The Sordid Story behind the Cork Fatal Accident : Manx2, Air Lada and Flightline
This is an in-depth look at the operations behind the crash that I wrote about last week: Manx 2 Fatal Accident at Cork: Below the Required Minima.
This might take a while, so get comfortable.
On the 10th of February in 2011, the Fairchild Metro III attempted to land at Cork in low visibility conditions.
The aircraft carried out two ILS approaches, both of which were continued beyond the OM equivalent point with conditions below required minima. On both of these approaches, descent was continued below [Decision Height], followed by a missed approach. The aircraft then entered a holding pattern following which a third ILS approach was made with conditions below required minima. This approach was continued below DH and a missed approach was initiated. Approaching the runway threshold, the aircraft rolled to the left, followed by a rapid roll to the right during which the right wingtip contacted the runway surface. The aircraft continued to roll and impacted the runway in an inverted position. The aircraft departed the runway surface to the right and came to rest in soft ground.
To understand the situation, we will have to untangle the complex relationships between the companies.
A Spanish bank owned the physical aircraft and leased it to Air Lada. In the accident report, Air Lada is referred to as the Owner. Air Lada subleased the flights to Flightline S.L., referred to in the report as the Operator. The service was sold by Isle of Man company Manx 2, referred to in the report as the Ticket Seller.
The Captain held a Commercial Pilot Licence issued in Spain and had a total flying time of 1,801 hours with 1,600 on type.
Records show that he had operated as a co-pilot (first officer) into Cork on 61 occasions and he flew in on seven occasions as Captain. There’s no records of any diversions on any of these flights. In addition, he’d never operated into Waterford or Kerry, which could have increased reluctance to divert.
He was promoted to Captain on the 6th of Feb 2011, four days before the accident.
Flightline’s Chief Instructor was involved in the training of both the Captain and the First Officer of the accident flight. He stated that although all the pilots were considered to be Flightline pilots, the pilots who flew the Metro III were paid by Air Lada.
He was the sole Class Rating Examiner at Flightline and it was his decision as to how many training sectors a candidate for captaincy would receive. The other Class Rating Instructor at Flightline had left the company shortly before. This meant that he both trained and checked the Captain. He agreed that there should be a separate Class Rating Instructor and Class Rating Examiner, but in the Captain’s case, this was not possible. He felt he would be able to objectively evaluate the Captain. He agreed that the command training of the Commander was very disrupted and thought it was possibly because they were tight in numbers and because the Captain had to travel from Belfast to Barcelona for training. He described the commander as enthusiastic with good crew resource management.
The First Officer held a JAA CPL issued in the United Kingdom and had a total flying time of 539 hours with 289 on type. He was employed as a co-pilot by the operator just three weeks before the crash. He went through a thirty-minute Operator’s Proficiency Check at that time. Flightline’s Chief Instructor described him as ‘was okay for his hours‘.
Flightline did not have any restrictions for newly qualified flight crew, so it was possible for newly qualified commanders and co-pilots to operate together.
The First Officer did not complete the line training and should only have flown with a training captain until he had completed his line training and passed a line check. The Flightline SL records show that all of First Officer’s flights were with line captains who were not instructors.
His CV indicated that he had studied Italian but there was no evidence of Spanish language competency.
It was quite clear that the duty and rest periods of the crew were not correctly documented.
The Co-pilot’s roster for February showed him ‘Libre’ (‘free’) between 8-12 February 2011. As another co-pilot requested a change of duty on 9 February, the Co-pilots duties were changed and he was required to operate the scheduled flights on 9 and 10 February 2011. The identity of the co-pilot was not noted in the flight paperwork of the short positioning flight between EGAA and EGAC on 9 February 2011. The Investigation is satisfied that the Co-pilot operated this flight and subsequently the two return flights to Cork. The two other possible candidates forwarded copies of their personal logbooks to the Investigation which showed they did not operate the sector.
The partner of the First Officer stated, “He did not have very much rest. He was working on a defined route incorporating some night-time flights carrying post.” She last spoke to him at 23:00 on 9th of February, the night before the crash.
Flightline, as the operator, was responsible for the flight crew, including ensuring staff competence and rest periods. The Quality Manager at Flightline stated that Air Lada produced a draft roster for flight crew, which Flightline would monitor and and amend as needed to ensure that flight time limitation rules were followed. Any roster change after the roster was published had to be approved.
