Manx2 Flight 7100

Manx2 Flight 7100 (NM7100/FLT400C) was a scheduled commercial flight from George Best Belfast City Airport in Belfast, Northern Ireland to Cork Airport in Cork, Republic of Ireland. On 10 February 2011, the Fairchild SA 227-BC Metro III aircraft flying the route with 10 passengers and 2 crew on board, crashed on its third attempt to land at Cork Airport, which was experiencing dense fog at the time. Six people, including both pilots, died. Six passengers survived, 4 receiving serious injuries, whilst 2 were described as walking wounded.^[1]

The crash led to the closure of the airport for more than 24 hours and the diversion of all flights.^[2][3] The final report on the incident was sent to the bereaved families and the six survivors^[4] over a week in advance of its official release on 28 January 2014, almost three years after the crash.^[5] The report stated that the probable cause of the accident was loss of control during an attempted go-around below decision height in instrument meteorological conditions.^[6](p152) It noted that there was an inappropriate pairing of flight crews, inadequate command training and checking and inadequate oversight of the chartered operation by the operator and the operator's state as contributory factors in the accident.^{[6](pp148–151)[7]}

Aircraft and crew

The aircraft, destroyed in the accident, was a Fairchild SA 227-BC Metro III,^[8] c/n BC-789B,^[9] registration EC-ITP.^[10] It was owned by a Spanish bank and leased to Líneas Aéreas de Andalucía, known as Air Lada based in Seville, Spain.^[6](p8) The aircraft was subleased to Flightline S.L. and was on the Air operator's certificate (AOC) of Flightline, which is based in Barcelona, Spain.^[6](p8) Tickets were sold by Manx2 which was based in the Isle of Man.^[6](p8) The aircraft was 19 years old at the time of the accident.^[9] It had undergone a maintenance check in the week prior to the accident.^[11]

The captain was 31-year-old Jordi Sola Lopez from Barcelona. The first officer was 27-year-old Andrew Cantle from Sunderland, England. Both were employed by Air Lada.^[6](p8) The captain had logged 1,800 total hours, of which 1,600 were on the Fairchild Metro III, and of which just 25 were as pilot-in-command on the aircraft. The co-pilot had logged 539 total hours, of which 289 were on the aircraft type. Their pairing together on the flight was considered inappropriate and highly unusual. Both pilots were certified for Instrument landing system CAT I; neither pilot, however, was certified for CAT II.^{[6](pp13–15)}

The captain had undergone an upgrade on 2 February 2011; he subsequently flew 7 sectors under supervision and completed two line checks. His first flight in command of the aircraft took place on 6 February 2011, four days prior to the accident. The captain had flown into Cork 61 times; his logbooks never showed a diversion.^[6](p14)

The first officer had joined another Spanish operator flying the Fairchild SA 227-BC Metro III for 270 hours before joining Air Lada. According to the logbooks, he subsequently flew with line captains who were not instructors. He accumulated 19 hours with Air Lada but never completed a line check although required.^[6](p15)

Accident

NM7100 was scheduled to depart Belfast City at 07:50 GMT arriving in Cork for 09:00 IST. On board were a crew of two and ten passengers.^[10]

Timeline

The aircraft arrived at Belfast City Airport at 07:15 after a short positioning flight from Belfast International Airport, and was refuelled for the planned route-trip to Cork and back. The flight specified Waterford Airport as the alternate airport for the sector to Cork. No second alternate was made. Boarding of the flight was delayed due to both crew members working on the passenger seats in the cabin; boarding commenced once that task was completed. Passengers chose their seats at random and the safety demonstration was carried out by the co-pilot.^[6](p9)

• 08:10 – The accident flight FLT400C (NM7100) departed and was estimated to arrive in Cork at 09:10, where the weather was foggy.^{[Note 1]}
• 08:34 – The aircraft established communication with Shannon Air Traffic Control.
• 08:48 – The aircraft was handed-over to a Cork Approach controller.
• 08:58 – The flight reports established on the ILS for Runway 17 and was handed-over to Cork Tower.
• 09:00 – Cork Tower passed on Instrumented Runway Visual Ranges (IRVRs) which were still below those required.
• 09:03 – The crew descended below the Decision Height (DH) of 200 ft and a missed approach (go-around) was carried out. The lowest recorded height on this approach was 101 ft.

