Western Air SF34 at Grand Bahamas on Feb 7th 2017, electrical problems, left main gear collapse on landing back
Last Update: February 12, 2018 / 17:31:19 GMT/Zulu time
The airline reported: "Shortly after take off, the Captain noticed an indication pertaining to one of the electrical systems, he communicated with air traffic control (ATC) and followed protocol to return the aircraft back to the airport as a precaution. The aircraft made a normal landing with both landing gears in place, however once the aircraft proceeded down the runway and was preparing to turn onto the taxiway, the left gear malfunctioned, causing the aircraft to swerve off the runway. All passengers and crew were evacuated of the aircraft safely."
According to local media reports two passengers were taken to a hospital for treatment of minor injuries.
Bahamas' Air Accident Investigation Department reported that shortly after takeoff the aircraft C6-HBW suffered a problem with its landing gear. The aircraft returned to the Freeport (Grand Bahamas) International Airport, shortly after touchdown the left main gear collapsed causing the aircraft to leave the runway and come to a stop on soft ground amid bushes on the left side of runway 06. Minor injuries were reported.
On Feb 12th 2018 Bahamas' Air Accident Investigation Department (BAAID) released their final report via the Swedish Haverikommission concluding the probable causes of the accident were:
- Ineffective CRM, complacency and a complete departure from company standard operating procedures and regulatory requirements were evidently a contributing factor in this accident.
- Inadequate training and systems knowledge of both airman greatly contributed to the accident.
- Hurried approach to get on the ground and failure to explore all available options to remedy the gear unsafe situation encountered was also a contributory factor.
The BAAID reported that about 2 minutes after the aircraft rotated for departure an alarm sounded, the crew commented "we lose all the avionics" and stated "right bus, left bus" consistent with the failure of both left and right main DC-busses as well as the left essential DC bus. Although the crew diagnosed the failure correctly, the unusual combination of failures resulted in confusion, which led to further confusion about the courses of action and situational awareness. Eventually the crew decided to return to Freeport but consulted the wrong checklist to work the faults at hand, the pilot monitoring (switched the QRH several times being unsure about which list was to be applied. All indications had been lost on the captain's (50, ATPL, 14,239 hours total, 1,832 hours on type) panel, the first officer's (54, ATPL, no hours known) instruments however remained working. The captain however assumed role as pilot flying instructing the first officer to feed him with the instrument readings while working the related checklists, which increased the workload of the first officer substantially.
The BAAID wrote:
The crew eventually realized that they were having indication problems with the landing gear.
Unsure of the position of the landing gear when selected to the down position, the crew requested the assistance from Freeport Air Traffic Control (ATC), to verify the gear was in the down position. The crew was given permission to overfly the airfield and after ATC advised that the gears appeared to be down, the crew decided to prepare for landing.
From CVR recording, the flight deck crew was overheard talking to the cabin attendant and advising her that a return to the field was imminent. No urgency or instructions on preparation for a possible gear up landing was captured on the CVR.
The CVR also captured the crew discussing taking of photographic and video evidence of the abnormal indication “so that management could see what was occurring so that they won’t blame us.”
This back and forth non-essential dialogue during a critical phase of flight, with system failures occurring without appropriate crew corrective input, continued for quite some time. While attempts were overheard to retrieve and complete the Quick Reference Handbook (QRH) instructions and pre-landing checklist, the appropriate checklist for the abnormal failures were not captured on the CVR as being located or completed. The pre-landing checklist was called for, but, it also was not captured on the CVR as being completed as per company’s SOPs, where checklist or QRH completion by the non-flying pilot is announced to the pilot flying as having been completed.
Ineffective crew resource management led to confusion on the flight deck with locating and completing the appropriate QRH and before landing checklist.
A missed approach procedure was executed on the first attempt at landing because the aircraft was aligned with the runway too late and too high for a safe landing. On the second attempt for a landing the aircraft was aligned with the runway, while still no safe gear indication was noted (as evidenced from the CVR recording). The approach was flown with a higher than normal airspeed as the landing flaps were not available due to the electrical failure as stated by the pilot flying.
Confusion continued up until seconds before the aircraft touched down as evidenced from the CVR recording.
Almost immediately upon touch down the left main landing gear collapsed, some 200 to 300 feet beyond the point on the runway where heavy tire marks were noted, which indicated initial touchdown point followed by immediate heavy right brake application. The aircraft touched down at a point almost half the length of the 10,979 foot useable runway at coordinates Latitude 26.557846 N and Longitude 78.698051W.
The CVR captured at touchdown, the nonflying pilot announcing that “the light came on.”
However, within a second of that announcement, the crew experienced a gear failure on the left side followed by the aircraft propeller and wing making contact with the runway surface. The aircraft started to leave the runway to the left side shortly thereafter, travelling approximately 1,600 feet additionally from the point where the propeller and engine nacelle made contact with the runway.
As a result of the touchdown impact, left gear collapse, and roll-out sequence, substantial damage was sustained by the left wing, left engine nacelle and left hand propeller. Extent of damage sustained by the left engine internally as a result of its propeller contact with the runway while power was still being produced, was not known.
The aircraft came to rest in a marshy area on the northern (left) side of runway 06, approximately 200 feet from the runway edge. When the aircraft came to a stop, the cabin attendant was overheard initiating the evacuation. Due to the high angle of the right wing, it was reported that evacuation occurred through the main entrance door and evacuation using the right side emergency exits was not considered.
The investigation team was advised that all emergency exits were opened, however, the additional openings occurred post evacuation.
Failure to adequately diagnose and remedy the landing gear unsafe condition, (one of the resultant compound dependent failures), and a rush by the crew to get the aircraft on the ground, resulted in the crew failing to explore and utilize other available alternative methods to ensure the gears were secured in the down and locked position. No reason was given by the crew as to why they did not explore available QRH instructions for abnormal gear position indications and emergency extension prior to attempting to land.
The BAAID analysed that the crew qualification and performance was questionable.
The BAAID analysed that comparism between the aircraft manufacturer's checklists and operator's checklists revealed the operator had omitted several annotations and wrote: "This information may have been essential for the crew guidance and considerations. "
The BAAID analysed that the captain was a new hire to the airline and did not receive sufficient training hours required by Bahama's laws.
Editorial note: the final report did not work out why the electrical failures occurred.
MYGF 080000Z 00000KT 99999 FEW020 SCT035 24/21 A2999
MYGF 072300Z 16003KT 9999 SCT020 25/19 A2999
MYGF 072200Z 15005KT 9999 BKN020 25/21 A2999
MYGF 072100Z 15008KT 9999 BKN020 26/21 A2999
MYGF 072000Z 17008KT 9999 BKN020 26/21 A3000
MYGF 071900Z 19007KT 9999 BKN020 27/21 A3002
MYGF 071800Z 14005KKT 9999 BKN025 27/21 A3005
This article is published under license from Avherald.com. © of text by Avherald.com.
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