|
1. |
factual
information |
| |
|
|
1.1 |
History of the flight |
| |
|
|
1.1.1 |
TF-FIO, a
Boeing 757-208 from Icelandair with the call sign of
FI-315, was on a scheduled flight from Keflavik Iceland (BIKF)
to ENGM. The flight departed BIKF 0735 UTC. The flying
time to Oslo was planned to be 2:10 hours. |
| |
|
|
1.1.2 |
The flight
was dispatched with the following equipment inoperative:
Right ILS, right GPS and center autopilot (A/P). |
| |
|
|
1.1.3 |
The
take-off and landing weights were within normal
limitations. |
| |
|
|
1.1.4 |
The
scheduled flight was uneventful until the descent and
approach to ENGM. The Commander was the pilot flying (PF)
and the First Officer performed the duties of the
non-flying pilot (PNF). The aircraft was flown by the
autopilots (AP). |
| |
|
|
1.1.5 |
At a
distance of approx. 200 NM from ENGM the First Officer
received and noted down the 0920 UTC Automatic Terminal
Information Service (ATIS) for ENGM, which stated RWY 01R
was in use and that the weather was satisfactory for an
approach to this RWY. The Commander planned for a
practice CAT II approach. Instruments and navigation aids
were set and the approach was briefed according to
Icelandair Standard Operating Procedures (SOP). |
| |
|
|
1.1.6 |
From ATC,
the crew received descent instructions and SIG 2E
arrival. (See Appendix no. 1: AIP NORGE/NORWAY AD 2 ENGM
4-16 and 4-15.) The descent was started at time 0930 UTC,
approx. 117 NM (track miles) from ENGM. During the
descend TF-FIO was cleared direct to SONER with free speed
below FL 100. Later the crew was informed that the runway
in use at ENGM was changed to runway 01L. The reason for
the runway change was snow clearing in progress on runway
01R. The whole descent and approach was made in strong
tailwind. ATC did not give any information regarding the
wind. The crew was initially aware of the strong
tailwind, but they also knew there was a light northerly
wind at the airport and due to the high workload in the
approach they failed to notice that the tailwind was much
stronger than forecasted. Wind information was available
through the flight deck instrument equipment. Later
TF-FIO was cleared direct to Non Directional Beacon (NDB)
Solberg (SLB). (See Appendix no. 2: AIP NORGE/NORWAY AD
2 ENGM 5-1.) The change of runway, the strong tail wind
and the shortened approach path resulted in the aircraft
becoming high on the approach profile. |
| |
|
|
1.1.7 |
The
aircraft was flown on the autopilot flight director system
(AFDS). As the aircraft was high on the descent profile,
the Commander extended speed brakes at times, trying to
maintain proper descent profile. During the descent the
aircraft’s speed was slowed down to approx. 240 kt. There
is no CAT II approach onto RWY 01L and the crew performed
a new approach briefing because of the change of runway.
Instrument and navigation aids were correctly set and
identified for a CAT I approach to RWY 01L. |
| |
|
|
1.1.8 |
At
distance 10 NM from SLB, the crew of TF-FIO was cleared to
descent to 3 000 ft and were told they could expect
inbound turn on the localizer (LLZ) in 8 NM. The aircraft
was slowed down to approx. 220 kt and flaps were
extended. Close to overhead the NDB SLB, the crew
received the clearance to intercept the LLZ at time 0945
UTC. Approach mode was selected on the Mode Control Panel
(MCP). The autopilot flight director system captured the
LLZ almost immediately, but the aircraft overshot the
centreline. After crossing the LLZ centreline due to the
limitations of the AFDS, an interception was made from the
right side of the LLZ. The aircraft was at this time
above on the Glide Path (GP). The AFDS corrected to the
left to intercept. At 3 000 ft, the tailwind velocity was
approx. 45 kt. The FDR data indicate the winds at 2 000
ft AGL were not constant, reducing from 30 to 20 kt from
an approximate heading of 200o. As altitude
decreased to 500 ft AGL the FDR winds shifted to a heading
of approximately 60o to 70o and
decreased to approximately 8 kt. (On the ground the wind
was light from the north). |
| |
|
|
1.1.9 |
At the
time, 0946 UTC, the aircraft was cleared by ATC down to 2
500 ft, and this altitude was set on the MCP. This
setting was maintained through the aborted approach. The
gear was selected down. When the aircraft finally was
established on the LLZ, it was at least 1 dot high on the
GP. Flaps 20o had been set with appropriate
speed selection. |
| |
|
|
1.1.10 |
As the
Commander doubted that the AP in AUTO mode could capture
the GP, he disconnected both AP’s and the Auto Throttle
(AT) with the thumb-switches in order to manually capture
the GP from above. The aircraft was flown manually the
remainder of the approach, and the throttles were also
operated manually until TOGA was initiated. Shortly there
after, the Commander noticed that raw data information of
the ILS on his ADI and HSI were lost. No flag warnings
were observed. The Commander reduced the rate of descent
because of the uncertaincy. The raw data signals on his
instrument panel appeared and disappeared again. The
First Officer was informed, but on his instruments all
indications were normal. The crew did not consider a
change of controls at this time. |
| |
|
|
1.1.11 |
The
aircraft descended through 1 000 ft AAL (Above Aerodrome
Level) in an unstabilized mode without the mandatory “call
out”. |
| |
|
|
1.1.12 |
At an
altitude of approx. 580 ft AAL (Flight Data Recorder (FDR)
radio altimeter reading) the Commander decided that he
discontinued the unstabilized approach and initiated a
missed approach. The time was 09:49:11 UTC. He announced
his decision to the First Officer and started a
“Go-Around” (GA). |
| |
|
|
1.1.13 |
The status
of the flight was as follows: The aircraft was above the
GP, and the SOP calls for the GA altitude to be set when
stabilized on GP, therefore the GA altitude was not set on
the MCP. Flaps were not in landing configuration, because
landing Check List was not completed. The Commander’s
instrument panel indicated intermittent ILS failures of
raw data without any flag warnings. The lowest altitude
AAL indicated on the FDR was approx 460 ft. |
| |
|
|
1.1.14 |
The “pitch
over” incident is here described mainly based on the FDR
information with the Commander’s and First Officer’s
reports incorporated: |
| |
|
|
1.1.14.1 |
When the go-around manoeuvre was started by the
use of the auto go-around system, the speed was 182 kt.
