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ASN Wikibase Occurrence # 231830
Last updated: 13 September 2020
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Date:08-OCT-2019
Time:18:03 LT
Type:Silhouette image of generic JS32 model; specific model in this crash may look slightly different
BAe Jetstream 3201EP
Owner/operator:AIS Airlines
Registration: PH-RCI
C/n / msn: 848
Fatalities:Fatalities: 0 / Occupants: 4
Other fatalities:0
Aircraft damage: Minor
Category:Serious incident
Location:Münster/Osnabrück Airport -   Germany
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Münster Airport (FMO/EDDG)
Destination airport:Stuttgart-Echterdingen Airport (STR/EDDS)
Investigating agency: BFU Germany
Narrative:
On the day of the incident, flight W26505 from Münster/Osnabrück Airport to Stuttgart, Germany was scheduled for departure at 17:30 hours. On board were two pilots, a flight attendant and a passenger. For the co-pilot this was the first training flight on a scheduled service (supervision flight) after obtaining the type rating. The pilot-in-command (PIC) was Line Training Instructor and responsible for training the co-pilot on the planned flight. The co-pilot was the controlling pilot (PF) and the PIC acted as the supervising pilot (PM).
The crew arrived early at the airport and went to the aircraft at about 16:30 hrs. The PIC first carried out the external check. Then the cockpit crew worked through the rest of the preflight checklist together. In the cockpit they learned that a slot was assigned to them for 18:01. According to the PIC, he was annoyed by the delayed departure time.
At 17:52 Münster Ground gave the pilots permission to start the engines and the flight was subsequently cleared to taxi over taxiways D and A to the taxi stop on runway 25.
According to the co-pilot, he felt "[...] a bit lost [...] behind the aircraft [...]" while taxiing. He attributed this to the fact that he had not flown on the aircraft type for 3 months.
Immediately after the first contact with Münster Tower, the tower controller gave the crew clearance for take-off for runway 25 at 18:01h. The pilots began to work through the line up checklist, with the co-pilot reading out the individual checklist items and carrying out or checking them. In doing so he overlooked the item "Flight Controls". At this point both pilots would have had to check the free movement of the flight controls and then confirm with "Checked". At the checklist item "Stall Protection" the co-pilot, according to his own statement, did not immediately find the switch positions for the left and right stall protection (stall warning), which the captain registered but considered not so important. So the left and right stall protection was not switched on before the start. At 18:02:56, 1 min 32 s after Münster Tower had given the go-ahead for take-off, the cockpit crew started the take-off. During take-off, the PIC first steered the aircraft via the nose wheel control using a lever on the left side of the cockpit. According to his own statement, he noticed that the stall protection and landing lights were not switched on. At 70 kt IAS he handed over control to the co-pilot at 18:03:02. When reaching the decision speed V1 of 108 kt IAS at 18:03:08 the PIC called out "V1, rotate". The copilot tried to rotate the aircraft and noticed that the aircraft control was blocked. This was announced with the words "[...] I cannot pull [...] the steering wheel [...]". According to the PIC, the aircraft had rolled straight ahead for a few seconds after handing over control until it drifted to the right. The PIC tried to counter-steer with the rudder pedals without success, aborted the take-off at 18:03:15 at approx. 130 kt IAS and finally steered the aircraft only with the help of the nose wheel control. During this aborted take-off, the aircraft came off about 1080 m laterally from runway 25 in a northerly direction. In doing so, it damaged a runway edge lighting and a sign and crossed the northern taxiway of runway 25. The maximum distance to the runway edge was approx. 23 m. After about 530 m on unpaved ground the aircraft returned to the runway.
At the time of the aborted take-off, a Robin DR.400 aircraft was waiting at the taxi stop of the northern taxiway, ready for take-off. The Jetstream 32 taxied off the runway past the DR.400 with approx. 119 kt IAS.
The tower controller asked the PIC for the reason for the aborted take-off. At 18:04:15, the PIC indicated a locked flight control lock (Gust Lock).
The flight crew taxied back to the apron and shut down the aircraft.

Preliminary findings by the BFU showed that the gust lock was still engaged as the aircraft began the takeoff roll.
By design the crew should not have been able to push the throttles past the flight idle position when the gust lock was engaged. A mechanical lock should have prevented this. However, due to internal damage this lock did not work.
This was a known issue and as of msn 937 the mechanical lock was strengthened. For older aircraft, this modification was published as a 'Highly Recommended' Service Bulletin.

The fact that the gust lock was still engaged was not recognized prior to takeoff because the company checklist did not include this item in the Taxi or Line Up checklist. The manufacturer's checklist did contain this item.

Sources:

https://www.bfu-web.de/DE/Publikationen/Bulletins/2019/Bulletin2019-10.pdf?__blob=publicationFile


Images:

Photo of PH-RCI courtesy AirHistory.net


Groningen - Eelde (EHGG / GRQ)
29 July 2017; (c) Kas van Zonneveld


Figure: AIP/BFU

Revision history:

Date/timeContributorUpdates
30-Dec-2019 20:37 harro Added
30-Dec-2019 20:51 harro Updated [Photo]

Corrections or additions? ... Edit this accident description