Manx2 Flight 7100
Fairchild Metro EC-ITP
|Date||10 February 2011|
|Summary||Loss of control during an attempted go-around in low visibility, impacted runway.|
|Aircraft type||Fairchild SA 227-BC Metro III|
|Flight origin||Belfast City|
Manx2 Flight 7100 (NM7100/FLT400C) was a scheduled commercial flight from George Best Belfast City Airport in Belfast, Northern Ireland to Cork Airport in Cork, Republic of Ireland. On 10 February 2011, the Fairchild SA 227-BC Metro III aircraft flying the route with 10 passengers and 2 crew on board, crashed on its third attempt to land at Cork Airport which was experiencing dense fog at the time, 6 people including both pilots were fatally injured. 6 passengers survived, 4 receiving serious injuries, whilst 2 were described as walking wounded.
It led to the closure of the airport for more than 24 hours and the diversion of all flights. The final report was released on 28 January 2014, almost three years after the accident. The report was sent to the families of those bereaved as well as the six survivors over a week prior to its release. The final report stated that the probable cause of the accident was loss of control during an attempted go-around below Decision Height in Instrument meteorological conditions. It noted that there was an inappropriate pairing of flight crews, inadequate command training and checking and inadequate oversight of the chartered operation by the operator and the operator's state as contributory factors in the accident.
- 1 Aircraft and crew
- 2 Accident
- 3 Victims
- 4 Investigation
- 5 Aftermath
- 6 Notes
- 7 See also
- 8 References
- 9 Further reading
- 10 External links
Aircraft and crew
The aircraft which was written-off in the accident was a Fairchild SA 227-BC Metro III, c/n BC-789B, registration EC-ITP which was owned by a Spanish bank, it was leased out to Líneas Aéreas de Andalucía known as Air Lada based in Seville, Spain. The aircraft was subleased to Flightline S.L. and was on the AOC of Flightline, which is based in Barcelona, also in Spain. Tickets were sold by Manx2 which was based in the Isle of Man. It was 19 years old at the time of the accident. The aircraft had undergone a maintenance check in the week prior to the accident.
The Commander was 31-year old Jordi Sola Lopez from Barcelona, Spain. The Co-pilot was 27-year old Andrew Cantle from Sunderland, England. Both were employed by Air Lada. The Commander had logged 1,800 total hours, of which 1,600 were on the Fairchild SA 227-BC Metro III. He held just 25 total hours in the command role on the aircraft. The Co-pilot had logged 539 total hours, of which 289 were on the aircraft type. Their pairing together on the flight was considered inappropriate and highly unusual. Both pilots were certified for CAT I, however, were not certified for CAT II.
The Commander had undergone an upgrade on 2 February 2011, he subsequently flew 7 sectors under supervision and completed two line checks. His first flight in command of the aircraft took place on 6 February 2011, 4 days prior to the accident. The Commander had flown into Cork 61 times, his logbooks never showed a diversion.
The first officer had joined another Spanish operator flying the Fairchild SA 227-BC Metro III for 270 hours, he then joined Air Lada. According to the logbooks he subsequently flew with line Commander's, who were not instructors. He accumulated 19 hours with Air Lada but never completed a line check although required.
- 06:15 - The accident Flight Crew commence duty at Belfast International Airport.
- 06:25 - The Flight Crew download flight documentation including meteorological information for Belfast City, Cork and Dublin Airport's in a handling agent's briefing office.
- 06:40 - The aircraft departs Belfast International as FLT4113 on a short positioning flight to Belfast City with the Commander as the Pilot Flying (PF). The aircraft was empty on this sector.
- 07:15 - The aircraft arrives on stand in Belfast City, leaving the Flight Crew with a 35 minute turnaround.
Within this period a fuel uplift of 800 litres is made, with a total quantity of 3,000 lbs being recorded in the technical log. This fuel load was sufficient for the planned route-trip to Cork and back to Belfast City with required reserves. The flight specifies Waterford Airport as the alternate airport for the sector to Cork. No second alternate is made. Boarding of the flight is delayed due to both crew members working on the passenger seats in the cabin, when this task is completed boarding commences. Passengers choose their seats at random and the safety demonstration is carried out by the Co-pilot.
