What happened
On 14 February 2012, at approximately 06:45 local time, a Saab 340A operated by RAF-AVIA, registration YL-RAG, was performing a cargo flight (NEF021) from Helsinki-Vantaa to Mariehamn. During the approach to runway 21 using the ILS Z procedure, the aircraft deviated from the established approach route.
As the aircraft drifted from the localizer, the flight crew failed to verify their position using available navigation aids. The captain attempted to correct the flight path, but these maneuvers resulted in an unusual flight attitude. The aircraft entered a significant left bank of up to 50 degrees and a nose-down pitch of 19 degrees. During this excursion, the aircraft descended below minimum safe altitudes, and the crew lost effective control of the aircraft. The Ground Proximity Warning System (GPWS) issued multiple alerts, which the crew did not heed. The captain managed to recover the aircraft at approximately 46 meters (150 feet) above the ground, roughly five kilometers from the runway, before completing the landing.
The investigation
The investigation focused on the crew's deviation from the approach path and the subsequent loss of situational awareness. Investigators examined the cockpit performance, noting that the crew did not utilize all available navigation systems to rectify the deviation. The investigation also reviewed the captain's adherence to the company's operations manual and the effectiveness of the ground proximity warnings.
Findings
- The primary cause of the serious incident was that the captain continued the approach despite the lack of necessary conditions for a safe landing.
- This led to a severe degradation of situational awareness, resulting in an unusual attitude and a near-loss of aircraft control.
- Poor crew resource management (CRM) was evident, specifically regarding inadequate communication between the pilot and the co-pilot.
- The crew failed to respond to multiple GPWS warnings.
- The captain did not follow the airline's established operations manual.
- The crew failed to cross-check their position with other navigation aids once the ILS deviation was noted.