Radar vectors were given by Cork Approach to the reciprocal runway 35, which the crew believed with the sun behind the aircraft, might make visual acquisition of the runway easier.^[6](p10)

• 09:10 – The aircraft is 8 miles from touchdown and was handed back to Cork Tower. Again the IRVRs passed on by Tower are below minima. The approach continued beyond the Outer Marker (OM).
• 09:14 – The aircraft again descended below the DH and a second missed approach was carried out. The lowest recorded height on this approach was 91 ft.
• 09:15 – The flight crew enter a holding pattern named ROVAL and maintained an altitude of 3,000 ft.

In the hold the flight crew requested weather conditions for Waterford which were below minima. The flight crew nominated Shannon as their alternate and requested the latest weather; again the weather there was below minima. Weather for Dublin is passed onto the flight crew and was also below minima. Cork Approach informed the flight crew about weather conditions in Kerry which were "good" with 10 km visibility.^[6](p(p10))

• 09:33 – FLT400C is still in the ROVAL hold, IRVRs for Runway 17 began to improve.
• 09:39 – Following further slight improvement in IRVR values, but with conditions still below minima, the flight crew elect to carry-out a third approach, and the second approach for Runway 17.
• 09:45 – FLT400C reports established on the ILS for Runway 17, during this time IRVRs improve further to 550m (the required minimum) which is passed onto the crew by Cork Approach. The flight is handed over to Cork Tower for the third time.
• 09:46 – Cork Tower passes on the latest IRVRs of 500/400/400, which were now again below minima.

The approach is continued beyond the OM, the commander takes over operation of the Power Levers. Descent is continued below the DH. A significant reduction in power and significant roll to the left follows, just below 100 ft, a third go-around is called by the commander which the co-pilot acknowledges. Coincident with the application of go-around power by the commander, control of the aircraft was lost. The aircraft rolls rapidly to the right beyond the vertical which brought the right wingtip into contact with the runway surface. The aircraft continued to roll and impacted the runway inverted. The stall warning sounded continuously during the final seven seconds of the CVR recording.^[6](p11)

At 09:50:34 following both initial impacts the aircraft continued inverted for a further 189 metres (207 yd)^[3][12] and came to a rest in soft ground to the right of the runway. During this time the Emergency Locator Transmitter (ELT) began to sound in the Control Tower at Cork Airport.^[6](p44) Post impact fires ensued in both engines, and from fuel leaking from the outboard right fuel tank. The fires were put out by the Airfield Fire Service (AFS) before they reached the fuselage.^[6](p53)[13] Of the twelve on board, six people were fatally injured^[14] including both pilots. Four of the survivors suffered serious injury whilst two received minor injuries and were described as walking wounded.^[15][16] A witness inside the airport terminal building stated that the fog was so thick that the crashed aircraft could not be seen.^[17] The airport fire service extinguished both post impact fires within ten minutes of the accident, and started to remove the casualties from the wreckage.^[6]pg.192 The injured were taken to Cork University Hospital for treatment.^[16][18][18] As a result of the accident, Cork Airport was closed until the evening of 11 February.^[3][6]

	Emergency Locator Transmitter (ELT) alarm Transmission of a distress radiobeacon on 121.5 MHz and 243 MHz
Problems playing this file? See media help.

Victims

The aircraft had a crew of two and ten passengers. Both crew members and four passengers were fatally injured.^[19][20][21]

Nationality	Crew	Passengers	Fatalities	Injured
British	1	5	4	2
Irish	–	5	1	4
Spanish	1	–	1	–
Total	2	10	6	6

Investigation

The Air Accident Investigation Unit (AAIU) opened an investigation into the accident.^[12] Four personnel from the AAIU were on scene within 90 minutes of the accident. They completed their survey of the wreckage that day.^[16] The cockpit voice recorder and flight data recorder were recovered from the wreckage. The CVR was sent to the Air Accident Investigation Branch in the United Kingdom for download.^[22] Flightline S.L. cooperated with the AAIU investigation.^[23] There were accredited representatives to the team from the United States Federal Aviation Administration and National Transportation Safety Board,^[3] the Aviation Incidents and Accidents Investigation (AIAI) of Israel (as the "State of Type Certificate Holder"), Spain's Civil Aviation Accident and Incident Investigation Commission and the British AAIB (which "provided expertise")^[6](p7)

The wreckage was transported to the AAIU's examination facility at Gormanston, Co. Meath, to allow investigators to reconstruct the aircraft as far as possible. By 14 February, five of the six survivors had been interviewed by the AAIU.^[3]

The preliminary report, issued on 16 March 2011, stated that the aircraft, being flown by the co-pilot, had deviated from the runway centre-line on final approach and that the crew decided to execute a third go-around four seconds before impact. The aircraft rolled to the left and to the right, and the right wing then impacted the runway. No deficiencies in the aircraft or the airfield infrastructure were identified. The report did not include any findings.^[24]