- 08:10 - The accident flight FLT400C (NM7100) departs and was estimated to arrive in Cork at 09:10, where the weather was foggy.[Note 1]
- 08:34 - The aircraft establishes communication with Shannon Air Traffic Control.
- 08:48 - The aircraft is handed-over to a Cork Approach controller.
- 08:58 - The flight reports established on the ILS for Runway 17 and was handed-over to Cork Tower.
- 09:00 - Cork Tower passes on Instrumented Runway Visual Ranges (IRVRs) which were still below those required.
- 09:03 - The crew descend below the Decision Height (DH) of 200 ft and a missed approach (go-around) was carried out. The lowest recorded height on this approach was 101 ft.
Radar vectors are given by Cork Approach to the reciprocal runway 35, which the crew believed with the sun behind the aircraft, might make visual acquisition of the runway easier.
- 09:10 - The aircraft is 8 miles from touchdown and was handed back to Cork Tower. Again the IRVRs passed on by Tower are below minima. The approach continues beyond the Outer Marker (OM).
- 09:14 - The aircraft again descends below the DH and a second missed approach was carried out. The lowest recorded height on this approach is 91 ft.
- 09:15 - The Flight Crew enter a holding pattern named ROVAL and maintained an altitude of 3,000 ft.
In the hold the Flight Crew requested weather conditions for Waterford which were below minima. The Flight Crew nominated Shannon as their alternate and request the latest weather, again the weather there was below minima. Weather for Dublin is passed onto the Flight Crew and was also below minima. Cork Approach informs the Flight Crew about weather conditions in Kerry which were significantly better with 10 km visibility, the crew considered Kerry as an alternate.
- 09:33 - FLT400C is still in the ROVAL hold, IRVRs for Runway 17 began to improve.
- 09:39 - Following further slight improvement in IRVR values, but with conditions still below minima, the Flight Crew elect to carry-out a third approach, and the second approach for Runway 17.
- 09:45 - FLT400C reports established on the ILS for Runway 17, during this time IRVRs improve further to 550m (the required minimum) which is passed onto the crew by Cork Approach. The flight is handed over to Cork Tower for the third time.
- 09:46 - Cork Tower passes on the latest IRVRs of 500/400/400, which were now again below minima.
The approach is continued beyond the OM, the Commander takes over operation of the Power Levers. Descent is continued below the DH. A significant reduction in power and significant roll to the left follows, just below 100 ft, a third go-around is called by the Commander which the Co-pilot acknowledges. Coincident with the application of go-around power by the Commander, control of the aircraft was lost. The aircraft rolls rapidly the right beyond the vertical which brought the right wingtip into contact with the runway surface. The aircraft continued to roll and impacted the runway inverted. The stall warning sounded continuously during the final seven seconds of the CVR recording.
At 09:50:34 following both initial impacts the aircraft continued inverted for a further 189 metres (207 yd) scattering debris over a wide area and finally came to a rest in soft ground to the right of the runway surface. Post impact fires ensued in both engines, which were quickly put out by the Airfield Fire Service (AFS). Of the 12 on board, 6 people were fatally injured including both pilots. Of the 6 survivors, 4 were seriously injured whilst 2 received minor injuries and were described as walking wounded. A witness inside the airport terminal building stated that the fog was so thick that the crashed aircraft could not be seen. The injured were taken to Cork University Hospital for treatment. As a result of the accident, Cork Airport was closed until the evening of 11 February.
ATC Transmissions at Impact
Transmission of a distress radiobeacon on 121.5 MHz and 243 MHz
|Problems playing this file? See media help.|
- 09:50:34 - [Approximate time of impact]
- 09:50:39 - Tower: [ELT audible in background] Flightavia 400C
- 09:50:43 - Tower: Flightavia 400C
- 09:50:49 - Tower: Flightavia 400C
- 09:51:36 - Ground: Flightavia 400C Ground, are you on frequency?
