Emergency landing after bird strike Boeing 737-4B6, Amsterdam Schiphol Airport, 6 June 2010

152 Pages·2011·7.55 MB·English

Emergency landing after bird strike
Boeing 737-4B6, Amsterdam Schiphol Airport,
E 6 June 2010
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Emergency landing after bird strike
Boeing 737-4B6, Amsterdam Schiphol Airport,
6 June 2010
The Hague, November 2011 (project number 2010034)
The Dutch Safety Board’s reports are in the public domain. All reports are also available through
The Dutch Safety Board’s website: www.safetyboard.nl
THE DUTCH SAFETY BOARD
The aim in the Netherlands is to reduce the risk of accidents and incidents as much as possible. If
accidents or near-accidents nevertheless occur, a thorough investigation into the causes of the
problem, irrespective of who is to blame for it, may help to prevent similar problems from occurring
in the future. It is important to ensure that the investigation is carried out independently from the
parties involved. This is why the Dutch Safety Board itself selects the issues it wishes to investigate,
mindful of citizens’ position of dependence with respect to public authorities and businesses.
Dutch Safety Board Guidance committee
Chairman: T.H.J. Joustra Chairman: F.J.H. Mertens
A. Brouwer-Korf A.H. Brouwer-Korf
F.J.H. Mertens E.J. Burmeister
J.P. Visser J. Marijnen
E.R. Muller J.A. Mulder
H. Munniks de Jongh Luchsinger
J.G.W. van Ruitenbeek
General secretary: M. Visser
Project Manager: K.E. Beumkes
Visiting address: Anna van Saksenlaan 50 Correspondence PO Box 95404
2593 HT The Hague, address: 2509 CK The Hague
The Netherlands
Telephone: [phone] Fax: [phone]
Internet: www.safetyboard.nl
This report is published in Dutch and English. In the event of any difference in interpretation the
Dutch text must be regarded as binding.
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TABLE OF CONTENTS
Consideration ...................................................................................................................5
LIST OF ABBREVIATIONS .................................................................................................9
1. Introduction .............................................................................................................11
1.1 Grounds ..............................................................................................................11
1.2 The investigation ..................................................................................................11
1.3 Reading guide ......................................................................................................12
2. Factual information ..................................................................................................13
2.1 Introduction .........................................................................................................13
2.2 Important terms and concepts ...............................................................................13
2.3 History of the flight ...............................................................................................16
2.4 Injuries to persons ................................................................................................21
2.5 Damage to the aircraft ..........................................................................................21
2.6 Other damage ......................................................................................................21
2.7 Personnel information ...........................................................................................22
2.8 Aircraft information...............................................................................................23
2.9 Meteorological information .....................................................................................23
2.10 Aids to navigation .................................................................................................23
2.11 Communications ...................................................................................................24
2.12 Aerodrome information .........................................................................................24
2.13 Flight recorders ....................................................................................................25
2.14 Medical and pathological information .......................................................................26
2.15 Fire .....................................................................................................................26
2.16 Survival aspects ...................................................................................................26
2.17 Tests and research ...............................................................................................26
2.18 Organizational and management information ...........................................................27
2.19 Additional information ..........................................................................................28
3. Parties and their responsibilities ..............................................................................30
3.1 Crew flight RAM685R ............................................................................................30
3.2 Atlas Blue ............................................................................................................30
3.3 Royal Air Maroc ....................................................................................................30
3.4 Ministry of Transport (Morocco) ..............................................................................31
3.5 Boeing ................................................................................................................31
3.6 CFM International .................................................................................................31
3.7 Federal Aviation Administration .............................................................................31
3.8 European Aviation Safety Agency ...........................................................................31
3.9 Amsterdam Airport Schiphol ..................................................................................32
3.10 Ministry of Infrastructure and the Environment ........................................................32
3.11 Air Traffic Control the Netherlands ..........................................................................33
3.12 Noord-Holland Fauna Management Unit ...................................................................33
3.13 Fauna fund ..........................................................................................................34
3.14 Municipality of Haarlemmermeer ............................................................................34
