'Poor Decision Making' in 2013 Sky Bahamas Crash Landing

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'Poor Decision Making' in 2013 Sky Bahamas Crash Landing

Unread post by bimjim » Fri Oct 06, 2017

http://www.tribune242.com/news/2017/oct ... ed-to-sky/

Report: 'Poor Decision Making' Contributed To Sky Bahamas Crash Landing In 2013
RICARDO WELLS Tribune Staff Reporter
Thursday, October 5, 2017

THE Air Accident Investigation Department has ruled the decision by crew to initiate and continue an instrument approach into "clearly identified thunderstorm activity" likely led to the 2013 crash landing of a Sky Bahamas Saab 340 in Marsh Harbour, Abaco.

In the report released by Air Accident Investigation Department (AAID) via Sweden's Haverikommission earlier this year, it was found that the "poor decision making and lack of situational awareness" while attempting to land, contributed to the severity of the accident.

The 25-page report also suggested those decisions likely resulted in a loss of control of the plane from which the flight crew was unable to recover.

The 34-seater aircraft reportedly landed very hard on the runway during a torrential rainstorm and according to passengers, the aircraft bounced off the tarmac three times before the right-wing and the landing gear broke.


At the time of the crash, however, several passengers and onlookers applauded the quick thinking of the pilot who, as soon as the wing collapsed, cut power to the engines and turned on the foam extinguishing system.

The crash resulted in the temporary closure of the Marsh Harbour International Airport.

Additionally the AAID report found that the flight crew did not prepare the cabin crew for departure as required by regulations and company procedures; and that "vital communication" was "nonexistent."

The report also pointed out that the crew failed to discuss the weather prior to departure or while en route to Marsh Harbour.

Furthermore, the crew failed to discuss "in the event of an emergency" scenarios during their "before departure" brief as is mandated by company procedures.

The findings also indicated the crew failed to complete several important checklists as required.

Moreover, the report ruled the checklists conducted were rushed and critical items omitted as evidenced by the cockpit voice recorder (CVR) recordings.

The report said the crew failed to observe sterile cockpit procedures during startup, run-up, taxi and takeoff, as idle inappropriate conversation was recorded on the CVR during these critical moments when sterile cockpit is essential.

The report noted: "Crew, because of their non-stop, idle, non-essential conversations from engine start-up failed to advise cabin crew of required instructions during approach to landing into the Marsh Harbour International Airport, again evidenced by CVR recordings.

"The crew did not conduct en route and approach checklist."

Additionally, the report also suggested the "before landing" checklist was conducted, but was so rushed and hurried that it appeared garbled and no challenge and response methodology was involved as required by company standard operating procedures.

Also, due to the lack of a challenge-response philosophy and the fact that the checklist was rushed, the AAID report noted that the non-flying pilot failed to advance the propeller to the recommended position as required by the "before landing" checklist. This failure was evident on the flight data recorder (FDR) data plots as the required propeller input remained the same from the en route phase up until the crash sequence.

The report also said the crew was aware of the weather conditions at the field at Marsh Harbour; however, never formulated a plan for diversion if the weather was bad at their time of arrival.

The report added that as approach continued, there were constant disagreements between both pilots as to who had the runway in sight.

Due to the weather conditions, visibility of the runway was intermittent, yet the crew continued descending visually in an attempt to land the aircraft on a runway that was not in sight and not served by an instrument landing system (ILS) or other navigational aid used during inclement weather or periods of reduced visibility.

"The non-flying pilot (captain) was adamant about landing at all cost, as he was overheard on the CVR stating, 'See if we can hurry and get in before....'

"The crew flew a non-stabilised approach and speed was not constant as they kept increasing and decreasing speed throughout the final approach," the report noted.


"The captain, who initially was the non-flying pilot, while on final approach and below 500 feet AGL, assumed control of the aircraft from the flying pilot (first officer). At some point the captain lost use of his windshield wiper as it went over-centre and was stuck during the final moments of the approach. The copilot again assumed control of the aircraft and seconds before touch down, the captain (despite having no visual contact with the runway due to the intense downpour of rain and the non-use of his windshield wiper), again took control of the aircraft from the first officer," the AAID report stated.

By the time the aircraft touched the runway, officials said there were several control wheel exchanges between both pilots while neither had a visual of the runway.

"The aircraft bounced three times, each bounce progressively larger and higher than the last.

"The last bounce was measured at 27 feet - FDR data proves this height -- above the runway. On the third bounce the nose gear broke and it is possible the wing may have started to fail at this point," the report noted.

"No aileron or elevator control input by the crew was detected during or after the touchdown as evidenced by the data retrieved from the FDR.

"This evidence further confirms that during the bounces and crash sequence neither of the pilots had positive control of the aircraft.

"The crew failed to instruct the evacuation process.

"The crew failed to conduct the emergency and evacuation checklist as required by company standard operation procedures.

"Crew failed to adhere to regulations which required aircraft to avoid thunderstorms by at least 20 miles.

"The thunderstorm was practically over the field at the time the crew attempted to land and try 'get in before it got worse.'

"The lack of proper crew resources management (CRM), complacency and a complete departure from company standard operating procedures and regulatory requirements were evident," the report's findings concluded.

The AAID, as a part of its list of recommendations, suggested that Sky Bahamas Airlines should be required to examine its policies.

Additionally, the AAID said a cultural change may need to be investigated and implemented to ensure crew are conducting themselves as professionals, despite their familiarity with each other during required duties.

The Air Accident Investigation Department is mandated by the Ministry of Transportation & Aviation to investigate air transportation accidents and incidents, determine probable causes of accidents and incidents, issue safety recommendations, study transportation safety issues and evaluate the safety effectiveness of agencies and stakeholders involved in air transportation.


In response to the AAID report yesterday, Sky Bahamas CFO and President Randy Butler said the document presented no significant changes and was laden with "unqualified opinions."

Mr Butler said nothing laid out in the report negated the role weather played in the crash landing and provided no evidence that company dynamics "contributed to the accident."

"Again we are very grateful that no one was injured in this incident," he told The Tribune.

"At Sky Bahamas, we go above and beyond the regulations and standards presented to us because we take the safety of our passengers that serious. The report doesn't conclude that the actions of our pilots contributed to this crash, but we are working to improve our procedures in this area."

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