However, none of the flight changes prior to the accident flight had been approved and Flightline were unaware that the co-pilot was on the flight until after the accident. The flight crew instruction regarding making a roster change request was in Spanish and no English translation was found. As a result of unofficial roster changes, neither the Captain nor the First Officer were fully rested at the time of the accident flight.
The aircraft had been involved in two previous significant events.
In the early mornings of 21 May 2004, EC-ITP was involved in a take-off incident at Palma de Mallorca Airport (LEPA). On take-off, the aircraft accelerated normally to 60 knots when the nose wheel steering (NWS) system was deactivated the aircraft veered to the right. The take-off was abandoned and reverse thrust applied but the aircraft departed the runway and incurred minor damage which was later repaired.
On 8 November 2009 EC-ITP suffered a heavy landing at Barcelona. As a result, the aircraft was ferried to an overhaul facility in Cologne for repair. This work was completed and the aircraft returned to service in October 2010, four months prior to the accident.
The repair for the heavy landing in November 2009 revealed that the left-hand engine installed in the engine was a loaner – meant for temporary use. It was removed and another loaner engine installed on 15 July 2010. The right-hand engine was removed from the aircraft on 27 April 2010 “for access to repair area” and re-installed on the right-hand side on 13 July 2010.
Despite the change of engine, a full Engine Ground Run check was not run. Instead, the checklist for engine adjustments was used. The engine ground runs did not include power lever split checks at Flight Idle.
On the last approach into Cork that day, the Captain, who was Pilot Not Flying, took control of the power on the last approach. At the decision height, he pulled back the power and called to continue, clearly hoping to spot the runway in the fog.
From last week’s blog post:
They once again descended below the decision height of 200 feet above the ground. However this time, the aircraft reduced power and at the same time experienced a roll to the left.
Terrain Awareness Warning System: ONE HUNDRED
Captain: Go around!
First Officer: Round.
Terrain Awareness Warning System: FIFTY
Terrain Awareness Warning System: FORTY
The Captain applied go-around power which is when they lost control of the aircraft. The aircraft rolled rapidly to the right and the right wingtip contacted the runway surface. The aircraft continued to roll.
It is likely that the First Officer, the pilot flying, did not realise what his Captain was doing with the power and made a control wheel input to the right to correct for the left roll.
The investigation cites three principle factors contributing to the loss of control:
The uncoordinated operation of the power levers and the flight controls, which were being operated by different Flight Crew members.
The retardation of the power levels below Flight Idle, an action prohibited in flight, and the subsequent application of power are likely to have induced an uncontrollable roll rate due to asymmetric thrust and drag.
A torque split between the powerplants caused by a defective Pt2/Tt2 sensor, became significant when the power levers were retarded below Flight Idle and the No. 1 powerplant entered a negative torque regime. Subsequently when the power levers were rapidly advanced during the attempted go-around, this probably further contributed to the roll behaviour as recorded on the FDR.
The Flight Data Recorder was recovered with 106 hours of data leading up to the accident. It showed that there as a mismatch between the torques being delivered by the two engines.
In general, the data showed that the torque being delivered by No. 2 engine exceeded that being delivered by No. 1 engine by up to 5%. It was also noticed that, as the power levers for both engines were being advanced prior to take-offs, the torque response for the No. 2 engine was faster than that for No. 1 engine.
The data showed that the pilots were adjusting the power levers to compensate for the engine torque differential. As the aircraft was descending towards the runway shortly before impact, the No. 1 engine was at 20-23% and the No. 2 engine was at 25-27%.
Then, 8 seconds before impact, a negative torque value was recorded. The next recorded values show the torques on both engines increasing but not in sync.
The next recorded values for this parameter [the No. 1 engine), following at intervals of one second, were +22%, +10%, +7% and +36%. Thereafter, recorded torque values for No. 1 engine rose rapidly. In a similar timeframe, the No. 2 engine torque values were recorded at +8%, 0%, +3%, +5% and +25%. Thereafter recorded torque values for No. 2 engine also rose rapidly to values in excess of 90%.
The negative torque the No. 1 engine caused the left roll. Then as both engines started to increase rapidly, the aircraft rolled to the right to 115° bank before the aircraft impacted.
The issue turned out to be a faulty sensor on the No. 2 engine. The defective engine intake air temperature and pressure sensor was caused by a crack in the side coil of the sensor bulb. The fracture surface was corroded, showing that the crack had been there for some time.