3.15 Ministry of Economic Affairs, Agriculture and Innovation ............................................34
3.16 Provincial government of Noord-Holland ..................................................................35
3.17 Game Management Unit ........................................................................................35
3.18 Aircraft Bird Strike Committee ..............................................................................36
3.19 Landscape Noord-Holland ......................................................................................36
3.20 Federation of Agriculture and Horticulture Noord ......................................................37
3.21 Society for the Preservation of Nature .....................................................................37
3.22 Dutch Bird Strike Control group ..............................................................................37
3.23 Schiphol Goose Roundtable ....................................................................................37
3.24 Schiphol Safety Platform and Schiphol Bird Strike Committee ....................................38
3.25 The Netherlands Society for the Protection of Birds...................................................38
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4. Analysis ....................................................................................................................39
4.1 Introduction .........................................................................................................39
4.2 Flight operation ....................................................................................................39
4.3 Engines ...............................................................................................................46
4.4 Aircraft bird deterring systems ...............................................................................47
4.5 Investigation of follow-up to recommendation by the Parliamentary Board of Inquiry ....48
4.6 Flying low over a built-up area in an emergency situation ..........................................52
4.7 Bird control at and around Schiphol airport .............................................................54
4.8 Measures taken after the serious incident ...............................................................60
5. Conclusions ..............................................................................................................62
6. Recommendations ....................................................................................................64
APPENDIX A: INVESTIGATION EXPLANATION ...............................................................65
APPENDIX B: COMMENTS PARTIES INVOLVED ...............................................................67
APPENDIX C: ENGINES - GENERAL .................................................................................76
APPENDIX D: BIRD CONTROL AMSTERDAM AIRPORT SCHIPHOL ..................................78
APPENDIX E: FLIGHT DATA RECORDER DATA ROYAL AIR MAROC FLIGHT RAM685R ......81
APPENDIX F: INVESTIGATION INTO BIRD CONTOL AT AND AROUND SCHIPHOL ...........82
APPENDIX G: BIRD INGESTION PROTECTION DEVICES FOR ENGINES ........................131
APPENDIX H: FRAME OF REFERENCE ..........................................................................132
APPENDIX I: GENERAL CREW RESOURCE MANAGEMENT STANDARDS .........................148
APPENDIX J: CERTIFICATION REQUIREMENTS - ENGINES ..........................................150
APPENDIX K: MAIN POINTS OF THE 3PR INVESTIGATION ..........................................152
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CONSIDERATION
In the evening of 6 June 2010, a Royal Air Maroc Boeing 737-4B6 encountered a bird strike at
Amsterdam Airport Schiphol. The Dutch Safety Board has conducted an investigation into this
serious incident and its consequences. This report contains the results of that investigation.
The Boeing 737-4B6 is a two-engine civil aircraft. There were six crew members and 156 passengers
on board. The flight was executed by a cockpit crew from Atlas Blue, an airline owned by Royal Air
Maroc.1
During the take-off from runway 18L, the aircraft collided with multiple Canada geese at a height of
approximately 16 feet. The left engine was severely damaged as a result, with thrust reduced to
approximately 45%. The nose gear indication was also “unsafe” as the landing gear was being
retracted. The crew decided to return to Schiphol airport immediately. The crew made a mayday
call and requested assistance from air traffic control. The aircraft’s climb capability was limited as
a result of the bird strike. The aircraft flew over the built-up area around Vijfhuizen, Haarlem and
Amsterdam’s western harbour area at a low altitude. A safe landing was then executed on runway
18R. Nobody on the aircraft was harmed.
The Safety Board’s investigation focuses on the following aspects:
1. the crew’s response to the engine failure;
2. aircraft flying over the built-up area around Schiphol at a low altitude during emergencies;
3. the problem of birds and bird strikes at and around Schiphol airport.
1. The crew’s response to the engine failure
After the bird strike had taken place, the crew made the correct decision and returned to Schiphol
airport. The bird strike resulted in a multiple failure: thrust loss in the left engine and an “unsafe”
indication for the nose gear.
However, the decision to return was not executed in accordance with commonly applied standard
operations procedures as defined in the operations manual used by Atlas Blue and Royal Air Maroc.
The crew diverged from these procedures in the following respects:
• instead of climbing straight ahead to the designated ‘clean up’ altitude with retracted landing
gear, the aircraft made a right turn with a bank angle of up to 37.5 degrees at an altitude of 280
feet;
• the landing gear was extended after having been retracted during take-off;
• the crew reduced the thrust of the undamaged right engine instead of utilising its maximum
thrust.
As a result, the aircraft had a limited rate of climb and could not reach the necessary safe altitude.
Communication and crew resource management between the crew members during the flight was
not in accordance with the internationally accepted standard for airline pilots. As a result of the
immediate right turn and limited rate of climb, the crew members were under increased pressure
as the autopilot may not be engaged at altitudes below 1000 feet. The pilots had to look outside to
identify obstacles. The crew was also forced to deal with complications such as (system) warnings
in the cockpit and an unstable flight path (variable heading, altitude, flight speed and rate of climb).
