Serious incident Saab 2000 HB-IZW, Thursday 10 December 2015
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Date:Thursday 10 December 2015
Time:13:21 UTC
Type:Silhouette image of generic SB20 model; specific model in this crash may look slightly different    
Saab 2000
Owner/operator:Etihad Regional/Darwin Airline
Registration: HB-IZW
MSN: 2000-039
Year of manufacture:1996
Fatalities:Fatalities: 0 / Occupants: 29
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:4.5 NM east of Billund Airport (EKBI) -   Denmark
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Berlin Tegel Airport (EDDT)
Destination airport:Billund Airport (EKBI)
Investigating agency: STSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
On 10 December 2015 at 12:14 UTC, the Saab 2000 aircraft took off from Berlin Tegel Airport (EDDT) for a scheduled flight to Billund Airport (EKBI) under flight number AB8054. On this flight, the commander was the pilot flying.
After an uneventful cruise flight, the pilots noticed problems with the glideslope indication during the approach to Billund Airport. At an altitude of 800 ft above ground and 250 ft below the minimum altitude stipulated for this position, the pilot flying initiated a go-around.
Because of the problems with the glideslope indication, the pilots decided to perform a nonprecision approach using the localiser for the second approach. During this approach, the aircraft descended too steeply and continued to descend below the stipulated minimum altitudes.
The excessive descent then triggered the ground proximity warning system to which the pilots reacted with another go-around. After they had completed an analysis of the problem, the crew decided to return to Berlin. The remainder of the flight was uneventful.

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.
The approach chart, which had no distance/altitude table and thereby impeded the monitoring of the approach, systematically contributed to the serious incident.
Although it did not influence the development and course of the serious incident, the following risk factor was identified during the investigation:
- The procedure following a warning from the enhanced ground proximity warning system (EGPWS) was not consistently applied.

Accident investigation:
cover
  
Investigating agency: STSB
Report number: 
Status: Investigation completed
Duration: 2 years and 11 months
Download report: Final report

Sources:

STSB
http://aerossurance.com/safety-management/saab2000-too-low-billund

History of this aircraft

Other occurrences involving this aircraft

28 November 2013 HB-IZW Darwin Airline 0 nr Lugano non
Engine failure

Images:


The vertical profile of the localiser approach according to the DFDR data (red line) compared to a continuous descent final approach (green line). The grey area shows the lower approach limit, which an aircraft must not fly below until reaching the outer marker (LOM). (Illustration: STSB)

Media:

Revision history:

Date/timeContributorUpdates
03-Jan-2019 16:40 harro Added
03-Jan-2019 17:47 harro Updated [Photo, ]
09-Dec-2020 22:54 Aerossurance Updated [Source, Accident report, ]
10-Dec-2020 08:08 Aerossurance Updated [Embed code, ]

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