Henan Airlines E190 at Yichun on Aug 24th 2010, impacted terrain short of runway and burst into flames
Last Update: June 29, 2012 / 14:40:08 GMT/Zulu time
Incident Facts
Date of incident
Aug 24, 2010
Classification
Crash
Aircraft Type
Embraer ERJ-190
ICAO Type Designator
E190
- In violation of the airline's flight operation manual the captain attempted the approach to Yichun below required visibility. The airport reported 2800 meters of visibility while the manual required 3600 meters of visibility to begin the approach.
- In violation of regulations by the Civil Aviation Authority the crew descended below minimum descent altitude although the aircraft was operating in fog and visual contact with the runway had not been established.
- Despite the aural height announcements and despite not seeing the runway the crew continued the landing in the blind without initiating a go-around resulting in impact with terrain.
Contributing factors were:
- The airline's safety management is insufficient:
* part of the flight crew arbitrarily implement the company's operations manual as the company does not follow up outstanding problems. Records suggest frequent deviations from approach profiles, i.e. deviation above or below glide slopes, excessive rates of descents and unstable approaches.
* crew rostering and crew cooperation: Each of the crew was flying into Yichun for the first time despite the known safety risks at the airport, the communication and cooperation within the crew was insufficient, the crew members did not monitor each other in order to reduce human errors.
* the airline's emergency training did not meet requirements, in particular the cabin crew training did not provide for hands on training on E190 cabin doors and overwing exits. Alternate means by the airline did prove ineffective and did not provide the quality China's Civil Aviation Authority requires thus leaving cabin crew unprepared to meet required cabin crew emergency response capabilities.
- Parent company's Shenzhen Airlines oversight insufficient
* Shenzhen Airlines, after having taken over Henan Airlines in 2006, did not provide sufficient funding and technical support affecting the stability and safety of staff and quality management.
* Air China, holding stock into Shenzhen Airlines, installed a safety supervisor but failed to address the safety management issues with Shenzhen and Henan Airlines.
- No supervision by China's Civil Aviation Authority
* the license to operate the flight from Harbin to Yichun was granted without route validation and without safety management in violation of regulations.
* to solve the lack of cabin crew flight attendants were certified although not meeting the relevant requirements for air transport operations.
* the regional office of the Civil Aviation Authority did not communicate to their superiors that they had approved the domestic operation of the route from Harbin to Yichun permitting non-standard procedures.
- China's Civil Aviation Authoritiy safety management loopholes
* On July 27th 2009 the meteorological database system administrator mistakenly had entered the airport identifier ZYID instead of ZYLD which prevented special weather reports from being entered into the system. Henan Airlines' dispatch therefore could not brief and remind the crews accordingly.
The captain (40, ATPL, no experience data provided) was pilot flying, the first officer (27, CPL) was pilot monitoring. The aircraft was enroute at 6300 meters of altitude/FL206 about 170km/92nm from Yichun when the crew first contacted Yichun airport and was advised visibility was 2800 meters/9200 feet due to fog, which was concentrated at the aerodrome. The crew subsequently conducted a briefing for the VOR/DME approach into runway 30 and specifically mentioned the minimum descent altitude was 440 meters/1443 feet. The aerodrome controller again advised that the vertical visibility was good however the horizontal visibility was poor. The aircraft subsequently overflew the aerodrome, the tower controller was able to see the aircraft. While the aircraft entered the procedure turn the first officer commented the runway was very bright. After completing the procedure turn the crew reported the runway in sight, tower cleared the flight to land on runway 30 and again reminded the crew of the minimum descent altitude of 440 meters. About 40 seconds later the first officer commented "we have to bear this mist", the CSAWS analysed the aircraft entered low level fog at that point, 15 seconds later the autopilot was disengaged with the captain steering the aircraft manually.
42 seconds after the autopilot was disengaged the aircraft descended through 440 meters (MDA) although the aircraft was flying in low level fog and there was no visual contact with the runway. 21 seconds later, 1.6nm from touchdown at an altitude of 335 meters the first officer called a high rate of descent reminding the captain to reduce the sink rate. Another 6 seconds later the GPWS called 50, 40, 20, 10 and the aircraft impacted the ground. 5 seconds after the GPWS called 50 the ELT transmitter activated alerting the tower also monitoring the emergency frequency, 32 seconds later the tower alerted emergency services having lost contact with the aircraft. Tower attempted to contact the aircraft for another 13 minutes without reply.
More than 1000 rescue workers were deployed in the meantime, the first responders reaching the crash site 2 minutes 15 after tower raised the alert. Rescue operations were finished 3.5 hours after the alert after rescue of 54 people and the recovery of 42 bodies. 37 people received serious, 17 minor injuries. One of the serious injured later succumbed to serious burns in Yichun hospital.
The investigation determined the aircraft hit trees 1110 meters before the runway threshold, the main wheels contacted ground 1080 meters short of the runway threshold, the engines came to rest 870 meters short of the threshold with the main portion of the fuselage coming to rest 690 meters short of the threshold at position N47.7478 E129.0428. The fuel wing tank ruptured in the crash sequence leaking and distributing fuel. Smoke filled the cabin rapidly, the survivors escaped through the left rear door, the cockpit's left sliding window and a gap in the fuselage, while all other doors could not be opened due to deformation of the fuselage and the smoke barrier.
The investigation released a number of safety recommendations, at the first and foremost:
Implement "Safety First" as responsibility of all aviation enterprises to correctly grasp the relationship between safety and development as well as safety and effectiveness.
Incident Facts
Date of incident
Aug 24, 2010
Classification
Crash
Aircraft Type
Embraer ERJ-190
ICAO Type Designator
E190
This article is published under license from Avherald.com. © of text by Avherald.com.
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