As a result, both pilots did not carry out their tasks - such as the execution of (follow-up) procedures
and completion of checklists – according to procedure. This caused an increased risk to the aircraft,
its occupants and the surrounding area.
1 Atlas Blue merged with Royal Air Maroc on 1 March 2011.
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2. Aircraft flying over the built-up area around Schiphol at a low altitude during emergencies
According to the outcome of an investigation by Air Traffic Control the Netherlands in response to
the 1992 aircraft disaster in Amsterdam Bijlmermeer, it is unfeasible to use ‘passageways’ through
unbuilt areas in view of the high density of the built-up area around Schiphol and the fact that civil
aircraft are difficult to manoeuvre as a result of their high flying speeds. Based on this conclusion,
Air Traffic Control the Netherlands determined that built-up areas should not be presented on the
radar screen. A decision was also made not to present all high obstacles on the radar screen.
Aircraft in distress must use existing runway arrival and departure routes where possible, since
these routes were selected to ensure an optimal balance between safety, efficiency and
environmental concerns, minimising flights over built-up areas.
Under extraordinary circumstances such as the Royal Air Maroc incident, Air Traffic Control the
Netherlands also applies the internationally recognised ‘assist principle’. According to this principle,
the captain is responsible for safe flight operation and the air traffic controller must support
decisions taken by the cockpit crew. In the interests of flight safety, Air Traffic Control is expected
to provide such support to the fullest possible extent.
As a result of the emergency situation, the crew diverted from the existing departure route and
flew over Vijfhuizen and Haarlem at an altitude of 380 to 480 feet. The route was within one
kilometre of a 479-foot tower located on the outskirts of Haarlem. The aircraft also flew close to
high obstacles (up to 587 feet) above Amsterdam’s western harbour area.
The Royal Air Maroc flight reached a maximum altitude of 730 feet. Flight altitudes were thus well
below the 1200 feet minimum vectoring altitude of the Schiphol control zone, which provides
obstacle clearance during air traffic control. As a result, the crew itself was responsible for avoiding
obstacles. Flight visibility was approximately seven kilometres at sunset, a distance within accepted
limits for visual meteorological conditions.
Air traffic controllers supported the crew during the flight by providing headings for the landing. No
information was provided regarding the presence of the aforementioned high obstacles, as these
obstacles were not presented on the air traffic controllers’ radar screen. Two other high obstacles
have been featured on the radar screen for several years, but they did not play any role in this
incident as they were not located along the aircraft’s flight path.
The fact that these high obstacles are not visible on air traffic control radar screens increases the
likelihood of collisions with a high obstacle when aircraft in distress are given headings while flying
below the minimum vectoring altitude.
3. The problem of birds and bird strikes at and around Schiphol airport
The number of birds in the area around Schiphol airport that represent a risk to flight safety has
almost doubled over the past ten years. This applies especially to the number of geese. The more
so the number of sightings of migrating geese increases each year. In 2010, the number of aircraft
taking off and landing at Schiphol airport remained the same as the number in 1998-1999. However,
the number of geese in 2010 was four to seven times as large as the number in 1998-1999. As a
result, the risk of bird strikes has increased significantly. In 2011, the number of aircraft take-offs
and landings is expected to rise by 5% in comparison with 2010. In view of the expected long-term
increase in the number of aircraft take-offs and landings, this risk will increase further if control
measures to reduce the number of birds in the area around Schiphol airport are not implemented
and intensified.
It has become clear that the parties responsible for managing the bird population at Schiphol
airport are taking every possible measure allowed within the current legislative framework.
Unfortunately, the measures needed to effectively control this bird population would have to be
taken largely outside of the airport grounds, where these parties have no statutory powers.
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There has been long-standing international and national agreement as to the required approach for
controlling the risk of bird strikes. This approach consists of four specific focus areas:
• Population reduction.
• Limiting the number of foraging areas in the airport’s surrounding area.
• Limiting the number of resting and breeding areas in the airport’s surrounding area.
• Technical measures aimed at enabling radar detection of birds and bird movements.
Although agreement has been reached on the aforementioned measures, our investigation showed
that as yet there is no agreement as to the exact level of danger these measures would help to
control. As a result, there are also differing views as to the implementation of these measures. This
especially applies to the question of which measures should be implemented in the short term.
Population reduction is now regarded as necessary and inevitable.