The aircraft was flown manually. The aircraft pitch was
increased to approx. 20o and the aircraft
started to climb. Upon initiating the go-around, the A/T
automatically engaged and increased the thrust to the EPR
(Engine Pressure Ratio) limit. In addition, the
application of the under wing engine power also gave pitch
up movement. During the climb the landing gear was
retracted. The flight director pitch initially targeted a
pitch attitude of 15o. The airspeed reached a
maximum of 198 kt before it started to decrease. |
| |
|
|
1.1.14.2 |
Because of
the aircrafts proximity to the MCP selected altitude of 2
500 ft when the go-around was started; the AFDS
transitioned to Altitude Capture almost immediately after
a positive rate of climb was achieved. At time 09:49:19
UTC the aircraft climbed rapidly through the MCP altitude
of 2 500 ft, The FD continued to give commands targeting
the MCP selected altitude. The A/T changed from go-around
mode to targeting the MCP selected speed (150 kt). The
maximum aircraft pitch (21o) was reached. The
thrust remained near maximum because the Commander held
the throttles forward. The speed was decelerating and
quickly dropped below MCP speed. The pitch flight
director continued to give command to lead the pilot back
to the MCP altitude. |
| |
|
|
1.1.14.3 |
At time
09:49:34 UTC the aircraft reached a peak altitude of 2895
ft (FDR QNH corrected altitude) and the speed had
decreased to 137 kt. (The reference speed for flaps 20o
is 131 kt.) Nose down was applied manually by the
control column. The First Officer called for “bug up”
(for the flap up manoeuvring speed) to set the airspeed
indicator, and the Commander pushed on the Flight Level
Change Switch (FLCH) button to break the flight director
altitude lock on. The speed selected on MCP was changed
from 150 kt to 210 kt. During the next seconds, a full
nose down input on the control column was made manually.
The aircraft pitched over to an attitude of approx. –30o,
and for a period of approx. 5 seconds the FDR indicates
negative g-values with a maximum load factor of –0.6 g. |
| |
|
|
1.1.14.4 |
The
control column was briefly returned to near neutral, and
then another abrupt large nose down column input was
made. The aircraft pitched over rapidly with the speed
increasing excessively. The FDR data show that the Ground
Proximity Warning System (GWPS) aural warning of “Pull up”
was activated. The aircraft was now in a steep dive and
rapidly descending. During the dive the flight director
pitch bar gave pitch up commands relative to the pitch
attitude. The A/T reduced the trust from 98% N1 to 45%
N1. At time 09:49:44 UTC the aircraft pitch attitude had
peaked at -49o and was beginning to increase
positively. |
| |
|
|
1.1.14.5 |
At this
time the First Officer called out “PULL UP!” - “PULL
UP!”. The GPWS aural warnings of “TERRAIN” and then “TOO
LOW TERRAIN” were activated. Both pilots were active at
the control columns and a maximum “up” input was made. A
split between left and right elevator was indicated at
this time. It appears the split occurred due to both
pilots being active at the controls. The pilots did not
register the aural warnings. During the dive the airspeed
increased to 251 kt and the lowest altitude in the
recovery was 321 ft radio altitude with a peaked load
factor of +3.59 g’s. |
| |
|
|
1.1.14.6 |
The
recovery continued with the aircraft pitch attitude
increasing to about 40o, and a
positive rate of climb was established. The AT increased
the thrust back to around 98% N1. Eventually a normal
trimmed flight was established, after a short level off
around 3 000 ft, finally at 4 000 ft, after several abrupt
control inputs. |
| |
|
|
1.1.15 |
Reports
from the chief cabin attendant and some of the passengers
on the status during the “pitch-over” can be summarized: |
| |
|
| |
| |
The
movement of the aircraft resulted in water being
expelled from toilets and all loose articles started
to move around. Bags stored from underneath seats
became loose, newspapers moved out of paper racks,
magazines and books out of seat pockets, mobile phones
and spectacles were lifted from pockets of personal
clothing. In some cases, articles belonging to
passengers sitting in front of the wing section ended
up in the aft galley. Fortunately, everybody, with
one exception, had their seatbelts fastened. He did
not know whether he had fastened it or if it had
become unfastened. He was in shock and demonstrated
several signs of distress.
The
passengers felt the positive and negative g-forces as
extreme and very uncomfortable. It led to chaos in
the cabin. The manoeuvres were very scaring, some
were screaming and others were praying to God. |
|
| |
|
|
1.1.16 |
When
established at 4 000 ft the appropriate selections were
made on the MCP. The AP was engaged. The First Officer
reported the missed approach to the Approach Control,
which gave TF-FIO vectors for a new approach. No
information about the incident was given, and ATC was not
made aware of the abnormal manoeuvre. |
| |
|
|
1.1.17 |
The whole
“pitch-over” manoeuvre was made in clouds. Some of the
passengers had a brief view of the ground when the
aircraft was at the lowest point. For the flight deck
crew, the incident took place in IMC. |
| |
|
|
1.1.18 |
The
Commander gave a short announcement to the passengers and
cabin attendants stating the approach had not been
successful. A new approach had been started, and a
landing could be expected within 10 minutes. When
established on final the Commanders ILS raw data
disappeared again. He handed over the control of the
aircraft to the First Officer who landed the aircraft at
time 1102. |
| |
|
|
1.1.19 |
Because of
the negative and positive load factors, the chaos in the
cockpit was identical to that in the cabin. Flight bags
and papers had been thrown about. During the taxiing-in
the pilots made a short review (debriefing) between
themselves of the “pitch-over” manoeuvre without coming to
a conclusion of what really had happened. |
| |
|
|
1.1.20 |
After
parking at the gate the passengers with destination Oslo
left the aircraft without any orientation/briefing of the
missed approach and the following manoeuvres. The
passengers were confused and many were shocked and
frightened. |
| |
|
|
1.1.21 |
When the
aircraft was parked, the pilots cleaned up the cockpit.
The Commander gave a short initial briefing to the cabin
attendants. He requested contact with a technician. The
First Officer had requested through Scandinavian Airlines
System (SAS), the ground-handling agent, a technician to
report to the aircraft. SAS contacted the Braathens
airline company and a technician arrived, informing the
Commander that his licence on B757 had expired, and as far
as he knew there were at present no maintenance contract
between Icelandair and Braathens. The technician also
informed the Commander that by contacting Icelandair the
validity of his licence could be extended. This would
probably take some 30 minutes. (A valid contract was in
force between Icelandair and the company Britannia of
Sweden which operates B757’s. However this company did
not operate at Gardermoen airport at the time of the
incident. It has later been confirmed that Britannia
technical personnel were available at the time of the
incident.) The Commander was not aware of this fact. |
| |
|
|
1.1.22 |
At the time
the Braathens’ technician arrived, the Commander was in
the telephone with the Icelandair Maintenance Control at
Keflavik. He informed the company of the failures of the
basic ILS data, the lack of flag warnings, and thereafter
handed the phone over to the technician. In agreement
with the Maintenance Control in Iceland, the Braathens’
technician made BITE tests of the instrument system. When
the tests were completed, he checked the raw data for
normal indications and informed the Commander about the
results. No information of load or speed exceedances was
given to the technician. |
| |
|
|
1.1.23 |
The
technician was finally asked by the Commander to check the
flaps operation. The flaps were extended and retracted.
A normal operation was indicated. |
| |
|
|
1.1.24 |
The
Commander took time to give a thorough briefing of what he
thought had taken place to the stunned cabin attendants.
