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Sunday, August 28, 2011

Pilot Error / Strong Winds Cause ATR-72 Crash in Ireland

Aug 23, 2011 - The Air Accident Investigation Unit of the Irish Department of Transport ahs released its report on a July 2011 crash of an ATR-72 at Shannon Airport.
The report points to pilot error and strong wind as the cause of the crash, an abbreviated version of the report is below, the complete report can be found here.

On the morning of 17 July 2011, the aircraft, operating as Flight No. EI3601 and Call sign REA61MA, departed Manchester Airport (EGCC) with a Shannon-based flight crew. The aircraft arrived at a point 15 nautical miles northeast of Shannon Airport (EINN) around 09:00 hrs and self-positioned for an Instrument Landing System approach to Runway 24. The Shannon Approach Charts include a caution which states; “Caution: Turbulence and/or wind-shear may be experienced on approach to RWY 24 when wind direction lies in the sector from 260° - 320° (clockwise) with wind speeds > 15 kts”. This caution was applicable given the prevailing weather conditions.

After the aircraft was transferred from Shannon Approach to Shannon Tower, the Tower cautioned the aircraft regarding turbulence in accordance with Air Traffic Control Standard Operating Procedures. The Captain, who was the Pilot Flying elected to aim for a touch-down at the end of the RWY 24 Touch-down Zone. This was to avoid possible turbulence during the final stages of the approach/landing. The PF considered, given the length of RWY 24 (10,000 ft) and the landing performance of the ATR 72, that the remaining runway length available was sufficient to achieve a safe landing.

The Flight Data Recorder data indicates that the aircraft experienced an extended landing flare. Engine torque was increased during the initial flare and then progressively reduced in stages. The Pilot Flying subsequently stated that difficulty was experienced in getting the aircraft to settle on the runway during this time. The PF became increasingly concerned about the remaining length of runway available and decided to positively land the aircraft by applying a forward input on the control column. This is confirmed by the FDR. At the same time engine torque reduced. This was followed by a nose-wheel contact with the runway, at an FDR-recorded pitch angle of 8° nose-down. The aircraft immediately bounced back into the air. The Pilot Flying applied power and initiated a go-around. During the go-around the undercarriage was retracted and normal cockpit indications were observed by the flight crew. No warning tones sounded during this landing and go-around.

The aircraft was then vectored by ATC for another ILS approach to RWY 24. The aircraft was established on this approach at the 6 mile point.

This time the Pilot Flying elected to aim for the middle of the Touch-down Zone. The FDR indicates a number of bounces which are also visible on poor quality CCTV. The final touch-down occurred at a pitch angle of 8° nose down and a G-spike of 2.3G. At this point the Blue hydraulic system lost pressure.

On the final touch-down the aircraft with the nose wheel collapsed and the nose scraped along the runway. Smoke/steam was observed emanating from the nose area. The aircraft continued along the runway, initially on the centreline. It gradually veered to the left and exited the runway surface onto the grass to the left of the runway, as it approached Taxiway Alpha. The left propeller struck a runway sign, demolishing it and damaging one propeller blade. The aircraft continued to turn to the left and came to a stop at the left edge of Taxiway Alpha, in line with the taxiway heading. The final stopping point was 1,200 metres from the initial impact marks on the runway.

The flight crew had no directional control of the aircraft from the initial runway impact to the final stopping point, as the nose wheel steering was inoperative due to the collapsed nose wheel and the rudder was jammed in the mid position. The flight crew were also unable to shut down the engines by retarding the condition levers, as the levers would not retard to the aft position. The flight crew therefore decided to stop the engines by pulling the fire handles.

The flight crew decided not to perform an emergency evacuation as they had not detected any evidence of fire or smoke. However the cabin crew subsequently detected a smell of burning and initiated an evacuation. Four passengers evacuated the aircraft via the rear (left) air-stairs before the airport fire services arrived on scene approximately 1 min 40 sec after the aircraft came to a stop.

METARS FOR SHANNON AIRPORT
EINN 171000Z 30023G35KT 9999 FEW010 SCT013 BKN017 14/11 Q1000 NOSIG
EINN 170930Z 30023KT 9999 -DZ FEW010 SCT014 BKN018 14/11 Q1000 NOSIG
EINN 170900Z 31020G32KT 9999 FEW010 SCT014 BKN018 14/11 Q0999 NOSIG
EINN 170830Z 31023G33KT 9999 FEW010 SCT013 BKN017 14/12 Q0999 NOSIG
EINN 170800Z 30020KT 9999 FEW010 BKN013 BKN018 14/12 Q0999 NOSIG
EINN 170730Z 30021G33KT 9999 SCT012 BKN015 OVC018 14/11 Q0999 NOSIG
EINN 170700Z 30022G32KT 9999 FEW010 BKN015 OVC018 13/11 Q0999 NOSIG


Media Photo's of the crash:





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