White AT72 at Fez on Jul 6th 2018, tail strike, hard landing and return flight

Last Update: December 28, 2019 / 20:48:58 GMT/Zulu time

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Incident Facts

Date of incident
Jul 6, 2018

Classification
Accident

Airline
White Air

Flight number
TP-1428

Destination
Fez, Morocco

Aircraft Registration
CS-DJG

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A White Air Avions de Transport Regional ATR-72-212A on behalf of TAP Portugal, registration CS-DJG performing flight TP-1428 from Lisbon (Portugal) to Fez (Morocco) with 58 passengers and 4 crew, landed on Fez's runway 27 but struck its tail onto the runway surface and touched down hard at about +2.7G, passengers and cabin crew clearly felt the impact. The aircraft rolled out without further incident and taxied to the apron.

The aircraft departed for the return flight TP-1427 to Lisbon about one hour after landing and landed in Lisbon without further incident.

Following the return flight the aircraft was removed from service, remained on the ground until the following day, when it departed Lisbon to Cascais (Portugal) for maintenance. The aircraft is in Cascais since.

The Aviation Herald received information that the cabin crew felt discomfort following the landing in Fez.

After learning about the occurrence on Jul 8th 2018 The Aviation Herald sent inquiries to the airline and Portugal's GPIAA but so far has not received a reply.

On Jul 24th 2018 the GPIAA released first information stating the first officer under training was pilot flying. The aircraft was on final approach to Fez's runway 27, Vapp was computed to 109 KIAS, winds from 350 degrees at 8 knots, visibility 10km or more, when during the flare, according to the captain, the aircraft "was litterally thrown onto the deck", the captain tried to grab and pluck the yoke in order to reduce the rate of descent but did not have sufficient time to do so. The aircraft suffered a hard landing at +2.88G, the tail bumper contacted the runway and the belly scraped the runway. The tail bumper received abrasion damage, the lower fuselage skin was abraded between frames 35 and 39. The captain performed a walk around focussing onto the gear without any findings. The aircraft performed the return flight with 55 passengers. In Lisbon maintenance determined several dents in the aft fuselage were out of limits. The BEA Maroc delegated the investigation to the GPIAA. The GPIAA rated the occurrence an accident and opened an investigation.

On Dec 27th 2019 Portugal's GPIAA released their final report concluding the probable cause of the accident was:

The investigation determined the accident most probable cause the flight crew performance on the landing maneuver, namely, with poor aircraft energy management while performing an unstable approach.

Contributing factors:

For the crew performance during the landing in Fez, the following direct contributing factors were identified:

¯ non-compliance by the PIC/LTC with the discontinued approach procedure,

¯ the PIC/LTC not performing the appropriate flight supervision techniques and the proper aircraft recovery from an unsafe condition on
the unstable approach,

¯ the training process (LIFUS) with the consequent authorization for the trainee copilot to fly as PF, without a safety pilot on board, taking into account her known difficulties controlling the aircraft at landing,

¯ the missing explicit definition of the stabilized approach criteria by the operator.

For the crew decision process to start the return flight to Lisbon, the following contributing factors were identified:

¯ Organizational culture with inadequate or nonexistent procedures and individualcentered decision-making without effective implementation of the CRM philosophy,

¯ Lack of operator’s oversight by NAA to comply with certification regulations, not adopting SARPs in compliance checks.

The GPIAA analyse:

At 240ft AAL (minimum decision height), without significant glide deviations, the IAS was 116 kt (recommended VAPP + 7 kt) and vertical rate was 800 ft/min.

From 200ft, the aircraft power was close to the minimum (FI) while the speed was decreasing.

At 50 feet RA, the nose-up command increased, and a flare was progressively initiated by the PF. IAS decreased to 109kt (VAPP), with engine torque of only 3%. The rate of descent was around
600 ft/min and increasing.

After 20 ft during flare, a nose up command was given by the PF and a nose up command was also added by PIC/LTC. None of the pilots applied
power to the engines, which when applied in a timely manner should decrease the high descent rate.

