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Final Report No. 2205 by the Swiss Accident Investigation Board SAIB

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Final Report No. 2205 by the Swiss Accident Investigation Board SAIB Schweizerische Unfalluntersuchungsstelle SUST Service d’enquête suisse sur les accidents SESA Servizio d’inchiesta svizzero sugli infortuni SISI Swiss Accident Investigation Board SAIB Aviation Division Final Report No. 2205 by the Swiss Accident Investigation Board SAIB concerning the accident involving the Embraer EMB-505 aircraft, CN-MBR on 6 August 2012 St. Gallen-Altenrhein (LSZR) regional aerodrome, Thal/SG municipality Aéropôle 1, CH-1530 Payerne Tel. +41 26 662 33 00, Fax +41 26 662 33 01 [email protected] www.saib.admin.ch Final Report CN-MBR Ursachen Der Unfall ist darauf zurückzuführen, dass das Flugzeug nach einem unstabilisierten Endan- flug spät und mit zu hoher Geschwindigkeit auf der Piste aufsetzte und diese in der Folge überrollte. Zum Unfall beigetragen haben folgende Faktoren: Die mangelhafte Zusammenarbeit und die unzureichende Situationsanalyse durch die Besatzung. Die auf rund 10 Grad blockierten Landeklappen, was ungefähr der Klappenstellung 1 entsprach. Spätes Einleiten einer Vollbremsung nach der Landung. Swiss Accident Investigation Board page 2 of 90 Final Report CN-MBR General information on this report This report contains the Swiss Accident Investigation Board’s (SAIB) conclusions on the cir- cumstances and causes of the accident, which is the subject of the investigation. In accordance with Art 3.1 of the 10th edition, applicable from 18 November 2010, of Annex 13 to the Convention on International Civil Aviation of 7 December 1944 and Article 24 of the Federal Air Navigation Act, the sole purpose of the investigation of an aircraft accident or serious incident is to prevent accidents or serious incidents. The legal assessment of acci- dent and serious incidents causes and circumstances is expressly no concern of the accident investigation. It is therefore not the purpose of this investigation to determine blame or clarify questions of liability. If this report is used for purposes other than accident prevention, due consideration shall be given to this circumstance. The definitive version of this report is the original in the German language. All times in this report, unless otherwise indicated, follow the coordinated universal time (UTC) format. At the time of the accident, Central European Summer Time (CEST) applied as local time (LT) in Switzerland. The relation between LT, CEST and UTC is: LT = CEST = UTC + 2 hours. Swiss Accident Investigation Board page 3 of 90 Final Report CN-MBR Contents Synopsis .................................................................................................................... 8 Investigation ............................................................................................................. 8 Summary ................................................................................................................... 8 Causes ....................................................................................................................... 9 Safety recommendations ......................................................................................... 9 1 Factual information ........................................................................................... 10 1.1 Pre-history and history of the flight .......................................................................................... 10 1.1.1 General .................................................................................................................................. 10 1.1.2 Pre-history .............................................................................................................................. 10 1.1.3 History of the flight ................................................................................................................. 10 1.1.4 Accident location .................................................................................................................... 16 1.2 Injuries to persons ...................................................................................................................... 16 1.2.1 Injured persons ...................................................................................................................... 16 1.2.2 Nationality of the occupants of the aircraft ............................................................................. 17 1.3 Damage to aircraft ...................................................................................................................... 17 1.4 Other damage .............................................................................................................................. 17 1.5 Personnel information................................................................................................................ 17 1.5.1 Flight crew .............................................................................................................................. 17 1.5.1.1 Commander ..................................................................................................................... 17 1.5.1.1.1 General ..................................................................................................................... 17 1.5.1.1.2 Flying experience ..................................................................................................... 17 1.5.1.1.3 Crew times ................................................................................................................ 18 1.5.1.1.4 Training ..................................................................................................................... 18 1.5.1.2 Copilot ............................................................................................................................. 19 1.5.1.2.1 General ..................................................................................................................... 19 1.5.1.2.2 Flying experience ..................................................................................................... 19 1.5.1.2.3 Crew times ................................................................................................................ 19 1.5.1.2.4 Training ..................................................................................................................... 20 1.5.2 Air traffic control personnel .................................................................................................... 20 1.6 Aircraft information .................................................................................................................... 20 1.6.1 General information ............................................................................................................... 20 1.6.2 Cockpit equipment ................................................................................................................. 22 1.6.2.1 General ............................................................................................................................ 22 1.6.2.2 Cockpit layout .................................................................................................................. 22 1.6.3 Aircraft systems ..................................................................................................................... 23 1.6.3.1 General ............................................................................................................................ 23 1.6.3.2 The aircraft control system .............................................................................................. 23 1.6.3.2.1 General ..................................................................................................................... 23 1.6.3.2.2 Flap system .............................................................................................................. 23 1.6.3.2.3 Spoiler ....................................................................................................................... 25 1.6.3.3 Limitations ....................................................................................................................... 26 1.6.3.4 Main brake system .......................................................................................................... 26 1.6.3.5 Calculation of landing distance ....................................................................................... 28 1.6.3.6 Warning devices .............................................................................................................. 31 1.6.3.6.1 General ..................................................................................................................... 31 1.6.3.6.2 Visual warnings ........................................................................................................ 31 1.6.3.6.3 Aural warnings .......................................................................................................... 31 1.6.3.6.4 Ground proximity warning system ............................................................................ 32 1.7 Meteorological information ....................................................................................................... 33 1.7.1 General meteorological situation ........................................................................................... 33 Swiss Accident Investigation Board page 4 of 90 Final Report CN-MBR 1.7.2 Meteorological information for flight preparation.................................................................... 33 1.7.3 Weather at the time and location of
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