What happened
On October 17, 2014, an Airbus A319-132, registration YU-APA, operated by Air Serbia, experienced a significant technical failure shortly after departing from Zurich Airport (LSZH). During the initial climb, the aircraft's right engine experienced a rapid drop in oil quantity, falling from 4.25 quarts to zero within seconds. This triggered a master warning for low oil pressure.
In response to the failure, the captain shut down the right engine. Following the engine shutdown, the crew requested radar vectors for an immediate return to the airport. The crew then decided to execute a visual approach to runway 28. During this maneuver, the aircraft maintained a high speed and a steep descent rate, significantly exceeding the nominal glidepath. The aircraft crossed the approach path at approximately 6,150 feet, roughly 1,750 feet above the intended glidepath, with a descent rate peaking at over 3,000 feet per minute. The aircraft landed 320 meters past the runway threshold, eventually coming to a stop after the deployment of ground spoilers and reverse thrust.
The investigation
The Swiss Transportation Safety Investigation Board (SUST) examined the flight data, cockpit voice recordings, and maintenance history. The investigation focused on the crew's decision-making process following the engine failure and the technical aspects of the oil leak in the air-cooled oil cooler. Investigators also reviewed the crew's adherence to standard operating procedures, including the execution of ECAM (Electronic Centralized Aircraft Monitoring) checklists and the completion of landing checklists.
Findings
The investigation determined that the primary cause of the incident was the crew's hasty initiation of a risky approach without performing a proper situational analysis following the engine shutdown. Several contributing factors were identified, including:
- Poor crew resource management (CRM) and a lack of cooperation between the pilot and co-pilot.
- Failure to follow established systemic and operational procedures.
- Limited experience of the crew on this specific aircraft type.
Additionally, the investigation noted secondary safety risks, such as the delay in shutting down the engine after the initial warning and the fact that the crew performed the landing without requesting or receiving explicit landing clearance from Air Traffic Control.