Munster

Probable Cause:
1. Excessive approach speed and inadequate control of aircraft pitch during a crosswind landing in very blustery conditions.
Contributory Factors:
1. Confusing wording in the FCOM that led the crew to compute an excessive wind factor in the determination of Vapp.
2. Incorrect power handling technique while landing.
3. Inexperience of the pilot in command.
4. Inadequate information provided to flight crew regarding crosswind landing techniques.

Loss of control during an attempted go-around initiated below Decision Height (200 feet) in Instrument Meteorological Conditions.
The following factors were considered as significant:
- The approach was continued in conditions of poor visibility below those required.
- The descent was continued below the Decision Height without adequate visual reference being acquired.
- Uncoordinated operation of the flight and engine controls when go-around was attempted
- The engine power-levers were retarded below the normal in-flight operational range, an action prohibited in flight.
- A power difference between the engines became significant when the engine power levers were retarded below the normal in-flight range.
- Tiredness and fatigue on the part of the Flight Crew members.
- Inadequate command training and checking.
- Inappropriate pairing of Flight Crew members, and
- Inadequate oversight of the remote Operation by the Operator and the State of the Operator.

The primary responsibility for the safe conduct of a flight rests with the cockpit crew and, in this regard, they have the Aircraft Flight Manual (AFM), company Standard Operating Procedures (SOP's) and other technical manuals at their disposal in the cockpit. In particular, the company lays down the SOP's to be followed by each and every cockpit crew member in the interests of standardisation and flight safety. The implementation of these measures and procedures is carried out by the cockpit crew and they are aided in this process by artificial mechanical/electrical warning systems and audio alerts. In the L188 in question the two audio alert systems consist of a Ground Proximity Warning System (GPWS) and the landing gear warning horn. The GPWS system sounded at about 700' AGL and this should have been sufficient to warn the crew that the landing gear handle was not down and consequently that the undercarriage was not in the landing configuration. The Flight Engineer, however, reached up and inhibited the GPWS. He said he did this because he understood the aircraft to have 78% flap set for landing and that this was why the GPWS warning sounded. He obviously confused this warning with a warning which he would have got below 200 feet radio height when the flaps are set at less than 100% for landing. The fact that this particular aircraft had no FLAP OVERRIDE switch, as the other two similar aircraft in the fleet had, would probably have added to this confusion. Whether the engineer was instructed to inhibit the GPWS by other crew members is not clear from the CVR. In the debrief following the accident the other crew members agreed that the engineer would have been correct in inhibiting the GPWS as they were landing with 78% flaps configuration. They, therefore, also misinterpreted the GPWS warning. Having failed to carry out the landing checks and with the undercarriage not down, the normal undercarriage warning horn should have sounded when the throttles were retarded for landing. However, it is possible to silence this warning in the 78% flap configuration, which would not have been possible if the flaps were set in the normal (100%) configuration for landing. It appears that as the throttles were being retarded the Flight Engineer pressed the warning horn button to prevent the alarm from sounding. Whether he was so instructed is not clear as parts of the CVR tape were difficult to interpret due to its poor quality. During the final stage of landing the throttles were advanced again thus negating the warning cancellation. As the aircraft rounded out for landing the warning horn was again free to sound, and it did, as the throttles were retarded. However, at this stage, there was too little time to lower the undercarriage and five seconds later the propellers stuck the runway surface.
The following findings were identified:
- The aircraft had a valid standard Airworthiness Certificate issued by the United States Department of Transportation, Federal Aviation Administration and had been maintained in accordance with an approved schedule.
- No evidence was found of any technical problems on the aircraft, or its systems, that could have had any bearing on the accident. In addition, the aircraft records show that the aircraft was dispatched on the accident flight with no deferred maintenance items.
- The crew were properly licensed, in accordance with US Federal Aviation Administration Regulations, to undertake this flight.
- The Captain stated that he had slight flu symptoms over the two days prior to the flight but that did not disbar him from undertaking the flight.
- The flight crew consisted of the Captain, First Officer and Flight Engineer. The First Officer was the handling pilot on this flight.
- No emergency call was made to ATC by the Captain or First Officer. The Shannon Radar controller provided invaluable voice and directional assistance to the crew as they struggled to maintain control of their seriously damaged aircraft and this was subsequently acknowledged by the crew.
- The subsequent actions of the crew in landing the aircraft safely from the second approach were commendable.
- The ILS for RWY 24 was fully serviceable.
- Crew fatigue is not considered a factor in this accident as they had sufficient time off duty in the days immediately prior to the flight and their overall flying duties are of average industry standards.
- Debris from the disintegrating No. 3 engine fell to earth on the western side of RWY 24, within the boundaries of Shannon Airport. Fortunately, there was no damage to property or people.
- The selection of 78% flap setting for the landing was in accord with the Operators SOP's for the prevailing landing conditions. However in selecting 78% flap setting the crew were of the mistaken opinion that the GPWS warning horn should be silenced even though the aircraft was not in the landing configuration.
- The Flight Engineer silenced the landing gear warning horn during the approach phase while the engine power levers were being retarded. It is only when these levers were slightly advanced, just before the round-out stage, that the landing warning horn system was again primed and subsequently sounded.
- The normal landing checks were not carried out by the flight crew. Not one crew member realised that the undercarriage gear was not down and locked.
- The crew stated that this was an inexplicable oversight on their part.

At the time of the accident, the runway visual range for runway 06 was 250 metres, which was considered as below the published procedures of the company and the airport which stipulated a minimum of 300 metres. No technical anomalies were found on the aircraft, its engines or instruments. The pilot took the decision to takeoff in below weather minimums and his experience was considered as insufficient with only 30 flying hours on type.

Failure of the captain to maintain control of the aircraft after becoming airborne due to either:
- A defective artificial horizon and/or
- A fault in the right-hand aileron tabs.
Contributory causes could have been unsuitable weather conditions and possible crew fatigue.

The accident was the consequence of the following factors:
- Poor crew coordination,
- Poor flight preparation,
- Lack of pilot experience.

No definite evidence leading to a particular reason for this accident was revealed by the investigation. It can only be concluded that the airplane lost height in a turn shortly after takeoff and struck the ground.