Crash of a Boeing 737-301F in East Midlands

Date & Time: Jun 15, 2006 at 0502 LT
Type of aircraft:
Operator:
Registration:
OO-TND
Flight Type:
Survivors:
Yes
Schedule:
Liège - Stansted
MSN:
23515/1355
YOM:
1987
Flight number:
TAY325N
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8325
Captain / Total hours on type:
4100.00
Copilot / Total flying hours:
1674
Copilot / Total hours on type:
1377
Aircraft flight hours:
45832
Aircraft flight cycles:
34088
Circumstances:
On a scheduled cargo flight from Liège Airport to London Stansted Airport the crew diverted to Nottingham East Midlands Airport due to unexpectedly poor weather conditions at Stansted. The weather conditions at EMA required a CAT IIIA approach and landing. On approach, at approximately 500 feet agl, the crew were passed a message by ATC advising them of a company request to divert to Liverpool Airport. The commander inadvertently disconnected both autopilots whilst attempting to reply to ATC. He then attempted to re-engage the autopilot in order to continue the approach. The aircraft diverged to the left of the runway centreline and developed a high rate of descent. The commander commenced a go-around but was too late to prevent the aircraft contacting the grass some 90 m to the left of the runway centreline. The aircraft became airborne again but, during contact with the ground, the right main landing gear had broken off. The crew subsequently made an emergency landing at Birmingham Airport (BHX).
Probable cause:
Causal factors:
1. ATC inappropriately transmitted a company R/T message when the aircraft was at a late stage of a CAT III automatic approach.
2. The commander inadvertently disconnected the autopilots in attempting to respond to the R/T message.
3. The crew did not make a decision to go-around when it was required after the disconnection of both autopilots below 500 ft during a CAT III approach.
4. The commander lost situational awareness in the latter stages of the approach, following his inadvertent disconnection of the autopilots.
5. The co-pilot did not call ‘go-around’ until after the aircraft had contacted the ground.
Contributory factors:
1. The weather forecast gave no indication that mist and fog might occur.
2. The commander re-engaged one of the autopilots during a CAT III approach, following the inadvertent disconnection of both autopilots at 400 feet aal.
3. The training of the co-pilot was ineffective in respect of his understanding that he could call for a go-around during an approach.
Final Report:

Crash of a Boeing 747-2B5F in Stansted: 4 killed

Date & Time: Dec 22, 1999 at 1839 LT
Type of aircraft:
Operator:
Registration:
HL7451
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Stansted - Milan - Seoul
MSN:
22480
YOM:
1980
Flight number:
KE8509
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
13490
Captain / Total hours on type:
8495.00
Copilot / Total flying hours:
1406
Copilot / Total hours on type:
195
Aircraft flight hours:
83011
Aircraft flight cycles:
15451
Circumstances:
Boeing 747 HL-7451 arrived at Stansted at 15:05 after a flight from Tashkent. Prior to leaving the aircraft, the flight engineer made an entry in the Technical Log stating "Captain's ADI [Attitude Director Indicator] unreliable in roll' he also verbally passed the details to the operator's ground engineer who met the aircraft on arrival. During turnover repair works on the ADI were carried out. Some cargo was offloaded and other cargo loaded for the flight to Milan-Malpensa (takeoff weight was 548,352 lb including 68,300 lb of fuel) and a new crew boarded the aircraft. After a delay of an hour, because ATC had not received the flight plan, Flight 8509 was cleared to depart Stand Alpha 6 and taxi to runway 23 holding point at 18:25. Subsequently, at 18:36 KAL 8509 was cleared to takeoff with a reported surface wind of 190deg/18 kt. The Dover 6R Standard Instrument Departure called for a climb ahead to 1.5 miles DME, then a left turn onto the 158 inbound radial to the Detling VOR. Climbing through 900 feet, the ADI 'Comparator' buzzer sounded three times. Shortly afterwards, the warning sounded a further two times, coincident with the captain expressing concerns over his DME indication. Climbing through 1400 feet, ATC instructed the crew to contact 'London Control'. And as the captain initiated the procedure turn to the left, the 'Comparator' warning sounded again some 9 times. The maximum altitude reached was 2,532 feet amsl. The aircraft then banked left progressively and entered a descent until it struck the ground in a approx. 40deg nose down pitch and 90deg bank to the left; the speed was high in the region of 250 to 300 kt.
Probable cause:
The following causal factors were identified:
- The pilots did not respond appropriately to the comparator warnings during the climb after takeoff from Stansted despite prompts from the flight engineer,
- The commander, as the handling pilot, maintained a left roll control input, rolling the aircraft to approximately 90° of left bank and there was no control input to correct the pitch attitude throughout the turn,
- The first officer either did not monitor the aircraft attitude during the climbing turn or, having done so, did not alert the commander to the extreme unsafe attitude that developed,
- The maintenance activity at Stansted was misdirected, despite the fault having been correctly reported using the Fault Reporting Manual. Consequently the aircraft was presented for service with the same fault experienced on the previous sector; the No 1 INU roll signal driving the captain's ADI was erroneous,
- The agreement for local engineering support of the Operator's engineering personnel, was unclear on the division of responsibility, resulting in erroneous defect identification, and misdirected maintenance action.
Final Report: