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ASN Wikibase Occurrence # 147104
Last updated: 25 August 2020
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Date:28-JUN-2002
Time:c. 18:00
Type:Silhouette image of generic SF34 model; specific model in this crash may look slightly different
Saab 340B
Owner/operator:Hazelton Airlines
Registration: VH-OLM
C/n / msn: 340B-205
Fatalities:Fatalities: 0 / Occupants: 32
Other fatalities:0
Aircraft damage: None
Location:7 km ESE of Bathurst, NSW -   Australia
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Sydney-Kingsford Smith International Airport, NSW (SYD)
Destination airport:Bathurst-Raglan Airport, NSW (BHS)
Narrative:
The Saab was approaching Bathurst's runway 17 with gear down and flaps at 20 degrees. At a radio altitude of 1,266 feet above ground level and a speed of 133 knots the captain commanded the autopilot to roll the aircraft to the right to begin tracking downwind for runway 17. It attained 28 degrees right roll after 7 seconds. Approximately 1 second later, the aircraft commenced an uncommanded roll to the left at a recorded airspeed of 114 knots and a nose-up pitch of 8 degrees. The aircraft rapidly rolled to the left reaching 109 degrees left bank within 4 seconds, before pitching 27 degrees nose down 3 seconds later. During the recovery the aircraft rolled back through wings level to 56 degrees right wing low. The aircraft descended approximately 1,080 feet in 16 seconds, and the minimum radio altitude recorded was 114 feet/35m above ground level. The aircraft's aerodynamic stall warning systems of stick shaker, audible alarm, visual warnings and stick pusher, did not activate.
SIGNIFICANT FACTORS:
1. Although provided with visual cues (windshield wiper), the flight crew did not detect airframe or wing ice during the descent and therefore did not take measures to remove the ice.
2. The flight crew left the power setting unchanged at 17 per cent after levelling out when 50 per cent-60 per cent would have been appropriate given the aircraft configuration and environmental conditions.
3. The flight crew allowed the aircraft’s speed to slow below a safe speed.
4. The stall warning system did not activate prior to the stall.
5. The aircraft was not fitted with the Canadian stall warning system modification. If this had been fitted and activated, it would have alerted the flight crew and provided them with between 3-4 seconds warning of the impending stall.
6. The SOP did not require activation of the de-ice boots in known icing conditions as per the manufacturer documentation.
7. The SOP allowed for the use of the autopilot during icing conditions which masked tactile cues regarding the increasing nose up attitude.
The investigation identified a number of other occurrences involving Saab 340 aircraft stalling where little to no stall warning had been provided to flight crew while operating in icing conditions. This included a Saab operated by an Australian operator, which resulted in a number of ATSB recommendations being issued in that investigation, not all of which were accepted and acted upon. Some of those recommendations have been re-issued.

Sources:


Safety recommendations:

Safety recommendation R20030179 issued 20 January 2004 by ATSB to Regional Express
Safety recommendation R20030180 issued 28 January 2004 by ATSB to Hazelton Airlines
Safety recommendation R20030181 issued 20 January 2004 by ATSB to Macair
Safety recommendation R20030182 issued 20 January 2004 by ATSB to CASA
Safety recommendation R20030183 issued 20 January 2004 by ATSB to Saab


Images:

Photo of VH-OLM courtesy AirHistory.net


Adelaide - International (YPAD / ADL)
23 August 2019; (c) Gavin Hughes

Revision history:

Date/timeContributorUpdates
26-Jul-2012 07:20 harro Added

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