Casualties unknown

2011-07-20: BRITISH AEROSPACE (REGIONAL AIRCRAFT) LTD AVRO 146-RJ100 (HB-IXP) — Zürich Flughafen (LSZH), ZH, CH

Zürich Flughafen (LSZH), ZH, CH

On July 20, 2011, a BRITISH AEROSPACE (REGIONAL AIRCRAFT) LTD AVRO 146-RJ100 (registration HB-IXP) was involved in an aviation accident near Zürich Flughafen (LSZH), ZH, CH. Investigators recorded the probable cause as: The serious incident is attributable to the fact that after the failure of a single system, the crew did not use the remaining systems appropriately and safe control of the aircraft was temporarily no longer ensured. This summary draws on records from the Swiss Transportation Safety Investigation Board (STSB / SUST).

Sourcesthe Swiss Transportation Safety Investigation Board (STSB / SUST)Primary reportUpdated 1785034239Data APIEditorial standards

On 20 July 2011, an AVRO 146-RJ100 (HB-IXP) experienced a serious incident at Zurich-Kloten airport after a single system failure led to loss of autopilot, autothrottle, and flight director. The crew struggled to maintain manual control, with inadequate CRM and situational awareness contributing to the event.

Synopsis

On 20 July 2011, flight LX 5187, an AVRO 146-RJ100 aircraft registered as HB-IXP, was involved in a serious incident at Zurich-Kloten airport. The incident occurred following the failure of a single system, which resulted in the loss of the autopilot, autothrottle, and flight director functions. The crew's subsequent handling of the situation led to a temporary loss of safe aircraft control.

History of the Flight

According to the investigation, the pre-flight and initial phases proceeded normally. During the approach to Zurich-Kloten, a system failure occurred, causing the autopilot, autothrottle, and flight director to become inoperative. The crew attempted to continue manually. The commander and copilot experienced difficulties: the copilot was unable to maintain manual flight, and the commander could only fly the aircraft to a limited extent using emergency instruments. Crew coordination was poor, and the crew did not conduct an adequate situational analysis. The incident was classified as serious but no further details on the outcome were provided.

Injuries and Damage

The report indicates that there were no injuries to persons. The aircraft sustained damage, but specific details were not disclosed in the summary.

Causes

The investigation determined that the serious incident was attributable to the crew's failure to appropriately use the remaining systems after a single system failure, leading to a temporary loss of safe aircraft control. Contributing factors included:

  • The crew had a fundamentally incorrect understanding of the technical problem underlying the system failure.
  • The copilot was unable to manually fly the aircraft after the failure of the autopilot, autothrottle, and flight director.
  • The commander could only fly the aircraft to a limited extent with the help of emergency instruments.
  • Crew resource management was deficient.
  • The crew did not perform an adequate situational analysis.
  • Training on flying with standby instruments and raw data in the simulator was only partially applied in the real situation.

Aircraft Information

The aircraft involved was an AVRO 146-RJ100, registration HB-IXP. The specific systems affected included the Electronic Flight Instrument System, Inertial Reference System, and flight guidance system. The aircraft was equipped with standby instruments for emergency use.

Personnel Information

The commander and copilot were both qualified for the flight. Their flying experience and rest periods were within regulatory limits. The report noted that the commander had significant experience, while the copilot had less time on type.

Meteorological Information

Weather conditions at the time were not a contributing factor. The report provided standard meteorological data including wind, visibility, and cloud conditions, but these were within normal limits for the approach.

Investigation

The Swiss Accident Investigation Board (SAIB) conducted the investigation. The final report was published as No. 2158. The investigation focused on the crew's actions and system failures, and did not assign legal blame. Safety recommendations were issued based on the findings.

Probable cause

The serious incident is attributable to the fact that after the failure of a single system, the crew did not use the remaining systems appropriately and safe control of the aircraft was temporarily no longer ensured.

Investigation report by the Swiss Transportation Safety Investigation Board (STSB / SUST). Original record: https://www.sust.admin.ch/inhalte/AV-berichte/2158_e.pdf. This page is a structured re-presentation; facts and quotes are in the Swiss Transportation Safety Investigation Board (STSB), Switzerland.