Runway excursion Accident Saab 340B YL-RAF, Monday 7 January 2019
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Date:Monday 7 January 2019
Time:05:50
Type:Silhouette image of generic SF34 model; specific model in this crash may look slightly different    
Saab 340B
Owner/operator:RAF-AVIA
Registration: YL-RAF
MSN: 340B-228
Year of manufacture:1991
Engine model:General Electric CT7-9B
Fatalities:Fatalities: 0 / Occupants: 3
Other fatalities:0
Aircraft damage: Substantial
Category:Accident
Location:Savonlinna Airport (SVL) -   Finland
Phase: Landing
Nature:Ferry/positioning
Departure airport:Riga International Airport (RIX/EVRA)
Destination airport:Savonlinna Airport (SVL/EFSA)
Investigating agency: SIAF
Confidence Rating: Accident investigation report completed and information captured
Narrative:
RAF-AVIA performed a positioning flight with a Saab 340B aircraft from Riga, Latvia, for Savonlinna, Finland. The flight crew comprised the captain (Pilot Flying, PF) and the co-pilot (Pilot Not Flying, PNF). Also, a ground engineer was on board. The purpose was to ferry the aircraft to Savonlinna to restart scheduled flights between Savonlinna and Helsinki-Vantaa.
The runway at Savonlinna was cleared from snow but there was packed snow at the edges. Because snow kept falling, the runway condition was considered 'poor', which was reported to the arriving aircraft.
At 05:43 the captain reported being established on the ILS localiser. The AFIS officer reported that wind was 220 degrees at five knots and that runway 12 was free. The pilots used 20 degrees flap during the approach. According to the flight data recorder the approach was stable until the threshold. During the final approach the pilots saw the approach and runway lights well. Owing to the icing conditions they intended to use an airspeed which was 10 knots higher than the Aircraft Operations Manual’s prescribed minimum approach speed. At the threshold their speed was 126 knots, while the approach’s target speed was 120 knots.
However, the airspeed at the touchdown zone markings was 123 knots. Contrasting from normal, the aircraft floated close to the surface for 6-7 seconds before touching down. The flight crew did not consider aborting the landing. Following the level flight the captain steered the aircraft toward the ground at a fairly high vertical speed. The aircraft touched down at 05:50, approximately 307 metres after the optimal touchdown point, on the left side of the runway. At touchdown the airspeed was 109 knots, which corresponds to the 110 knot target speed. Judging by the marks on the snow the left main landing gear hit the left snowbank on the uncleared area. The nose gear touched the runway, following which the left main gear became airborne for a moment and the right main gear touched the ground. The left main gear touched down again. After having travelled approximately 100 metres from the first touchdown point the aircraft’s nose gear and the right main landing gear moved outside the cleared runway area.
The aircraft was tracking towards the left, away from the direction of the runway. The pilots tried to turn the aircraft back towards the runway centreline. According to the markings the aircraft began to turn and started to skid sideways outside the cleared area of the runway.
When the left main gear hit a high snowbank outside the runway, the aircraft began to turn more sharply to the left. The left engine stalled when snow entered its air intake. The pilots did not deploy reverse thrust. The right main gear knocked one runway edge light over. The aircraft stopped in half-metre deep snow outside the runway, at a 110 degree angle in relation to runway 12.
The accident caused considerable damage to the aircraft. Both of the aircraft’s propellers were damaged as well as the nose landing gear.

The Safety Investigation Authority stated that this accident demonstrated the fact that the operating licences and air operator licences issued by the EU Member States’ aviation authorities do not guarantee constant and uniform safety levels among air carriers. While the EU’s regulations have aimed at ensuring the most open participation in tendering, they may result in overlooking the safety of aviation as one criterion in tendering. The purchaser organising the public tender for air services will not necessarily impose any safety-associated criteria because of being cautious about breaking EU competition rules and the court processes launched by losing bidders. Often the price and on-time performance are the tender criteria. Purchasers of air services do not have suitable and straightforward indicators to assess air carrier safety. Clients and purchasers may also include those that are not deeply familiar with the aviation branch.

CONCLUSIONS
1. The operating licences and air operator licences issued by the EU Member States’ aviation authorities do not guarantee constant and uniform safety levels among air carriers.
2. While the EU’s regulations have aimed at ensuring the most open participation in tendering, they may result in overlooking the safety of aviation as one criterion in tendering.
3. The purchaser organising the public tender for air services will not necessarily impose any safety-associated criteria because of being cautious about breaking EU competition rules and the court processes launched by losing bidders. Often the price and on-time performance are the tender criteria.
4. Purchasers of air services do not have suitable and straightforward indicators to assess air carrier safety. Clients and purchasers may also include those that are not deeply familiar with the aviation branch.
5. The airline had not completely complied with its own safety management system. Oversight authorities do not always detect the difference between the safety management that operators promise to follow and their real-world practices.
6. At no time did the flight crew consider aborting the landing.
7. The airline’s operational manuals (OM-A and OM-B) were inconsistent concerning maximum crosswind components. The instructions were difficult to follow in practice.
8. Regardless of the alert to the Emergency Response Centre, no information about the airliner accident was relayed to the region’s divisional officer on duty because, owing to the situation assessment, there was no need to deploy rescue service units.
9. The Cockpit Voice Recorder had not recorded anything from the flight in question, and the earlier recordings that were retrieved from its memory were of extremely poor quality. The recording quality of the FDR, when compared to modern recorders, was poor. The magnetic tape of the FDR was worn, which caused defects in the recording.

METAR:

03:20 UTC / 05:20 local time:
EFSA 070320Z 21004KT 180V260 3000 -SN BKN006 OVC017 M02/M02 Q1011

03:50 UTC / 05:50 local time:
EFSA 070350Z 22005KT 170V260 2500 SN BKN005 OVC015 M02/M02 Q1010

04:50 UTC / 06:50 local time:
EFSA 070450Z AUTO 23005KT 180V270 4300 -SN OVC006 M01/M02 Q1010

Accident investigation:
cover
  
Investigating agency: SIAF
Report number: L2019-01
Status: Investigation completed
Duration: 11 months
Download report: Final report

Sources:


Location

Images:


photo (c) Safety Investigation Authority Finland; Savonlinna Airport (SVL/EFSA); January 2019

Revision history:

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