Narrative:The Fokker F-27 was operating on a cargo flight to Guernsey, carrying newspapers. The aircraft departed Luton at 16:14. and climbed to cruising altitude FL150 / 160). The descent was begun at about 60 miles from Guernsey Airport and the aircraft was vectored onto final approach by Jersey Radar. The approach checklist was actioned and the flaps were lowered to 16° just before the aircraft was turned to intercept the ILS localizer. With less than six miles to run to the threshold the commander told the first officer that he could see the runway and was content to continue the approach visually. The first officer informed ATC that they wished to continue the approach visually; they were given the appropriate clearance and control of the aircraft was then handed over to Guernsey Tower. Initially the aerodrome controller cleared the aircraft to continue the approach (there was departing traffic on the runway) and the commander called for flaps to 26° followed by the landing checklist. About one minute later the commander said "three whites" (meaning that he was aware that the aircraft was slightly high on the glide path indicated by the precision approach path indicator lights) which the first officer acknowledged. The commander then said "ok the decision is to land, speed below one four four, flaps forty". The first officer acknowledged the instruction to select flaps to 40° and announced "running". There followed a pause of about five seconds before the first officer said, "flaps fourty gear and clearance you have - oops". The commander then said, in an anxious tone of voice "ok flaps twenty six" and the engines could be heard accelerating on the cockpit voice recording. There then followed a number of expletives from the commander interspersed with some loud clicks as controls or switches were operated and the sound of a warning horn which stopped before the end of the recording. On approach the aircraft had lost control, attaining a nose-high attitude. The plane stalled, clipped a house on Forest Road with its left wing and ploughed into a field short of the runway.
Probable Cause:
PROBABLE CAUSE: "The investigation identified the following causal factors: (i) The aircraft was operated outside the load and balance limitations; (ii) Loading distribution errors went undetected because the load sheet signatories did not reconcile the cargo distribution in the aircraft with the load and balance sheet.; (iii) The crew received insufficient formal training in load management."
Accident investigation:
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Investigating agency: | AAIB (U.K.) |
Status: | Investigation completed |
Duration: | 1 year and 2 months | Accident number: | AAIB AAR 2/2000 | Download report: | Final report
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Classification:
Centre of Gravity outside limits
Loss of control
Sources:
»
SKYbrary
Follow-up / safety actions
Seven safety recommendations were issued;
- 4 to the Channel Express company a.o. to modify operating procedures regarding loading of cargo; cargo loading instructions; personnel training; and to review the quality system to meet JAR-OPS requirements.
- 1 to the Airside Safety Management Working Group to encourage handling agents to ask for written loading instructions when loading cargo on to unfamiliar aircraft types;
- 1 to the CAA to require certain aircraft to be modified to enable the recording of pitch attitude, roll attitude and engine thrust;
- 1 to the CAA and JAA to review the appropriate Joint Aviation Requirements (JAR) with a view to requiring that pitch attitude, roll attitude and engine thrust is recorded on all aircraft which carry an FDR.
AAIB issued 7 Safety Recommendations
Issued: 29-FEB-2000 | To: Channel Express | 99-13 |
It was recommended to Channel Express that the company should modify its operating procedures to ensure that the person who signs the traffic officer\'s certificate:
a. Has inspected the load and reconciled the actual load distribution with the loading instructions or load report.
b. Has ensured that the load is properly restrained throughout the cargo compartments.
c. Is appropriately trained, qualified and periodically examined on his or her competency to carry out the above.
d. Has sufficient time to carry out meaningful checks. |
Issued: 29-FEB-2000 | To: Channel Express | 99-14 |
It was recommended to Channel Express that the company should:
a. Review and amend its Loading Instructions to make them practicable and consistent with minimising risk.
b. Issue personal copies of Loading Instructions to pilots. |
Issued: 29-FEB-2000 | To: Channel Express | 99-15 |
It was recommended to Channel Express that the company should:
a. Amend its induction training to ensure that the topic of load distribution is covered in greater detail.
b. Ensure that command training courses include the opportunity to devise and supervise a loading operation under the supervision of a suitably qualified line-training Captain.
c. Provide pilots with substantial initial and recurrent training on the planning, loading, carriage and restraint of cargo.
d. Use only appropriately qualified and experienced training staff.
e. Assess the effectiveness of its training by periodic testing. |
Issued: 29-FEB-2000 | To: Channel Express | 99-16 |
It was recommended to Channel Express that the company should review and amend its quality system to ensure that it fully meets the requirements specified in JAR-OPS. |
Issued: 29-FEB-2000 | To: CAA | 99-64 |
It is recommended that the Airside Safety Management Working Group considers an addition to CAP 642 which encourages handling agents to ask for written loading instructions when loading cargo on to unfamiliar aircraft types. |
Issued: 29-FEB-2000 | To: CAA | 99-65 |
It is recommended that the CAA require operators to reassess the relevant equipment and engine fit on all UK registered aircraft subject to the requirements of the Air Navigation Order, Schedule 4, Scale P and require that, where now practicable, those aircraft are modified to enable the recording of pitch attitude, roll attitude and engine thrust. |
Issued: 29-FEB-2000 | To: CAA | 99-66 |
It is recommended that the CAA in conjunction with the JAA review the appropriate Joint Aviation Requirements with a view to requiring that pitch attitude, roll attitude and engine thrust is recorded on all aircraft which carry a Flight Data Recorder. |
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Photos
accident date:
12-01-1999type: Fokker F-27 Friendship 600
registration: G-CHNL
accident date:
12-01-1999type: Fokker F-27 Friendship 600
registration: OY-SRZ
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from London-Luton Airport to Guernsey Airport, Channel Islands as the crow flies is 311 km (195 miles).
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.