- 09:52:14 - Airfield Fire Officer (AFO): Ground, AFO at the station
- 09:52:18 - Ground: AFO, Ground
- 09:52:19 - AFO: Ground AFO, turning out from the station area, any other information?
- 09:52:24 - Ground: AFO, we have no contact with the aircraft, we suspect it has crashed on landing, unsure of the position [ELT sounding in the background] proceed unrestricted onto Taxiway Alpha out on to 17-35
- 09:52:33 - AFO: That's copied Ground, and have you any information on the aircraft type please? [no response on Mains Comms or RBS]
- 09:53:18 - AFO: That's copied
- 09:53:21 - AFO: Ground AFO
- 09:53:23 - Ground: AFO Ground
- 09:53:24 - AFO: Confirm crash, crash, crash, I repeat, crash, crash, crash, just the western side of 17, there is a fire, I repeat there is a fire
- 09:53:36 - Ground: AFO that's copied, thank you
At 09:59:43 - The AFO confirms that both post impact fires had been extinguished and reports at 10:01:47 that the first casualty had been removed.
The Air Accident Investigation Unit (AAIU) opened an investigation into the accident. The cockpit voice recorder and flight data recorder were recovered from the wreckage. Four personnel from the AAIU were on scene within 90 minutes of the accident. They completed their survey of the wreckage that day. The AAIU were assisted in the investigation by personnel from the Air Accident Investigation Branch in the United Kingdom and the Civil Aviation Accident and Incident Investigation Commission from Spain. Flightline S.L. assisted the AAIU in the Investigation. Assistance was also given by the Federal Aviation Administration and National Transportation Safety Board from the United States. The Aviation Incidents and Accidents Investigation (AIAI) of Israel as well as the European Aviation Safety Agency (EASA) also provided assistance.
The wreckage was transported to the AAIU's examination facility at Gormanston, Co. Meath to allow investigators to reconstruct the aircraft as far as possible. By 14 February, five of the six survivors had been interviewed by the AAIU.
The preliminary report, issued on 16 March 2011, stated that the aircraft, being flown by the Co-pilot, had deviated from the runway centre-line on final approach and that the crew decided to execute a third go-around four seconds before impact. The aircraft rolled to the left and to the right, and the right wing then impacted the runway. No deficiencies in the aircraft or the airfield infrastructure were identified. The report did not include any findings.
An Interim Statement was published in February 2012 in line with European Union regulatory requirements. Inspection of the engines revealed that the right engine had consistently been developing up to five percent more torque than the left engine, as a result of a defective right engine intake air temperature and pressure sensor. The defective sensor meant that the engine would deliver more torque than the left engine and also respond more rapidly to commands to increase power from the engine's power lever than the left engine. The investigation also determined that both engines were developing go-around power at the moment of impact; however both engines were below flight idle power at eight to six seconds before impact. At eight seconds before impact the right engine reached a minimum of zero torque while the left engine reached -9 percent torque (which means the left propeller was driving the engine instead of the engine driving the propeller). The stall warning horn also sounded repeatedly in the seven seconds prior to impact.
Combined Standardisation Inspection by EASA
The issue of regulatory oversight of AOC operations by Spain was considered. The Investigation Team was informed by EASA that following a “Combined Standardisation Inspection carried out in respect of Spain in September 2010, the identified “areas of concern” had included:
- Initial certification (issuance of AOCs).
- Continued oversight of AOC holders.
- Resolution of safety concerns.
As a result, a “Corrective Action Plan” had been prepared and implemented, but EASA was of the opinion that “it is unlikely that such action would have shown a major effect on the system at the time of or prior to, the accident”.
On 28 January 2014, the AAIU released its final report on the accident. The report confirmed details previously released in the two interim statements published in 2011 and 2012 respectively. The final report, 244 pages long comprised 54 findings (detailed in the final report), a probable cause, 9 contributing factors and 11 safety recommendations - all detailed in sections below.