He also asked them if they wanted to continue onwards on
the scheduled flight. All five of them agreed to continue
their duties. |
| |
|
|
1.1.25 |
After a discussion with the First Officer who was
concerned of possible exceedance of maximum flaps 20o
speed, the Commander decided to continue the flight
according to schedule. The First Officer agreed to the
continuation of the flight. The flight crew were not at
the time aware of the fact that the aircraft had been
overstressed. Possible exeedances of load factors were
not discussed. When the continuing passengers for
Stockholm boarded, they also received a briefing of the
missed approach and the following “pitch-up”. |
| |
|
|
1.1.26 |
The flight
continued to ESSA and later on to Iceland. The flights
were uneventful, and all systems worked normally. |
| |
|
|
1.1.27 |
During the
stop at ESSA, a phone call to the company chief pilot was
made. The Commander requested a meeting for a debriefing
of the aborted approach at Oslo airport Gardermoen upon
arrival Iceland. |
| |
|
|
1.1.28 |
After
landing at Keflavik airport Iceland, the chief pilot of
the Icelandair met the crew of TF-FIO at Reykjavik.
Details from the manoeuvring of the aircraft were given.
The FDR was removed from the aircraft upon order from the
chief pilot. |
| |
|
|
1.1.29 |
The
aircraft continued operating until 25th of
January when a C-check was performed. The aircraft was
released on the 7th of February, and was flying
on scheduled flights until 13th of March when
the Boeing Company recommended further inspections after
evaluating data of the incident from the FDR. |
| |
|
| |
|
|
1.2 |
Injuries to persons |
| |
| INJURIES |
CREW |
PASSENGERS |
OTHERS |
| FATAL |
|
|
|
| SERIOUS |
|
|
|
| MINOR/NONE |
7 |
75 |
|
|
| |
|
| |
|
|
1.3 |
Damage to aircraft |
| |
|
| |
None |
| |
|
| |
|
|
1.4 |
Other damage |
| |
|
| |
None |
| |
|
| |
|
|
1.5 |
Personnel information |
| |
|
|
1.5.1 |
The
Commander |
| |
|
|
1.5.1.1 |
The
Commander, a male aged 43, possessed an ATPL-A (Airline
Transport Pilot Licence (Aircraft)) valid for Boeing
757/767 type rating. The licence was valid until the 23rd
of August 2006. His last Class 1 medical examination was
carried out on the 21st of August 2001 and was
valid until 21st of February 2002. The
Commander’s Proficiency Check was valid until the end of
March 2002. |
| |
|
|
1.5.1.2 |
The
Commander began his flying career in April 1986. |
| |
|
|
1.5.1.3 |
In June 1975 the Commander started work for
Icelandair as a baggage handler and worked as such on his
school vacations for some years. He started working for
the company as an aircraft maintenance technician and in
April 1986 he started his career as a First Officer flying
the Fokker F-27. |
| |
|
|
1.5.1.4 |
The
Commander had 581 flying hours the previous year and had
accumulated a total of 8 034 hours of flying time. |
| |
|
|
1.5.1.5 |
| FLYING
EXPERIENCE |
TOTAL |
ON TYPE |
| LAST 24
HOURS |
2:40 |
2:40 |
| LAST 3
DAYS |
2:40 |
2:40 |
| LAST 30
DAYS |
34:35 |
34:35 |
| LAST 90
DAYS |
126:20 |
126:20 |
|
| |
|
|
1.5.1.6 |
The
Commander was off duty the last four days before the
incident. The incident took place on the first of three
scheduled flight sectors that day. |
| |
|
|
1.5.2 |
The
First Officer |
| |
|
|
1.5.2.1 |
The First
Officer, a 26-year old male, possessed a CPL-A (Commercial
Pilot Licence (Aircraft)) valid for Boeing 757/767. The
licence was valid until 23rd of August 2006.
His last Class 1 medical examination had been carried out
on the 21st of August 2001 and was valid until
23rd of August 2002. The First Officer’s
Company Proficiency Check was valid until the end of March
2002. |
| |
|
|
1.5.2.2 |
The First
Officer started to work with Icelandair as a dispatcher.
1st April 1999 he began his flying career as
First Officer flying the Fokker 50. |
| |
|
|
1.5.2.3 |
The First
Officer had 495 flying hours during the previous year and
had accumulated a total of 2 485 hours of flying time. |
| |
|
|
1.5.2.4 |
| FLYING
EXPERIENCE |
TOTAL |
ON TYPE |
| LAST 24
HOURS |
7:19 |
7:19 |
| LAST 3
DAYS |
14:27 |
14:27 |
| LAST 30
DAYS |
30:53 |
30:53 |
| LAST 90
DAYS |
107:45 |
107:45 |
|
| |
|
|
1.5.2.5 |
The
First Officer was on the first sector of three, on the
second day of a two-day schedule. His flight duty period
on the previous day was 9:29 hours. He had a rest period
of 13 hours before returning to work on the 22nd
of January. |
| |
|
| |
|
|
1.6 |
Aircraft information |
| |
|
|
1.6.1 |
Boeing
757-208, registered TF-FIO, is a medium range twin
turbofan airliner. It is powered by two 178,4 kN (40,100
lb st) Rolls-Royce RB211-535-E4 turbofans. The aircraft
was manufactured in 1999. |
| |
|
| |
The
aircraft was dispatched from Keflavik with the following
equipment inoperative: Right ILS, Right GPS and Center
autopilot. These dispatch deviations were allowed
according to the Minimum Equipment List (MEL) and accepted
by the Commander of the flight. |
| |
|
|
1.6.2 |
In February
2002, after the incident, the aircraft went through a
C-check. When Boeing became aware of the seriousness of
the incident, the company requested Icelandair to perform
a very extensive structural inspection on the airplane.
The inspection was focused on the fuselage, wings,
empennage and the engine strut connection. The inspection
asked to look for distortion, flaked paint, cracks, and
buckled structure and for fasteners that have pulled out
or “are not there”. The inspection was very detailed, and
required many of the inspection tasks that already had
been accomplished during the above-mentioned C-check. The
Boeing Company sent a wing structure engineer specialist
to assist with determining possible damage, and to
determine if further inspection would be required. It
turned out that a re-inspection of the parts that had been
inspected during the C-check was not necessary. As a
result of this, the extent of the inspection decreased.
It was apparent that the airplane’s structure had not been
damaged. As a precaution, the following parts were
exchanged: |
| |
|
| |
| |
1. |
Six fuse bolts in
the engine strut connection |
| |
2. |
The forward bolts
on the flap track to wing connection |
| |
3. |
The two bolts that
run through the two main rollers, on each flap track. |
|
| |
|
| |
The engine
manufacturer, Rolls Royce, decided after contact with
Icelandair that no special inspection would be necessary
on the engines. Rolls Royce did, however, recommend that
the engines mount connection points should be inspected
next time the engines were removed. |
| |
|
| |
|
|
1.7 |
Meteorological
information |
| |
|
|
1.7.1 |
The flight
en route was made in VMC and in strong tailwind. |
| |
|
|
1.7.2 |
The missed
approach and the following manoeuvre were made in IMC (in
clouds). |
| |
|
|
1.7.3 |
The
forecast for ENGM at 0500 UTC for the period 06 –15: Wind:
Variable 05 kt. Visibility 2 000 m in snow. Clouds:
Scattered at 500 ft, broken at 1 000 ft. Temporary 06 –
15: Visibility 1 000 m in snow, vertical visibility 400
ft. |
| |
|
|
1.7.4 |
The actual
weather at ENGM 0620 UTC: Wind: 020o 5 kt.
