THE FINAL REPORT into the Cork Airport crash that killed six people in 2011 has identified a number of “systemic deficiencies” that were significant to the fatal flight, concluding that the Spanish operator and Spain’s aviation regulator contributed to the incident.
After a three-year probe, the Air Accident Investigation Unit concluded that the probable cause of the crash was “loss of control during an attempted go-around initiated below decision height (200 feet) in instrument meteorological conditions”.
“Systemic deficiencies at the operational, organisational and regulatory levels were also identified by the investigation. Such deficiencies included pilot training, scheduling of flight crews, maintenance and inadequate oversight of the operation by the operator and the State of registration,” the report stated.
The AAIU identified a number number of factors as being “significant”, including tiredness and fatigue on the part of the flight crew members and inadequate command training and checking.
The investigators also said there was an “inappropriate pairing” of flight crew members and “inadequate oversight” of the remote operation by the operator and the State of the operator – in this case, Spain.
The aircraft, a Fairchild SA 227‐BC Metro III registered in Spain as EC‐ITP, was operating a scheduled commercial air transport flight from Belfast City to Cork on 10 February 2011 with two flight crew members and ten passengers on board.
The AAIU said it was the “most challenging” probe it has ever had to complete.
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“The complexity of the accident sequence, examination of components at overseas locations, the international dimension of the operation including the intricate relationship between the various agencies and associated undertakings, translation of technical documents and natural justice obligations determined the time taken to finalise this report,” it explained in a statement.
The Transport Department’s investigations unit also extended its sympathies to the bereaved, thanking the families for their patience and understanding while waiting for the final report.
The day’s events
On 10 February at 9.50am, the flight’s pilot tried to approach Cork airport in low-visibility conditions. His first two attempts to land on the runway failed. During the third try, control of the aircraft was lost during an attempted go-around.
According to the final report, the aircraft impacted the runway surface, inverted and came to rest in soft ground to the right of the runway.
Post-impact fires broke out in both engines. Six people, including both pilots, were fatally injured.
Four passengers were seriously injured, while another two people received minor injuries.
As well as tiredness, inappropriate training and inadequate oversight, the investigation also listed a number of other significant factors, including some of the pilots’ decisions:
- The approach being continued in conditions of poor visibility “below those required”;
- The descent was continued below the decision height without adequate visual reference being acquired;
- Uncoordinated operation of the flight and engine controls when go-around was attempted;
- The engine power-levers were retarded below the normal in-flight operational range, an action prohibited in flight.
The investigators also said that power difference between the engines “became significant when the engine power levers were retarded below the normal in-flight range”.
A total of 11 safety recommendations were made on foot of the report, including four to the European Commission about flight time limitations, the role of the ticket seller and the improvement of safety oversight and the oversight of operating licences.
Two were given to the operator, Flightline SL, regarding its policies and training.
Another was made to the Spanish Civil Aviation Regulatory Authority about its oversight of air carriers.
The European Aviation Safety Agency were also given a recommendation in connection with the number of successive approaches that can be allowed in certain weather conditions. ]
The AAIU noted that a safety recommendation does not create a presumption of blame or liability.
“The sole objective of AAIU investigations is the prevention of aviation accidents and serious incidents. It is not the purpose of any such investigation and the associated investigation report to apportion blame or liability,” it explained.