Poor pilot decisions and 'systemic' failure Cork plane disaster probe finds
The Irish Air Accident Investigation Unit (AAIU) has identified a series of poor operational decisions by the pilots, a range of serious systemic failures, and issued 11 safety recommendations following its exhaustive probe into the 2011 Cork Airport plane crash disaster.
This led to the loss of control of the aircraft which crashed in dense fog with the loss of six lives, the report published this morning has confirmed.
But it has also identified a catalogue of systemic deficiencies at the operational, organisational and regulatory levels which oversaw the operation of the flight, including pilot training, scheduling of flight crews, and maintenance.
These deficiencies led to tiredness and fatigue on the part of the flight crew, inadequate command training and checking, inappropriate pairing of flight crew members, and inadequate oversight.
The aircraft, a Fairchild SA 227-BC Metro III registered in Spain as EC-ITP, was on route from Belfast City to Cork on Feb 10, 2011 with two pilots and 10 passengers on board.
The flight involved three separate undertakings - the operator, Spanish company Flightline BCN, which held a Spanish Air Operator Certificate (AOC), a ticket seller, Manx2, based in the Isle of Man, and another Spanish company, AirLada, which supplied the aircraft and flight crew under an agreement with Manx2.
The aircraft crashed inverted at around 9.50am while on its third attempt to land in dense fog. Six people, including both pilots, were killed.
Four passengers were seriously injured and two received minor injuries.
It was the worst aviation disaster in Ireland in some 50 years.
In its final report, the AAIU said 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’.
The unit also identified the following factors as being significant:
• The approach was continued in conditions of poor visibility below those required.
• The descent was continued below the decision height without adequate visual reference being acquired.
• There was an uncoordinated operation of the flight and engine controls when the go-around was attempted.
• The engine power-levers were retarded below the normal in-flight operational range, an action prohibited in flight.
• And a power difference between the aircraft's two engines, identified by the AAIU in 2012, then became significant when the engine power levers were retarded.
The AAIU has now made 11 safety recommendations to various entities across the EU in the hope of preventing future similar accidents.