Visibility: 1 500 m in snow. Vertical visibility: 600
ft. Temperature and dew point: -4 oC / -5
oC. QNH: 990 hPa.
Temporary: Visibility 1 000 m in snow. |
| |
|
|
1.7.5 |
Automatic
Terminal Information System (ATIS): |
| |
| |
Information OSCAR
at 0920 UTC: |
| |
Braking Action at
time 0810, 43-43-46. Runway 01R in use. W/V 010/3.
Visibility 3 000 m, light freezing drizzle. Few
clouds at 200 ft, scattered clouds at 300 ft, broken
cloud base at 500 ft. TEMPO visibility 1 000 m,
freezing drizzle and mist, vertical visibility 400
ft. Tailwind reported 20 kt down to 200 ft. |
|
| |
|
|
1.7.6 |
Actual
weather at 0950 UTC: Wind: 360o 2 kt.
Visibility: 2 700 m. Weather: Freezing drizzle, mist.
Clouds: Few at 100, scattered at 200, broken at 300.
Temperature and dew point: -4o C / -4o
C. QNH: 985 hPa. Temporary: Visibility: 1 000 m,
freezing drizzle, mist, vertical visibility 200 ft. |
| |
|
|
1.7.7 |
January 22
at 0850 an “Aerodrome warning” was issued by AIS/MET
Department ENGM: |
| |
|
| |
| |
2. |
Crosswind: |
Wind 2 000 ft 170o
/ 10 kt |
| |
|
|
Wind 3 000 ft 245o
/ 40 kt |
| |
|
|
Wind 4 000 ft 240o
/ 45 kt |
| |
3. |
Freezing: |
|
| |
|
Rain/Drizzle: |
Icing condition due
to intermittent freezing drizzle |
|
| |
|
| |
|
|
1.8 |
Aids to navigation |
| |
|
| |
Ground
based aids to navigation had no effect on the incident. |
| |
|
| |
|
|
1.9 |
Aerodrome information |
| |
|
|
1.9.1 |
Oslo
airport Gardermoen (ENGM) is equipped with modern
communication- and navigation equipment. There are
several area radio navigation- and approach-aids. These
consists of NDB’s, DME’s and DME/VOR’s. There are
installed ILS to all runways. Runway 01R has a ILS of CAT
II standard, while runway 01L’s ILS is of CAT I standard.
The aerodrome is furnished with both approach- and ground
radar. All aids worked normally at the time of the
incident. |
| |
|
| |
|
|
1.10 |
Communications |
| |
|
|
1.10.1 |
The radio
communications between TF-FIO and the different ATC
controllers functioned normally. Judging from the
recordings, radio reception was good and there was no
interference on the frequency. The phraseology used was
mainly in accordance with the instructions. |
| |
|
| |
|
|
1.11 |
Flight recorders |
| |
|
|
1.11.1 |
The
aircraft was equipped with a Honeywell flight data
recorder, P/N 980-4700-042, S/N 3979. The FDR was removed
from the airplane January 22th 2002. The data
has been of great use for this investigation. |
| |
|
|
1.11.2 |
A cockpit
voice recorder (CVR), type L3 Communication (Fairchild)
type 2100-1020-00 was installed. As the flight continued
after the incident with electrical power on the system, no
information from the CVR has been available to AAIB/N. |
| |
|
| |
|
|
1.12 |
Wreckage and impact information |
| |
|
| |
Not
relevant. |
| |
|
| |
|
|
1.13 |
Medical and
pathological information |
| |
|
| |
There were
no medical cause factors in this incident. |
| |
|
| |
|
|
1.14 |
Fire |
| |
|
| |
Not
relevant |
| |
|
| |
|
|
1.15 |
Survival aspects |
| |
|
| |
Not
applicable. |
| |
|
| |
|
|
1.16 |
Test and research |
| |
|
| |
Not
relevant. |
| |
|
| |
|
|
1.17 |
Organizational and
management information |
| |
|
|
1.17.1 |
The
airline |
| |
|
|
1.17.1.1 |
Icelandair
as an airline traces its roots to the year 1937 when a
fledging airline, Flugfelag Akureyrar, was founded at
Akureyri on the north coast of Iceland. In 1943 the
company moved its headquarters to the capital city,
Reykjavik, and changed its name to Flufelag Íslands. The
airline later assumed the international trade name of
Icelandair. |
| |
|
|
1.17.1.2 |
Another
important milestone was passed in 1944, when three young
Icelandic pilots, returning from their flight training in
Canada, founded Loftleidir, which later became known as
Icelandic Airlines. Initially both companies concentrated
on Icelandic domestic air services. However, in 1945
Flugfelag Íslands made its first international flights to
Scotland and Denmark. Loftleidir started international
operations in 1947. It’s pioneering low-fare services
across the North-Atlantic commenced in 1953. |
| |
|
|
1.17.1.3 |
In 1973 it
was agreed to merge Flugfelag Íslands and Loftleidir under
a new holding company, Flugleidir. In October 1979
Flugleidir assumed all operating responsibilities of its
two “parents”, and decided to use Icelandair as its
international trade name, only retaining the Flugleidir
name in the Icelandic domestic market. |
| |
|
|
1.17.1.4 |
The company
is 100% privately owned by 4517 Icelandic shareholders.
It is the largest private company in Iceland, employing
over 2 000 people. |
| |
|
|
1.17.1.5 |
Icelandair has been a member of IATA
(International Air Transport Association) since 1950, a
member of AEA (Association of European Airlines) since
1957, and a member of the Flight Safety Foundation since
1966. |
| |
|
|
1.17.2 |
Organization |
| |
|
|
1.17.2.1 |
Icelandair operated scheduled passenger, cargo and
charter flights primarily between Iceland, Europe and
North America. It is one of the largest aviation
operators in Iceland and has a long and distinguished
operational record. In 1990 the airline started to expand
and restructure its aircraft fleet. It is presently
operating a fleet of 11 Boeing 757-200 and 757-300
aircraft. |
| |
|
|
1.17.2.2 |
Authority
for operation is by an Air Operators Certificate (AOC)
issued by the CAA of Iceland. Iceland is a member of the
JOINT AVIATION AUTHORITIES, and Icelandair operates
according to JAR-OPS 1 requirements. |
| |
|
|
1.17.2.3 |
An
Accountable Manager has the overall responsibility for all
aspects of aircraft operation and Nominated Post Holders
are responsible for: |
| |
|
| |
| - |
Flight Operation |
| - |
Maintenance Systems |
| - |
Crew training |
| - |
Ground Operations |
|
| |
|
| |
At the time
of the incident one person is Nominated Post Holder for
Flight Operation, Crew Training and Ground Operation. |
| |
One other
person is Nominated Post Holder for Maintenance Systems. |
| |
|
|
1.17.2.4 |
A
comprehensive Flight Operations Manual (FOM), supplemented
by Aeroplane Operating Manual (AOM), Route Manual (RM) and
Training Manual (TM) controls the different aspects of
Flight Operations. A Manual System described by a “manual
tree” places the different manuals in relation to each
other. |
| |
|
|
1.17.2.5 |
Crew selection, initial technical- and flight
training and recurrent training satisfy the requirements
from the authorities. The training is organized in a
series of modules given at different times and at
different locations. Crew Resource Management (CRM) is
one such module. The modular system places increased
workload on Flight Operations management in the areas of
checking and supervision in order to assure that all
safety critical items and procedures are adequately
addressed. The new training facility in Reykjavik was
opened in December 2001 before the incident occurred.
After the incident Icelandair has started using the new
in-house training facility utilizing the latest
state-of-the-art training aids. |
| |
|
|
1.17.2.6 |
Icelandair
was not at the time of the incident utilizing a systematic
analysis of flight recorder data of all flights for
supervision, control and monitoring of the company’s
operational standard. The present aircraft fleet is
equipped with Quick Access Recorders making such analysis
possible. |
| |
|
|
1.17.2.7 |
Icelandair
has a philosophy and a set of policies as well as
procedures and practices in order to maximize the safety
of all flights. |
| |
|
|
1.17.3 |
Training
and selection |
| |
|
|
1.17.3.1 |
In order to
be accepted as a pilot candidate for Icelandair, the
flying experience required is either: |
| |
|
| |
|
1) |
having previously received type rating on an
aircraft requiring two pilots or |
|
2) |
having
accumulated at least 1 500 flight hours, or |
|
3) |
having
accumulated at least 500 flight hours and completed
specific training courses approved by ICAA in
preparation for training on turbo-jet airplanes. |
|
| |
|
|
1.17.3.2 |
The pilot
candidates to Icelandair must in addition pass an
extensive selection process before being accepted for
pilot training in the company. |
| |
|
|
1.17.3.3 |
The
candidates have to undergo several psychological tests
like MMPI (Minnesota Multiphasic Personality Inventory).
(MMPI is a method for measurement of traits of
personality, such as those having to do with interests,
attitudes, emotional adjustment and social relations,
all-important aspects of a pilot’s personality and
abilities). In addition the pilot candidates are checked
for psycho-technical abilities, communication skills,
leadership potential, stress tolerance and inductive
intelligence. Further the candidates have to demonstrate
basic flying and CRM (in this connection Cockpit Resource
Management) skills in a flight-training device where two
applicants are tested at the same time. |
| |
|
|
1.17.3.4 |
Being
accepted as a pilot in Icelandair the pilots undergo an
initial course including type rating, and a four weeks
ground course followed by two weeks of simulator
training. Finally landing and line flying under
supervision is given for 1 – 3 weeks. Both flight
crewmembers had undergone this flight training. |
| |
|
| |
|
|
1.18 |
Additional
information |
| |
|
|
1.18.1 |
From Icelandair Standard
Operating Procedure (SOP): |
| |
|
|
1.18.1.1 |
2.1
Checklists |
| |
---------.
The pilot assigned to read the checklist will not initiate
a checklist but he will remind the PF when he feels the
call for the checklist is becoming overdue. ----------. |
| |
|
|
1.18.1.2 |
2.4 FCM/CDU |
| |
---------. In-flight: FMC/CDU route and approach
modifications should be inserted by the PNF and executed
only after confirmation by the PF. --------. |
| |
|
|
1.18.1.3 |
2.9 Approach considerations |
| |
---------.
Crews can reduce risk with planning and vigilance.
--------. Plan to abandon the approach if company
standards for a stabilized approach are not met. |
| |
|
| |
After
commencement of an approach, a missed approach should be
conducted when: |
| |
|
| |
| - |
Confusion exists or crew coordination breaks
down; |
| - |
There
is uncertainty about situational awareness; |
| - |
Checklists are being conducted late or the crew is
task overloaded; |
| - |
Any
malfunction threatens the successful completion of the
approach; |
| - |
The
approach becomes unstable in altitude, airspeed, glide
path, course or configuration; |
| - |
---------. |
|
| |
|
|
1.18.1.4 |
2.10
Stabilized approach |
| |
An approach
is stabilized when the airplane is flown: |
| |
|
| |
|
- |
Along the desired
flight path in landing configuration; |
|
- |
With a heading
needing only small corrections to maintain the desired
flight path; |
|
- |
At the correct
approach speed including relevant and agreed upon
corrections; maintaining an acceptable rate of
descent; and |
| - |
At a thrust setting
needing only small corrections to maintain the desired
flight path. |
|
| |
|
| |
In IMC the
approach should be stabilised no later than 1 000 ft AAL. |
| |
|
|
1.18.1.5 |
2.12 Flight
deck Discipline |
| |
Both pilots
should be aware of altitude, aeroplane position and
situation. If any doubt, investigate. |
| |
-----------. Use standard callouts at all times. The
pilot not flying should accomplish callouts based on
instrument indications or observations for the appropriate
condition. -------- If the PNF fails to make the
required callout the PF should make it. -------. Pilots
are expected to give all commands, challenges and
responses in a command tone (clearly). |
| |
|
|
1.18.1.6 |
Descent/Approach Procedures |
|
|
In these
procedures it is stated that PNF shall call out at 1 000
ft AAL (QNH): “One thousand” and the PF shall
confirm. |
| |
It is also
stated: “Accomplish landing checklist to flaps at glide
slope intercept. When landing flaps are set, complete
landing checklist. |
| |
|
|
1.18.1.7 |
7.7 Missed
Approach Procedure. ILS Approach |
| |
The SOP has
a detailed procedure of what PF’s and PNF’s duties. It
starts with the PF shall announce go-around, he shall push
the GA switch and order “FLAPS TWENTY”. Both pilots shall
verify rotation to go-around attitude and thrust increase,
and verify flight mode annunciation on ADI for proper
mode. The PNF shall verify go-around thrust and adjust if
necessary. He shall call out “POSITIVE CLIMB”. The
procedure continuous with gear retraction and the setting
of climb power. |
| |
|
| |
|
|
1.19 |
Useful or effective
investigation techniques |
| |
|
|
1.19.1 |
Nothing
other than routine investigative methods have been used in
this investigation. |
| |
|
| |
|
|
2. |
Analysis |
| |
|
|
2.1 |
The descent and the unstabilized
approach: |
| |
|
|
2.1.1 |
The descent
was started at normal time and distance from the planned
landing runway. After the descent had been initiated,
there was a change of runway; but this made only a minor
shortening of the distance. Later the descent distance
was shortened twice by ATC. This, together with the
strong tailwind, caused the aircraft to become high on the
approach profile. Contributing to this incident was also
the air traffic controller’s vectoring of the airplane.