In order to ensure aviation safety, the risk of bird strikes will have to be considerably reduced as
soon as possible. In view of the fact that three of the four aforementioned focus areas will only
yield results over a longer time period, population reduction remains the only effective potential
measure in the short term. The Safety Board thus calls for vigorous implementation of this
measure. These problems affect all of the parties involved, and an effective response will require
centralised supervision from the Ministry of Infrastructure and the Environment, the body
responsible for aviation safety. This ministry is responsible for aviation safety and is thus effectively
the ‘problem owner’.
The Safety Board is aware of the public debate on goose population management in the Netherlands.
In part, this debate was sparked by the damage to agricultural plots and natural areas caused by
large goose populations. Current discussions partly revolve around a recommendation from seven
civil-society organisations, including various environmental organisations, united in the “Goose 7”
(Ganzen-7). The recommendation outlines several measures to reduce and stabilise the populations
of various species of geese in the Netherlands. However, the danger these geese pose to aviation
safety has played an insubstantial role in the social debate. Implementation of the recommendation
in the short term would help reduce the risk of bird strikes. Due to the high level of urgency
involved, there is no time to wait for the outcome of ongoing pilots to assess alternative control
measures. However, the development of more structural risk management measures, such as
limiting the number of foraging areas, developing technical measures to enable radar detection and
the scaring off of birds should also be intensified.
The Dutch Safety Board has formulated the following recommendations with regard to this serious
incident:
Royal Air Maroc
The Safety Board recommends that Royal Air Maroc demonstrate to the Moroccan Ministry of
Transport that:
1. the procedures for communication and crew resource management between crew members
have been harmonised with the international standard for airline pilots.
2. pilot training has been expanded to include simulations of multiple unexpected failures.
Air Traffic Control the Netherlands and the minister of Infrastructure and the Environment
The Safety Board recommends that Air Traffic Control the Netherlands and the minister of
Infrastructure and the Environment:
3. ensure that aircraft in distress flying under the minimum vectoring altitude are informed about
high obstacles in the Schiphol control zone.
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Minister of Infrastructure and the Environment
The Safety Board recommends that the minister of Infrastructure and the Environment, responsible
for aviation safety:
4. take proactive measures to ensure the minimisation of bird strike risks.
5. with the greatest possible urgency and vigour implement effective measures to reduce and
stabilise the population of various goose types in the Netherlands at a certain level in accordance
with the “Goose 7” recommendation in order to reduce the risk of bird strikes.
6. ensure that the interests of aviation safety are safeguarded within the various relevant policy
domains, by preparing enforceable emergency measures that allow for intervention if the risk
of bird strikes becomes too great.
7. conduct studies to assess the potential of technical measures to reduce the risk of bird strikes.
T.H.J. Joustra M. Visser
Chairman of the Dutch Safety Board General Secretary
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LIST OF ABBREVIATIONS
AAS Amsterdam Airport Schiphol [the organisation]
AIP Aeronautical Information Publication
AFM Aircraft Flight Manual
AGL Above Ground Level
AIS Aviation Information and Services
AMvB General Administrative Order
ATC Air Traffic Control
ATPL(A) Airline Transport Pilot Licence (Aeroplane)
BEA Bureau d’Enquêtes et d’Analyses (Authority responsible for investigations into civil
aviation accidents or incidents in France)
CAP Civil Aviation Publication (from the UK Civil Aviation Authority)
CFR Code of Federal Regulations (United States of America)
CRM Crew Resource Management
CSN Cycles Since New
CTR Control Zone
CVL Aircraft Bird Strike Committee (Commissie Vogelaanvaringen Luchtvaartuigen)
CVR Cockpit Voice Recorder
DEGAS Dutch Expert Group Aviation Safety
DGAC Directorate-General for civil aviation of a particular state
DGCA Directorate-General for civil aviation of a particular state
DGLM Directorate-General of Aviation and Maritime Affairs (Netherlands)
EASA European Aviation Safety Agency
ECAC European Civil Aviation Conference
EG European Community
EHAM Amsterdam Schiphol Airport
EU European Union
FAA Federal Aviation Administration (United States of America)
FAR Federal Aviation Regulations
FBE Fauna Management Unit (Faunabeheereenheid)
FCOM Flight Crew Operations Manual
FCTM Flight Crewe Training Manual
FDR Flight Data Recorder
FL Flight Level
GE General Electric company
GMMW Nador International Airport
GMT Greenwich Mean Time
GPWS Ground Proximity Warning System
HPC high-pressure compressor
HPT high-pressure turbine
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