Final Report of 2011 Cork Airport crash published

28th Janaury 2014
By Elaine Murphy
elaine@TheCork.ie

Air Accident Investigation Unit (AAIU)

The Air Accident Investigation Unit has published its Final Report
into the fatal public transport accident that occurred at Cork Airport
in February 2011. The AAIU recognises that this is a difficult time
for those families who lost loved ones and the surviving passengers
who suffered injuries in this tragic accident. Our deepest sympathies
to all concerned.

This particular Investigation was the most challenging of the more
than 500 Investigations that have been completed by the Unit since its
formation in 1994. The complexity of the accident sequence,
examination of components at overseas locations, the international
dimension of the Operation including the intricate relationship
between the various agencies and associated undertakings, translation
of technical documents and natural justice obligations determined the
time taken to finalise this Report. The AAIU wishes to acknowledge
the patience and understanding shown by all affected families while
the Unit fulfilled its legal obligation to complete a detailed and
independent safety investigation.

The aircraft, a Fairchild SA 227‐BC Metro III registered in Spain as
EC‐ITP, was operating a scheduled commercial air transport flight from
Belfast City to Cork with two Flight Crew members and ten passengers
on board. The flight involved three separate undertakings; the
Operator which held a Spanish Air Operator Certificate (AOC), a Ticket
Seller based in the Isle of Man, and a Spanish company which supplied
the aircraft and flight crew under an agreement with the Ticket
Seller.

At 09.50 hrs while on the third approach to Cork in low visibility
conditions, control of the aircraft was lost during an attempted
go-around. The aircraft impacted the runway surface, inverted and
came to rest in soft ground to the right of the runway. Post impact
fires occurred in both engines which were expeditiously extinguished
by the Airport Fire Service. Six persons, including both pilots, were
fatally injured. Four passengers were seriously injured and two
received minor injuries.

The Investigation determined that the probable cause was ‘Loss of
control during an attempted go‐around initiated below Decision Height
(200 feet) in Instrument Meteorological Conditions’.

The Investigation identified the following factors as being significant:

**The approach was continued in conditions of poor visibility below
those required.
The descent was continued below the Decision Height without adequate
visual reference being acquired.
*Uncoordinated operation of the flight and engine controls when
go-around was attempted.
*The engine power-levers were retarded below the normal in-flight
operational range, an action prohibited in flight.
*A power difference between the engines became significant when the
engine power levers were retarded below the normal in-flight range.
*Tiredness and fatigue on the part of the Flight Crew members.
*Inadequate command training and checking.
*Inappropriate pairing of Flight Crew members, and
*Inadequate oversight of the remote Operation by the Operator and the
State of the Operator.

Systemic deficiencies at the operational, organisational and
regulatory levels were also identified by the Investigation. Such
deficiencies included pilot training, scheduling of flight crews,
maintenance and inadequate oversight of the operation by the Operator
and the State of Registration.

In accordance with the Investigation’s objective of preventing future
accidents and incidents, a total of 11 Safety Recommendations have
been made to various entities as follows:

*Four are made to the European Commission Directorate responsible for
Commercial Air Transport regarding Flight Time Limitations, the role
of the ticket seller, the improvement of safety oversight and the
oversight of Operating Licences.
*Three are made to the European Aviation Safety Agency (EASA)
regarding the number of successive instrument approaches that can be
conducted to an aerodrome in certain meteorological conditions, the
syllabus for appointment to Commander and the process by which Air
Operator Certificate (AOC) variations are granted.
*Two are made to the Operator, Flightline S.L., regarding its
operational policy and training.
*One is made to Agencia Estatal de Seguridad Aérea (AESA), the Spanish
Civil Aviation Regulatory Authority, regarding oversight of air
carriers.
*One is made to the International Civil Aviation Organization (ICAO),
regarding the inclusion of the approach capability of aircraft/flight
crew on flight plans.

The sole objective of AAIU investigations is the prevention of
aviation accidents and serious incidents. It is not the purpose of any
such investigation and the associated investigation report to
apportion blame or liability. A safety recommendation shall in no
case create a presumption of blame or liability for an occurrence.

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