To compensate, the Commander was using speed brakes.
In
spite of this, the aircraft was still high when
approaching the point of the glide path capture for runway
01L. The Commander did not contact ATC in order to extend
the descent distance. To get rid of the high energy of
the aircraft became a problem. A stabilized approach is
critical for a safe landing. Everyone involved in the
system has an important role to play. When the last turns
were made to intercept the LLZ, they were made too late
with the result that the aircraft overshot. A new
intercept from the opposite side had to be made. During
the hearing of this report AAIB/N received the following
from CAA Iceland: |
| |
|
| |
“We think
that there should be more emphasis on the captains
responsibility to plan his approach in such a way that a
stable approach can be made, to follow standard operating
procedures and to follow and see to it that CRM procedures
are followed. If the captain fails in his duties, the
first officer should of course draw the captains attention
to the irregularity.” |
| |
|
| |
AAIB/N are in agreement with this statement. |
| |
|
|
2.1.2 |
When,
finally, the aircraft was stabilized on the LLZ, it was
high on the glide path, the correct flap setting was not
made, and the approach speed was varying, being too high.
The final landing checklist could not be completed
according to SOP, as the completion of this checklist
depended on being stabilized on the glide path. The
Commander analysed the situation during the continued
approach, and finally, when he also lost raw data from the
ILS on his instruments, he correctly decided – late in the
sequence - to abandon the approach and to perform a
go-around. |
| |
|
|
2.1.3 |
AAIB/N
consider that the Commander entered into a situation of
mental overload. The overload started when he did not
comprehend the problem being high on the descent profile.
The aircraft ended being unstabilized on the final
approach. According to SOP, the aircraft should be in
landing configuration and only very small corrections to
speed, power and attitude should be rendered at this final
stage of approach. |
| |
|
|
2.1.4 |
In an
approach in marginal weather, there should normally be a
high degree of cooperation between the crewmembers. AAIB/N
have reached the opinion that sufficient cooperation did
not take place. The SOP and the flight crew training,
especially the CRM-training, should have lead to a more
active crew cooperation. The hesitant attitude of the
First Officer during the approach is considered an
important factor for the unstabilized approach and the
Commander’s mental overload situation. It is of no less
importance the obligation of the Commander to remind the
Co-pilot of his duties as Pilot Not Flying. The lack of
call-outs regarding altitudes and speeds reinforced the
difficult situation that eventually developed. The decent
and approach were not performed according to the company
SOP. |
| |
|
| |
|
|
2.2 |
The go-around: |
| |
|
|
2.2.1 |
It is
difficult to fully understand why the crew unintentionally
entered the extreme manoeuvres following the abortion of
the approach. This part of the flight was performed in
IMC. In trying to understand why it happened, it is
necessary to look into details of the “upset”. |
| |
|
|
2.2.2 |
When the
Commander finally, too late in the sequence in the opinion
of AAIB/N, decided to discontinue the unstabilized
approach, he was flying the aircraft manually. When
initiating the auto “Go-around”, the auto throttle became
engaged, and increased automatically the engine trust to
the EPR limit. The application of the under wing engine
power also gave a pitch up movement. The flight director
pitch bar commanded a pitch attitude of 15o.
(The AFDS commanded a level off at 2 500 ft (the last
assigned altitude by ATC). The AFDS calculates the high
closure rate to 2 500 ft and captures that altitude
almost immediately; causing the A/T to change from
Go-around mode to retard power to MCP selected speed (150
kt)). The aircraft therefore climbed very rapidly through
the MCP selected altitude of 2 500 ft and with the
aircraft pitch increasing to 21o. AAIB/N
considers that the Commander at this time had lost
situational awareness (being “behind the aircraft”). |
| |
|
|
2.2.3 |
As the
Commander noticed the speed to be rapidly decreasing, he
pushed the control column forward. This was in order to
follow the command of level off at 2 500 ft. Pushing the
control column forward is also an elementary flying
procedure to increase the speed and to prevent the
aircraft from entering a stall. |
| |
|
|
2.2.4 |
The First
Officer at this time called for “Bug up”. The Commander
reached for and resat the MCP speed. This was contrary to
company Standard Operation Procedure. Simultaneously the
Commander continued to push the control column even more
forward. The aircraft reached a maximum altitude of 2 895
ft and the load factor reached a negative g-value of –0.6. |
| |
|
|
2.2.5 |
The
aircraft then entered a rapid dive, and the speed
increased. Different warnings were given of ground
proximity and the command of pull up by the aircraft
systems, but not registered by the crew. The A/T reduced
the trust from 98% N1 (full power) to 45% N1 (idle
power). The negative pitch reached a maximum value nose
down of 49o. Up to this time the First Officer
had been somewhat passive and confused. Now he acted as
an active and co-operative crew member and asked: “What
are you doing” and next, he called out: “Pull up!” -
“Pull up!”. Both pilots pulled back on their control
columns, and the aircraft, after reaching a maximum speed
of 251 kt, recovered from the dive with a clearance of 321
ft (radio height) over the north end of the runway 01L.
During the pull-up the load factor increased to positive
G-value of 3.59. |
| |
|
| |
To
the hearing of this report the Commander gave AAIB/N the
following statement: |
| |
|
| |
“I
believe my First Officer acted as an active and
co-operative crewmember throughout the flight, but in the
final approach, due to the abnormally high workload, both
of us became occupied handling details instead of looking
at the whole picture. And when we suddenly got the
altitude capture commands from our FDS, when both of us
were mindset for a go-around, we became confused and later
on the unbelievable nose down pitch attitude, we became
even more confused.” |
| |
|
|
2.2.6 |
The
aircraft pitch then increased to about 40o nose
up, and after several abrupt control inputs, the aircraft
was levelled off at 4 000 ft. Pitch upsets are defined as
pitch in excess of 25o up and 10o
down. As the pitch values were outside these limits, the
artificial horizon indication became all brown as
registered by the Commander when the aircraft descended.
This baffled the Commander even more. (There is at least
0.25 inches of blue visible on the HSI during this
situation on the accident airplane as delivered.) |
| |
|
|
2.2.7 |
The
importance of crew cooperation is imperative. In this
case, AAIB/N is of the opinion there was a complete
breakdown of crew management and a lack of interaction at
an early stage. When the confusion started, the
combination of one pilot manually operating the controls
partly in opposition to the automatic throttle movement
made this “upset” understandable. This can be referred to
as an “automation trap”. When “bug-up” is selected to
target speed, this command gets cancelled by selection of
“Flight Level Change” or by altitude capture. The speed
then becomes “present speed”. This caused the aircraft to
act differently than the pilots had anticipated. This
resulted in confusion and was probably a factor in causing
the incident to occur. In the opinion of AAIB/N it is not
satisfactory that a seemingly properly trained and
qualified airline crew should end up loosing control of a
modern airliner and cause an incident like this one. |
| |
|
| |
|
|
2.3 |
Background - training |
| |
|
|
2.3.1 |
Selection
of individual crewmembers, initial training, type training
and recurrent training in Icelandair confirms to the
traditional pattern found in most airlines. The training
is organized in modules and subcontractors may present the
different modules individually in different locations.
