Incident Overview

Date: Monday 4 April 1994
Aircraft Type: Saab 340B
Owner/operator: KLM Cityhopper
Registration Number: PH-KSH
Location: Amsterdam-Schiphol Airport (AMS) – ÿ Netherlands
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 3 / Occupants: 24
Component Affected: Aircraft Flight Controls (specifically the asymmetric control system)Aircraft Flight Controls (specifically the asymmetric control system)
Investigating Agency: RvdLRvdL
Category: Accident
KL433 experienced a significant incident during a flight to Cardiff, UK, due to a combination of factors related to asymmetric flight control, inadequate understanding of the aircraft system, and poor crew resource management. The flight began with a successful takeoff and climb, but quickly deteriorated when the Master Warning triggered, leading to a critical engine issue. The captain initiated a return to Amsterdam, resulting in a series of maneuvers including a go-around, a landing, and a controlled descent. The aircraft experienced a loss of control during the go-around, resulting in a significant impact with the ground, causing a right bank and a loss of airspeed. The incident highlights a failure to adequately manage asymmetric flight conditions and a lack of awareness regarding critical system limitations.KL433 experienced a significant incident during a flight to Cardiff, UK, due to a combination of factors related to asymmetric flight control, inadequate understanding of the aircraft system, and poor crew resource management. The flight began with a successful takeoff and climb, but quickly deteriorated when the Master Warning triggered, leading to a critical engine issue. The captain initiated a return to Amsterdam, resulting in a series of maneuvers including a go-around, a landing, and a controlled descent. The aircraft experienced a loss of control during the go-around, resulting in a significant impact with the ground, causing a right bank and a loss of airspeed. The incident highlights a failure to adequately manage asymmetric flight conditions and a lack of awareness regarding critical system limitations.

Description

KLM Cityhopper flight 433 took off from runway 24 at Amsterdam-Schiphol Airport, the Netherlands for a 1 hour and 18 minute flight to Cardiff, U.K. Eleven minutes after takeoff, at 14:30 hours local time, the flight passed FL165, climbing to FL200 when the Master Warning was triggered by the no. 2 engine oil pressure light. The Master Warning was reset and the captain retarded the no. 2 engine power lever slowly to flight idle, causing the engine torque to decrease from 78% to 10%. Retarding the power lever is not part of the Emergency Checklist (ECL) procedure. Possibly this was done to prevent damage to the right-hand engine. The ECL Engine Oil Pressure Low procedure was then started. The ECL states that the engine must be shut down if the oil pressure warning light is on and oil pressure below 30psi. If the warning light is on and the engine oil pressure is above 30psi, normal operation should be continued. As the no. 2 engine pressure was above 50psi, both flight crew members agreed normal operation should be continued. The captain didn’t want to continue to Cardiff and elected to return to Amsterdam. At 14:33 Amsterdam Radar was contacted with a PAN-call and a request to maintain FL160 and return to Amsterdam. One minute later a clearance was received to descend to FL70. KL433 was offered a straight in approach for either runway 06 or runway 01R. The captain decided to use runway 06 and was cleared to descend to 2000 feet. Landing clearance was given at 14:42 and one minute later the ILS localizer and glide slope were intercepted. The captain, not realising the consequences of flying with one engine in flight idle and was not able to anticipate correctly on the airspeed variations which resulted in an approach not stabilized in power, airspeed and pitch during the final approach. The speed had decreased to 115 knots and the crew reacted by applying an aggressive increase in torque (from 40% to 65%) with limited corrections for asymmetry. This placed the aircraft to the right of the extended centreline at an altitude of 90 feet. At 14:45:53 the captain called for a go-around and no. 1 engine torque was set at 98% with the no. 2 engine remaining at flight idle. Flaps were set at 7 degrees and the gear was retracted. The aircraft rolled right and pitched up to a maximum of 12 degrees. The stall warning system activated as the airspeed decreased and continued until impact. The Saab struck the ground with an approx. 80 degree right bank and broke up. PROBABLE CAUSES: “Inadequate use of the flight controls during an asymmetric go around resulting in loss of control. Contributing factors: Insufficient understanding of the flight crew of the SAAB 340B engine oil system; lack of awareness of the consequences of an aircraft configuration with one engine in flight idle; poor crew resource management.”

Primary Cause

Inadequate use of the flight controls during an asymmetric go around, resulting in loss of control.Inadequate use of the flight controls during an asymmetric go around, resulting in loss of control.

Share on:

Leave a Reply

Your email address will not be published. Required fields are marked *