Accident Boeing 737-4B6 CN-RMF, Sunday 6 June 2010
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Date:Sunday 6 June 2010
Time:21:42
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different    
Boeing 737-4B6
Owner/operator:Royal Air Maroc - RAM
Registration: CN-RMF
MSN: 24807/1880
Year of manufacture:1990
Engine model:CFMI CFM56-3C1
Fatalities:Fatalities: 0 / Occupants: 162
Other fatalities:0
Aircraft damage: Substantial, repaired
Category:Accident
Location:Amsterdam-Schiphol International Airport (AMS) -   Netherlands
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Destination airport:Nador-Taouima Airport (NDR/GMFN)
Investigating agency: Dutch Safety Board
Confidence Rating: Accident investigation report completed and information captured
Narrative:
A Boeing 737-400, registered CN-RMF, sustained damage following a birdstrike at Amsterdam-Schiphol International Airport (AMS/EHAM), the Netherlands.
The aircraft had multiple bird strikes with geese during takeoff from runway 18L. This resulted in heavy damage and loss of the left engine. The crew declared an emergency and the aircraft was vectored to runway 18R immediately. The aircraft’s climb performance was degraded. The highest altitude during the flight was approximately 630 feet. The aircraft made an overweight landing six minutes after takeoff and the tires of the right main landing gear were blown.

CAUSAL FACTORS:
1. Shortly after take-off a bird strike occurred which caused damage to the left engine and reduced thrust to approximately 45%. The flight crew then took the right decision to return to Schiphol airport.
2. However, this decision was not executed in accordance with standard operational procedures. The deviations from the standard operational procedures after an engine failure were:
- The Initiation of a (right) turn at 280 feet with a bank angle of up to 37.5 degrees instead of climbing to the prescribed 'clean up' altitude with retracted landing gear.
- Selecting gear down at very low altitude after it had first been selected up.
- Reducing the thrust on the undamaged right engine from 94% N1 to 83% N1 instead of selecting maximum thrust.
These deviations from the standard operational procedures resulted in the aircraft only being able to achieve a limited rate of climb, causing it to be unable to achieve the required minimum safe flying altitude. The flight crew had dif ficulty controlling the aircraft and were distracted by various audio and visual warnings in the cockpit which were the consequence of incorrectly completed cockpit procedures.

CONTRIBUTING FACTORS:
3. During the flight the crew resource management and crew communication were not in accordance with the international standard for airline pilots.
- The immediately initiated right turn and the marginal remaining flying performance made the tasks more difficult and led to complications which meant that both pilots were unable to fulfil their tasks, such as the completion of cockpit procedures and checklist readings, in the prescribed manner. This in turn led to new complications such as unnecessary warnings and an unstable flight path.
4. During the refresher training for Atlas Blue and Royal Air Maroc pilots, they were not trained to deal with multiple malfunctions during the flight.
- Prior to every recurrent training pilots of Atlas Blue and Royal Air Maroc were taught about the specific malfunctions that would occur. This is not unusual In the context of flight training practice, but the consequence was that the pilots did not leam how to respond to unexpected effects.
- Dealing with multiple malfunctions featured only in the initial training for captains.
- Although the Flight Crew Training Manual and the Flight Crew Operations Manual contain the procedures and checklists required for the adequate tackling of malfunctions which occurred during this flight, the flight crew and the training managers of Atlas Blue and Royal Air Maroc regarded this serious incident as a unique event which pilots cannot be trained in.
5. The analysis of measures implemented in response to the 3PR Investigation (initiated in response to the recommendation by the Bijlmermeer Air Disaster Parliamentary Board of Inquiry) failed to take account of the risks caused by aircraft in distress situations flying below the minimum vectoring altitude. These aircraft are given headings In the Schiphol control zone, despite the fact that air traffic controllers do not have information on high obstacles in the flight path. This unnecessarily increases the risk of a collision. This problem is all the more urgent when aircraft are flying outside visual meteorological conditions.
- The Investigation conducted by Air Traffic Control the Netherlands in response to the recommendation by the Bijlmermeer Air Disaster Parliamentary Board of Inquiry has resulted In a policy framework on the supervision of aircraft in distress situations and on flying over densely populated areas. According to this policy framework for aircraft in distress situations, the captain is responsible for flight operation white the air traffic controller provides assistance to the cockpit crew. Aircraft in distress must use existing runway arrival and departure routes where possible, which limits the amount of flying over densely populated areas. The Directorate-General of Aviation and Maritime Affairs has approved the aforementioned policy framework. As a result of this policy framework,

Accident investigation:
cover
  
Investigating agency: Dutch Safety Board
Report number: 2010034
Status: Investigation completed
Duration: 1 year and 4 months
Download report: Final report

Sources:

SKYbrary 

Location

Images:


photo (c) Willem Göebel; Amsterdam-Schiphol International Airport (AMS/EHAM)

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