Status: | Accident investigation report completed and information captured |
Datum: | Donnerstag 12 Dezember 2002 |
Zeit: | 13:09 |
Flugzeugtyp: |  British Aerospace BAe-146-200 |
Fluggesellschaft: | Flybe |
Kennzeichen: | G-JEAX |
Werknummer: | E2136 |
Baujahr: | 1989-06-30 (13 years 6 months) |
Triebwerk: | 4 Lycoming ALF502R-5 |
Besatzung: | Todesopfer: 0 / Insassen: 5 |
Fluggäste: | Todesopfer: 0 / Insassen: 36 |
Gesamt: | Todesopfer: 0 / Insassen: 41 |
Sachschaden: | nicht beschädigt |
Unfallort: | nahe Birmingham ( Großbritannien)
|
Flugphase: | Während des Fluges (ENR) |
Betriebsart: | Inländischer planmäßiger Passagierflug |
Flug von: | Birmingham International Airport (BHX/EGBB), Großbritannien |
Flug nach: | Belfast City Airport (BHD/EGAC), Großbritannien |
Flugnummer: | 046 |
Unfallbericht:Flight BE 046 departed Birmingham at 12:52 for a flight back to Belfast. During the climb, the flight crew noticed that the aircraft was oscillating in pitch more than was customary. The autopilot remained engaged for significant portions of the climb but the level-off at FL240 was flown manually. Shortly after establishing level flight, the autopilot was re-engaged but the aircraft began to oscillate in pitch and diverge from its assigned flight level. The captain disengaged the autopilot and was immediately aware of a strong pitch-up tendency. He applied an increasing forward pressure on the control column and supplemented this with electric elevator trim in the nose-down sense. At FL242 the aircraft was reported to have pitched down at a marked rate. Having pitched to below the straight and level attitude, the captain then tried to counter this with a progressive rearwards force on the controls. Both pilots then pulled back with considerable force. The control column suddenly moved aft, the aircraft pitched up and the flight crew felt a violent shudder through the whole airframe that lasted for two or three seconds. After this the control forces returned to normal and they were able to level the aircraft at FL240. During the pitching manoeuvres, two of the three cabin crew had fallen in the cabin aisle, sustaining serious injuries. The elevator control difficulties might have been caused by natural icing; investigation is still ongoing.
Probable Cause:
PROBABLE CAUSE: "Exposure of the aircraft to precipitation on the ground in near freezing conditions prior to take off, resulting in accumulations of snow, rain or hail in the elevator/servo tab gaps which then freeze in flight."
Accident investigation:
|
Investigating agency: | AAIB (U.K.)  |
Status: | Investigation completed |
Duration: | 1 year and 2 months | Accident number: | AAIB S1/2003 | Download report: | Final report
|
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Sicherheitsempfehlungen
AAIB issued 6 Safety Recommendations
Issued: -- | To: EASA | 2003-109 |
It is recommended that the European Aviation Safety Agency review the design characteristics of the door operating, attachment and restraint mechanisms of the Dornier 328 aircraft type, in order to minimise the possibility of inadvertent door operation and to ensure that there is sufficient residual strength in the door/airstair attachments to prevent separation of the door in the event of a door coming open during takeoff or initial climb. (Partially Accepted - open) |
Issued: -- | To: CAA UK | 2003-119 |
It is recommended that the Civil Aviation Authority require operators of aircraft with nonpowered flying controls that are vulnerable to the effects of freezing of re-hydrated de-icing fluid residues, to establish engineering procedures for the inspection and removal of such residues from critical flying control surfaces. (Accepted - closed) |
Issued: -- | To: CAA UK | 2003-120 |
On behalf of EASA the CAA should take an oversight on the manufacturers proposed flight crew abnormal and emergency checklist procedure for recognising and responding to frozen flight controls on the 146/RJ series aircraft to ensure the timely introduction of a suitable procedure. (Accepted - closed) |
Issued: -- | To: BAe Systems | 2003-121 |
The aircraft manufacturer, BAE Systems, should alert operators of 146/RJ series aircraft to the possibility of precipitation accumulating in the elevator gaps whilst the aircraft is parked in near freezing conditions, or following a hailstorm, and that if untreated, this precipitation can lead to pitch control problems in flight. (Accepted - closed) |
Issued: -- | To: CAA UK | 2003-122 |
The CAA should require UK AOC holders operating BAe 146/RJ series aircraft to issue instructions to their staff for inspecting the gaps between the elevator and the tailplane and between the elevator and the trim and servo tabs for any precipitation contamination prior to departure, with a recommendation to de-ice the aircraft, when any doubt exists. (Accepted - closed) |
Issued: -- | To: BAe Systems | 2003-123 |
The aircraft manufacturer, BAE Systems, should consider the introduction of a sampling programme for the elevator servo tab bearings and other flight control system bearings that are vulnerable to the effects of aircraft washing and de-icing, with a view to establishing a regular maintenance or replacement requirement for those bearings as necessary. (Accepted) |
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Birmingham International Airport to Belfast City Airport as the crow flies is 361 km (226 miles).
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.
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