Operation of the accident aircraft
Having examined all the evidence, the Investigation concluded that the operation of the accident aircraft was being controlled by the ‘Owner’ from the Isle of Man, a British Crown Dependency outwith both the UK and the EU and that “under Regulation (EC) No 785/2004, the ‘aircraft operator’ was in fact the ‘Owner’ who had effective disposal of the use or operation of the aircraft.” The implication of this situation was considered to be that “the duties and responsibilities of the AOC holder were…not carried out in accordance with EU-OPS”. It was further concluded that: “This situation, where a commercial air service was being operated within the EU and the air carrier was not the ‘aircraft operator’, was in contravention of Regulation (EC) No 1008/2008.”
Given that there was considerable evidence of visible ‘branding’ of the aircraft and crew with the identity of the ‘Ticket Seller’, it was further noted that: “The Investigation is of the opinion that the ‘Ticket Seller’, an ‘air carriage contractor’ as defined in Regulation (EC) No 2111/2005, Article 2 (c), was portraying itself as an airline. The Investigation further considers that in the eyes of the travelling public, an airline is synonymous with an air carrier, an entity which is required to hold a valid operating licence. Such an operating licence can only be held by the holder of a valid AOC.” In the light of the complexity of the inter-relationship between the various entities involved in the operation of the accident aircraft, the Investigation considered that an inevitable consequence would be that there would be “no overall effective oversight of the Operation being carried out by the AOC holder”. The Investigation also took the view that: “The role of a ticket seller who engages in providing passenger air services is not clear. While the role and responsibilities of an air carrier are well defined, the involvement of ticket sellers in this activity requires that their role and responsibilities should be clearly defined.”
Issues with the Operator's State
The Investigation identified a specific concern in respect of the lack of circumstantial review by the AOC issuer, the Agencia Estatal de Seguridad Aérea (AESA) - the Spanish CAA - when Flightline S.L. applied for and were granted a variation to their initially issued AOC to add two Metro III aircraft in 2010. AESA was reported to have specifically stated to the Investigation that “it did not feel it was within its remit to look for additional organisational and financial information to ensure that the Operator was adequately resourced to operate two additional aircraft.” However, it was noted that AESA had been aware that the two aircraft added to the AOC had previously been operated from an Isle of Man base for the same ‘Ticket Seller’ under a Spanish AOC held by a Company called Eurocontinental Air which they had suspended because of “problems that arose in that operation” and following “an extended ramp inspection” at the Isle of Man. It was noted that AESA had advised the Investigation that it:
- Had no knowledge of the ‘Owner’, which was a commercial company and therefore not within its regulatory remit
- Was unaware of the connection between the ‘Ticket Seller’ and the ‘Owner’
- Was unaware that two former Eurocontinental Air pilots had moved with the aircraft to the ‘Operator’
- Was unaware of the remote Operation of the Metro III aircraft following their addition to the Operator’s AOC during 2010 and that had it known this, it would have taken a greater interest.
The Investigation therefore expressed its concern that “the regulatory authority of the State of the Operator did not identify the Operator’s shortcomings, thereby contributing to the cause of the accident.” It noted that, since the UK and Irish regulators were expressly prohibited by Regulation (EC) 1008/2008 from exercising any regulatory function in respect of the operation of aircraft from other Member States within and between their territories, both were obliged to rely on the oversight of Spain “to ensure compliance in regulatory matters”. It was concluded that in practice “the evidence shows that such oversight was of limited scope and low effectiveness.” In this situation, the only “control” on safety standards was observed to have been the SAFA programme of ramp checks which in this case had not identified the extent of systemic shortcomings. However, it was accepted by the Investigation that “SAFA inspections are limited ….in what can be achieved in the protection of the aviation system”. It was also noted that AESA oversight of the Operation required by Regulation (EC) 1008/2008 required that Member State issuing an AOC must also take responsibility for the corresponding Operating Licence. It was concluded that “there was no evidence of any such oversight (of the Operation ) being conducted by Spain”, although noted that “the Regulation makes no provision nor provides procedures of how oversight should be conducted, in particular where operations are carried out from a base outside a Member State” (in this case the Isle of Man). Finally, the Investigation noted the involvement of the EU Air Safety Committee in relation to the Accident Operator in the months following the investigated accident and considered that the scope of its remit might usefully be widened “as part of the EU aviation safety net”.
