What happened
On March 19, 2008, a Dornier Do 328-100 was performing a landing at Mannheim City. During the approach, the crew conducted a non-precision approach that did not comply with the airline's standard operating procedures or the requirements set forth in the AIP. The aircraft subsequently overran the runway, resulting in five minor injuries to the occupants and heavy damage to the aircraft. There was also minor damage to property on the ground.
The investigation
The BFU investigation examined the flight sequence, crew coordination, and the technical design of the aircraft's engine controls. The investigation reconstructed the chronology of the landing, analyzed the cockpit voice recorder and flight data recorder, and evaluated the crew's adherence to stabilized approach criteria. The investigators also reviewed the runway markings and the safety area at the end of runway 27 at Mannheim City.
Findings
Several contributing factors were identified in the accident:
- The crew performed a non-precision approach that deviated from established company and regulatory procedures.
- The design of the power levers lacked sufficient fault tolerance, creating a risk of inadvertent movement.
- The landing area at Mannheim City lacked clearly marked touchdown zones.
- The safety area at the end of runway 27 was insufficient to meet ICAO safety standards.
- Existing risks regarding power lever operation had been previously identified in other incidents but had not been effectively mitigated by authorities or the type certificate holder.
Safety action
The BFU issued several safety recommendations, including:
- Expanding flight data analysis programs for the airline's Do 328 fleet to monitor stability criteria.
- Marking touchdown zones at Mannheim City in accordance with ICAO recommendations.
- Expanding the safety areas at the end of the runway or installing energy-absorbing surfaces.
- Implementing stricter stabilized approach and landing criteria within airline operating manuals.