Each module in itself can be fully satisfactory as far as
contents and presentation is concerned, but the challenge
for the airlines operational management is to assure that
the total training program, with all its interfaces,
fulfils the goal of the operator as well as the
requirements of the aviation authorities. A Quality
Assurance System with the necessary oversight- and
supervision systems are required to monitor the complete
training process to detect possible “glitches” in the
interfaces between modules in order to prevent latent
failures in the system. |
| |
|
|
2.3.2 |
CRM
training could be used as an integration tool in order to
identify problem areas and at the same time prepare
crewmembers for better cooperation when handling unusual
and unexpected occurrences during flight. |
| |
|
|
2.3.3 |
A system
utilizing Flight Recorder Data for continuous monitoring
of the flight operational standard and the effectiveness
of company procedures and regulations were not in use in
Icelandair at the time of the incident. Such a system,
based on data from the QAR (Quick Access Recorder), and
used to collect statistical data, has been found by many
operators to give valuable early warnings about problems
not easily detected by other means. The technical
equipment needed for the collection of such data is
already installed in Icelandair's Boeing 757 fleet. |
| |
|
| |
|
|
2.4 |
Crew Resource Management (CRM) |
| |
|
|
2.4.1 |
CRM
training is required for JAR OPS 1 operations. The
application of CRM concepts can approve crew performance
through enhanced communication training, problem solving,
decision-making and workload management. In the present
situation the crew demonstrated omission of action: ie.
insufficient approach briefings, failure to administer
high workload and a lack of risk assessment - recognize
failure from standard procedures. Failures in CRM may be
associated with complacency or overconfidence. |
| |
|
|
2.4.1.1 |
An
important part of pilot training today is CRM training.
CRM is not a universal recipe for safety, but a highly
effective and essential aspect of flight crew training.
CRM has passed through a number of generations during its
lifetime of less than 20 years. The original CRM was a
response to human errors, especially those associated with
ineffective teamwork and decision-making. The fifth
generation is based on the fact that there will always be
human errors and that they are inevitable. To be
effective, the training must therefore credibly
communicate the limits of human factor performance with
regard to mental capacity to function under stress, and
thus make the crew more aware of personal limits and
capabilities. |
| |
|
|
2.4.1.2 |
In addition
the effect of CRM training is dependent of different
cultures under which it is performed. In Icelandair one
would presume that all the crew have the same national
culture thus simplifying many aspects of the training.
However, one must realise that crew behaviour is shaped by
three additional cultures: professional culture,
organizational culture and the company’s safety culture. |
| |
|
|
2.4.1.3 |
Professional culture reflects the attitudes and values
associated with an occupation. For pilots this often
means unrealistic denial of vulnerability to the multiple
stressors of the occupation. Such attitudes may reduce
the acceptance of CRM training. Further we have
organizational culture, which is manifested in the
openness between management and employees or in the
attitudes and behaviour of critical role models such as
air check men. Finally a negative organizational culture
can result in CRM being viewed as yet another square
filling exercise rather than the reflection of the
organizations standards. |
| |
|
|
2.4.1.4 |
Last but
not least will the company’s safety culture be manifested
in knowing channels to communicate safety concerns and a
sense that these should be addressed. It is essential
that training and evaluation not only focus on the
avoidance of error, but also on the management of error.
In accordance with this view the last generation of CRM
training is trying to get rid of the term “pilot flying
and pilot not flying” and substitute it with “pilot flying
and pilot monitoring”. In the present situation the crew
did not function as a crew, but rather as two individuals
in the same cockpit without a common plan for the flight
and landing. The CRM training they had received prior to
the incident had not been integrated in their behaviour
the way it was supposed to: ”CRM is the utilization of all
available resources to achieve safe and efficient
operation to enhance the communication and the management
skills of the flight crewmember concerned”. Lack of
planning left the pilots in a stressed state where they no
longer were able to communicate their doubts or actions.
Rather than hiding errors or shortcomings, the open
sharing of error and the effective management of error
provide reinforcement of CRM practice. |
| |
|
|
2.4.1.5 |
Lack of joint CRM training with the rest of the
crew was obvious in the way the crew managed the situation
immediately after landing: It took some minutes before
the cabin crew got any information from the cockpit about
the incident, therefore they were not able to inform the
passengers properly about the situation or make sure the
passengers got a psychological debriefing immediately
after leaving the plane. The way the situation was
handled gave the passengers unnecessary problems, which
may take them some time to solve. |
| |
|
|
2.4.2 |
Icelandair
should consider its plans for a colleague support program
in connection with accidents and incidents. Such programs
have proven to be helpful to pilots and cabin attendants
after stressful situations, reducing the time away from
active duty and fewer reports on delayed emotional
reactions caused by stressful experiences. |
| |
|
| |
|
|
2.5 |
Organization and management |
| |
|
|
2.5.1 |
Icelandair
is organized and managed in accordance with the
requirements of JAR-OPS 1 and the Icelandic CAA. Rapid
expansion and recent re-organization has resulted in
“growing pains” in the organization. And the management,
being aware of the situation, is monitoring the process
closely. |
| |
|
|
2.5.2 |
An
investigation of Icelandair’s Organization and Management
along the vertical line: Philosophies, Policies,
Procedures, Practices and along the horizontal line of the
modules: Crew Recruitment, Initial Training, Technical
Training, Flight Training, CRM training, Commanders
Training and Recurrent Training demonstrated certain weak
points: Philosophies and policies were not sufficiently
documented in the manuals to assure that all personnel
respond in the required and correct manner during
operation of aircraft. |
| |
|
|
2.5.3 |
Icelandair
has a philosophy and a set of policies as well as
procedures and practices in order to maximize the safety
of all flights. A more clear documentation of the
philosophy and the policies in the different manuals would
be of advantage to personnel at all levels of the Company. |
| |
|
| |
|
|
2.6 |
Dispatch of aircraft from Keflavik with
inoperative equipment |
| |
|
| |
AAIB/N is
of the opinion that the inoperative equipment according to
MEL: Right ILS, right GPS and center autopilot did not in
any way affect the operation or performance of the
aircraft with regard to the incident over Gardermoen
airport. However, the inoperative equipment may have been
a distracting factor for the Commander. |
| |
|
| |
|
|
2.7 |
The Commander’s analysing of the
situation after landing ENGM, and his decision to continue
the flight |
| |
|
|
2.7.1 |
After the
parking of the aircraft, the crew became organized. They
had been overwhelmed, stunned and surprised of what had
taken place. Between them they discussed the incident.
