Accident and Serious Incident Reports: EMG
Accident and Serious Incident Reports: EMG
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This page contains lists of accidents and serious incidents involving emergency procedures.
Emergency Descent
On 8 June 2016, a Boeing 737-800 en-route to Seville, Spain, had already reverted to alternate automatic pressurisation control when this also failed. Manual system control was attempted but was unsuccessful, so an emergency descent followed by diversion to Toulouse, France, was completed without further event. A similar pressurisation control fault had occurred earlier that day but had not been properly dealt with by an appropriately qualified engineer. Both system controllers were showing faults and were replaced, as were a ruptured flexible hose and a series of malfunctioning drain valves. More reliable controllers and routine checking of system performance were recommended.
On 8 February 2022, a Boeing 767-300ER inbound to Madrid at FL340 experienced a failure of automatic pressurisation control, followed almost three hours later by a failure of manual control and rapidly rising cabin altitude. An emergency was declared and descent made to FL120 where manual control was regained. The flight was completed without recurrence. The failure cause was found to have been water leaking from a tube with a broken clamp which, when it froze, had blocked the air conditioning outflow valve doors. Elements of the system design, scheduled maintenance requirements, and fault detection were identified as contributing factors.
On 17 November 2021, after a Boeing 737-800 commenced initial descent into Patna from FL350, a cautionary alert indicating automatic pressurisation system failure was annunciated. When the initial actions of the prescribed non-normal procedure did not resolve the problem, the system outflow valve was fully opened, and a rapid depressurisation followed. After this incorrect action, the relevant crew emergency procedures were then not properly followed. It was further concluded that the captain had temporarily lost consciousness after a delay in donning his oxygen mask. The context for the mismanaged response was identified as outflow valve in-service failure.
On 13 July 2018, a Boeing 737-800 cruising at FL370 at night experienced a sudden rapid depressurisation. An emergency descent to FL 090 followed but the cabin altitude was not manually controlled and after the cabin pressure had risen to that equivalent to 7000 feet below sea level, immediate equalisation of cabin and actual altitudes resulted in a second sudden depressurisation. Diversion to Frankfurt Hahn was completed without further event. The first depressurisation had resulted from a transient and rare pressure controller malfunction but passenger injuries were considered attributable to a complete absence of pressurisation control during the emergency descent.
On 18 March 2020, a Fokker 100 en-route to Port Moresby experienced a failure of the cabin pressurisation and air conditioning system due to a complete failure of the bleed air system. An emergency descent and a PAN were declared and a diversion to Madang completed. The Investigation noted unscheduled work on the bleed air system had occurred prior to the departure of the flight and that long running problems with this system had not been satisfactorily resolved until after the investigated occurrence when four malfunctioning components had finally been systematically identified and replaced.
Emergency Evacuation
On 6 November 2022 adverse weather delayed an ATR42 beginning its visual-only approach to Bukoba. When an approach was commenced, adequate visual reference was not maintained due to continued adverse weather. No corrective action was taken in response to three successive automated excessive descent rate alerts or the first officer’s calls to reduce descent rate. Although response did follow a ‘PULL UP’ warning, it was too late to prevent a high-energy impact with the surface of Lake Victoria close to the shoreline, and both pilots and 17 of the passengers were killed.
On 23 October 2022, an Airbus 330-300 failed to complete three night approaches to runway 22 at Mactan-Cebu due respectively to adverse weather, a low height ‘SINK RATE’ warning and a system fault. Touchdown followed the fourth approach but the aircraft failed to stop on the 3,300 metre-long runway and sustained major damage before coming to a stop 235 metres beyond the runway end. All occupants successfully evacuated without serious injuries. The lack of braking was found to have been caused by damage during brief aircraft ground contact just before the beginning of the runway during the second approach.
On 16 July 2023, an Airbus A320 hit a bird at high speed during takeoff from Barcelona. The first officer was the pilot flying (PF). The captain’s airspeed indicator failed at that time but the first officer’s did not, so he called V1. The captain responded with a “stop” call and rejected the takeoff. The aircraft stopped with 600 metres of runway remaining. When the aircraft could not be moved, concern about rising wheel temperatures led the captain to order an emergency evacuation during which 15 passengers received minor injuries. The inability to taxi the aircraft was found to be because the autobrake was still at MAX.
On 22 July 2020, a Boeing 777F main deck cargo fire warning was annunciated as the aircraft was preparing for departure from Shanghai. Fire service was requested and a MAYDAY declared to expedite this. All crew evacuated as the main deck cargo main door was being opened. Smoke appeared immediately and flames followed. The fire took almost three hours to extinguish and resulted in major damage. The investigation concluded that the fire had resulted from spontaneous ignition of a shipment of chlorine disinfection tablets loaded as undeclared dangerous goods, due a combination of high ambient humidity and temperature.
