back to 5000 feet. Radar also reacted to the descent below 5000 feet, the captain transmitted an apology.

The aircraft reached the final approach fix at a calibrated airspeed of 197 knots and approx 4700 feet MSL and began a descent along the localizer on autopilot in vertical speed mode. During the descent the configuration for landing was done, the first stages of flaps were selected at 9nm before touchdown, descending through 2200 feet and 4.5nm the gear was lowered, at 3nm before touchdown and 1400 feet the flaps reached landing position.

The aircraft crossed a power line about 2nm before touchdown prompting the captain to recommend to descend the aircraft onto "three reds" (referring to PAPI indication three reds one white), the vertical speed increased to 1500 feet per minute. 26 seconds before touchdown the captain checked the airspeed at 118 knots, remarked "good, continue", the speed subsequently reduced to the briefed Vapp of 110 knots. At 135 feet AGL the power was slightly increased. The aircraft crossed the runway threshold at 40 feet AGL at 114 knots calibrated airspeed, the pitch was 4.4 degrees nose down (normal attitude 2-3 degrees nose up). The GPWS announced "fourty, thirty, twenty, ten", the first officer began to flare the aircraft and the nose rose to about 3 degrees nose up, the vertical acceleration increased to +1.3G.

The aircraft did not touch down but floated along the runway at low height, the first officer stated "your control". The captain acknowledged "my control" and took control of the aircraft, about 200 meters past the runway threshold, the engines had spooled down to about 20% torque. During then ext 5-6 seconds the captain attempted to get the aircraft down varying the pitch between 1 degrees nose down and 2.5 degrees nose up.

The BFU stated that witnesses on the ground reported the aircraft touched down in the second half of the runway. According to the flight data recorder the aircraft had first ground contact 480 meters before the runway end at 108 KIAS, the torque of both engines was still 20%. The weight on wheel sensor for the right gear indicated first, followed by both sensors indicating on the ground for three seconds, then both indicated in the air for one second before the aircraft finally settled on the ground at 93 KIAS. The captain and first officer commented simultaneously "no beta", the captain instructed "emergency/park brake". The first officer did not engage the E/P brake however, the captain thus moved his hand off the power levers to activate the E/P brake. At that time the first officer pulled the power levers to idle and into reverse, at that moment the propellers went into Beta and the spoilers engaged in full ground deflection about 10 seconds after touch down, the flight data recorder showed deceleration significantly increased from -0.3G to -0.85G. The aircraft crossed the runway end at 50 knots and crossed the end of paved surface at 30 knots. Immediately after leaving paved surface the left main gear hit a shaft cover and collapsed, the left wing and engine collided with an earth wall before the aircraft came to rest.

About 8 seconds after the aircraft stopped the captain ordered the evacuation of the aircraft.

5 passengers received minor injuries, 4 passengers received contusions and abrasions, one passenger received a whiplash.

The BFU analysed that the approach and landing did not entirely meet the stabilized approach criteria referring towards the pitch angle of 4.4 degrees nose down while crossing the runway threshold.

The engines remained at 20% torque instead of reducing to flight idle, the resulting thrust prevented the aircraft from settling on the runway and produced a continued float along the runway. This unusual float was immediately recognized by the first officer without however recognizing the cause. A quick check of the engine instruments and reduction to flight idle at that time would have been the appropriate response, the hand over of controls to the captain however was not appropriate.

After the hand over of controls the captain could have immediately pulled the power levers to idle. At that point the remaining runway length was still sufficient to stop the aircraft within the runway boundaries. However, the power levers were not pulled to idle but remained at 20% torque so that the aircraft floated another 300 meters. A first ground contact occurred far beyond the touch down zone. According to operating manual a balked landing (go-around) would have been necessary already before that so that the BFU did not engage in checking whether a go-around from that position would have been possible, the BFU however believes a go around would have been possible because the engines were still at 20% torque.

The aircraft finally settled about 150 meters before the runway end at 93 knots.

The BFU further analysed that the instruction by the captain to engage the emergency/park brake did not match any standard operating procedure, it was therefore correct that the first officer did not comply with that instruction. Instead the BFU annotated that the first officer's reaction to reduce the power levers to idle and into reverse was the proper response - however this was only possible because the captain had moved his hand to the E/P brake switch and thus released the power levers.

Both reactions were spontaneous and not covered by standard operating procedures. At that point however there were no alternatives available anymore. The go-around should have been initiated way earlier.

The BFU analysed that following the instruction to evacuate the aircraft the flight crew became completely uncoordinated while attempting to shut the aircraft down and work the evacuation checklist.

The BFU reported that despite the accident another aircraft was cleared to land a few minutes later. The BFU condemned this clearance as "not acceptable".

The BFU analysed that the airline had documented an altitude for IFR approaches after which the approach had to be continously stabilized, however there was no such requirement for visual approaches. This is unacceptable. The pitch as well as rate of descent substantially exceeded the required criteria for stabilized instrument approach and thus would have required an immediate go around.

The BFU further analysed that the captain had contacted dispatch while below FL100 and thus executed tasks unrelated to the conduct of the flight. This was a contributing factor to the accident sequence.

The BFU further analysed that after the first officer showed uncertainty during the final approach there was no proactive reaction by the captain e.g. by taking control or initiating a go-around.

The BFU further analysed that despite the incomplete approach briefing the captain did not take corrective measures.

The BFU analysed that the behaviour of both flight crew did not resemble the professional cooperation of a crew of two, but resembled more the relation of a flight instructor and trainee.

The BFU analysed that the failed exams in the beginning of the career of the captain did not disqualify him. His deficiencies were subsequently dealt with, the airline recognized and reacted to the deficiencies by aborting the first supervision period for captaincy and instead used the pilot as first officer for two years. The BFU however voiced concern with the second supervision results being illogical as several supervision reports, although stating good performance, mentioned deficiencies that have significant parallels with the accident sequence. The BFU thus is dissastisfied with the results of the second supervision period for captaincy.
Incident Facts

Date of incident
Mar 19, 2008

Classification
Report

Flight number
C9-1567

Aircraft Registration
D-CTOB

Aircraft Type
DORNIER 328

ICAO Type Designator
D328

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