SkyBahamas SF34 at Marsh Harbour on Jun 13th 2013, runway excursion
Last Update: April 26, 2017 / 16:04:20 GMT/Zulu time
Incident Facts
Date of incident
Jun 13, 2013
Classification
Accident
Cause
Runway excursion
Airline
SkyBahamas
Aircraft Registration
C6-SBJ
Aircraft Type
SAAB 340
ICAO Type Designator
SF34
The Air Accident Investigation Department has determined that the probable cause of this accident was the decision of the crew to initiate and continue an instrument approach into clearly identified thunderstorm activity over the landing field during landing, resulting in a loss of control of the airplane from which the flight crew was unable to recover and subsequent collision with obstacles and terrain resulted during the runway excursion.
Contributing to the severity of the accident was the poor decision making and lack of situational awareness by the crew while attempting to land during a thunderstorm.
Also contributing to the severity of the accident was the thunderstorm, convective activity and heavy rain over the field at the time of the accident.
The BAAID reported at the time of the approach of the aircraft with 21 passengers and 3 crew thunderstorms were active over the aerodrome. The crew decided to use runway 09. The crew began to configure the aircraft for landing about 4.2nm out and had the aircraft configured gear down and landing flaps at 20 degrees about 1.9nm before the runway threshold. The aircraft crossed the runway threshold at 50 feet AGL at 171 KIAS, the crew subsequently encountered reduced visibility due to rain showers. 14 seconds after crossing the threshold the aircraft touched down at a vertical acceleration of +2.16G, the aircraft bounced reaching a (calculated) height of 15 feet and touched down a second time at +3.19G with a attitude of 1.8 degrees nose down and 106 KIAS. The aircraft bounced again and touched down a third time at +3.66G, 2.2 degrees nose down and 98 KIAS resulting in damage to the right hand wing, right hand propeller and engine, which suffered a rapid loss of power and subsequent stop of the propeller. The aircraft veered about 30 degrees to the right at a magnetic heading of 131 degrees and exited the right hand edge of the runway about 6,044 feet past the runway threshold at 44 KIAS and came to stop about 5 seconds later at a heading of 231 degrees.
Passengers and crew evacuated the aircraft. There were no injuries, the aircraft received substantial damage.
The BAAID wrote as last sentences of the factual presentation of the sequence of events:
The cockpit voice recorder (CVR) uncovered that this crew used no crew resource management or adherence to company standard operating procedures.
During the final seconds of the flight, there was complete confusion on the flight deck as to who was in control of the aircraft.
After failure of the windshield wiper on the left side of the aircraft, the captain continued to maneuver the aircraft despite having no visual contact of the field due to heavy rain.
Sterile Cockpit procedures were not adhered to by this crew as they continued with non-essential conversation throughout the flight regime from engine start up in KFLL up until the “before landing checklist” was requested prior to landing.
The captain (30, ATPL, 8,500 hours total, 4,700 hours on type) was pilot monitoring, the first officer (21, CPL, hours unknown) was pilot flying.
The BAAID analysed:
As the airplane commenced its approach, the pilot flying requested a “before landing check.” This check was so rushed by the non-flying pilot that it could not be interpreted from the CVR. Again, all checks are a challenge and response. As this check was so rushed the non-flying pilot forgot to advance the propeller to the recommended position as required by checklist. This failure was evident on the FDR data plots as the propeller level stayed the same from the enroute phase up until the crash sequence.
Crew resource management (CRM) was not evident during the approach phase of flight. The crew was aware of the thunderstorms and the fact that it was over the field, as on the CVR they both made reference to the fact that it was over the field.
Knowing the condition of the weather, the crew still never discussed the choice of diverting to another airport or entering a holding pattern until the weather passed. The non-flying pilot was adamant about landing at all cost, as he was overheard stating, “See if we can hurry and get in before….”
The pilot flying never challenged the non-flying pilot, as they were both stating at differing times that they had the runway in sight, then they lost sight of it, then they had it again and then lost it again, this process repeated several times up to the point of touch down. It was evident from the CVR recording that neither pilot definitively had the runway in sight. Both pilots was aware of the weather before 500 feet in altitude, which gave them adequate time to shoot a missed approach, divert to another airport with VFR weather or hold at a predetermined position until the field had cleared enough to attempt a landing.
No CVR recording showed where crew advised traffic in the area of Marsh Harbor of their approach and intention of landing.
Descending through 500 feet and just prior to touch down, the pilot flying stated that he lost sight of the runway; just prior to this the non-flying pilot (PIC) lost his windshield wiper, as for whatever reason, it went over center and was stuck to the left side of the windshield. No decision was made to execute a missed approach as a result of the problems the crew encountered. The non-flying pilot, who just prior lost his windshield wiper, assumed control of the aircraft despite not being able to see the runway due to the heavy rain downpour. After realizing that he could not see the runway either, the flying pilot decided to give control of the aircraft back to the original flying pilot who again stated he had no visual. By this time the aircraft had touched down and bounce back in the air. The atmosphere in the cockpit at this time was chaotic as the control wheel was being exchanged between the pilot flying and pilot non flying based on who had sight of the runway at the time. It was evident from the CVR recordings that no one had a definitive visual of the runway and the field was zero-zero visibility in heavy rain.
Aircraft airspeed during the approach was unstable and non-standard. A go around or diversion was not considered nor attempted. There was a constant battle between the crew to slow down, or hurry up, or put in flaps to slow down, all of these non-standard procedures were an attempt to “beat” the weather in to land.
This constant exchange of the control wheel was not consistent with control wheel exchange as approved in the SOP and training program of SkyBahamas Airlines. As a result of no visual contact of the runway, the aircraft bounced three (3) times, each bounce progressively larger and higher than the last. The last bounce was measured at 27 feet (FDR data proves this height) above the runway. On the third bounce the nose gear broke and it is possible the wing may have started to fail at this point.
No aileron or elevator control input by the crew was observed during or after the touchdown as per the FDR data reviewed which further confirms that during the bounces and crash sequence neither pilot had positive control of the aircraft.
No instructions were recorded on the CVR where the flight crew;
a. Advised the cabin attendant to commence the evacuation nor
b. Conducted the evacuation checklist
The crew had several opportunities to either divert to an airport with visual weather or hold and wait for the thunderstorm over the field to pass. Instead they elected to try and beat the weather as evidenced from the CVR.
Although the investigation made no reference to Bahamas' Flight Standards Inspectorate in both factual, analysis and conclusions part of the report numerous safety recommendations were made to the Flight Standards Inspectorate, e.g. to reevaluate the Standard Operating Procedures by the airline, to monitor the airline, to monitor the flight crew performance and culture of the airline, monitor aircraft to ensure reliability of aircraft systems (e.g. transducers of elevator and rudder) and ultimately recommending to remove this crew from active line duty and re-examine for their fitness to hold a type rating on this aircraft type.
Incident Facts
Date of incident
Jun 13, 2013
Classification
Accident
Cause
Runway excursion
Airline
SkyBahamas
Aircraft Registration
C6-SBJ
Aircraft Type
SAAB 340
ICAO Type Designator
SF34
This article is published under license from Avherald.com. © of text by Avherald.com.
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