On 17 February 2025 a Mitsubishi (formerly Bombardier) CRJ-900LR was on final approach to Toronto International and touched down at a high rate of descent on the right main landing gear, which collapsed inwards. This caused the right wing to break from the fuselage, which then rolled inverted, detaching the tailplane. The fuselage slid for some distance before stopping, complicating the evacuation. A fuel-fed fire immediately ignited around the right wing/fuselage attachment point but all 80 occupants escaped, almost all using just two exits. There were only two serious injuries and 19 minor injuries.
Precautionary Rapid Disembarkation
On 10 February 2023, a Boeing 767-300ER had problems setting climb thrust after takeoff from Edinburgh, and a right engine control fault was annunciated. It was decided that the intended transatlantic flight should divert to Prestwick. Right engine vibration became apparent and the engine was set to idle, and it shut down after landing. On arrival at the assigned parking position, fuel was seen leaking from the right wing, and a rapid passenger disembarkation was completed. Vibration due to engine imbalance after turbine blade fracture was found to have caused the fuel leak.
On 10 August 2019, the left Rolls Royce Trent 1000 engine of a Boeing 787-8 just airborne from Rome Fiumicino suddenly malfunctioned and was shut down. A MAYDAY was declared, and the flight returned for an overweight landing during which all four left main gear tyres deflated. The underlying cause of the engine failure was found to have been intermediate-pressure turbine blade detachment attributable to previously identified serviceability issues. Wider concerns were identified in relation to underlying engine certification standards and to the hazard created by ejection of large quantities of engine debris into a densely populated area.
On 2 July 2021, during pre-departure loading of a Boeing 777-300 at Heathrow prior to passenger boarding with only the operating crew on board, a rear hold fire warning was annunciated and smoke and fumes subsequently entered the passenger cabin. The Investigation found that the source was a refrigerated container which had been subject to abnormal external impact prior to or during loading causing a short circuit in its battery pack. The refrigeration system involved was found by design to inhibit fire following a short circuit but it was noted that QRH response procedures did not apply to the circumstances.
On 27 October 2019, an under-floor hold fire warning was annunciated in the flight deck of a Boeing 737-900 which had been pushed back at Paris CDG and was about to begin taxiing. Since there were no signs of fire in the passenger cabin or during an emergency services external inspection, a non-emergency disembarkation of all occupants was made. The hold concerned was then opened and fire damage sourced to the overheated lithium battery in a passenger wheelchair was discovered. The Investigation identified a number of weaknesses in both the applicable loading procedures and compliance with the ones in place.
On 2 November 2017, the flight crew of an Airbus A320 climbing out of Cork detected a “strong and persistent” burning smell and after declaring a MAYDAY returned to Cork where confusing instructions from the crew resulted in a combination of the intended precautionary rapid disembarkation and an emergency evacuation using escape slides. The Investigation highlighted the necessity of clear and unambiguous communications with passengers which distinguish these two options and in particular noted the limitations in currently mandated pre flight briefings for passengers seated at over wing emergency exits.
Evacuation Injuries
On 23 October 2022, an Airbus 330-300 failed to complete three night approaches to runway 22 at Mactan-Cebu due respectively to adverse weather, a low height ‘SINK RATE’ warning and a system fault. Touchdown followed the fourth approach but the aircraft failed to stop on the 3,300 metre-long runway and sustained major damage before coming to a stop 235 metres beyond the runway end. All occupants successfully evacuated without serious injuries. The lack of braking was found to have been caused by damage during brief aircraft ground contact just before the beginning of the runway during the second approach.
On 17 February 2025 a Mitsubishi (formerly Bombardier) CRJ-900LR was on final approach to Toronto International and touched down at a high rate of descent on the right main landing gear, which collapsed inwards. This caused the right wing to break from the fuselage, which then rolled inverted, detaching the tailplane. The fuselage slid for some distance before stopping, complicating the evacuation. A fuel-fed fire immediately ignited around the right wing/fuselage attachment point but all 80 occupants escaped, almost all using just two exits. There were only two serious injuries and 19 minor injuries.
On 23 February 2016, a Boeing 737-800 departing New Chitose encountered sudden-onset and unforecast heavy snowfall whilst taxiing out. When the right engine ran down and cabin crew reports of unusual smells in the cabin and flames coming from the right engine were received, it was decided that an emergency evacuation was required. During this evacuation three passengers were injured, one seriously. The engine fire was found to have been in the tailpipe and caused by an oil leak due to engine fan blade and compressor icing which had also led to vapourised engine oil contaminating the air conditioning system.
