Accident
Last updated: 24 November 2014
Status:Definitief
Datum:donderdag 10 februari 2011
Tijd:09:50
Type:Silhouette image of generic SW4 model; specific model in this crash may look slightly different
Swearingen SA227-BC Metro III
Vloog voor:Manx2
Gehuurd van:Flightline
Registratie: EC-ITP
Constructienummer: BC-789B
Bouwjaar: 1992
Aantal vlieguren:32653
Aantal vluchten:34156
Motoren: 2 Garrett TPE331-12UHR-701G
Bemanning:slachtoffers: 2 / inzittenden: 2
Passagiers:slachtoffers: 4 / inzittenden: 10
Totaal:slachtoffers: 6 / inzittenden: 12
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:Cork Airport (ORK) (   Ierland) show on map
Fase: Landing (LDG)
Soort vlucht:Internationale lijnvlucht
Vliegveld van vertrek:Belfast City Airport (BHD/EGAC), Verenigd Koninkrijk
Vliegveld van aankomst:Cork Airport (ORK/EICK), Ierland
Vluchtnummer:7100
Beschrijving:
A Swearingen SA-227BC Metro III passenger plane, registered EC-ITP, was damaged beyond repair in a landing accident at Cork Airport (ORK), Ireland. There were 10 passengers and two crew members on board. Both crew members and four passengers were killed.
The airplane operated on Manx2 flight NM7100 from Belfast City Airport (BHD) to Cork Airport (ORK). Following a fuel uplift a total fuel quantity of 3,000 lbs was recorded, which was sufficient for the planned round trip to Cork and back to Belfast. The flight plan specified Waterford Airport (EIWF) as the alternate for the sector to Cork.
The accident flight took off from Belfast at 08:10 hrs, and climbed to Flight Level (FL) 120. The co-pilot was Pilot Flying (PF) with the commander acting as Pilot Non Flying (PNF).
At 08:48 the flight contacted Cork Approach Control. The Cork ATIS information stated that runway 35 was the active runway with Low Visibility Procedures (LVP) in operation. Cork Approach also informed the flight crew that runway 35 was the active runway with CAT II available for runway 17. The RVRs on runway 17 were passed by Cork Approach as 300 m (touchdown), 350 m (midpoint) and 550 m (stop-end) (300/350/550). Flight 7100 was given the choice of runways, and while runway 35 was initially considered by the flight crew, a decision was made to opt for an approach to runway 17. This was acknowledged by Cork Approach who stated "...that’s copied, just check IRVRs Runway 17 for CAT II, currently at 350, 350, and 450."
The aircraft first established on the ILS approach to runway 17 at 08:58 and was handed over to Cork Tower. The RVRs passed by Cork Tower at 09:00 hrs were 300/400/375. The approach was continued beyond the 3.5 nautical miles (nm) DME point (outer marker equivalent). A missed approach was carried out at 09:03 hrs, the lowest height recorded on this approach was 101 ft radio altitude.
A second ILS approach was then flown, to the reciprocal direction runway 35, with the aircraft being handed over to Cork Tower at 09.10 at 8 nm from touchdown. At 09:10:56 the flight crew reported established on the ILS runway 35. The RVRs passed by the Tower at this time were 350/350/350. Descent was continued beyond the 4.9 nm DME point (outer marker equivalent). A missed approach was carried out at 09:14, the lowest height recorded on this approach was 91 ft radio altitude.
At 09:15 hrs the flight crew requested to enter a holding pattern for 15 to 20 minutes to see if the weather would improve. The flight took up the holding pattern at point ROVAL maintaining an altitude of 3,000 ft. The flight crew requested the weather for Waterford. This weather, which was below minima, was provided by Cork Approach. The flight crew nominated Shannon Airport as their second alternate and requested weather information. Shannon weather was passed by Cork Approach, it was below minima. Weather for Dublin Airport was then sought by the flight crew. This was acknowledged by Cork Approach who offered to provide the weather for Kerry Airport also. The weather at Kerry was passed with the visibility being reported as greater than 10 kilometres. Weather conditions at Dublin, which were marginal, were obtained and passed to the flight crew at 09:35 hrs.
At approximately 09:32 hrs, with EC-ITP still in the ROVAL hold, the RVR values on runway 17 at Cork began to improve. Following a further improvement to 500/450/400 at 09:39 hrs, the flight crew elected to attempt another approach to runway 17.
At 09:45 the aircraft reported established on the ILS, and was configured with landing gear down and 1/2 flaps selected. At 09:45:26, when EC-ITP was at 11 nm DME on the ILS, the RVR (touchdown) improved to 550 m, which was passed to the flight crew by Cork Approach.
At 09:45:38, the flight was handed over to the Cork Tower and the flight crew reported to the Tower at 09:46:00 passing 9 nm DME. The final RVRs passed to EC-ITP at 09.46:15 were 500/400/400 when the aircraft was 9.6 nm from the threshold of runway 17. At approximately 400 ft radio altitude, recorded data shows the aircraft deviated to the right of the runway centreline, paralleling the centreline track.
The descent was continued below Decision Height (DH). Power was reduced momentarily before being re-applied. Just below 100 ft radio altitude, a go-around was called by the PNF and was acknowledged by the PF.
Recorded data shows that the aircraft rolled significantly to the left as the aircraft tracked towards the runway centreline. This was immediately followed by a rapid roll to the right which brought the right wingtip into contact with the runway surface. Runway surface contact was made with a roll angle of 97 degrees to the right. The initial impact mark was located 86 m from the runway threshold, and 2 m left of the centreline.
The aircraft continued to roll rapidly to the right and struck the runway in the fully inverted position 25 m beyond the initial impact point. The inverted aircraft departed the runway surface on a heading of approximately 195° M and came to a rest 189 m from the initial impact point. The propeller blades on both engines were severely damaged; three of the four propeller blades on the right-hand engine detached during the inverted impact. Fire occurred in both engines post impact.

