Final Report RL 2014:19E
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Final report RL 2014:19e Serious incident at Malmö Airport on January 10, 2014 involving the aircraft SE-LIS of the model Fokker F27 Mark 050, operated by Amapola Flyg AB. File number L-04/14 2014-12-16 RL 2014:19e SHK investigates accidents and incidents from a safety perspective. Its investigations are aimed at preventing a similar event from occurring again, or limiting the effects of such an event. The investigations do not deal with issues of guilt, blame or liability for damages. The report is also available on SHK´s web site: www.havkom.se (ISSN 1400-5719) This document is a translation of the original Swedish report. In case of discrepancies between this translation and the Swedish original text, the Swedish text shall prevail in the interpretation of the report. Photos and graphics in this report are protected by copyright. Unless otherwise noted, SHK is the owner of the intellectual property rights. With the exception of the SHK logo, and photos and graphics to which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 2.5 Sweden license. This means that it is allowed to copy, distribute and adapt this publication provided that you attribute the work. The SHK preference is that you attribute this publication using the following wording: “Source: Swedish Accident Investigation Authority”. Where it is noted in the report that a third party holds copyright to photos, graphics or other material, that party’s consent is needed for reuse of the material. Cover photo three - © Anders Sjödén/Swedish Armed Forces. Postadress/Postal address Besöksadress/Visitors Telefon/Phone Fax/Facsimile E-post/E-mail Internet P.O. Box 12538 Sveavägen 151 +46 8 508 862 00 +46 8 508 862 90 [email protected] www.havkom.se SE-102 29 Stockholm Stockholm Sweden RL 2014:19e Contents General observations ...................................................................................................... 5 The investigation ............................................................................................................ 5 SUMMARY ................................................................................................................... 8 1. FACTUAL INFORMATION ............................................................................ 9 1.1 History of the flight ............................................................................................ 9 1.1.1 Circumstances ........................................................................................ 9 1.1.2 History of the flight ............................................................................. 10 1.1.3 Other .................................................................................................... 11 1.2 Injuries to persons ............................................................................................ 12 1.3 Damage to aircraft............................................................................................ 12 1.4 Other damage ................................................................................................... 12 1.4.1 Environmental impact.......................................................................... 12 1.5 Personnel information ...................................................................................... 12 1.5.1 The commander ................................................................................... 12 1.5.2 The co-pilot ......................................................................................... 12 1.5.3 The pilots’ duty schedule ..................................................................... 13 1.6 Aircraft information ......................................................................................... 13 1.6.1 The aircraft .......................................................................................... 13 1.6.2 The pressurization and the oxygen systems......................................... 14 1.6.3 Flight controls ...................................................................................... 14 1.6.4 The aircraft´s vertical stabilizer and the weathervane effect ............... 15 1.7 Meteorological information ............................................................................. 15 1.8 Aids to navigation ............................................................................................ 17 1.9 Communications .............................................................................................. 17 1.10 Aerodrome information ................................................................................... 17 1.11 Flight recorders ................................................................................................ 18 1.11.1 Flight Data Recorder (FDR) ................................................................ 18 1.11.2 Cockpit Voice Recorder (CVR) .......................................................... 18 1.12 Site of occurrence ............................................................................................ 18 1.13 Medical and pathological information ............................................................. 19 1.13.1 Fatigue ................................................................................................. 19 1.13.2 Regulations on medical examinations ................................................. 21 1.13.3 Hypoxia ............................................................................................... 22 1.14 Fire ................................................................................................................... 22 1.15 Survival aspects ............................................................................................... 23 1.15.1 Provisions on rescue services .............................................................. 23 1.15.2 The rescue operation ............................................................................ 23 1.16 Tests and research ............................................................................................ 23 1.16.1 Wind limitations regarding flight planning ......................................... 23 1.16.2 Operational crosswind limitations and procedures .............................. 24 1.16.3 Reference friction measurement .......................................................... 25 1.16.4 FDR data .............................................................................................. 25 1.16.5 Previous incidents ................................................................................ 27 1.17 Organisational and management information .................................................. 27 1.18 Additional information..................................................................................... 28 1.18.1 Air traffic control´s clearance and phraseology ................................... 28 1.18.2 Measures taken by the operator after the incident ............................... 28 1.19 Special methods of investigation ..................................................................... 28 3 (33) RL 2014:19e 2. ANALYSIS ..................................................................................................... 29 2.1 Circumstances.................................................................................................. 29 2.1.1 General ................................................................................................ 29 2.1.2 The crew´s lack of sleep ...................................................................... 29 2.1.3 Planning of the flight ........................................................................... 29 2.2 The flight towards Malmö ............................................................................... 30 2.2.1 The cabin decompression .................................................................... 30 2.2.2 The clearance to Flight Level 80 ......................................................... 30 2.2.3 Weather follow-up .............................................................................. 30 2.3 The landing and excursion ............................................................................... 30 2.3.1 The landing.......................................................................................... 30 2.3.2 The roll-out, thrust reversal and excursion .......................................... 30 2.3.3 The evacuation and rescue operation .................................................. 31 2.4 Medical examinations ...................................................................................... 31 3. CONCLUSIONS ............................................................................................. 32 3.1 Findings ........................................................................................................... 32 3.2 Factors as to Cause and Contributing Factors ................................................. 32 3.3 Factors as to Risk ............................................................................................. 32 4. SAFETY RECOMMENDATIONS ................................................................ 33 4 (33) RL 2014:19e General observations The Swedish Accident Investigation Authority (Statens haverikommission – SHK) is a state authority with the task of investigating accidents and incidents with the aim of improving safety. SHK accident investigations are intended to clarify, as far as possible, the sequence of events and their causes, as well as damages and other consequences.