Potential Stall Occurs During Return to Perth Following De-ice System Fault

No fatalities • 30.7 km south-west of Perth Airport, Western Australia

A flight crew's decision to return to Perth due to a de-ice system malfunction led to a period of unnoticed airspeed decay and a near-stall event.

What happened

Following departure from Perth, the flight crew identified a fault within the de-ice system. This malfunction was likely caused by the delamination of a de-ice boot on the underside of the right wing, which failed during its inflation cycle just before the aircraft entered forecasted icing conditions. Due to the low freezing level and the presence of icing along the route, the crew elected to return to Perth.

During the maneuver to return to the airport, the crew reduced engine power to descend from 7,000 ft to 5,000 ft. Upon reaching the target altitude of 5,000 ft, the engine power was not increased. As a result, the aircraft's airspeed continued to decay. The autopilot attempted to maintain the 5,000 ft altitude by pitching the nose upward, which further increased the angle of attack and decreased the airspeed. This developing condition remained undetected by the crew until the activation of the stick shaker.

The investigation

The investigation focused on the crew's management of the aircraft during the descent and the factors contributing to the loss of airspeed awareness. It was determined that the pilot flying, the first officer, likely experienced task saturation while managing the transition to a descent, level flight, and a turn, alongside communicating with Air Traffic Control. Simultaneously, the captain, acting as the pilot monitoring, was focused on communication tasks related to the return to Perth and was not monitoring critical flight parameters.

Findings

  • The de-ice system fault was likely triggered by the delamination of the inboard de-ice boot on the right wing.
  • The pilot flying became task saturated due to the high workload of managing flight state changes and ATC instructions.
  • The crew failed to monitor airspeed and engine power, leading to a lack of awareness regarding the decaying airspeed.
  • Neither pilot recognized the high workload of the first officer, and no attempt was made to reduce communication demands to allow the crew to refocus on flight instruments.

Probable cause

The potential stall was caused by the crew's failure to monitor airspeed and engine power during a period of high workload and task saturation, following a decision to return to Perth due to a de-ice system malfunction.

Frequently asked questions

What happened in the 2021-07-06 Saab Aircraft Co. 340B accident near 30.7 km south-west of Perth Airport, Western Australia?

A flight crew's decision to return to Perth due to a de-ice system malfunction led to a period of unnoticed airspeed decay and a near-stall event.

Were there any fatalities in the 2021-07-06 Saab Aircraft Co. 340B accident?

No fatalities were recorded in this accident.

What aircraft was involved and where did it happen?

The accident on 2021-07-06 involved a Saab Aircraft Co. 340B, registration VH-ZLJ, operated by Regional Express, at 30.7 km south-west of Perth Airport, Western Australia.

What was the probable cause of the accident?

The potential stall was caused by the crew's failure to monitor airspeed and engine power during a period of high workload and task saturation, following a decision to return to Perth due to a de-ice system malfunction.

Loading the flight search…