On 2 October 2021, an Airbus A320neo ingested a large bird into its right engine (a Pratt & Whitney PW1100G) during takeoff at Atlantic City and a high speed rejected takeoff followed. When leaked fuel pooling within the engine cowling subsequently ignited, an on-runway emergency evacuation was completed with the fire service in attendance. The Investigation identified the ingested bird as a bald eagle with a mass above the applicable certification standard and the fuel leak a secondary consequence of a fan blade broken by bird impact. Engine component design improvements to address the fire risk following large bird ingestion are being developed.
On 15 December 2019, an Airbus A330-200 turned back to Sydney shortly after departure when a major hydraulic system leak was annunciated. The return was uneventful until engine shutdown after clearing the runway following which APU use for air conditioning was followed by a gradual build up of hydraulic haze and fumes which eventually prompted an emergency evacuation. The Investigation found that fluid leaking from ruptured rudder servo hose had entered the APU air intake. The resulting evacuation was found to have been somewhat disorganised with this being attributed mainly to a combination of inadequate cabin crew procedures and training.
Aircraft Exit Injuries
On 2 January 2024, an Airbus A350-900 collided with a Bombardier DHC8-300 almost immediately after the A350 made a night touchdown in good visibility at Tokyo Haneda. The DHC8 had entered the runway for departure without clearance. Both aircraft caught fire. The DHC8 was destroyed and five of the six occupants died. The A350 then veered off the runway and stopped. All 379 occupants evacuated the A350 prior to its complete destruction by fire. A tower visual-only runway incursion warning was unnoticed for over a minute, and stop bar lighting was out of service for upgrading.
On 2 July 2021, during pre-departure loading of a Boeing 777-300 at Heathrow prior to passenger boarding with only the operating crew on board, a rear hold fire warning was annunciated and smoke and fumes subsequently entered the passenger cabin. The Investigation found that the source was a refrigerated container which had been subject to abnormal external impact prior to or during loading causing a short circuit in its battery pack. The refrigeration system involved was found by design to inhibit fire following a short circuit but it was noted that QRH response procedures did not apply to the circumstances.
On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.
On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.
On 15 December 2015, a Boeing 737-300 crew inadvertently taxied their aircraft off the side of the taxiway into a ditch whilst en route to the gate after landing at Nashville in normal night visibility. Substantial damage was caused to the aircraft after collapse of the nose landing gear and some passengers sustained minor injuries during a subsequent cabin crew-initiated evacuation. The Investigation found that taxiing had continued when it became difficult to see the taxiway ahead in the presence of apron lighting glare after all centreline and edge lighting in that area had been inadvertently switched off by ATC.
Slide Malfunction
On 18 November 2022, the crew of an Airbus A320neo about to become airborne as it departed Lima were unable to avoid a high-speed collision with an airport fire appliance, which unexpectedly entered the runway. The impact wrecked the vehicle, killing two of its three occupants, and a resultant fuel-fed fire severely damaged the aircraft, although with no fatalities amongst its 107 occupants. The vehicle was found to have entered the runway without clearance primarily as a consequence of inadequate briefing for an exercise to validate emergency access times from a newly relocated airport fire station.
On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.
On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.
On 24 January 2005, an Atlas Air Boeing 747-200F overran the end of the landing runway at Düsseldorf after runway braking action notified just prior to landing as medium due to snowfall unexpectedly deteriorated after the snowfall intensified. The overrun led to collision with ground obstacles and engines 2 and 3 caught fire. Escape slide malfunction at the forward left hand door led to an alternative non standard crew evacuation route being used. Significant damage to the aircraft resulted in it being declared a hull loss. The Investigation took almost 8 years to complete and publish.
On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.
RFFS Hazard to Evacuees
On 17 February 2025 a Mitsubishi (formerly Bombardier) CRJ-900LR was on final approach to Toronto International and touched down at a high rate of descent on the right main landing gear, which collapsed inwards. This caused the right wing to break from the fuselage, which then rolled inverted, detaching the tailplane. The fuselage slid for some distance before stopping, complicating the evacuation. A fuel-fed fire immediately ignited around the right wing/fuselage attachment point but all 80 occupants escaped, almost all using just two exits. There were only two serious injuries and 19 minor injuries.
On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.
