Unfallbericht:A Boeing 737-400, registered CN-RMF, sustained damage following a birdstrike at Amsterdam-Schiphol International Airport (AMS/EHAM), the Netherlands.
|Datum:||Sonntag 6 Juni 2010|
|Fluggesellschaft:||Royal Air Maroc - RAM|
|Baujahr:|| 1990-06-14 (19 years 12 months)|
|Triebwerk:|| 2 CFMI CFM56-3C1|
|Besatzung:||Todesopfer: 0 / Insassen: 6|
|Fluggäste:||Todesopfer: 0 / Insassen: 156|
|Gesamt:||Todesopfer: 0 / Insassen: 162 |
|Sachschaden:|| schwer beschädigt|
|Unfallort:||Amsterdam-Schiphol International Airport (AMS) (Niederlande)
|Flugphase:|| Start (TOF)|
|Flug von:||Amsterdam-Schiphol International Airport (AMS/EHAM), Niederlande|
|Flug nach:||Nador-Taouima Airport (NDR/GMFN), Marokko|
The aircraft had multiple bird strikes with geese during take-off from runway 18L. This resulted in heavy damage and loss of the left engine. The crew declared an emergency and the aircraft was vectored to runway 18R immediately. The aircraft’s climb performance was degraded. The highest altitude during the flight was approximately 630 feet. The aircraft made an overweight landing six minutes after takeoff and the tires of the right main landing gear were blown.
1. Shortly after take-off a bird strike occurred which caused damage to the left engine and reduced thrust to approximately 45%. The flight crew then took the right decision to return to Schiphol airport.
2. However, this decision was not executed in accordance with standard operational procedures. The deviations from the standard operational procedures after an engine failure were:
- The Initiation of a (right) turn at 280 feet with a bank angle of up to 37.5 degrees instead of climbing to the prescribed 'clean up' altitude with retracted landing gear.
- Selecting gear down at very low altitude after it had first been selected up.
- Reducing the thrust on the undamaged right engine from 94% N1 to 83% N1 instead of selecting maximum thrust.
These deviations from the standard operational procedures resulted in the aircraft only being able to achieve a limited rate of climb, causing it to be unable to achieve the required minimum safe flying altitude. The flight crew had dif ficulty controlling the aircraft and were distracted by various audio and visual warnings in the cockpit which were the consequence of incorrectly completed cockpit procedures.
3. During the flight the crew resource management and crew communication were not in accordance with the international standard for airline pilots.
- The immediately initiated right turn and the marginal remaining flying performance made the tasks more difficult and led to complications which meant that both pilots were unable to fulfil their tasks, such as the completion of cockpit procedures and checklist readings, in the prescribed manner. This in turn led to new complications such as unnecessary warnings and an unstable flight path.
4. During the refresher training for Atlas Blue and Royal Air Maroc pilots, they were not trained to deal with multiple malfunctions during the flight.
- Prior to every recurrent training pilots of Atlas Blue and Royal Air Maroc were taught about the specific malfunctions that would occur. This is not unusual In the context of flight training practice, but the consequence was that the pilots did not leam how to respond to unexpected effects.
- Dealing with multiple malfunctions featured only in the initial training for captains.
- Although the Flight Crew Training Manual and the Flight Crew Operations Manual contain the procedures and checklists required for the adequate tackling of malfunctions which occurred during this flight, the flight crew and the training managers of Atlas Blue and Royal Air Maroc regarded this serious incident as a unique event which pilots cannot be trained in.
5. The analysis of measures implemented in response to the 3PR Investigation (initiated in response to the recommendation by the Bijlmermeer Air Disaster Parliamentary Board of Inquiry) failed to take account of the risks caused by aircraft in distress situations flying below the minimum vectoring altitude. These aircraft are given headings In the Schiphol control zone, despite the fact that air traffic controllers do not have information on high obstacles in the flight path. This unnecessarily increases the risk of a collision. This problem is all the more urgent when aircraft are flying outside visual meteorological conditions.
- The Investigation conducted by Air Traffic Control the Netherlands in response to the recommendation by the Bijlmermeer Air Disaster Parliamentary Board of Inquiry has resulted In a policy framework on the supervision of aircraft in distress situations and on flying over densely populated areas. According to this policy framework for aircraft in distress situations, the captain is responsible for flight operation white the air traffic controller provides assistance to the cockpit crew. Aircraft in distress must use existing runway arrival and departure routes where possible, which limits the amount of flying over densely populated areas. The Directorate-General of Aviation and Maritime Affairs has approved the aforementioned policy framework. As a result of this policy framework, densely populated areas are not presented on air traffic controllers' radar screens.
- Schiphol airport is practically surrounded by a great number of populated/built-up areas. The consequence is that manoeuvring between those areas is not feasible for airliners (in distress) when taking the speed and turn radius of airliners into consideration.
- The maximum height above the ground of the aircraft during the flight was 730 feet and this was well under the minimum vectoring altitude for Schiphol of 1200 feet.
- Only two obstacles are displayed on the radar screen, of which one is in the Schiphol control zone. In the Schiphol control zone there are a number of other obstacles which might pose a risk to aircraft flying lower than the minimum vectoring altitude. This is particularly the case when flying outside visual meteorological conditions.
6. The presence of one or more birds with a large total mass in the flight path of an aircraft is a risk to f11ght safety. This particularly applies to geese due to their considerable mass and because they fly in groups. Most bird strikes occur during the take-off and landing phases of the flight.
7. The investigation has shown that parties that have a direct influence on bird control at Schiphol airport have exhausted their options. Except for the closing of active runways more often, it is up to other parties, therefore, to take further measures to reduce the safety risk caused by bird strikes.
8. All the aviation, agricultural, and bird and environmental protection parties acknowledge the bird strike risk as such and the need to reduce this risk. Although the parties agree on the necessary measures, there is no such consensus with regard to their effect. As a result, there are also differing views as to the (cost-)effective implementation of these measures.
9. Due to the high level of urgency involved, there is no time to wait for the outcome of ongoing pilots to assess alternative control measures that would yield results in the longer term. The reduction of goose populations represents the most effective short-term measure. In the longer term, habitat management and improvement of the measures to detect and scare off birds could also help structurally reduce the risk of bird strikes.
10. Seven civil-society organisations united in the "Goose 7" recently prepared a joint national and regional recommendation, outlining measures to reduce and stabilise the population of various types of geese in the Netherlands at a certain level. The implementatioo of this recommendation as a short-term measure will require the approval of the State Secretary of Economic Affairs, Agriculture and Innovation, which approval thus far has not been forthcoming.
11. The Ministry of Infrastructure and the Environment, responsible for aviation safety, has not sufficiently coordinated measures aimed at reducing the risk of bird strikes.
Official accident investigation report
|investigating agency: ||Dutch Safety Board|
|report status: ||PRELIM.|
|report number: ||Preliminary report|
|duration of investigation:||37 days (1.2 months)|
|download report: ||
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.