The GPIAA further analysed: "Despite the non-stabilized approach in Fez, the PIC/LTC did not call for a go-around." stating that there was no clear reference in the flight crew operating manual of when an approach is considered to be stable and when a go around is to be initiated, such guidance is only found in the flight crew training manual referring to many other documents.

The GPIAA analysed:

From the collected data, the aircraft touched the ground with a calculated descent rate of -740 ft/min and an indicated airspeed of only 103 KIAS, 6 KIAS below the calculated value. Although there was an attempt to reduce the pitch angle at 5 ft with the elevators acting to lower the nose, this action had no effect on the aircraft dynamics.

The aircraft touches the ground with a pitch angle of 6.4°. With the high descent rate, the main landing gear compression was immediate, with tail contact inevitable at that time, with +3.0 Gs vertical acceleration recorded. Engine power remained reduced.

Regarding the aircraft fuselage geometry, the tail bump height to ground is about 0,8 meters, creating the necessary conditions for an easy assessment of the condition of the aircraft according to the manufacturer's procedure. The PIC/LTC stated that he could not see the damage on the fuselage underside due to the relative position on the inspecting angle during the preflight inspection.

The GPIAA analysed with respect to flight crew:

Overall, at the time of the event, airliners were experiencing difficulties to maintain their pilot workforce due to the job market. As referred in 1.17.1, the operator’s pilots’ shortage, in special of experienced SICs, may have conditioned the trainee co-pilot release for flight without a safety pilot onboard, even though she revealed aircraft handling difficulties during landing phase.

...

Direct commander entry, within a short time interval, does not promote the correct understanding of procedural information, operator policies and culture to commanders, who in return, cannot actively contribute to spread the message to the new co-pilots arriving at the air operator.

Despite audits carried out by the Civil Aviation Authority (ANAC), for the purposes of Part ARO.GEN.300 “Supervision of Crew Training”, with a positive result, and compliance by the operator with its OM-D, these control measures showed not to be effective.

...

As demonstrated by the co-pilot events and, despite documenting its definition and the policy for inexperienced pilots as required in partORO.FC.200, the operator showed weaknesses in the control and supervision of the crew members training programs, not implementing the
necessary mitigation actions over detected problems recorded in the LIFUS, such as tailoring the training to the needs of each pilot with specific training and dedicated TRIs.

With respect to the preflight inspection the GPIAA analysed:

The PIC/LTC stated that he opened the cargo net and exited the aircraft through the cargo door aiming the pre-flight inspection. During the external inspection, he stated that he focused his attention on the landing gear, stating also that he did not detect any anomalies in the aircraft.

The PIC stated that due to the low position of the tail skid, he did not visualize the aircraft fuselage damage or the red-marked angle, which are intended and designed to highlight a possible fuselage touch on the ground.

In the FCOM on DSC.32 sheet. 01, it is clearly stated that the skid shoe of the tail bumper needs to be inspected during each walk around and clearly defines the condition where maintenance action is required.

...

The PIC/LTC did not properly check the tail bumper nor did he realize the extent of the damage sustained by the aircraft during landing.

Although the PIC/LTC has stated that he actively sought out any problems with the aircraft, a hint that there was a concern about the aircraft condition, the PIC/LTC did not properly assessthe tail skid’s condition, deciding and consequently accepting the risk to fly the aircraft back to Lisbon, even with possible doubts as the attempt to access the ACMS suggests.

The GPIAA analysed with respect to the operator's oversight:

The PIC/LTC at a first stage, and the operator at a subsequent stage, failed to report the occurrence to the Portuguese Authorities as required by EU regulation 376/2014 on the reporting, analysis and follow-up of occurrences in civil aviation, and by the European Commission implementing regulation 2015/1018 which makes reporting hard landings mandatory.
Incident Facts

Date of incident
Jul 6, 2018

Classification
Accident

Airline
White Air

Flight number
TP-1428

Destination
Fez, Morocco

Aircraft Registration
CS-DJG

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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