The investigation identifies not only a probable cause of the accident but looks beneath the surface and uncovers some fundamental failings in Europe’s aviation safety environment.
On February 10, 2011 a Fairchild SA 227-BC Metro III (ECITP) departed Belfast City (EGAC) Ireland for Cork Airport (EICK) with two flight crew and ten passengers. Upon its third attempt to land under low visibility at Cork the twin turboprop aircraft crashed on the runway killing its flight crew and six passengers.
After an in-depth investigation, the Irish Air Accident Investigation Unit (AAIU) identified loss of control during an attempted go-around as the probable cause of the fatal accident. Along with that, it points at several significant contributing factors such as superficial oversight by aviation authorities, breach of existing aviation regulation by operators and company owners, insufficient pilot training, pilot fatigue and other operational and organizational deficiencies.
“In the past years, many in our industry kept reassuring themselves that aviation has never been safer before,” says Nico Voorbach, European Cockpit Association (ECA) President and an active pilot. “This report is a much needed wake-up call to pay attention to the growing number of signs that there are deeply rooted operational, organizational and regulatory deficiencies in the aviation sector to be addressed.” Among the report’s conclusions are:
- Both pilots were most likely fatigued and had insufficient rest. The investigation identifies a total of five breaches of Flight and Duty Time Limitations (FTL) and Rest Requirements.
- The Operator and Authorities failed to carry out adequate safety oversight. The operator did not have sound management structures and procedures in place to ensure safe operations. Equally, the national authorities in the state of the operator (Spain) failed to ensure adequate safety oversight.
The pilot training had been inadequate and not in accordance with EU laws. The Commander, who had made his first flight in command only four days prior to the accident, had had little continuity in his command training, and was scheduled to operate together with a recently joined co-pilot, who had not yet completed his line training with the Operator.
“The string of events described in this report makes it clear that the aviation safety system has blatantly failed,” says Philip von Schöppenthau, ECA Secretary General. “Lack of oversight at various levels, inadequate training, intricate relationships between aircraft owner and different undertakings are a worrying mix. The problem is that this mix is spreading quickly in some parts of the industry, whereas oversight authorities are less and less able to keep pace and oversee operations that become very complex and hard to track.”
The accident investigation report contains 11 safety recommendations to EASA, the European Commission, the Operator, the Spanish Civil Aviation Authority and ICAO. “We welcome the thorough work done by the Irish investigation authority and call on the national and European authorities to step up their efforts,” says Pete Kaumanns, ECA Technical Affairs Board Director. “The accident shows why adhering solely to the letter of the law – if at all – and not its spirit is insufficient. Also without adequate regulation and proper safety oversight, such accidents are bound to happen again.”
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