On 8 September 2015, a catastrophic uncontained failure of a GE90-85B engine on a Boeing 777-200 taking off from Las Vegas was immediately followed by a rejected takeoff. A fuel-fed fire took hold and a successful emergency evacuation was completed. The Investigation traced the failure to a fatigue crack in the high pressure compressor well within the manufacturer s estimated crack initiation life and appropriate revisions to risk management have followed. The main operational risk concern of the Investigation was the absence of any procedural distinction in crew emergency responses for engine fires beginning in the air or on the ground.
RFFS Procedures
On 22 July 2020, a Boeing 777F main deck cargo fire warning was annunciated as the aircraft was preparing for departure from Shanghai. Fire service was requested and a MAYDAY declared to expedite this. All crew evacuated as the main deck cargo main door was being opened. Smoke appeared immediately and flames followed. The fire took almost three hours to extinguish and resulted in major damage. The investigation concluded that the fire had resulted from spontaneous ignition of a shipment of chlorine disinfection tablets loaded as undeclared dangerous goods, due a combination of high ambient humidity and temperature.
On 2 February 2013, an ATR 72-500 bounced repeatedly when making a night landing at Rome Fiumicino which, in the presence of dual control inputs causing a pitch disconnect, resulted in complete detachment of the landing gear and a veer off before stopping. The accident was attributed to uncharacteristic mishandling by the type experienced Captain in the presence of ineffective crew resource management because of an extremely steep authority gradient resulting from a very significant difference in flight time on the aircraft type (9607 hours / 14 hours). The Investigation attributed an unacceptable delay in the rescue services’ response to managerial incompetence.
On 24 April 2019, the engine of a Beech B200 en-route from Winnipeg to Churchill at FL 250 failed due to fuel exhaustion and the crew realised that they had forgotten to refuel before departure. An emergency was declared and a diversion to the nearest available airport was commenced but the right engine later failed for the same reason leaving them with no option but to land on a frozen lake surface. The Investigation concluded that confusion as to relative responsibility between the trainee Captain and the supervising pilot-in-command were central to the failure to refuel prior to departure as intended.
On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an Airbus A319 taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.
On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.
Cabin Baggage Issues
On 15 December 2019, an Airbus A330-200 turned back to Sydney shortly after departure when a major hydraulic system leak was annunciated. The return was uneventful until engine shutdown after clearing the runway following which APU use for air conditioning was followed by a gradual build up of hydraulic haze and fumes which eventually prompted an emergency evacuation. The Investigation found that fluid leaking from ruptured rudder servo hose had entered the APU air intake. The resulting evacuation was found to have been somewhat disorganised with this being attributed mainly to a combination of inadequate cabin crew procedures and training.
On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.
On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an Airbus A319 taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.
On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.
On 24 May 2013 the fan cowl doors on both engines of an Airbus A319 detached as it took off from London Heathrow. Their un-latched status after a routine maintenance input had gone undetected. Extensive structural and system damage resulted and a fire which could not be extinguished until the aircraft was back on the ground began in one engine. Many previously-recorded cases of fan cowl door loss were noted but none involving such significant collateral damage. Safety Recommendations were made on aircraft type certification in general, A320-family aircraft modification, maintenance fatigue risk management and aircrew procedures and training.
Airport Emergency Medical Response
On 13 July 2018, a Boeing 737-800 cruising at FL370 at night experienced a sudden rapid depressurisation. An emergency descent to FL 090 followed but the cabin altitude was not manually controlled and after the cabin pressure had risen to that equivalent to 7000 feet below sea level, immediate equalisation of cabin and actual altitudes resulted in a second sudden depressurisation. Diversion to Frankfurt Hahn was completed without further event. The first depressurisation had resulted from a transient and rare pressure controller malfunction but passenger injuries were considered attributable to a complete absence of pressurisation control during the emergency descent.
On 13 September 2017, the airspeed of a Boeing 737-800 unexpectedly increased during an intentionally high speed descent and the Captain’s overspeed prevention response, which followed his taking over control without following the applicable procedure, was inappropriate and led directly to cabin crew injuries, one of which was serious. The Investigation found that the speed increase had been the result of a sudden decrease in tailwind component associated with windshear and noted that despite moderate clear air turbulence being forecast for the area, this had not resulted in the seat belt signs being on or any consequent cabin crew briefing.
On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.
On 28 September 2012, control of a Sita Air Dornier 228 being flown by an experienced pilot was lost at approximately 100 feet aal after take off from Kathmandu in benign daylight weather conditions and the aircraft stalled without obvious attempt at recovery before impacting the ground where a fire broke out. All occupants were killed and the aircraft was destroyed. The comprehensive investigation found that insufficient engine thrust was being delivered to sustain flight but, having eliminated engine bird ingestion and aircraft loading issues, was unable to establish any environmental, airworthiness or loading issue which might have caused this.
