Skyway Enterprises SH36 at Sint Maarten on Oct 29th 2014, impacted waters shortly after takeoff
Last Update: October 30, 2018 / 17:31:45 GMT/Zulu time
Incident Facts
Date of incident
Oct 29, 2014
Classification
Crash
Airline
Skyway Enterprises
Flight number
SKZ-7101
Departure
Sint Maarten
Destination
San Juan, Puerto Rico
Aircraft Registration
N380MQ
Aircraft Type
SHORT SD3-60
ICAO Type Designator
SH36
Rescue and Recovery services located one body, the other pilot is still missing. Coast guard believes they found the first officer's body between Mullet Bay and Cupecoy.
The FAA reported N380MQ crashed after departure into the water, there were 2 persons on board, one was fatally injured, one unconfirmed fatally.
Sint Maarten's Civil Aviation Authority (SMCAA) released their final report concluding the causes of the crash were:
The investigation believes the PF experienced a loss of control while initiating a turn to the required departure heading after take-off. Flap retraction and its associated acceleration combined to set in motion a somatogravic illusion for the PF. The PF’s reaction to pitch down while initiating a turn most likely led to an extreme unusual attitude and the subsequent crash. PM awareness to the imminent loss of control and any attempt to intervene could not be determined. Evidence show that Crew resource management (CRM) performance was insufficient to avoid the crash.
Contributing factors to the loss of control were environmental conditions including departure from an unfamiliar runway with loss of visual references (black hole), night and rain with gusting winds.
The SMCAA reported that the cargo aircraft did not carry a cockpit voice or flight data recorder and was not required to carry any of them. The recorders, that were originally fitted to the aircraft, were removed during the cargo conversion.
The SMCAA summarized the sequence of events: "At 1839 local, Juliana Tower cleared the aircraft for takeoff Runway 28 - maintain heading 230 until passing 4000 feet. At 1840 local, Tower observed the aircraft descending visually and the radar target and data block disappeared. There were no distress calls. Night conditions and rain prevailed at the time of the accident. Coast Guard search crews discovered aircraft debris close to the shoreline about 1 ½ hours later." Night conditions and rain prevailed at the time of the crash. The SMCAA wrote: "A handheld GPS device was later recovered from submerged wreckage. Following download, recorded data indicated the aircraft past the departure runway threshold on take-off and attained a maximum GPS altitude of 433 feet at 119 knots groundspeed at 18:39:30L. The two remaining GPS data points were over the sea and recorded decreasing altitude and increasing airspeed."
The crew consisted of a captain (49, ATPL, 5,318 hours total, 361 hours on type) and a first officer (26, CPL, 1,040 hours total, 510 hours on type), the investigation was unable to establish who was pilot flying. The weight and balance was within required limits.
The SMCAA analysed the loss of control:
As the factual data was assembled and analyzed, the investigation team recognized the high probability of a Loss of Control15 scenario. Data indicated a flight regime that progressed in less than 30 seconds from a normal flight path to an aircraft upset and unusual attitude resulting in a crash into the sea. The investigation sought to identify and address combinations and sequencing of LOC causal and underlying contributing factors which could be associated with this scenario.
Operations at SXM throughout the year favor runway 10 over 90% of the operating hours. Night departures from runway 10 overfly an illuminated area during initial climb out. On the night of the accident, the wind was from 230 degrees, 10 knots, gusting to 20 knots and direction variable from 220 to 270 degrees. The airport was operating for take-offs on both runway 28 and 10; night landings, runway 10 only. The take-off direction on runway 28 toward the open sea on a 230 heading under the existing weather conditions, was relatively unfamiliar to the both the PF and the PM. A lack of visual references after passing over a shoreline at night is described by many pilots as a “black hole” effect.
Although the possibility of thunderstorms and wind shear were forecast in the area, no severe weather was detected or reported by airport workers or search teams at the aerodrome. However, darkness, rain, and wind gusts were present during the accident scenario. These environmental conditions are cause related because they presented a loss of visual references after liftoff. The PF was required to transition from visual conditions to primary flight instrument references and to use attitude instrument flying skills. Facts indicate the aircraft was observed to take-off and attain a normal initial climb. Then a major deviation from the climb out profile occurred and the aircraft started to descend and disappeared from visual and radar view.
...
Wreckage inspection revealed the landing gear was retracted and the flaps were most probably retracted to UP. GPS data indicated that aircraft attained a maximum height of about 400 feet and 119 knots groundspeed after becoming airborne for about 30 seconds. Considering a westerly wind of 10 knots, the accident aircraft was approaching 130 KIAS. Operations procedures in the SWE Training Manual prescribe a schedule for flap retraction; accelerating thru 120 KIAS, Flaps – 5, and accelerating thru 125 KIAS, Flaps – UP. The Training Manual also presents the PF/PNF command/response and monitoring actions to accomplish the configuration changes. The longitudinal acceleration at this point provided an apparent pitch up moment (g force). Susceptibility varies between persons and circumstances as to the magnitude of misperception. In this case, external visual cues were nonexistent. The start of a left bank combined with g effect is considered sufficient to be misinterpreted as a sensation of pitch up leading to a somatogravic illusion.
Loss of situational awareness may have had an early effect on crew performance. The investigation believes the presence of an unfamiliar runway in a night and rain environment provided a basis for high stress. The obligation to comply with ATC instructions to turn left to 230 degrees after take-off, and commanded flap retraction with associated acceleration, combined to set in motion a somatogravic illusion for the PF. The PF’s unintended mishandling of the flight controls and a desire to pitch down while initiating a left turn quickly led to an extreme unusual attitude and the subsequent crash.
Metars:
TNCM 292300Z 22008KT 160V270 9000 -SHRA FEW010CB BKN012TCU 27/25 Q1010 A2983 RERA, TEMPO SHRA RMK CB/LTG NW
TNCM 292300Z 22008KT 160V270 9000 -SHRA FEW010CB BKN012TCU 27/25 Q1010 A2983 RERA,TEMPO SHRA RMK CB/LTG NW
TNCM 292238Z 23010G20KT 200V270 4000E -SHRA BKN013TCU 26/25 Q1010 A2983 TEMPO SHRA RMK TCU ALQDS
TNCM 292200Z 22011KT 180V260 9000 VCSH BKN013TCU 28/25 Q1010 A2982 RERA TEMPO SHRA/ RMK TCU/SHRA NE TO N AND SW TO W
TNCM 292100Z 21010KT 160V250 9999 -SHRA BKN015TCU 28/25 Q1009 A2982 TEMPO SHRA RMK TCU SE, N, W
TNCM 292100Z 21010KT 160V250 9999 -SHRA BKN015TCU 28/25 Q1009 A 2982 TEMPO SHRARMK TCU SE
TNCM 292000Z 20007KT 140V240 9999 BKN015TCU 28/25 Q1010 A2982 TEMPO SHRA RMK JP FROM N THRGH SW, E
TNCM 291900Z 19004KT 130V300 9999 SCT017TCU 29/25 Q1010 A2983 N OSIG RMK JP TO SW,W
TNCM 291800Z 21005KT 150V260 9999 BKN017TCU 30/25 Q1010 A2984 NOSIG
Aircraft Registration Data
Incident Facts
Date of incident
Oct 29, 2014
Classification
Crash
Airline
Skyway Enterprises
Flight number
SKZ-7101
Departure
Sint Maarten
Destination
San Juan, Puerto Rico
Aircraft Registration
N380MQ
Aircraft Type
SHORT SD3-60
ICAO Type Designator
SH36
This article is published under license from Avherald.com. © of text by Avherald.com.
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