- Loss of control during an attempted go-around below Decision Height in Instrument Meteorological Conditions (IMC).
Loss of Control summary in detail
The technical log for the flight indicated that the Co-pilot was pilot flying (PF) for the flight. The CVR and ATC recordings also indicate that the Co-pilot was PF during the flight. Furthermore, injuries sustained by the Co-pilot to his right hand are consistent with him handling the aircraft at the time of impact. As no autopilot or flight director (FD) was fitted, the PF was under a high workload throughout the flight. This was especially so as three approaches were made in poor weather to below minima with two go-arounds. Normally the PF handles both flight and engine controls in a coordinated manner to achieve the required flight path; the PNF carries out other tasks including monitoring the aircraft's flight path, radio communications and keeping the flight log. The CVR indicates that the Commander (PNF) took control of the power levers during final approach, this action being acknowledged by the PF. This was significant, as both power levers were subsequently retarded below Flight Idle - an action which would have been unexpected by the PF.
The recorded data shows that the No. 1 engine reached a minimum torque level of -9% in Beta range, while No. 2 engine reached a minimum of 0%. This thrust asymmetry was coincident with the aircraft commencing a roll to the left (maximum recorded value of 40 degrees bank). It is possible that the PF may have made a control wheel input to the right in response to the unanticipated left roll. However, without FDR parameters of control wheel or control surface position the Investigation could not determine if such an input was made. The subsequent application of power to commence the go-around, at approximately 100 feet, coincided with the commencement of a rapid roll to the right and loss of control. The roll continued through the vertical, the right wingtip struck the runway and the aircraft inverted.
Three principal factors contributed to the loss of control:
- Uncoordinated operation of the power levers and the flight controls, which were being operated by different Flight Crew members.
- The retardation of the power levers below Flight Idle, an action prohibited in flight, and the subsequent application of power are likely to have induced an uncontrollable roll rate due to asymmetric thrust and drag.
- A torque split between the powerplants, caused by a defective Pt2/Tt2 sensor, became significant when the power levers were retarded below Flight Idle and the No. 1 powerplant entered negative torque regime. Subsequently, when the power levers were rapidly advanced during the attempted go-around, this probably further contributed to the roll behaviour as recorded on the FDR.
- 1. Continuation of approach beyond the Outer Marker (OM) equivalent position without the required minima.
- 2. Continuation of descent below Decision Height (DH) without adequate visual reference.
- 3. Uncoordinated operation of the power levers and the flight controls.
- 4. In-flight operation of the power levers below Flight Idle.
- 5. A torque split between the engines that became significant when the power levers were operated below Flight Idle.
- 6. Tiredness and fatigue on the part of the Flight Crew members.
- 7. Inadequate command training and checking during the command upgrade of the Commander.
- 8. Inappropriate pairing of Flight Crew members.
- 9. Inadequate oversight of the remote Operation by the Operator and the State of the Operator.