The effects of this fault were
- Slower engine speed response when the speed lever was advanced
- Faster engine torque response when the power lever was advanced
- Higher torque for a given power level angle
Manx 2, based at Ronaldsway Airport on the Isle of Man, is referred to in the report as the “Ticket Seller”. They did not have an operating licence or an Air Operator’s Certificate, which is the approval required for an aircraft operator to use aircraft for commercial flights.
Instead, Manx 2 had contractual relationship with four AOC holders, including Flightline.
Flight crew on the flights wore a Manx 2 uniform and aircraft were painted with Manx 2 livery. However, the company did not want to have the “regulatory complexity and crewing problems associated with holding an AOC”. Manx 2 didn’t need an Air Travel Organisers Licence to sell the tickets, as none of the aircraft had in excess of 19 seats.
The UK Civil Aviation Authority was concerned that Manx 2 gave the impression that it was a licensed airline, at which point Manx 2 updated the website to state that it was a Marketing Group and acting as an agent for the four AOC holders.
In 2006, Manx 2 had made an arrangement with Air Lada (the owner of the two Metro IIIs) to use the aircraft using an Air Operator’s Certificate held by Eurocontinental Air. In 2009, the UK Department for Transport suspended Eurocontinental’s AOC following a series of safety incidents in UK airspace.
Agencia Estatal de Seguridad Aérea (AESA), the Spanish aviation safety and security agency, suspended Eurocontinental’s AoC and then revoked it completely in 2011.
Manx 2 stated that it was unaware of the number of safety occurrences reported because they were not included in the occurrence reporting list.
In November 2009, Air Lada and Flightline agreed to the operation of the two Metro IIIs under Flightline’s Air Operator’s Certificate. Operations and scheduled maintenance of the aircraft were to be conducted under Flightline’s AOC while Air Lada would arrange commercial arrangements and flight scheduling. All maintenance costs were met by Air Lada.
AESA accepted the transfer of the two Metro IIIs from a suspended AOC to a new AOC holder as Flightline had different procedures and management structure. The application provided no details regarding how the aircraft would be used. AESA had no knowledge of Air Lada or Manx 2’s history with the aircraft, nor that Air Lada were the owners of the aircraft. They were also unaware that the two former Eurocontinental Air pilots had moved with the aircraft to Flightline.
Thus, AESA approved the request to include the two aircraft on Flightline’s AOC. The AOC approval forms did not approve low visibility operations for Take-Off, Approach and Landing for either plane. This means that both aircraft were only permitted to operate in CAT I limits.
Once the transfer was complete, in 2010, the two Metro IIIs resumed flying for Manx 2 under Flightline’s AOC, offering the new service between Belfast City and Cork as well as night cargo flights for the Royal Mail. Manx 2 worked directly with Air Lada and there is no evidence of any direct contact between Manx 2 and Flightline. Although there were various documents which referred to the operator, the Operations Manager worked for Air Lada and the address and contacts used were all for Air Lada’s office in the Isle of Man.
The Isle of Man has its own Civil Aviation Administration and a flight to or from the Isle of Man and the UK by a non-UK AOC holder requires permits from the UK and the Isle of Man. The permits were applied for by the Operations Manager of Manx 2 on behalf of Flightline, with Flightline named as the airline.
A new operational procedures document still in draft had only contacts for Manx 2. The Operator’s Quality Manager named in the document was one of the pilots supplied by Air Lada. There was no evidence that Flightline appointed him to this position.
Flightline audited the operation on the Isle of Man two weeks after the new operation started in Ireland. The audit comments include the following:
The meteorology of the Isle of Man in particular, with strong winds and low minimum temperatures, and of England in general, necessitates a different approach to the operation. Both the commander and the co-pilot must be experienced and have a good level of English. Our company should guarantee this. Pilots who are currently operating do not have any problem in this sense.
5. Operational aspects
They must change the normal checklist and adapt it to our company, carry out the pre-flight inspection, sign it and apply the anti-icing system before entering the clouds. It is important to study the [Standard Operating Procedures] well, as well as clearly specifying in its list who is responsible for what and when…
The audit clearly states that experienced crews were required for the scheduled flights. Eight months later, the crew comprised of a Captain with questionable training who had been promoted four days earlier and a First Officer who had not completed his line check.
No further audits were done by Flightline.
Over the three months prior to the accident, there were no pilot reports, defects or maintenance entries made in the Technical Log. The Technical Log for the other Metro III included only two entries in its period of operation, both relating to an ignition problem.
