ASN Wikibase Occurrence # 319921
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| Date: | Thursday 23 February 2017 |
| Time: | 16:54 |
| Type: |  de Havilland Canada DHC-8-402Q Dash 8 |
| Owner/operator: | Flybe |
| Registration: | G-JECP |
| MSN: | 4136 |
| Year of manufacture: | 2006 |
| Total airframe hrs: | 20477 hours |
| Cycles: | 23889 flights |
| Engine model: | Pratt & Whitney Canada PW150A |
| Fatalities: | Fatalities: 0 / Occupants: 63 |
| Aircraft damage: | Substantial, repaired |
| Category: | Accident |
| Location: | Amsterdam-Schiphol International Airport (AMS) -
 Netherlands
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Edinburgh-Turnhouse Airport (EDI/EGPH) |
| Amsterdam-Schiphol International Airport (AMS/EHAM) | |
| Investigating agency: | Dutch Safety Board |
| Confidence Rating: |  Accident investigation report completed and information captured |
Flybe flight 1284, a DHC-8-402Q, suffered a landing accident at Amsterdam-Schiphol International Airport, the Netherlands.
The aircraft departed Edinburgh, Scotland, on a scheduled passenger service to Amsterdam at 14:21 UTC. About 15:22 UTC the aircraft entered a holding pattern over the North Sea off the western coast of the Netherlands because landing runways available were limited at Schiphol because of the strong surface wind.
It left the holding about 15:38 UTC and positioned for an ILS approach to runway 22. During the approach to Schiphol, at approximately 16:30 hours, ATC requested the crew to hold over reporting point SUGOL at flight level (FL) 110 for 20
minutes because landing runways available were limited at Schiphol because of the strong surface wind. ATIS information Kilo reported winds from direction 240° with a
velocity of 35 knots, gusting to 40 knots. METAR information reported winds at 37 knots
gusting to 46 at 15.55 (UTC, 16.55 local time).
From SUGOL the crew initially received radar vectors inbound Schiphol. They then were
cleared to intercept the Instrument Landing System (ILS) for runway 22. The ILS for the
approach to runway 22 was intercepted at 18 NM.
During the descent, at 15:49 UTC, the autopilot disengaged because of gusting winds in the approach and was reengaged by the crew shortly after.
The arrival was flown in speed control mode with an airspeed of 170 knots. Final speed was selected at 130 knots, i.e. normal landing threshold speed (VREF) plus 10 knots to compensate for the gusting winds. At around 15:51 UTC, approximately 5.5 NM from the runway touchdown point, the landing gear was selected down, giving three greens indication in the cockpit shortly after. The crew confirmed the indication, 15 degrees flaps were selected and de-icing systems were selected.
The crew then changed radio frequency to Schiphol Tower and received a clearance for landing on runway 22. The air traffic controller reported the wind from direction 240 degrees with speeds of 36 knots gusting to 48 knots. The crew finished the before landing checklist. They then selected 5 degrees flaps and selected gear down. They confirmed ice protection on, landing gear three greens, selected 15 degrees flaps and checked bleed air on.
At an altitude of 300 feet the flight crew disengaged the autopilot for landing. On short final the crew noticed the PAPI showing they were on the glide path. Although the pilots were aware they would encounter strong winds during landing, including crosswinds, the wind conditions were not extreme and were not above the aircrafts limitations. Short final was flown under crosswind conditions, with the nose of the aircraft about 20 degrees right of centre line. Just before touch down the pilot flying aligned the nose of the aircraft with the runway centreline and lowered the right wing to compensate for the crosswind, causing the right-hand main wheel to touch the runway first. The aircraft touched down at 15:54 UTC. The crew considered the landing to be firm, but not hard. Almost immediately after touch down the crew noticed the right wing dropping, and a red warning light appeared on the landing gear panel in the cockpit.