On 16 September 2007, an MD-82 being operated by One Two Go Airlines attempted a missed approach from close to the runway at Phuket but after the flight crew failed to ensure that the necessary engine thrust was applied, the aircraft failed to establish a climb and after control was lost, the aircraft impacted the ground within the airport perimeter and was destroyed by the impact and a subsequent fire. Ninety of the 130 occupants were killed, 26 suffered serious injuries and 14 suffered minor injuries.
MAYDAY declaration
On 5 December 2019, the first officer of a Cessna 208 on a scheduled Indonesian domestic passenger flight close to Timor-Leste became physically ill during normal unpressurised cruise at 10,000 feet during conversation about a family health issue. When he briefly lost consciousness, the captain declared a MAYDAY and diverted to Dili. The first officer recovered and when hospital checks were passed, the flight to the intended destination was completed. An in-depth medical investigation found no evidence of physical illness and concluded that unmanaged emotional stress had led to hyperventilation followed by a temporary incapacitation.
On 23 July 2024, an ATR 42-600 was en route at FL180 when a contained failure of the left engine occurred. Despite a successful engine shutdown, fire occurred within the engine due to a fuel leak which may have been caused by a fuel line loosened when the engine failure happened. Both left engine fire bottles were required to extinguish the fire. With a MAYDAY declared, diversion to the nearest suitable airport, Aberdeen, was made. The engine failure resulted from undetected damage to its number six bearing which resulted in the high-pressure turbine no longer being correctly located.
On 29 July 2024, a Piper PA46 Malibu making an eastbound transatlantic flight via Narsarsuaq was descending southwest of the airport when the engine failed. A successful ditching occurred, and the two occupants evacuated into a life raft. Rescue occurred without significant delay due to the fortuitous presence of military airborne and marine assets in the vicinity. The cause of the engine failure could not be determined but there was no evidence that it could have been foreseen prior to flight. Proper continuing airworthiness-related actions had been taken ahead of the flight departure.
On 20 October 2020, the crew of a Sikorsky S92A en route overwater to an offshore oilfield southwest of Stavanger received an engine 1 fire warning. They responded by shutting down the engine, deploying both fire extinguishing bottles, and eventually declaring a MAYDAY without taking all recommended steps to confirm an actual fire existed. They were aware that false engine fire warnings on this helicopter type had become a fairly regular occurrence, and when the warning persisted, they restarted the engine which ran normally. The flight was completed and made an uneventful landing on a platform close to the originally planned destination.
On 21 December 2023 a Boeing 787-8 crew inbound to Manchester on a day of significant weather-related flight disruption over northern England decided to divert to their nominated alternate East Midlands. When a landing there was denied, the flight proceeded to the nearest available alternate, Birmingham. After a windshear-related missed approach and subsequent low fuel MAYDAY declaration, a second approach led to a successful landing but with significant use of final reserve fuel. The operators of East Midlands and Birmingham airports subsequently revised their procedures for determining and communicating capacity for diversions and prioritising flights declaring low-fuel emergencies.
PAN declaration
On 21 July 2022, one minute after takeoff from Surabaya, an Airbus A320 first officer acting as pilot flying (PF) saw that the captain was “in a rigid position." A medically qualified passenger was identified but could not find signs of life. A ‘PAN’ was declared and a return to land requested but due to resuscitation attempts, it was over 40 minutes before a landing occurred. The captain was subsequently confirmed deceased. The captain’s most recent medical examination was found not to have included a sufficiently in-depth assessment of his ongoing vascular risk factors before renewal of his medical certification.
On 23 July 2024, an ATR 42-600 was en route at FL180 when a contained failure of the left engine occurred. Despite a successful engine shutdown, fire occurred within the engine due to a fuel leak which may have been caused by a fuel line loosened when the engine failure happened. Both left engine fire bottles were required to extinguish the fire. With a MAYDAY declared, diversion to the nearest suitable airport, Aberdeen, was made. The engine failure resulted from undetected damage to its number six bearing which resulted in the high-pressure turbine no longer being correctly located.
On 29 July 2024, a Piper PA46 Malibu making an eastbound transatlantic flight via Narsarsuaq was descending southwest of the airport when the engine failed. A successful ditching occurred, and the two occupants evacuated into a life raft. Rescue occurred without significant delay due to the fortuitous presence of military airborne and marine assets in the vicinity. The cause of the engine failure could not be determined but there was no evidence that it could have been foreseen prior to flight. Proper continuing airworthiness-related actions had been taken ahead of the flight departure.