Not a single normal maintenance issue over three months: no lights burned out, no oil top-ups, no defects at all. And no reference to the fact that the pilots were having to manually adjust the power levers to compensate for the engine torque differential. Scheduled maintenance was performed on the plane but, without a report, it’s very unlikely that the crack in the sensor coil could be spotted.
Flightline should have questioned the suspicious lack of defects in two of their aircraft. But for all intents and purposes, operations for the two aircraft were based on the Isle of Man and controlled by Air Lada and Manx 2, while using the operator’s certificate from Flightline in Spain.
Meanwhile, continuing oversight of the operator and its operation fell under the remit of AESA.
In the year before the accident, AESA performed eight audits and inspections were carried out on Flightlines flight operations. The evaluations included how the airline monitors and controls its operations.
However, they were unaware that the two aircraft were operating in the Isle of Man. There’s no obligation for an operator to inform the Authority regarding remote operations, although AESA did state that, had it known that the operation was remote and such a small number of people were involved, they would have taken a greater interest.
In the twelve months leading up to the accident, both Metro IIIs were subject to SAFA (Safety Assessment of Foreign Aircraft) ramp checks in Germany and Ireland. Both inspections included findings and, in one instance, the aircraft was not allowed to depart until the crew cleared the baggage/cargo which was blocking the emergency exits.
During the Eurocontinental Air operation, AESA had sent inspectors to the Isle of Man to carry out an extended ramp inspection. However, as they were unaware that the two aircraft had resumed operations there, no inspectors were sent.
AESA further informed the investigation that ‘in order to have better tools/procedures for proper oversight of a remote operation, EU regulation should require the operators to provide the certifying Authority with a formal declaration stating which are the organizations that ultimately decide the flight’s schedule, routes, crew roster, etc.’
After the accident, the EU Air Safety Committee met with AESA to clarify whether AESA’s surveillance activity of Flightline had provided the evidence that Flightline was capable of adequately supervising its remote operations. AESA stated that ‘they decided to limit the AOC of Flightline to prevent operation of the Fairchild Metro 3s, and that they had initiated the process to suspend the AOC.’
Commission Implementing Regulation (EU) No 390 of 2011 (establishing the European Community list of air carriers which are subject to an operating ban within the Community) stated the following:
Flightline explained that they had entered into a business arrangement with the company Air Lada, not a certified air carrier, to operate two Fairchild Metro 3 aircraft, registrations EC-GPS and EC-ITP, using pilots provided by Air Lada. The Commission pointed out to Flightline that the same aircraft had previously been operating within the AOC of Eurocontinental, another air carrier certified in Spain and that as a result of SAFA inspections and significant safety incidents with the operation of these aircraft, AESA had suspended Eurocontinental Air’s AOC.
The Commission invited the air carrier to make a presentation to the Air Safety Committee and noted that AESA had decided to limit the AOC of Flightline to prevent operation of the Fairchild Metro 3s, and that they had initiated the process to suspend the AOC.
At a meeting on the 19th of October 2011, AESA briefed the Commission on ‘the actions taken to date to address the identified safety issues with Spanish air carriers in a sustainable manner’. Flightline’s AOC was renewed, following corrective actions, but limited to exclude the aircraft of the type Metro III.
In 2010, Welsh ministers working with Manx 2 and FLM Aviation to provide a scheduled air service between Cardiff Airport and RAF Valley on Anglesey. However, the AOC of FLM Aviation, one of the four other operators working with Manx 2, was revoked by the German regulatory authority. Manx 2 continued to sell tickets for the route, replacing FLM Aviation with an air carrier operating under a UK AOC.
In late 2012, Manx 2 informed the investigation that its assets were being sold to a new company as a part of a management buy-out. The new company commenced operation on the 2nd of January 2013 and continued to sell tickets on the route.
The Manx 2 website was updated on 28th of January 2014 with a full statement regarding the final report.
Manx2 contracted all the flying to EU airlines licensed and required, as was the Operator, to operate in compliance with the stringent standards and controls of the European Aviation Safety Agency (EASA), recognised to be among the most stringent in the world, under the oversight of their national aviation safety authorities. Unfortunately, the report is clear that the prime causes of the accident were decisions made by the Flightline crew in adverse weather conditions, compounded by inappropriate crew rostering by the Operator and a significant lack of oversight by the Spanish air safety authority.
The investigation concluded that the the commercial model of a ticket seller providing an air service is not in the best interests of passenger safety, as the ticket seller has “an inappropriate and disproportionate role with no accountability regarding air safety”. It’s sad to note that in the end, they didn’t take responsibility and the new company that was formed uses the exact same model.