The right-hand propeller, right-hand engine nacelle, lower fuselage, wing tip and aileron collided with the runway and the aircraft continued for several hundred meters before coming to a complete stop. This resulted in damage to the right hand propeller, the lower fuselage structure and right-hand outboard wing tip. The right-hand fuselage was also damaged due to fragments from the right-hand propeller and stone strikes. The left-hand main landing gear and nose gear remained extended.
The crew transmitted a MAYDAY call and after coming to a complete stop the cabin attendants started evacuating the passengers via the two aft doors. The crew then shut down the aircraft in accordance with the checklist. As a precaution, they also pulled the circuit breakers from the flight data and cockpit voice recorders. During the accident and following evacuation no-one was injured.
Conclusions:
- Maintenance was performed on the night before the day of the mishap flight, during maintenance the MLG brace was replaced. The maintenance crew stated they did not find anything unusual during the installation of the brace.
- After the accident, the newly installed stabilizer brace showed no deformation, nor did the attachment lugs on the yoke or the forward nacelle.
- The PSEU showed several fault codes which were consistent with the condition of the aircraft during the approach and after the incident.
- One of the MLG down lock sensors was found unreliable. The faulty sensor prevented the PSEU logic from closing the aft RH MLG doors and activating the unlock actuator.
- The unlock actuator not being activated prevented the brace being aided to maintain its over centred position by hydraulic pressure.
- The RH MLG yoke was found deformed. Analyses, and the fact no deformation was present on the stabilizer brace assembly, indicate that the deformation on the yoke was present prior to touchdown at Schiphol, and that this deformation was caused when NO stabilizer brace assembly was installed.
- The deformation of the yoke placed the RH MLG in a condition outside the certification state, thereby exposing the RH MLG stabilizer brace assembly to the potential of unlocking.
- The bent yoke caused friction in the MLG yoke and brace combination, which prevented at least one of the two stabilizer brace apex joints from achieving an over centre condition when the MLG was extended prior to landing. Although not designed for this, not hydraulically activating the unlock actuator after the gear was in the down position, prevented the brace assembly from being retained into over centre position.
- Despite the fact the gear was not fully locked, and outside certification condition, three green lights indicated to the crew that the gear was down and locked. Although not noticed by the flying crew, the amber caution light indicating the aft RH MLG were open, most likely was lit during landing.
- The combination of friction caused by the bent yoke, and faulty sensors preventing the unlock actuator to be activated, caused a situation whereby the stabilizer brace of the RH MLG did not get into over centre position causing an instable situation, despite the three LG green lights illuminated.
- During an asymmetric (rolled) touchdown in Amsterdam torsion loads were applied to the MLG, and the MLG strut collapsed almost immediately after touchdown of the RH MLG, causing the accident to happen.
METAR:
14:55 UTC / 15:55 local time:
EHAM 231455Z 23034G48KT 180V260 9999 FEW022 09/03 Q0985 TEMPO 7000 -RA BKN020
15:25 UTC / 16:25 local time:
EHAM 231525Z 24037G51KT 9999 -RA FEW020 SCT032 08/04 Q0985 TEMPO 7000 BKN020
15:55 UTC / 16:55 local time:
EHAM 231555Z 24031G46KT 210V270 9999 -RA FEW020 SCT028 BKN037 08/04 Q0985 TEMPO 7000 BKN020
Accident investigation:
 |
|
Sources:
Location
Images:
photo (c) Onderzoeksraad voor Veiligheid; Amsterdam-Schiphol International Airport (AMS); 23 February 2017
photo (c) Onderzoeksraad voor Veiligheid; Amsterdam-Schiphol International Airport (AMS); 23 February 2017
photo (c) Onderzoeksraad voor Veiligheid; Amsterdam-Schiphol International Airport (AMS); 23 February 2017
photo (c) Onderzoeksraad voor Veiligheid; Amsterdam-Schiphol International Airport (AMS); 23 February 2017
photo (c) Flightradar24; Amsterdam-Schiphol International Airport (AMS); 23 February 2017
photo (c) Werner Fischdick; Düsseldorf International Airport (DUS/EDDL); 15 June 2013
Revision history:
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