On 25 October 2021, a Boeing 737-800 had just reached its cruise altitude after takeoff from Perth, Australia, when a fuel imbalance message was displayed. Despite specified indications for a fuel leak as the cause of this message not being met, it was determined that the left engine should be shut down. A ‘PAN’ was declared and a diversion to Kalgoorlie completed. Inspection there found the fuel imbalance was within normal limits and that crew diagnosis of a fuel leak had been flawed. Non-standard closure of the crossfeed valve was suspected as the origin of the imbalance.
On 17 January 2022, about 30 minutes after takeoff from Fort-de-France, Martinique, on an Extended Operations (ETOPS) flight, an Airbus A330-900 was approaching its initial cruise altitude when the apparently unconscious captain appeared initially unresponsive. On being more aggressively roused, he seemed normal, and a doctor on board initially assessed him as fit to continue. However, about two hours into the flight, his condition subsequently deteriorated. The first officer called the chief purser to take his seat to assist. A PAN, later upgraded to a MAYDAY, was declared and a diversion was made to the Azores where the captain was hospitalised.
“Emergency” declaration
On 17 February 2024, an Airbus A321 captain was initially unable to re-enter the flight deck after a short absence in cruise. On succeeding, he discovered that the first officer had become incapacitated with what ICAO classifies as a ‘seizure disorder,’ which was subsequently found to have occurred almost immediately after the captain had left. Once back on the flight deck, an emergency was declared with immediate diversion to Madrid Barajas where the first officer was hospitalised. A safety recommendation to consider further assessment of the risks of one pilot being alone on a secured flight deck was made.
On 18 December 2022, an Airbus A330-200 in cruise at FL400 in visual meteorological conditions (VMC) was flown through the isolated top of a building convective cloud after its vertical development rate was underestimated. A short but severe turbulence upset and brief loss of control resulted. A few minutes earlier air traffic control (ATC) had advised that “moderate to extreme precipitation and turbulence could be expected for the next 40 miles." Cabin service was in progress, and the turbulence resulted in 24 unsecured cabin crew and passengers being injured, four seriously. Some cabin trim detached and some equipment was damaged.
On 6 April 2022, a Boeing 767-300 lost left engine oil pressure whilst eastbound and passing south of Cork, Ireland. The aircraft diverted to Shannon after declaring an emergency due to intended engine shutdown. During the subsequent taxi in, a brake fire was observed and extinguished. The aircraft was towed to the terminal after an initial fire service request for evacuation had been withdrawn. An engine oil leak from a chip detector, which had been routinely inspected by a company engineer prior to departure but not reinstalled correctly, was found to have caused the leak and thus the loss of oil pressure.
On 8 February 2022, a Boeing 767-300ER inbound to Madrid at FL340 experienced a failure of automatic pressurisation control, followed almost three hours later by a failure of manual control and rapidly rising cabin altitude. An emergency was declared and descent made to FL120 where manual control was regained. The flight was completed without recurrence. The failure cause was found to have been water leaking from a tube with a broken clamp which, when it froze, had blocked the air conditioning outflow valve doors. Elements of the system design, scheduled maintenance requirements, and fault detection were identified as contributing factors.
On 19 November 2022, an Airbus A320 was descending below 13,000 feet towards its destination of Omaha, clear of clouds at night and at 290 knots, when an explosive decompression occurred as a result of bird strike damage. An emergency was declared, and once on the ground, three locations where the fuselage skin had been broken open were discovered. The structural damage was assessed as substantial, and the aircraft was withdrawn from service for major repairs. The birds involved were identified by DNA analysis as migrating Snow or Ross’s Geese, the former of which can weigh up to 2.6kg.
Delay in Declaration of Emergency
On 1 June 2019, a Boeing 787-8 lost all cabin air conditioning after both packs failed less than an hour from its destination, Narita. When the Cabin Altitude reached 10,000 feet, the descent already commenced was completed as an emergency descent and the flight thereafter was without further event. The Investigation found that although an amended non normal procedure restricting pack resets to a maximum altitude of 35000 feet had been issued almost two months earlier, it was still “under review” at the operator which has since amended their procedures for assessing manufacturer communications which have operational safety implications.
On 5 March 2011, a Finnair Airbus A320 was westbound in the cruise in southern Swedish airspace after despatch with Engine 1 bleed air system inoperative when the Engine 2 bleed air system failed and an emergency descent was necessary. The Investigation found that the Engine 2 system had shut down due to overheating and that access to proactive and reactive procedures related to operations with only a single bleed air system available were deficient. The crew failure to make use of APU air to help sustain cabin pressurisation during flight completion was noted.
