What happened
On 21 December 2016, an ATR 72-2 and12 A, registration G-COBO, was conducting a scheduled passenger flight from Guernsey to Manchester. During the climb, the aircraft entered a weather front and began accumulating airframe ice. As the aircraft climbed, the crew received 'degraded performance' and 'increase speed' caution messages from the Aircraft Performance Monitoring system.
In an effort to climb above the cloud layer, the crew did not fully execute the required checklists. Instead, they varied the airspeed between the minimum icing speed and the recommended safety margin. While attempting to level off at FL130 and initiating a turn via the lnav mode, the aircraft experienced a severe upset. The aircraft rolled as much as 73 degrees and pitched nose-down by 16 degrees, triggering the stick shaker and stick pusher. The crew managed to recover the aircraft to controlled flight and subsequently declared a MAYDAY, returning to Guernsey for an uneventful landing. There were no injuries among the 61 passengers and 4 crew members.
The investigation
The AAIB investigation examined the aircraft's flight data, cockpit voice recordings, and the crew's response to the icing conditions. The investigation looked into the functionality of the Aircraft Performance Monitoring (APM) system, noting that recent technical logs had recorded reports of spurious warnings on this specific aircraft. The investigators also reviewed the manufacturer's Quick Reference Handbook (QRH) procedures and the crew's training regarding icing encounters.
Findings
- The aircraft encountered significant airframe icing while climbing through a frontal weather system.
- The crew focused on climbing out of the icing conditions rather than following the prescribed 'DEGRADED PERF' and 'SEVERE ICING' checklists.
- The crew failed to maintain the required minimum speed of red bug +10 kt, which increased the risk of a loss of control.
- The transition to lnav mode for the turn deactivated high bank protection, contributing to the upset.
- A lack of confidence in the APM system, due to previous reports of spurious warnings, may have led the commander to partially disregard the caution messages.