The AOC of the operator contained approval for the aircraft to operate CAT I approaches only. In this case a decision height of 200 feet at an RVR (touchdown) minimum of 550 m for runway 17 and 750 m for runway 35.


The Investigation determined that the probable cause was ‘Loss of control during an attempted go-around initiated below Decision Height (200 feet) in Instrument Meteorological Conditions’.

The Investigation identified the following factors as being 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.

Bronnen:
» Irish Aviation Authority (IAA) statement
» Six killed as passenger plane crashes in fog at Cork airport (Irish Times, 10-2-2011)
» Irish Examiner

Official accident investigation report
investigating agency: Air Accident Investigation Unit (AAIU) - Ireland
report status: Final
report number: AAIU Report No. 2014-001
report released:28-JAN-2014
duration of investigation:1083 days (2 years 11.8 months)
download report: Accident Fairchild SA-227-BC Metro III, EC-ITP, Cork Airport, Ireland 10 February 2011 (AAIU Report No. 2014-001)
cover

Veiligheidsmaatregelen
Following the accident Flightline introduced revised procedures to enhance the operational control of Flightline flights, particularly those operating away from their main base. The airline amended their Operations Manual to include guidance on the use of alternate aerodromes, amended their training programme to reinforce pilot knowledge of operating procedures, and revised their pilot selection procedures.

The Spanish authorities, AESA, limited the Flightline AOC in March 2011 to prevent operation of the Fairchild Metro 3s.

AAIU issued 11 Safety Recommendations

Show all AD's and Safety Recommendations

Foto's

photo of Swearingen SA.227BC Metro III EC-ITP
photo of Swearingen SA.227BC Metro III EC-ITP
photo of Swearingen SA.227BC Metro III EC-ITP
photo of Swearingen SA.227BC Metro III EC-ITP
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Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Belfast City Airport en Cork Airport bedraagt 352 km (220 miles).

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