They were not aware of the problems with the high load
factors. The crew did not register these values. But
they were concerned about a possible exceedence of
airspeed limits. However, they were not aware of the
gross exceedence that had taken place. |
| |
|
|
2.7.2 |
The
Commander’s primary concern was the failure of the basic
ILS data, and when this was remedied by the BITE test, the
remaining problem was the overspeed. When the technician
could confirm normal operation of the flaps, the Commander
decided in co-operation with the First Officer, that the
flight could proceed according to schedule. AAIB/N is of
the opinion there should be clear, updated instructions
available for the Commander whom to contact at an outside
station in case of technical problems. AAIB/N questions
the Commander’s decision to continue the flight without a
more thorough inspection made on the aircraft. Detailed
information of the serious incident should have been given
to a responsible operative leader i.e. chief pilot or
operational manager before the flight was continued to
Stockholm. |
| |
|
| |
|
|
2.8 |
The situation in cabin |
| |
|
|
2.8.1 |
It is the
opinion of AAIB/N that cabin crew and passengers could
have been better taken care of. It is understandable that
the lack of time and the technical problems present put a
heavy load on the Commander. It is also possible that he
was not aware of the strain they had been through.
According to cabin- and passenger reports the situation in
the cabin was rather dramatic. The heavy positive and
negative load factors together with the loose items being
thrown around in the cabin were for them a scaring
experience. Many passengers have fear of flying. An
incident as this one increases the fear and uncertainty
for such passengers. A quick debriefing before the
departing passengers left the aircraft would have been a
great relief for the concerned passengers. According to
letters AAIB/N has received, many of them were scared and
as they didn’t receive any information from the crew or
from station personnel after disembarkation, it has taken
a long time for some of these passengers to treat the
personal problems related to this flight. The company
should consider reviewing its procedures of informing the
passengers after unwanted occurrences. |
| |
|
| |
|
|
2.9 |
The crew
procedures/performance in relation to Standard Operating
Procedures (SOP) |
| |
|
| |
The SOP
covers in detail the handling of the aircraft in normal
and abnormal situations. AAIB/N is of the opinion that
had the company’s basic procedures been adhered to by the
crew, this incident would not have happened. Thus the
planning of the final stage of this flight in marginal
weather was not thorough enough. The Commander let the
flight become unstabilised in speed and attitude. Correct
call-outs were not made. A detailed plan for a possible
go-around was not made. The final check list could not be
completed since the final flap setting had not been made.
The approach was aborted late on final in spite of the
flight not being stabilized in correct configuration in
IMC at 1 000 ft AAL. It is possible that the airport’s
relatively high elevation may have been of importance in
this case. Most of the airports which are used by
Icelandair crew are situated at or close to sea level.
Gardermoen’s elevation is 681 ft. When finally the
go-around was started, the Commander let the airplane fly
away from him, and the crew cooperation broke down. All
these details are covered in the SOP. |
| |
|
| |
|
|
3. |
CONCLUSION |
| |
|
|
3.1.1 |
General |
| |
|
| |
| a. |
The
flight from Keflavik airport to Oslo airport
Gardermoen was uneventful until the descent was
started. |
| b. |
The
descent and approach was made in strong tailwind. |
| c. |
The
aircraft overshot of the LLZ initially. |
|
d. |
The
aircraft descended on the LLZ unstabilized in height
and speed. |
|
e. |
After
the Commander started the missed approach, the
aircraft entered a dramatic manoeuvre with exceedences
in pitch, speed and load factors. |
|
f. |
After
the landing, the Commander was concerned primarily
regarding the ILS raw data failures and not so much
regarding the exceedences. |
|
g. |
The
flight continued to Stockholm airport Arlanda and back
to Keflavik airport without a thorough technical
inspection to be performed. |
|
| |
|
|
3.1.2 |
The
aircraft |
| |
|
| |
|
a. |
The
aircraft had been maintained and was serviceable with
no significant defects. The equipment not being
operative upon departure Keflavik did not have any
effect regarding this incident. |
|
b. |
The raw
data information of the ILS on the Commander’s flight
instruments disappeared intermittently at times during
the approach to Gardermoen. |
|
c. |
The
mass and balance of the aircraft were within the
normal operating limits at the time of the incident. |
|
d. |
The aircraft did not receive any damage during the
“upset” in spite of the exceedences of both speed and
load factors. As a precaution some components were
later replaced. |
|
| |
|
|
3.1.3 |
Flight
Operations |
| |
|
| |
|
a. |
A comprehensive
Flight Operations Manual, supplemented by Aeroplane
Operating Manual, Route Manual and Training Manual
controls the different aspects of Flight Operations. |
|
b. |
Crew selection,
initial technical- and flight training and recurrent
training satisfy the requirements from the
authorities. |
|
c. |
The Company was at
the time of the incident not utilizing a systematic
analysis of flight recorder data of all flights for
supervision, control and monitoring of the Company’s
operational standard. |
|
d. |
A more clear
documentation of the philosophy and the policies in
the different manuals would be of advantage to
personnel at all levels of the Company. |
|
| |
|
|
3.1.4 |
The crew |
| |
|
|
|
| a. |
The
crewmembers were properly licensed. |
| b. |
Working
hours and rest periods prior to the incident were
within the limits prescribed by regulations. |
| c. |
The
proficiency checks for both pilots were valid. |
| d. |
Both
pilots had gone through the company’s technical and
operational flight training without waivers. |
| e. |
Both
pilots had received the planned CRM company training. |
|
| |
|
|
3.1.5 |
Organisation and management |
| |
|
| |
|
a. |
Icelandair is
organized and managed in accordance with the
requirements of JAR-OPS 1 and the Icelandic CAA. |
|
b. |
A more clear
documentation of the philosophy and the policies would
be of advantage to personnel in the company. |
|
| |
|
| |
|
|
4. |
safety RECOMMENDATIONS |
| |
|
| |
AAIB/N
recommends: |
| |
|
|
4.1.1 |
That the
aviation community should review the operational procedure
regarding discontinued approaches. The company should
also review the flight crew training regarding an
unstabilized approach followed by a go-around
(Recommendation no 4/2003). |
| |
|
|
4.1.2 |
That the
company should consider its plans for colleague support in
relation to accident and incidents (Recommendation no
5/2003). |
| |
|
|
4.1.3 |
That the
company should consider utilizing the quick access
recorders for continuous monitoring of flight operations
standards (Recommendation no 6/2003). |
| |
|
|
4.1.4 |
That CAA/N
should consider the effect of ATC shortening the
approaches in IMC for airline-crew with possible limited
experience of the Oslo area, and the effect it has on the
crew’s ability to manage the aircraft energy and to
stabilize the approach (Recommendation no 7/2003). |
| |
|
| |
|
|
5. |
appendices |
| |
|
| |
1.
A AIP NORGE7NORWAY AD2 ENGM 4-15 |
| |
1.
B AIP NORGE7NORWAY AD2 ENGM 4-16 |
| |
2.
AIP NORGE/NORWAY AD 2 ENGM 5-1 |
| |
3.
Glossary of abbreviations |
AAIB-N
report 2003/7
