L2012-02 Risk of an Airliner Colliding with Terrain in the Vicinity of Mariehamn Airport on 14 February 2012

A serious incident occurred to the Latvian RAF-AVIA Airlines on 14 February 2012 at 6.45 Finnish time as it was approaching Mariehamn airport. The aircraft was on a Nordflyg cargo flight from Helsinki-Vantaa to Mariehamn. There were two crew members and cargo on board. The serious incident was caused because the captain continued the approach in a situation which did not meet the requirements of a successful approach and landing. This degraded the flight crew´s situational awareness to the extent threat the captain flew the aircraft into an unusual attitude and the crew lost control of the aircraft. This resulted in the risk of the colliding with terran. The ground Proximity Warning System warnings were also ignored. The captain managed to recover the aircraft about two seconds before they would have collided with the ground. The investigation revealed shortcomings in the crew cooperation. Furthermore the captain did not comply with the company´s operations manual.

The Safety Investigation Authority (SIA) recommends that

1. The investigation revealed non-synergetic crew cooperation between the members of the crew of NEF021. Among the shortcomings that were found were the captain’s insufficient communication to the co-pilot of the FMS mode selections and the flight crew’s failure to check their position from the other navigational aids when they questioned the functioning of the Flight Management System.

“Safety Investigation Authority, Finland recommend that the Latvian Civil Aviation Agency ensure that RAF-AVIA pilots receive additional Crew Resource Management training.“

2. RAF-AVIA’s Operations Manual calls for prompt evasive action to be initiated immediately upon receiving a GPWS warning and for immediate corrective action to clear the situation. Nevertheless, the flight crew did not react to the GPWS warnings.

“Safety Investigation Authority, Finland recommend that the Latvian Civil Aviation Agency ensure that RAF-AVIA pilots receive additional training as regards the operating procedures of the Ground Proximity Warning System.“

3. Finavia Oyj has published regulation IAM RAC 89 (15 Nov 2006) “The use of radar monitors at ATS units” (this investigation report uses the term ATS monitor). The regulation lists the processes in which air traffic controllers can use ATS monitors. When an air traffic controller notices from the ATS monitor that an aircraft significantly deviates from the air traffic control clearance the controller may ask the pilot of the aircraft for verification. Should the pilot’s reply confirm the assumed incorrect positional information, the pilot must be notified of this.

“Safety Investigation Authority, Finland recommend that Finavia Oyj update its regulation IAM RAC 89 (15 Nov 2006) “The use of radar monitors at ATS units” in such a manner that the air traffic controller also has the option of notifying the pilot when the information on the ATS monitor and the pilot’s position report diverge.“

Additional Information
Executive director of Safety Investigation Authority
Veli-Pekka Nurmi
02951 50701

L2012-02 Report (pdf, 0.63 Mt)