What happened
On August 9, 2016, a Japan Coast Guard Agustawestland AW139, registered JA968A, was engaged in a sea rescue operation near Shichi-ga-hama Town, Miyagi Prefecture. Following the successful hoisting of two survivors from the water, the crew decided to land on a nearby sandy beach to deliver the rescued individuals to a ground team.
During the approach, the aircraft encountered challenging weather conditions, including strong winds and unpredictable downdrafts caused by a recent typhoon. As the aircraft descended to approximately 150 feet, an aural warning triggered to indicate the landing gear had not been extended. However, the captain silenced the warning to avoid distraction during the high-workload rescue phase. The aircraft subsequently touched down on the beach with the gear retracted, resulting in substantial damage to the fuselage bottom, outer skin panels, and various antennas.
The investigation
The Japan Transport Safety Board (JTSB) examined flight data, cockpit voice recordings, and crew statements to reconstruct the sequence of events. The investigation focused on the crew's workload, the execution of flight procedures, and the effectiveness of Crew Resource Management (CRM) during the mission. Investigators also reviewed the aircraft's mechanical condition and the environmental factors present at the time of the landing.
Findings
- The captain failed to perform the required before-landing checklist due to a high concentration of simultaneous tasks, including managing the aircraft through heavy downdrafts and coordinating the delivery of survivors.
- The captain's mental focus remained on the rescue operation, leaving insufficient time to transition to standard landing procedures.
- The co-pilot was primarily focused on monitoring engine torque to prevent overtorque conditions and did not initiate or verify the landing gear status.
- The landing gear was not extended because the crew failed to carry out the necessary checks prescribed in the flight manual.
- Effective Crew Resource Management (CRM) was compromised as each crew member was preoccupied with their specific assigned duties, preventing the necessary coordination to catch the oversight.