An interim statement was published in February 2012 in line with European Union regulatory requirements.^[25] Inspection of the engines revealed that the right engine had consistently been developing up to five percent more torque than the left engine, as a result of a defective right engine intake air temperature and pressure sensor. The defective sensor meant that as well as delivering more torque than the left engine it would also respond more rapidly to commands to increase power from the engine's power lever than the left engine.^[25] The investigation also determined that both engines were developing go-around power at the moment of impact; however both engines were below flight idle power at eight to six seconds before impact.^[25] At eight seconds before impact the right engine reached a minimum of zero torque while the left engine reached −9 percent torque (which means the left propeller was driving the engine instead of the engine driving the propeller). The stall warning horn also sounded repeatedly in the seven seconds prior to impact.^[25]

Combined Standardisation Inspection by EASA

The issue of regulatory oversight of AOC operations by Spain was considered. The investigation team was informed by EASA that following a "Combined Standardisation Inspection carried out in respect of Spain in September 2010, the identified "areas of concern" had included:

• Initial certification (issuance of AOCs).
• Continued oversight of AOC holders.
• Resolution of safety concerns.

As a result, a “Corrective Action Plan” had been prepared and implemented, but EASA was of the opinion that “it is unlikely that such action would have shown a major effect on the system at the time of or prior to, the accident”.^[6]

Final report

On 28 January 2014, the AAIU released its final report on the accident. The report confirmed details previously released in the two interim statements published in 2011 and 2012 respectively. The final report, 244 pages long, comprised 54 findings (detailed in the final report), a probable cause, 9 contributing factors and 11 safety recommendations – all detailed in sections below.^{[6](pp152–154)}

Operation of the accident aircraft

Manx2's Belfast-Cork route was operated on the Air Operator Certificate (AOC) of Flightline S.L., based in Barcelona. As such Flightline was responsible for controlling all operational matters relating to that service. In practice many day-to-day decisions were taken by Manx2 in its Isle of Man office. One such decision was the pairing of Lopez and Cantle to crew flight 7100 on 10 February. Correct adherence to European aviation regulations (EU-OPS) by the AOC-holder should have prevented this inappropriate pairing of a newly promoted captain with a relatively inexperienced first officer. It had come about because Cantle was drafted in to replace the pilot who was originally rostered as first officer for the flight when he became unavailable. Flightline was not aware of the change in personnel.^{[6](pp127–130)}

Issues with the operator's state

The Investigation identified a specific concern in respect of the lack of circumstantial review by the AOC issuer, the Agencia Estatal de Seguridad Aérea (AESA) – the Spanish CAA – when Flightline S.L. applied for and were granted a variation to their initially issued AOC to add two Metro III aircraft in 2010. AESA was reported to have specifically stated to the Investigation that “it did not feel it was within its remit to look for additional organisational and financial information to ensure that the Operator was adequately resourced to operate two additional aircraft.” However, it was noted that AESA had been aware that the two aircraft added to the AOC had previously been operated from an Isle of Man base for the same Ticket Seller under a Spanish AOC held by a Company called Eurocontinental Air which they had suspended because of "problems that arose in that operation" and following "an extended ramp inspection" at the Isle of Man. It was noted that AESA had advised the Investigation that it:

• Had no knowledge of the ‘Owner’, which was a commercial company and therefore not within its regulatory remit
• Was unaware of the connection between the ‘Ticket Seller’ and the ‘Owner’
• Was unaware that two former Eurocontinental Air pilots had moved with the aircraft to the ‘Operator’
• Was unaware of the remote Operation of the Metro III aircraft following their addition to the Operator’s AOC during 2010 and that had it known this, it would have taken a greater interest.

The Investigation therefore expressed its concern that "the regulatory authority of the State of the Operator did not identify the Operator’s shortcomings, thereby contributing to the cause of the accident." It noted that, since the UK and Irish regulators were expressly prohibited by Regulation (EC) 1008/2008 from exercising any regulatory function in respect of the operation of aircraft from other Member States within and between their territories, both were obliged to rely on the oversight of Spain "to ensure compliance in regulatory matters". It was concluded that in practice "the evidence shows that such oversight was of limited scope and low effectiveness." In this situation, the only "control" on safety standards was observed to have been the SAFA programme of ramp checks which in this case had not identified the extent of systemic shortcomings. However, it was accepted by the Investigation that "SAFA inspections are limited ….in what can be achieved in the protection of the aviation system". It was also noted that AESA oversight of the Operation required by Regulation (EC) 1008/2008 required that Member State issuing an AOC must also take responsibility for the corresponding Operating Licence. It was concluded that "there was no evidence of any such oversight (of the Operation ) being conducted by Spain", although noted that "the Regulation makes no provision nor provides procedures of how oversight should be conducted, in particular where operations are carried out from a base outside a Member State" (in this case the Isle of Man). Finally, the Investigation noted the involvement of the EU Air Safety Committee in relation to the Accident Operator in the months following the investigated accident and considered that the scope of its remit might usefully be widened "as part of the EU aviation safety net".^[6](p138)

Probable cause

• Loss of control during an attempted go-around below Decision Height in Instrument Meteorological Conditions (IMC).