- 1. The Director-General for Mobility of Transport, European Commission should review the obligations of Member States to implement penalties, in accordance with the Standardisation Regulation (EU) No 628/2013, as a result of transgressions including Flight Time Limitations as provided for in Regulation (EC) No 216/2008. [IRLD2014001]
- 2. The European Aviation Safety Agency should provide guidance to Operators concerning successive instrument approaches to an aerodrome in IMC (Instrument meteorological conditions) or night VMC (Visual meteorological conditions) where a landing cannot be made due to weather reasons and incorporate guidance in Commission Regulation (EU) No 965/2012 accordingly. [IRLD2014002]
- 3. The European Aviation Safety Agency should review Council Regulation (EEC) No 3922/91 as amended by Commission Regulation (EC) No 859/2008, to ensure that it contains a comprehensive syllabus for appointment to Commander and that an appropriate level of Command training and checking is carried out. [IRLD2014003]
- 4. Flightline S.L. should review its current operational policy of an immediate diversion following a missed approach due to weather. [IRLD2014004]
- 5. Flightline S.L. should implement suitable and appropriate training for personnel responsible for flight safety and accident prevention. [IRLD2014005]
- 6. The Director-General for Mobility of Transport, European Commission should review the role of the ticket seller when engaged in providing air passenger services and restrict ticket sellers from exercising operational control of air carriers providing such services, thus ensuring that a high and uniform level of safety is achieved for the travelling public. [IRLD2014006]
- 7. The European Aviation Safety Agency should review the process by which AOC (Air Operator Certificate) variations are granted to ensure that the scope of any new operation is within the competence of the air carrier. [IRLD2014007]
- 8. Agencia Estatal de Seguridad Aérea (AESA) should review its policy with regard to continuing oversight of air carriers, in particular those conducting remote operations. [IRLD2014008]
- 9. The Director-General for Mobility of Transport, European Commission should review Regulation (EC) No 216/2008 in the context of Implementing Regulation (EU) No 628/2013 in order to improve safety oversight including the efficacy and scope of SAFA (Safety Assessment of Foreign Aircraft) Inspections and to provide for the extension of oversight responsibilities, particularly in cases where effective oversight may be limited due to resource issues, remote operation or otherwise. [IRLD2014009]
- 10. The Director-General for Mobility of Transport, European Commission should review the scope of the Air Safety Committee, and consider including oversight of Operating Licences issued by Member States and the processes by which such oversight is carried out. [IRLD20140010]
- 11. The International Civil Aviation Organization should consider the inclusion of information regarding the flight-specific approach capability of aircraft/flight crew within the proposed 'Flight and flow - Information for a Collaborative Environment (FF-ICE)'. [IRLD2014011]
Martin McGuinness, the deputy First Minister of Northern Ireland, revealed that he had intended to be on the flight, but had changed his travel plans. McGuinness was due to travel to Cork to campaign in the forthcoming Irish general election, scheduled for 25 February.
On 22 April 2011, it was revealed that the EASA had initiated a procedure to suspend the AOC of Flightline S.L. Eventually the AOC was not revoked, but restrictions were put in place banning Flightline from operating Fairchild Metro IIIs.
It was revealed on 29 April 2011, that former pilot Oliver Lee who regularly flew Manx2 services between Belfast City and Cork had committed suicide. He had left the airline days before the accident to join British airline Jet2.com and was known by frequent travellers on the route. Lee reportedly felt a sense of guilt following the accident.
On 4 May 2011, the BBC Radio 4 programme Face the Facts investigated the circumstances of the accident. It stated that the crew breached air safety regulations on all three approaches by descending below the decision height of 200 ft (61 m) before initiating a missed approach. On 6 May, the Civil Aviation Authority in the United Kingdom issued a Safety Notice advising all operators within the United Kingdom of new rules regarding Non-Precision Approaches and Minimum Descent Altitudes, applicable from 16 July 2011.
Following the release of the final report on 28 January 2014, family members of those bereaved in the accident as well as those injured announced intentions to pursue legal action against all 3 companies involved in the accident. An inquest was opened on 10 June 2014. It was scheduled to last two days. On 11 June, a jury returned verdicts of accidental death on all six victims.
- ^ The METAR in force at the time of the accident was: EICK 100930Z 08005KT 050V110 0300 R17/0375N R35/0350N FG BKN001 04/04 Q1010 NOSIG.
- Translation: METAR for Cork Airport, issued on the 10th of the month at 09:30 Zulu time. Wind from 080° at 5 knots (9.3 km/h; 5.8 mph), varying from 050° to 110°. Visibility 300 metres (980 ft), Runway visual range for Runway 17 is 375 metres (1,230 ft) with no significant change, Runway visual range for Runway 35 is 350 metres (1,150 ft) with no significant change, fog, broken clouds at 100 feet (30 m) above ground level, temperature 4 °C, dew point 4 °C, QNH 1010 hPa, no significant change expected.
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