L2019-01 Airliner Veering Off the Runway During Landing Roll at Savonlinna on 7 January 2019

An airliner veered off the runway during a landing roll at Savonlinna Airport on 7 January 2019 at 05:50. It was a Latvian A/S RAF-AVIA airline positioning flight with a Saab 340B aircraft from Riga. The approach proceeded normally until the aircraft passed the threshold. At the final phase of the landing the aircraft floated close to the surface for 6–7 seconds before touchdown, following which the touchdown point moved farther down the runway than normally. Extra airspeed after the threshold partly contributed to this. The captain steered the aircraft toward the ground at a fairly high vertical speed. At that time the aircraft was already over the snowbank at the edge of the cleared area of the runway. Despite the pilot’s corrective control actions the aircraft veered off the runway into the snowbank. The flight crew comprised of two pilots and a ground engineer. Nobody was injured but the aircraft suffered significant damage.

At no time did the pilots consider aborting the approach or landing, i.e. going around. The airline’s operational manuals (OM-A and OM-B) were inconsistent concerning maximum crosswind components. The instructions were difficult to follow in practice.

Despite the alert to the Emergency Response Centre, information about the accident was not relayed to the rescue department’s divisional officer on duty. This was because, according to the situational assessment, there was no need to dispatch any rescue units.

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.

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.

The accident demonstrates 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.

The Safety Investigation Authority recommends that

• The Finnish Transport and Communications Agency explore and instruct how operators’ aviation safety and safety management performance, as criteria, can be used in tendering for air services, taking the EU’s regulations into account.

• The European Commission see to it that a process is created by which it becomes possible to impartially assess operators’ safety management performance and safety levels in tendering for air services.

• The European Union Aviation Safety Agency (EASA) ensure that the audits conducted by the EU Member States on operators also cover the practical functioning and performance of safety management systems.

• The European Union Aviation Safety Agency (EASA) set a deadline for the use of flight data recorders recording on magnetic tape.

L2019-01 Investigation report (pdf, 1.89 Mt)

 
Published 10.12.2019