Loss of control in detail

The technical log for the flight indicated that the co-pilot was pilot flying (PF) for the flight. The CVR and ATC recordings also indicate that the co-pilot was PF during the flight. Furthermore, injuries sustained by the co-pilot to his right hand are consistent with his having been handling the aircraft at the time of impact. As no autopilot or flight director (FD) was fitted, the PF was under a high workload throughout the flight. This was especially so as three approaches were made in poor weather to below minima with two go-arounds. Normally the PF handles both flight and engine controls in a coordinated manner to achieve the required flight path; the PNF carries out other tasks including monitoring the aircraft's flight path, radio communications and keeping the flight log. The CVR indicates that the commander (PNF) took control of the power levers during final approach, this action being acknowledged by the PF. This was significant, as both power levers were subsequently retarded below Flight Idle – an action which would have been unexpected by the PF.

The recorded data shows that the No. 1 engine reached a minimum torque level of −9% in Beta range, while No. 2 engine reached a minimum of 0%. This thrust asymmetry was coincident with the aircraft commencing a roll to the left (maximum recorded value of 40 degrees bank). It is possible that the PF may have made a control wheel input to the right in response to the unanticipated left roll. However, without FDR parameters of control wheel or control surface position the Investigation could not determine if such an input was made. The subsequent application of power to commence the go-around, at approximately 100 feet, coincided with the commencement of a rapid roll to the right and loss of control. The roll continued through the vertical, the right wingtip struck the runway and the aircraft inverted.

Three principal factors contributed to the loss of control:^{[6](pp107–108)}

• Uncoordinated operation of the power levers and the flight controls, which were being operated by different flight crew members.
• The retardation of the power levers below Flight Idle, an action prohibited in flight, and the subsequent application of power are likely to have induced an uncontrollable roll rate due to asymmetric thrust and drag.
• A torque split between the powerplants, caused by a defective Pt2/Tt2 sensor, became significant when the power levers were retarded below Flight Idle and the No. 1 powerplant entered negative torque regime. Subsequently, when the power levers were rapidly advanced during the attempted go-around, this probably further contributed to the roll behaviour as recorded on the FDR.

Contributing factors

The contributing factors were:^[6]

1. Continuation of approach beyond the Outer Marker (OM) equivalent position without the required minima.
2. Continuation of descent below Decision Height (DH) without adequate visual reference.
3. Uncoordinated operation of the power levers and the flight controls.
4. In-flight operation of the power levers below Flight Idle.
5. A torque split between the engines that became significant when the power levers were operated below Flight Idle.
6. Tiredness and fatigue on the part of the flight crew members.
7. Inadequate command training and checking during the command upgrade of the commander.
8. Inappropriate pairing of flight crew members.
9. Inadequate oversight of the remote Operation by the Operator and the State of the Operator.

