Incident Overview
Description
A White Airways ATR 72-600, operating flight 1428 on behalf of TAP, experienced a hard landing at Fez-Sais Airport, Morocco. The co-pilot was the pilot flying (PF); this was her first airline aircraft type and she was on training. The crew conducted an approach to Fez runway 27 with a computed Vapp of 109 KIAS and the aircraft weight was 21.0 t. The weather reported by Fez ATIS information R for that period on approach and landing was: surface wind 350ø at 8 kt, visibility 10 km or more, air temperature 33øC and QNH 1019mbar. The captain, as pilot monitoring (PM), reported that during the final flare, the aircraft was “literally thrown to the deck” and on the final moments, he grabbed the yoke, trying to reduce the rate of descent, but did not have sufficient time. This resulted in a firm landing, during which the tail bumper contacted the ground and the belly scraped the runway. The aircraft flight data and management system recorded a vertical acceleration at touchdown of +2,88G. The damage sustained was an abrasion of the tail bump and part of lower fuselage skin between frames FR35 and FR39. The aircraft rolled out without further incident and taxied to the apron. An external inspection and a walk around were performed by the captain, focused on the landing gear without any findings. According to the operator data, the aircraft continued in-service, departing for the next scheduled flight, TP1427 from Fez, about one hour after landing, with 55 passengers on board to Lisbon. Probable causes: The investigation determined the accident most probable cause the flight crew performance on the landing maneuver, namely, with poor aircraft energy management while performing an unstable approach. Contributing factors: For the crew performance during the landing in Fez, the following direct contributing factors were identified: – non-compliance by the PIC/LTC with the discontinued approach procedure, – the PIC/LTC not performing the appropriate flight supervision techniques and the proper aircraft recovery from an unsafe condition on the unstable approach, – the training process (LIFUS) with the consequent authorization for the trainee co-pilot to fly as PF, without a safety pilot on board, taking into account her known difficulties controlling the aircraft at landing, – the missing explicit definition of the stabilized approach criteria by the operator. For the crew decision process to start the return flight to Lisbon, the following contributing factors were identified: – Organizational culture with inadequate or nonexistent procedures and individual-centered decision-making without effective implementation of the CRM philosophy, – Lack of operators oversight by NAA to comply with certification regulations, not adopting SARPs in compliance checks.
Primary Cause
Flight crew performance on the landing maneuver, specifically poor aircraft energy management while performing an unstable approach.Flight crew performance on the landing maneuver, specifically poor aircraft energy management while performing an unstable approach.Share on:
