ASN Wikibase Occurrence # 220486
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| Date: | Thursday 10 December 2015 |
| Time: | 13:21 UTC |
| Type: |  Saab 2000 |
| Owner/operator: | Etihad Regional/Darwin Airline |
| Registration: | HB-IZW |
| MSN: | 2000-039 |
| Year of manufacture: | 1996 |
| Fatalities: | Fatalities: 0 / Occupants: 29 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | 4.5 NM east of Billund Airport (EKBI) -
 Denmark
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | Berlin Tegel Airport (EDDT) |
| Billund Airport (EKBI) | |
| Investigating agency: | STSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
On 10 December 2015 at 12:14 UTC, the Saab 2000 aircraft took off from Berlin Tegel Airport (EDDT) for a scheduled flight to Billund Airport (EKBI) under flight number AB8054. On this flight, the commander was the pilot flying.
After an uneventful cruise flight, the pilots noticed problems with the glideslope indication during the approach to Billund Airport. At an altitude of 800 ft above ground and 250 ft below the minimum altitude stipulated for this position, the pilot flying initiated a go-around.
Because of the problems with the glideslope indication, the pilots decided to perform a nonprecision approach using the localiser for the second approach. During this approach, the aircraft descended too steeply and continued to descend below the stipulated minimum altitudes.
The excessive descent then triggered the ground proximity warning system to which the pilots reacted with another go-around. After they had completed an analysis of the problem, the crew decided to return to Berlin. The remainder of the flight was uneventful.
Causes
The serious incident emerged from the aircraft’s descent below the stipulated minimum altitude
for a non-precision approach. Therefore, a safe altitude above the obstacles was no longer
guaranteed.
The crew’s poor monitoring of the vertical flight path has been identified as the direct cause of
the incident.
The following factors have been identified as directly contributing to the serious incident:
- Deficient approach planning with regards to the vertical flight path.
- Reduced performance of the pilot flying, probably due to tiredness.
The approach chart, which had no distance/altitude table and thereby impeded the monitoring of the approach, systematically contributed to the serious incident.
Although it did not influence the development and course of the serious incident, the following risk factor was identified during the investigation:
- The procedure following a warning from the enhanced ground proximity warning system (EGPWS) was not consistently applied.
Accident investigation:
 |
|
Sources:
STSB
http://aerossurance.com/safety-management/saab2000-too-low-billund
History of this aircraft
Other occurrences involving this aircraft
| 28 November 2013 | HB-IZW | Darwin Airline | 0 | nr Lugano |  |
non |
| Engine failure | ||||||
Images:
The vertical profile of the localiser approach according to the DFDR data (red line) compared to a continuous descent final approach (green line). The grey area shows the lower approach limit, which an aircraft must not fly below until reaching the outer marker (LOM). (Illustration: STSB)
Media:
#OTD 2015 An omission of a vertical profile on the Jeppesen chart, a demoted/confused FO plus a tired Commander... A vertical profile was programmed in the FMS, but crews weren't told. https://t.co/9XoTNiFVFG #flightsafety #aviationsafety #humanfactors pic.twitter.com/1jl14ZbjhX
— Aerossurance (@Aerossurance) December 10, 2020
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 03-Jan-2019 16:40 | harro | Added |
| 03-Jan-2019 17:47 | harro | Updated [Photo] |
| 09-Dec-2020 22:54 | Aerossurance | Updated [Source, Accident report] |
| 10-Dec-2020 08:08 | Aerossurance | Updated [Embed code] |
Corrections or additions? ... Edit this accident description
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