Instrument malfunction led to West Atlantic CRJ200 freighter crash
Swedish air accident investigators have concluded that an instrument failure was the root cause of the crash of a Swedish cargo aircraft in January 2016.
The West Atlantic Sweden Bombardier CRJ 200, SE-DUX, crashed Jan. 8 while on a night flight from Oslo Gardermoen airport to Tromsø Langnes airport in the far north of Norway. The aircraft came down just over the border in Sweden.
Both pilots, the only people on board, died in the crash.
The investigators have called for the implementation – throughout the commercial air transport industry – of a system of initial standard calls for the handling of abnormal and emergency procedures.
The final accident report by Statens Haverikommission (SHK), the Swedish Accident Investigation Authority, says that flight was uneventful until the approach briefing for Tromsø, in level flight at FL 330.
The night was moonless, without clouds or turbulence. This lack of external visual references rendered the pilots totally dependent on their instruments, which included three independent attitude indicators.
According to information from the flight data recorder, a very fast increase in pitch was displayed on the left attitude indicator. The displayed pitch change meant that the pilot in command, who was the pilot flying, was subjected to a surprise effect and a degradation of spatial orientation.
“The autopilot was, most probably, disconnected automatically, a ‘cavalry charge’ aural warning and a single chime was heard, the latter most likely as a result of miscompare between the left and right pilots’ flying displays (PFD),” the report said.
Both elevators moved towards nose down and nose down stabilizer trim was gradually activated. The aircraft started to descend.
“About 13 seconds after the start of the event the crew were presented with two contradictory attitude indicators with red chevrons pointing in opposite directions. Bank angle warnings were heard and the maximum operating speed and Mach number were exceeded 17 seconds after the start of the event, which activated the overspeed warning,” the report said. “The speed continued to increase, a distress call was transmitted and the engine thrust was reduced to flight idle.”
The report continued: “the crew was active during the entire event. The dialogue between the pilots consisted mainly of different perceptions regarding turn directions. They also expressed the need to climb. At this stage, the pilots were probably subjected to spatial disorientation.”
“The aircraft collided with the ground one minute and twenty seconds after the initial height loss,” the report said.
SHK’s investigation found that the erroneous attitude indication on PFD 1 was caused by a malfunction of the Inertial Reference Unit.
The pilots initially became “communicatively isolated” from each other, says the SHK and a system for efficient communication was not in place.
Among its recommendations, “SHK considers that a general system of initial standard calls for the handling of abnormal and emergency procedures and also for unusual and unexpected situations should be incorporated in commercial aviation.”
“The accident was caused by insufficient operational prerequisites for the management of a failure in a redundant system,” the report concluded. “Contributing factors were: the absence of an effective system for communication in abnormal and emergency situations; the flight instrument system provided insufficient guidance about malfunctions that occurred; and the initial maneuver that resulted in negative G-loads probably affected the pilots' ability to manage the situation in a rational manner.”
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