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ASN Wikibase Occurrence # 147132
Last updated: 23 July 2020
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Date:11-NOV-1998
Time:
Type:Silhouette image of generic SF34 model; specific model in this crash may look slightly different
Saab 340A
Owner/operator:Kendell Airlines
Registration: VH-LPI
C/n / msn: 340A-151
Fatalities:Fatalities: 0 / Occupants: 31
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Eildon Weir, VIC -   Australia
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Albury Airport, NSW (ABX)
Destination airport:Melbourne (unknown airport), VIC
Investigating agency: ATSB
Narrative:
The aircraft was operating in instrument meteorological conditions en route to Melbourne and had accumulated a deposit of ice on the wings and windscreen wipers. The crew interpreted this ice deposit as being less than that required for them to activate the de-ice systems on the wing leading edges, in accordance with the aircraft flight manual procedures. As the aircraft approached Melbourne the crew were instructed to enter a holding pattern at Eildon Weir. The crew acknowledged this instruction and reduced power in order to slow the aircraft to the holding pattern airspeed. The crew subsequently allowed the airspeed to fall below the target speed of 154 knots, and despite remedial action, did not regain the target speed.
Shortly after the aircraft entered the holding pattern it suffered an aerodynamic stall and rolled approximately 126 degrees to the left and pitched nose down to approximately 35 degrees. The crew regained control after approximately 10 seconds. The aircraft lost 2,300 feet of altitude. The crew was not provided with a stall warning prior to the stall.
The investigation found that despite being certified to all required certification standards at the time, the Saab 340 aircraft can suffer from an aerodynamic stall whilst operating in icing conditions without the required warnings being provided to flight crew. This problem had been highlighted when the aircraft was introduced to operations in Canada and as a result a modified stall warning system was mandated for aircraft operated in Canada. This modification was not fitted to other Saab 340 aircraft worldwide.
SIGNIFICANT FACTORS:
1. The stall warning system did not activate prior to the stall.
2. The crew allowed the aircraft’s speed to slow below the published holding speed.
3. The crew interpreted the ice deposit as being less than that specified in the aircraft flight manual for activation of the wing de-ice system.
4. The crew misinterpreted the pre-stall buffet as propeller ice vibration.
5. The Saab 340 aircraft is capable of accreting ice deposits without visual clues being provided to the flight crew.
6. The aircraft was not fitted with the Canadian Stall warning system. If this had been fitted and activated, it would have (and activated) provided the crew with between 10 to 18 seconds warning of the impending stall.

Sources:

ATSB Occurrence Nr. 199805068

Safety recommendations:

Safety recommendation IR19980269 issued 18 December 1998 by ATSB to Kendell Airlines
Safety recommendation IR19980270 issued 18 December 1998 by ATSB to Hazelton Airlines
Safety recommendation IR19980271 issued 18 December 1998 by ATSB to Macair
Safety recommendation IR19980272 issued 18 December 1998 by ATSB to CASA
Safety recommendation IR19980273 issued 18 December 1998 by ATSB to Saab
Safety recommendation IR19980274 issued 18 December 1998 by ATSB to Saab
Safety recommendation IR19990072 issued 3 June 1999 by ATSB to Saab
Safety recommendation IR19990073 issued 3 June 1999 by ATSB to FAA
Safety recommendation IR19990074 issued 3 June 1999 by ATSB to JAA
Safety recommendation IR19990075 issued 3 June 1999 by ATSB to Luftfartsverket
Safety recommendation IR19990076 issued 3 June 1999 by ATSB to CASA
Safety recommendation R20010049 issued 1 March 2001 by ATSB to Saab
Safety recommendation R20010050 issued 1 March 2001 by ATSB to Saab

Accident investigation:
cover
  
Investigating agency: ATSB
Status: Investigation completed
Duration:
Download report: Final report


Images:

Photo of VH-LPI courtesy AirHistory.net


Avalon (YMAV / AVV)
1 March 2011; (c) Andrei Bezmylov

Revision history:

Date/timeContributorUpdates
26-Jul-2012 07:21 harro Added

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