Lake, Sea, Ocean, River

The reported loss of engine power from the left engine, and the failure of the left propeller to feather for undetermined reasons, resulting in the inability to maintain altitude, and subsequent ditching.

The accident under examination, as most aviation accidents, has been determined by a series of events linked one another, which caused the final ditching. The ditching was primarily due to the both engines flame out because of fuel exhaustion. The incorrect replacement of the fuel quantity indicator (FQI) was one of the contributing factors which led irremediably to the accident. The accident’s cause is therefore traceable firstly to the incorrect procedure used for replacing the FQI, by means of the operator’s maintenance personnel. This shall be considered the disruptive element, which caused the final ditching of the aircraft due to the lack of fuel that caused the shutdown of both engines. As said before the accident was determined by a series of events (contributing factors) linked one another. Hereafter are listed some considered of major importance.
- Errors committed by ground mechanics when searching for and correctly identifying the fuel indicator.
- Errors committed by the flight crew: non-respect of various operational procedures.
- Inadequate checks by the competent office of the operator that flight crew were respecting operational procedures.
- Inaccuracy of the information entered in the aircraft management and spares information system and the absence of an effective control of the system itself.
- Inadequate training for aircraft management and spares information system use and absence of a responsible person appointed for managing the system itself.
- Maintenance and organization standards of the operator unsatisfactory for an adequate aircraft management.
- Lack of an adequate quality assurance system;
- Inadequate surveillance of the operator by the competent Tunisian authority.
- Installation characteristics of fuel quantity indicators (FQI) for ATR 42 and ATR 72 which made it possible to install an ATR 42 type FQI in an ATR 72, and vice versa.
The analysis of various factors that contributed to the event has been carried out according to the so called Reason’s "Organizational accident" model. Active failures, which had triggered the accident, are those committed both by ground mechanics/technicians the day before the event while searching for and replacing the fuel quantity indicator, and by the crew who did not verify and fully and accurately complete the aircraft’s documentation, through which it would have been possible to perceive an anomalous situation regarding the quantity of fuel onboard. Latent failures, however, remained concealed, latent in the operator’s organizational system until, some active errors (by mechanics and pilots) were made, overcoming the system’s defence barriers, causing the accident. Analysing latent and active failures (errors) traceable to various parties, involved in the event in several respects, it clearly emerges that they were operating in a potentially deceptive organizational system. When latent failures remain within a system without being identified and eliminated, the possibility of mutual interaction increases, making the system susceptible for active failures, or not allowing the system to prevent them, in case of errors. Active failures were inserted in a context characterised by organizational and maintenance deficiencies. The error that led to the accident was committed by mechanics who searched for and replaced the FQI, but this error occurred in an organizational setting in which, if everybody were operating correctly, probably the accident would not have occurred. Inaccuracy of information entered in the aircraft management and spares information system, particularly regarding the interchangeability of items and the absence of an effective control of the system itself, has been considered in fact one of the latent failures that contributed to the event. The maintenance and organization standards of the operator, at the time of event, were not considered satisfactory for an adequate management of the aircraft. The flight crew and maintenance mechanics/technicians involved in the event, when they made incorrect choices and took actions not complying with standard procedures, did not receive sufficiently effective aid from the system in order to avoid the error.

Engine failure for unknown reasons.

Findings as to Causes and Contributing Factors:
1. The aircraft was loaded in such a manner that the C of G was beyond the rearward limit. This resulted in the aircraft’s aerodynamic pitch control limitation being exceeded.
2. A weight and balance report was not completed by the pilot prior to departure and, as a consequence, he was unaware of the severity of the aft C of G position.
Finding as to Risk:
1. The weight of the passengers was underestimated due to the use of standard weights. This increased the potential of inadvertently loading the aircraft in excess of its maximum certified take-off weight.

It is believed that the loss of control upon landing was the consequence of the combination of a poor management of the factor P on part of the pilot-in-command, and microbursts. However, a technical problem was not ruled out.

The accident was caused by aircraft colliding with the water surface shortly after take off. While the aircraft had gathered sufficient energy to sustain climb, the crew failed to monitor altitude and react correctly in the short time that the aircraft was airborne. This resulted in the aircraft going into descent till it reached an altitude where recovery was not possible. The possibility of crew fatigue as a contributory factor in this accident cannot be ruled out.

The crew continued the approach below MDA until the aircraft impacted water and crashed. The crew failed to follow the published procedures and to initiate a second go-around procedure.

The investigation identified the following causal factors:
1. The pilot allowed the aircraft to descend below the minimum altitude for the aircraft’s position on the approach procedure, and this descent probably continued unchecked until the aircraft flew into the sea.
2. A combination of fatigue, workload and lack of recent flying practise probably contributed to the pilot’s reduced performance.
3. The pilot may have been subject to an undetermined influence such as disorientation, distraction or a subtle incapacitation, which affected his ability to safely control the aircraft’s flightpath.

Loss of control during initial climb due to windshear after weather conditions suddenly changed as a thunderstorm was approaching the airport.