Finnish investigators have highlighted the risks of rapid fleet expansion, following an extraordinary incident in which an inexperienced ATR crew’s botched landing attempt resulted in four missed approaches, several ground-proximity system alerts, and a stall warning.
In its inquiry into the Finncomm Airlines incident last year, the Finnish Accident Investigation Board has catalogued a series of deficiencies with the carrier’s organisation, at a time when it was broadening its regional network to serve as a feeder for Finnair.
The board states that the carrier had been unprepared for a rapid introduction of ATR turboprops and did not have the resources to cope.
Finncomm set up its own type-rating training organisation to overcome the difficulties of sourcing pilots. But its ATR conversion syllabus was “the briefest in the business”, says the board, having been condensed to feature only necessities.
This meant pilots lacked adequate training and system familiarity, while the carrier had too few type-rating instructors and other examination personnel.
Shortcomings in training and a high pilot turnover meant the airline was “unable to breed a dedicated cadre” of senior pilots to maintain a safety culture among younger crew members.
On 1 January last year two pilots – a 36-year old captain with just 51 hours on type and a 28-year old co-pilot with only 82 – were inadvertently crewed together on an ATR 42-500 to operate the domestic Helsinki-Seinajoki service. Both were formally classified as ‘inexperienced’, because neither had accumulated 100 hours on ATRs, and should not have been paired.
During rushed preparations for the NDB approach to Seinajoki’s runway 14 the approach check was left incomplete and the co-pilot, who was flying the aircraft, failed to reset the altimeter to the local air pressure. This meant the ATR was flying some 950ft lower than indicated.
The turboprop descended to a “dangerously” low altitude – reaching a minimum height of just 342ft – and the ground-proximity warning system sounded. But the captain was still hoping to make visual contact with the runway and, contrary to procedures, did not call a go-around until 30s later.
“When they received the warning, the captain first supposed that there was a fault in the aircraft’s systems instead of analysing the actual cause of the warning,” state the investigators, adding that this implied “quantitative and qualitative shortcomings” in type-rating training.
With the altimeter still incorrectly set, the crew opted to fly the opposite-direction instrument landing system approach to runway 32, with the intention of circling to land on runway 14. Again the aircraft descended too low, this time to 425ft, and a ground-proximity alarm forced another go-around.
During this missed approach the aircraft’s engine power control was configured to ‘maximum continuous thrust’. When engine power is reduce at this setting, propeller pitch causes a rapid reduction in airspeed. As the co-pilot manoeuvred the aircraft, he reduced engine power, leading to a sudden drop in airspeed from 150kt to less than 130kt. The stall warning sounded and the stick-pusher activated twice.
Owing to a brief blanking of his instruments, the captain believed at this point that the aircraft was experiencing an electrical problem and the ATR climbed to flight level 70 to give the crew a chance to assess the problem.
After deciding that the systems had returned to normal, the crew chose to retry the runway 32 ILS approach, and circle for runway 14.
As the aircraft descended the ground-proximity warning sounded a third time, at 460ft, and another missed approach was executed. Only at this point did the crew realise that the co-pilot’s altimeter had not been reset.
After being asked to make a cabin announcement to reassure increasingly-uneasy passengers, the crew followed the agreed approach. Despite the preceding events, and the co-pilot’s deteriorating performance, the captain did not take control of the aircraft.
In the late stages of the approach the pilots received a configuration alert from the ground-proximity system and, as the co-pilot turned the aircraft onto final, it twice banked to around 50°, generating two bank-angle warnings.
The crew again carried out a missed approach – incorrectly following the procedure, and drifting into military airspace – before informing air traffic controllers that they would divert to Vaasa, citing an electrical malfunction. The ATR landed at Vaasa without further incident, with no injuries to its occupants.
In its analysis of the event, the investigation board says: “The company had not sufficiently prepared for the challenges of the then-ongoing business expansion.”
It highlights the relatively brief ATR experience of the two pilots. Although the captain was Finncomm’s ATR fleet chief commander, both he and the co-pilot had been type rated on the aircraft for less than seven weeks. Inadequate training, says the board, meant neither was particularly familiar with ground-proximity warning system characteristics and other features of the ATR.
The co-pilot had never flown the Seinajoki runway 14 approach and the board states: “Because of his relatively short flying experience, his familiarity with procedures was a little shaky. He no longer remembered how to fly a single-beacon approach because a year had gone by since [receiving procedures training] and he had never flown one on an airliner.”
But the board stresses that, as a consequence of the Seinajoki incident and others which occurred at around the same time, the airline has undergone an extensive overhaul of its crewing requirements, training, flight procedures and its management structure.
Source: flightglobal.com's sister premium news site Air Transport Intelligence news
Source: Flight International