ASN Aircraft accident Saab 340A C6-HBW Freeport-Grand Bahama International Airport (FPO)

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Status:	Accident investigation report completed and information captured
Date:	Tuesday 7 February 2017
Time:	0.27735114097595
Type:	Saab 340A
Operator:	Western Air
Registration:	C6-HBW
MSN:	340A-067
First flight:	1986-08-22 (30 years 6 months)
Crew:	Fatalities: 0 / Occupants: 3
Passengers:	Fatalities: 0 / Occupants: 31
Total:	Fatalities: 0 / Occupants: 34
Aircraft damage:	Substantial
Location:	Freeport-Grand Bahama International Airport (FPO) ( Bahamas)
Phase:	Landing (LDG)
Nature:	Domestic Scheduled Passenger
Departure airport:	Freeport-Grand Bahama International Airport (FPO/MYGF), Bahamas
Destination airport:	Nassau-Lynden Pindling International Airport (NAS/MYNN), Bahamas
Flightnumber:	WT708

Narrative:
Western Air flight 708, a Saab 340, suffered a runway excursion after landing rollout at Freeport-Grand Bahama International Airport, Bahamas.
About three minutes into the flight there was a failure of the left main and essential bus that prompted a return to Freeport. Upon landing on runway 06, there was a collapse of the left main gear and subsequently a runway excursion occurred. Minor injuries were reported to passengers.

Probable Cause:

The Air Accident Investigation Department has determined that the probable cause of this accident was ineffective crew resource management and an unstable approach which led to the failure of the left main landing gear upon touchdown. Contributing factors to this accident includes; inadequate systems knowledge, lack of situational awareness and failure to diagnose and remedy multiple system failures in a timely manner resulted in compound failures being escalated to an emergency. The apparent rush to get on the ground without exploring other possible options to identify and verify landing gear security also contributed to the severity of this accident.
CONTRIBUTING FACTORS
- Ineffective CRM, complacency and a complete departure from company standard operating procedures and regulatory requirements were evidently a contributing factor in this accident.
- Inadequate training and systems knowledge of both airman greatly contributed to the accident.
- Hurried approach to get on the ground and failure to explore all available options to remedy the gear unsafe situation encountered was also a contributory factor.

Accident investigation:

Investigating agency:	AAID Bahamas
Status:	Investigation completed
Duration:	1 years
Accident number:	A17-000602
Download report:	Final report

Classification:

Landing gear collapse
Runway excursion (veer-off)

Sources:

» Air Accident Investigation Department of The Bahamas

Follow-up / safety actions

AAID Bahamas issued 8 Safety Recommendations

Issued: --	To: Bahamas CAA	C6-HBW(1)
The BCAA should immediately ensure that all aircraft on Bahamas registry or operated by Bahamas Air Operators, if they are required to have an installed CVR or FDR, that they are in compliance with Annex 6 and BASR Schedule 7 requirements.
Issued: --	To: Bahamas CAA	C6-HBW(2)
1. A qualified inspector conducts all evaluation and approvals of training facilities in the future. 2. All assignments of duties by a POI to anyone acting on his/her behalf are clearly documented and communicated to the assigned inspector. 3. All inspector assigned duties are fully aware and knowledgeable of the functions they are assigned and required to perform. 4. A full report of actions carried out when assigned, is documented and communicated back to the POI. 5. An audit is carried out by the POI (or some other assigned person), of any evaluations for approvals prior to it being submitted to the manager for approval.
Issued: --	To: Bahamas CAA	C6-HBW(3)
It is the recommendation of the AAID that the BCAA ensure recurrent training and demonstration of the correct method to complete job aids be reinforced among its inspectors.
Issued: --	To: Bahamas CAA	C6-HBW(4)
1. Ensure that checklists required for emergency or abnormal situations for the SF-340 aircraft by this, and other operators of this type of aircraft, are in conformance with the manufacturers guidance and notes and other information of a guidance nature are not excluded, as these additional information could possibly lead the crew into additional actions that could be taken to avoid the kind of accident that occurred. 2. The co-location of both SF340A and SF340B Quick Reference Handbook items should be disallowed, as in an emergency, it is possible to select and use the wrong checklist. This can consume considerable time and cause delays while dealing with an emergency if the wrong reference is selected.
Issued: --	To: Bahamas CAA	C6-HBW(5)
1. Should ensure that the difference training program previously approved for Western Air Limited be cancelled as they do not meet the requirement that warrants a difference training curriculum. 2. Should ensure that any reduction in training granted in respect of any training curriculum is fully documented in the Operator file. 3. Should ensure that this crew undergo a full initial training curriculum as their actions and responses were questionable and system knowledge was inadequate.
Issued: --	To: Bahamas CAA	C6-HBW(6)
BCAA should re-evaluate the authority given to the operator to conduct their own training and checking. Additionally, BCAA should ensure that any individual providing checking on its behalf is fully aware of the requirements for such checking.
Issued: --	To: Bahamas CAA	C6-HBW(7)
1. Also addressed to the BCAA was the recommendation that as the operator does not have the SF340B model aircraft in its fleet, any reference to the B Model should be removed from its training manuals, curriculums check lists and quick reference handbooks to avoid any future confusion. 2. Additionally, also advised to the BCAA was the recommendation that the operator not be allowed to conduct training in a B model simulator and then conduct a difference training in the A model. They should only be allowed to train in the simulator for the model of aircraft in their fleet.
Issued: --	To: Western Air	C6-HBW(8)
Recommendation was made to the BCAA to reevaluate the training that was provided by Western Air Limited to its crew.

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Photos

accident date: 07-02-2017
type: Saab 340A
registration: C6-HBW

Video, social media

Western Air plane crash-lands at Grand Bahama International Airport - https://t.co/nAeRxmphu3 pic.twitter.com/iv6tKeVmrL
— Kwk Media (@KwkMedia) February 8, 2017

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 Freeport-Grand Bahama International Airport to Nassau-Lynden Pindling International Airport as the crow flies is 208 km (130 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.

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