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-   -   Serious incident in BLL 10DEC15 - final report (https://www.pprune.org/rumours-news/617005-serious-incident-bll-10dec15-final-report.html)

SMT Member 7th Jan 2019 12:07

Serious incident in BLL 10DEC15 - final report
 
Final report is out on the Darwin Airlines S2000, which got very low during approach to BLL airport. Here's an excerpt of the final conclusions:

3.2 Causes The serious incident emerged from the aircraft’s descent below the stipulated minimum altitude for a non-precision approach. Therefore, a safe altitude above the obstacles was no longer guaranteed. The crew’s poor monitoring of the vertical flight path has been identified as the direct cause of the incident.

The following factors have been identified as directly contributing to the serious incident:
  • Deficient approach planning with regards to the vertical flight path.
  • Reduced performance of the pilot flying, probably due to tiredness
Full report here: https://www.sust.admin.ch/inhalte/AV...hte/2342_e.pdf

PiC had arrived in PRG at 22:32 the night before, and was picked up from the hotel the following morning at 05:20 for a planned 5-sector day. How that's even remotely legal is truly baffling.

nicolai 7th Jan 2019 22:15

... and in those three years the airline has ceased operations.

During an admittedly quick scan through, I didn't see any recommendation to give the pilot enough rest - although perhaps lack of rest is not a novel problem to issue recommendations about, it's straight-up breach of regs. Some unanswered questions, definitely; anyone know if the airline had any other action taken against them by the regulator for this apparently rather out-of-regulations rest incident?

exeng 7th Jan 2019 22:39

From the official report:
Commander

Whilst working with Etihad Regional / Darwin Airline, the commander had the following additional functions: Theoretical Knowledge Instructor, ATR Chief Fleet, Training Captain, SAAB Chief Fleet
Mistrust in management would seem to be the case here.

F/O

Whilst working at Etihad Regional / Darwin Airline, the first officer had the following additional functions: Deputy Post Holder Flight Operations, Post Holder Flight Operations, Flight Ops Engineering
Also regarding the F/O [QUOTESince 2010, the first officer, who was then employed as a captain, had a history of shortcomings in the areas of systematics, communication and compliance with standard operating procedures (SOP). The training department tried to correct these shortcomings through discussions and additional training. After a line check in 2013, it was decided to roster him again as a first officer. Since then he has held the rank of a captain but has been flying as a first officer. ][/QUOTE]

What a complete mess - no wonder this outfit has ceased operations. Amazing it even managed to start.


Kind regards
Exeng

Anilv 8th Jan 2019 00:05

Vary apt name for the airline.. should be included in the Darwin awards thread.

Cheers
bug


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