Loss of control Accident Saab 340B PH-KSH, Monday 4 April 1994
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Date:Monday 4 April 1994
Time:14:46
Type:Silhouette image of generic SF34 model; specific model in this crash may look slightly different    
Saab 340B
Owner/operator:KLM Cityhopper
Registration: PH-KSH
MSN: 340B-195
Year of manufacture:1990
Total airframe hrs:6558 hours
Engine model:General Electric CT7-9B
Fatalities:Fatalities: 3 / Occupants: 24
Other fatalities:0
Aircraft damage: Destroyed, written off
Category:Accident
Location:Amsterdam-Schiphol Airport (AMS) -   Netherlands
Phase: Landing
Nature:Passenger - Scheduled
Departure airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Destination airport:Cardiff-Wales Airport (CWL/EGFF)
Investigating agency: RvdL
Confidence Rating: Accident investigation report completed and information captured
Narrative:
KLM Cityhopper flight 433 took off from runway 24 at Amsterdam-Schiphol Airport, the Netherlands for a 1 hour and 18 minute flight to Cardiff, U.K. Eleven minutes after takeoff, at 14:30 hours local time, the flight passed FL165, climbing to FL200 when the Master Warning was triggered by the no. 2 engine oil pressure light. The Master Warning was reset and the captain retarded the no. 2 engine power lever slowly to flight idle, causing the engine torque to decrease from 78% to 10%. Retarding the power lever is not part of the Emergency Checklist (ECL) procedure. Possibly this was done to prevent damage to the right-hand engine. The ECL Engine Oil Pressure Low procedure was then started. The ECL states that the engine must be shut down if the oil pressure warning light is on and oil pressure below 30psi. If the warning light is on and the engine oil pressure is above 30psi, normal operation should be continued. As the no. 2 engine pressure was above 50psi, both flight crew members agreed normal operation should be continued. The captain didn't want to continue to Cardiff and elected to return to Amsterdam. At 14:33 Amsterdam Radar was contacted with a PAN-call and a request to maintain FL160 and return to Amsterdam. One minute later a clearance was received to descend to FL70. KL433 was offered a straight in approach for either runway 06 or runway 01R. The captain decided to use runway 06 and was cleared to descend to 2000 feet. Landing clearance was given at 14:42 and one minute later the ILS localizer and glide slope were intercepted. The captain, not realising the consequences of flying with one engine in flight idle and was not able to anticipate correctly on the airspeed variations which resulted in an approach not stabilized in power, airspeed and pitch during the final approach. The speed had decreased to 115 knots and the crew reacted by applying an aggressive increase in torque (from 40% to 65%) with limited corrections for asymmetry. This placed the aircraft to the right of the extended centreline at an altitude of 90 feet. At 14:45:53 the captain called for a go-around and no. 1 engine torque was set at 98% with the no. 2 engine remaining at flight idle. Flaps were set at 7 degrees and the gear was retracted. The aircraft rolled right and pitched up to a maximum of 12 degrees. The stall warning system activated as the airspeed decreased and continued until impact. The Saab struck the ground with an approx. 80 degree right bank and broke up.

PROBABLE CAUSES: "Inadequate use of the flight controls during an asymmetric go around resulting in loss of control.
Contributing factors: Insufficient understanding of the flight crew of the SAAB 340B engine oil system; lack of awareness of the consequences of an aircraft configuration with one engine in flight idle; poor crew resource management."

Accident investigation:
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Investigating agency: RvdL
Report number: final report
Status: Investigation completed
Duration: 1 year and 6 months
Download report: Final report

Sources:


Location

Images:


photo (c) ANP / H. Pieterse; Amsterdam-Schiphol Airport (AMS); 05 April 1994; (CC:by-nc-nd)


photo (c) ANP / C. Mulder; Amsterdam-Schiphol Airport (AMS); 05 April 1994; (CC:by-nc-nd)


photo (c) ANP / C. Mulder; Amsterdam-Schiphol Airport (AMS); 05 April 1994; (CC:by-nc-nd)


photo (c) Raad voor de Luchtvaart; Amsterdam-Schiphol Airport (AMS); 05 April 1994


photo (c) Ardenau4; Amsterdam-Schiphol Airport (AMS); 04 April 1994; (CC:by-sa)


photo (c) Richard Wagner, via Werner Fischdick; Nürnberg Airport (NUE); December 1990


photo (c) Harro Ranter; Maastricht/Aachen Airport (MST); 13 January 1994; (CC:by-nc-nd)


photo (c) Harro Ranter; Maastricht/Aachen Airport (MST); 13 January 1994; (CC:by-nc-nd)

Revision history:

Date/timeContributorUpdates
05-Apr-2024 07:47 ASN Updated [Source]

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