On 29 November 2016, a BAe Avro RJ85 failed to complete its night charter flight to Medellín (Rionegro) when all engines stopped due to fuel exhaustion and it crashed in mountainous terrain 10 nm from its intended destination killing almost all occupants. The Investigation noted the complete disregard by the aircraft commander of procedures essential for safe flight by knowingly departing with significantly less fuel onboard than required for the intended flight and with no apparent intention to refuel en route. It found that this situation arose in a context of a generally unsafe operation subject to inadequate regulatory oversight.
On 3 June 2012, the crew of a Boeing MD-83 experienced problems in controlling the thrust from first one engine and then also the other which dramatically reduced the amount of thrust available. Eventually, when a few miles from destination Lagos, it became apparent that it would be impossible to reach the runway and the aircraft crashed in a residential district killing all 153 occupants and 6 people on the ground. The Investigation was unable to conclusively identify the cause of the engine malfunctions but attributed the accident outcome to the crew's failure to make a timely diversion to an alternative airport.
On 6 November 2015, a Boeing 737-900 overran the 2,200 metre-long landing runway at Yogyakarta after a tailwind approach with airspeed significantly above the applicable Vref followed by a long landing on a wet runway without optimum use of deceleration devices. The flight crew management of the situation once the aircraft had come to a stop was contrary to procedures in a number of important respects. The aircraft operator took extensive action to improve crew performance following the event. The Investigation found significant fault with the airport operator's awareness of runway surface condition and an absence of related significant risk management.
Evacuation difficulties in Water
On 3 May 2019, a Boeing 737-800 significantly overran the wet landing runway at Jacksonville Naval Air Station at night when braking action was less than expected and ended up in shallow tidal water. The Investigation found that although the approach involved had been unstabilised and made with a significant tailwind and with only a single thrust reverser available, these factors had not been the cause of the overrun which was entirely attributable to attempting to complete a landing after touching down on a wet runway during heavy rain in conditions which then led to viscous aquaplaning.
On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.
On 22 October 2009, a BN2 Islander suspected to have been overloaded experienced an engine failure shortly after departure from Curaçao. Rather than return, the Pilot chose to continue the flight to the intended destination but had to carry out a ditching when it proved impossible to maintain height. All passengers survived but the Pilot died. The cause of the engine failure could not be established but the Investigation found a context for the accident which had constituted systemic failure by the Operator to deliver operational safety which had been ignored by an inadequate regulatory oversight regime.
On 23 August 2013, the crew of a Eurocopter AS332 L2 Super Puma helicopter making a non-precision approach to runway 09 at Sumburgh with the AP engaged in 3-axes mode descended below MDA without visual reference and after exposing the helicopter to vortex ring conditions were unable to prevent a sudden onset high rate of descent followed by sea surface impact and rapid inversion of the floating helicopter. Four of the 18 occupants died and three were seriously injured. The Investigation found no evidence of contributory technical failure and attributed the accident to inappropriate flight path control by the crew.
On 13 January 1982, an Air Florida Boeing 737-200 took off in daylight from runway 36 at Washington National in moderate snow but then stalled before hitting a bridge and vehicles and continuing into the river below after just one minute of flight killing most of the occupants and some people on the ground. The accident was attributed entirely to a combination of the actions and inactions of the crew in relation to the prevailing adverse weather conditions and, crucially, to the failure to select engine anti ice on which led to over reading of actual engine thrust.
Uncontrolled Water Impact
On 14 March 2017, control of a Sikorsky S92A positioning in very poor visibility at 200 feet over the sea in accordance with an obstacle-marked FMS ground track in order to refuel at a coastally-located helipad was lost after it collided with late-sighted terrain ahead before crashing into the sea killing all on board. The Investigation attributed the accident to the lack of crew terrain awareness but found a context of inadequate safety management at the operator, the comprehensively ineffective regulatory oversight of the operation and confusion as to responsibility for State oversight of its contract with the operator.
On 9 July 2018, an ATR 72-600 continued a non-precision approach to Al Hoceima below the procedure MDA without obtaining visual reference and subsequently struck the sea surface twice, both times with a vertical acceleration exceeding structural limits before successfully climbing away and diverting to Nador having reported a bird strike. The Investigation attributed the accident to the Captain’s repeated violation of operating procedures which included another descent below MDA without visual reference the same day and the intentional deactivation of the EGPWS without valid cause. There was significant fuselage structure and landing gear damage but no occupant injuries.
On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John's, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.