Safety recommendations

1. The Director-General for Mobility of Transport, European Commission should review the obligations of Member States to implement penalties, in accordance with the Standardisation Regulation (EU) No 628/2013, as a result of transgressions including Flight Time Limitations as provided for in Regulation (EC) No 216/2008. [IRLD2014001]
2. The European Aviation Safety Agency should provide guidance to Operators concerning successive instrument approaches to an aerodrome in IMC (Instrument meteorological conditions) or night VMC (Visual meteorological conditions) where a landing cannot be made due to weather reasons and incorporate guidance in Commission Regulation (EU) No 965/2012 accordingly. [IRLD2014002]
3. The European Aviation Safety Agency should review Council Regulation (EEC) No 3922/91 as amended by Commission Regulation (EC) No 859/2008, to ensure that it contains a comprehensive syllabus for appointment to commander and that an appropriate level of Command training and checking is carried out. [IRLD2014003]
4. Flightline S.L. should review its current operational policy of an immediate diversion following a missed approach due to weather. [IRLD2014004]
5. Flightline S.L. should implement suitable and appropriate training for personnel responsible for flight safety and accident prevention. [IRLD2014005]
6. The Director-General for Mobility of Transport, European Commission should review the role of the ticket seller when engaged in providing air passenger services and restrict ticket sellers from exercising operational control of air carriers providing such services, thus ensuring that a high and uniform level of safety is achieved for the travelling public. [IRLD2014006]
7. The European Aviation Safety Agency should review the process by which AOC (Air Operator Certificate) variations are granted to ensure that the scope of any new operation is within the competence of the air carrier. [IRLD2014007]
8. Agencia Estatal de Seguridad Aérea (AESA) should review its policy with regard to continuing oversight of air carriers, in particular those conducting remote operations. [IRLD2014008]
9. The Director-General for Mobility of Transport, European Commission should review Regulation (EC) No 216/2008 in the context of Implementing Regulation (EU) No 628/2013 to improve safety oversight including the efficacy and scope of SAFA (Safety Assessment of Foreign Aircraft) Inspections and to provide for the extension of oversight responsibilities, particularly in cases where effective oversight may be limited due to resource issues, remote operation or otherwise. [IRLD2014009]
10. The Director-General for Mobility of Transport, European Commission should review the scope of the Air Safety Committee, and consider including oversight of Operating Licences issued by Member States and the processes by which such oversight is carried out. [IRLD20140010]
11. The International Civil Aviation Organization should consider the inclusion of information regarding the flight-specific approach capability of aircraft/flight crew within the proposed 'Flight and flow – Information for a Collaborative Environment (FF-ICE)'. [IRLD2014011]

Source:^{[6](pp153–154)}

Aftermath

Martin McGuinness, the deputy First Minister of Northern Ireland, revealed that he had intended to be on the flight, but had changed his travel plans. McGuinness was due to travel to Cork to campaign in the forthcoming Irish general election, scheduled for 25 February.^[18]

As a result of the accident, Manx2 terminated its contract with Flightline,^[23] and suspended its Belfast City – Cork route effective 13 March 2011.^[26]

In March 2011, EASA initiated a procedure to suspend the AOC of Flightline S.L.^[27] Eventually the AOC was not revoked, but restrictions were put in place banning Flightline from operating Fairchild Metro IIIs.^[25]

In April 2011, pilot Oliver Lee who formerly flew Manx2 services between Belfast City and Cork committed suicide.^[28] He had left the airline days before the accident to join British airline Jet2.com and was known by frequent travellers on the route. Lee reportedly felt a sense of guilt following the accident.^[29]

The preliminary investigation report stated that the crew breached air safety regulations on all three approaches by descending below the decision height of 200 ft (61 m) before initiating a missed approach.^[30] On 6 May, the Civil Aviation Authority in the United Kingdom issued a Safety Notice advising all operators within the United Kingdom of new rules regarding Non-Precision Approaches and Minimum Descent Altitudes, applicable from 16 July 2011.^[31]

On 31 December 2012, Manx2 ceased operations and the company was liquidated. On 2 January 2013, as a result of a management buyout, the assets of the company and the whole management team transferred to its successor Citywing.^[32]

Following the release of the final report on 28 January 2014, family members of those bereaved in the accident as well as those injured announced intentions to pursue legal action against all three companies involved in the accident.^[33] An inquest was held in June 2014,^[34] in which a jury returned verdicts of accidental death on all six victims.^[35]

On 9 February 2015, the accident was featured in the episode "Third Time Unlucky" of Mayday (known as Air Crash Investigation in UK, Australia, South Africa and Asia).^[36]

Notes

1. ^ The METAR in force at the time of the accident was: EICK 100930Z 08005KT 050V110 0300 R17/0375N R35/0350N FG BKN001 04/04 Q1010 NOSIG.^[6]

Translation: METAR for Cork Airport, issued on the 10th of the month at 09:30 Zulu time. Wind from 080° at 5 knots (9.3 km/h; 5.8 mph), varying from 050° to 110°. Visibility 300 metres (980 ft), Runway visual range for Runway 17 is 375 metres (1,230 ft) with no significant change, Runway visual range for Runway 35 is 350 metres (1,150 ft) with no significant change, fog, broken clouds at 100 feet (30 m) above ground level, temperature 4 °C, dew point 4 °C, QNH 1010 hPa, no significant change expected.

See also

• Crew Resource Management (CRM)
• European Aviation Safety Agency
• Fatigue
• SAFA programme

References

Further reading

• Streitfield, David. "A Virtual Airline, a Real Crash." The New York Times. 7 February 2014.

External links

• Air Accident Investigation Unit
  • Interim statement (Archive)
  • Second interim statement (Archive)
  • Final Report (Archive)
• BBC Radio 4 Documentary on the crash