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ASN Wikibase Occurrence # 231830
Last updated: 29 April 2021
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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
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.

The runway departure during the takeoff run occurred because the controls were locked due to the Gust Lock not being released, causing the pilots to briefly lose control of the aircraft.
Contributing Factors:
- Lack of supervision, support and oversight by the Line Training Instructor.
- Inexperience of the young co-pilot with a long time gap between training on the type and the first operation in commercial line service
- Poor crew resource management within the crew
- Self-generated time pressure between engine start and takeoff
- Non-stringent application and incorrect processing of checklists
- Checklist items and procedures, as well as wording in the air carrier's checklists that did not fully reflect those of the aircraft manufacturer
An additional contributing factor was a mechanical defect in the Gust Lock system, which allowed the engine power of both engines to be increased simultaneously despite the Gust Lock being activated.

Sources:

BFU

Accident investigation:
cover
  
Investigating agency: BFU Germany
Status: Investigation completed
Duration: 1 year and 4 months
Download report: Final report


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]
11-Feb-2021 18:33 harro Updated [Source, Narrative, Accident report]

Corrections or additions? ... Edit this accident description