On 29 June 2009, an Airbus A310-300 making a dark-night visual circling approach to Moroni crashed into the sea and was destroyed. The Investigation found that the final impact had occurred with the aircraft stalled and in the absence of appropriate prior recovery actions and that this had been immediately preceded by two separate GWPS 'PULL UP' events. It was concluded that the attempted circling procedure had been highly unstable with the crew's inappropriate actions and inactions probably attributable to their becoming progressively overwhelmed by successive warnings and alerts caused by their poor management of the aircraft's flight path.
On 19 October 2013, an ATR42 freighter departing Madang had to reject its takeoff when it was impossible to rotate and it ended up semi-submerged in a shallow creek beyond the airfield perimeter. The Investigation found that loading had been contrary to instructions and the aircraft had a centre of gravity outside the permitted range and was overweight. This was attributed to the aircraft operator s lack of adequate procedures for acceptance and loading of cargo. A lack of appreciation by all parties of the need to effectively mitigate runway overrun risk in the absence of a RESA was also highlighted.
Fuel Status
On 21 December 2023 a Boeing 787-8 crew inbound to Manchester on a day of significant weather-related flight disruption over northern England decided to divert to their nominated alternate East Midlands. When a landing there was denied, the flight proceeded to the nearest available alternate, Birmingham. After a windshear-related missed approach and subsequent low fuel MAYDAY declaration, a second approach led to a successful landing but with significant use of final reserve fuel. The operators of East Midlands and Birmingham airports subsequently revised their procedures for determining and communicating capacity for diversions and prioritising flights declaring low-fuel emergencies.
On 17 October 2022, an Airbus A320neo was unable to make an approach at either its intended destination of Riohacha or its designated alternate after those airports were both closed because of convective weather which developed over a significant part of Northern Columbia. A MAYDAY was declared due to low fuel and only 282 kg remained after the eventual landing at Santa Marta. Decision-making by both the aircraft operator and the flight crew and a lack of reliable communication between them was deemed contributory to what came very close to becoming a hull loss accident.
On 27 August 2023, a Boeing 737-800 was subjected to significant ATC delay whilst en route from Glasgow to Palma de Mallorca after adverse weather affected all three Balearic Islands. After multiple ATC errors, a MAYDAY was declared for low fuel before a landing with less than Final Reserve Fuel despite extra fuel having been carried. Confused ATC flight handling in both French and Spanish airspace was attributed to an excessive workload, which resulted in no pre-tactical measures taken and subsequent errors in the implementation of the tactical response, which then led to use of reserve fuel.
On 29 November 2021, the crew of a Bombardier CRJ900 (C-GJZV) which had just taken off from San Diego at night were presented with a fuel imbalance indication. The imbalance slowly increased until, once level at FL340, a further annunciation indicated that the maximum permitted imbalance had been reached. Actioning the corresponding checklist did not resolve the problem, so procedurally recommended shutdown of the low fuel side engine was performed, followed by a MAYDAY diversion to Los Angeles. The imbalance was attributed to inadvertent crew selection of ‘gravity crossflow’ prior to takeoff instead of the immediately adjacent ‘crossflow auto override.'
On 21 December 2023, a Boeing 737-800 experienced a flap load protection response to turbulence during a night go-around at Billund, which locked the flaps in a mid-range position. A diversion to Copenhagen was commenced, but when it became clear that the fault would result in landing with slightly below minimum reserve fuel, a MAYDAY was declared. The flight was completed without further event. It was concluded that flap system locking had probably resulted from the crew’s manual selection of 15° flap just as the flap load relief system was responding, as designed, to a turbulence-caused flap overspeed condition.
Ballistic Recovery System Status
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Aircraft/ATC comms difficulties
On 8 July 2018, a Boeing 737-800 discontinued three consecutive approaches at its intended destination Toyama because, despite unexceptional weather conditions, it was in each case, impossible to achieve or continue a stabilised approach within the operator s applicable criteria. Diversion to the designated alternate was then commenced with just sufficient fuel to reach it without using final reserve fuel. However, en-route the crew became concerned at their fuel status and ATC initially had difficulty receiving their emergency communications resulting in a MAYDAY declaration. An expedited routing then followed with a landing which just avoided the use of final reserve fuel.
On 10 June 1990, a BAC One-Eleven climbing through FL173 suddenly lost its left windscreen when the increasing cabin differential pressure overcame undersized securing bolts. The captain was sucked almost completely out of the resulting aperture and was restrained by cabin crew whilst the first officer declared a MAYDAY and diverted to Southampton. Only on the ground was it possible to recover the seriously injured captain into the flight deck. The flight was the first since the windscreen had been replaced, and the maintenance error involved was attributed to systemic failures in maintenance practices and their oversight.
ATC internal comms difficulties
none on SKYbrary
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