Regional CAE E145 at Ljubljana on May 24th 2010, hard landing

Last Update: June 27, 2012 / 14:26:13 GMT/Zulu time

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Incident Facts

Date of incident
May 24, 2010

Classification
Report

Cause
Hard landing

Flight number
YS-3104

Departure
Paris Charles de Gaulle, France

Destination
Ljubljana, Slovenia

Aircraft Registration
F-GUBF

A Regional Compagnie Aerienne Europeene Embraer ERJ-145, registration F-GUBF performing flight YS-3104 from Paris Charles de Gaulle (France) to Ljubljana (Slovenia) with 49 passengers and 3 crew, was on approach to Ljubljana maintaining 7000 feet MSL, radar vectors for an ILS approach to runway 31 were provided by ATC, weather conditions - winds from northwest at 8 knots, visibility beyond 10km, broken stratocumulus at FL060 - permitted a visual approach, so that the captain (54, 12,812 hours total, 5,900 hours on type), pilot monitoring, suggested to the first officer (54, 9,994 hours total, 2,392 hours on type), pilot flying, to descend to 4000 feet and continue on a visual approach, the first officer accepted that proposal, air traffic control approved the request. At an altitude of 6500 feet, about 4.5nm from the runway threshold, the aircraft turned onto base leg, air traffic control cleared the aircraft for the visual approach thus removing the altitude constraint when the aircraft descended through 5500 feet. The first officer wasn't able to see the runway to the left from his seat and flew the turn onto final with the guidance of the captain and established the aircraft on final course about 2.9nm from the threshold at 2900 feet MSL and 1709 feet AGL. The EGPWS issued "SINK RATE", the first officer indicated he was in trouble with the profile, the captain took control of the aircraft. About 1 to 1.5nm from the threshold the aircraft levelled at 800 feet AGL to reduce the speed of the aircraft, flaps were deployed to 45 degrees, then the captain pushes the aircraft into a descent, the EGPWS again complains about "SINK RATE" and after 6 seconds alerts "PULL UP!" for 11 seconds. The aircraft by then is at 100 feet AGL and the captain begins the flare, which forces the captain to take the nose unusually high with a rapid variation of pitch angle. At about 10 feet AGL the power levers were advanced to about half travel and pulled back to idle again, the captain nonetheless is unable to arrest the sink rate and impacts the runway at a vertical rate of descent of about 1300 feet per minute and a vertical acceleration in excess of 4G, the aircraft bounces off and touches down a second time at 2.26G followed by a roll out without further incidents. The captain taxied the aircraft to the apron, where passengers disembarked normally. No injuries occurred in the accident, the aircraft received substantial damage.

The French Bureau dÂ’Enquetes et dÂ’Analyses (BEA) released their final report in French concluding the probable cause of the accident was:

Overconfidence by the captain paired with the passivity of the first officer following the transfer of control generated a steep gradient of authority which led to the crew not considering a go-around despite multiple EGPWS warnings and alerts and stabilised approach criteria not met. Being cleared for a visual approach the crew turned onto base leg too early and too high causing the aircraft to be above final approach profile at too high a speed. The continuation of the unstabilized landing in turbulent conditions produced a hard landing.

Contributing factors were:

- lack of updated approach briefing following the change from ILS to visual approach
- assessment of the situation during the visual approach without considering available information at the crew's disposal, that would especially have been valuable in mountaineous terrain where the relief can mislead the perceiption of the approach.
- the work distribution amongst the cockpit crew, in fact the first officer was unable to see the runway or locate ground during turns onto base and final legs from his seat.

The BEA reported that the aircraft deformed the axles of both left and right hand main gear dampers, the axle of the left hand shock absorber was deformed and the re-inforcing plate of the fairing between fuselage and wing was twisted with a number of rivets fractured. Both main landing gear legs needed to be replaced.

The aerodrome is equipped with PAPI's, the ILS approach runway 31 starts at 4000 feet with the final approach point at 8.9nm ILS DME.

The computed approach speed was 134 KIAS, on final descent at 1334 feet AGL the aircraft was configured with flaps at 22 degrees, gear down and was doing 170 KIAS. At 800 feet AGL the captain levelled off and reduced the airspeed deploying the flaps to 45 degrees at the same time.

The BEA analysed that the transfer of control to the captain during final approach placed the first officer into a difficult position even though he still had the power to call a go around at any time. He had found himself gradually more and more behind the aircraft, felt uncomfortable with the progress of the approach and verbalized his uneasiness, however the apparent ease of the captain taking control of the aircraft probably forced the first officer into the role of an observer rather than a pilot monitoring.

The AOM by the airline permitted the crew in visual meteorologic conditions to either adjust the flight path to stop the alert or go-around in case of an EGPWS "PULL UP" alert, also stating that if the approach was unstable the only option was to go-around. The manual continues that if the captain does not adhere to EGPWS alerts the first officer must assume the captain was incapacitated and needed to take positive control of the aircraft to execute the necessary procedures.

The captain was experienced glider and aerobatics pilot as well, which may have influenced his judgement convincing him a landing was still possible despite the EGPWS alerts.

The crew said in post flight interviews, that there had been turbulence from FL100 to landing, moderate turbulence on final approach. They did not reference the PAPIs. Neither crew recalled the normal callouts by the GPWS like "one hundred".
Incident Facts

Date of incident
May 24, 2010

Classification
Report

Cause
Hard landing

Flight number
YS-3104

Departure
Paris Charles de Gaulle, France

Destination
Ljubljana, Slovenia

Aircraft Registration
F-GUBF

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