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 MK Airlines crash B-747 Halifax excerpts Final Report

 

 

 

Factual Information

 

1.1 History of the Flight

The series of flights for this crew originated at Luxembourg-Findel Airport, Luxembourg, on 13 October 2004, as MK Airlines Limited Flight 1601 (MKA1601), destined to Bradley International Airport, Windsor Locks, Connecticut, United States. The aircraft operated as MK Airlines Limited Flight 1602 (MKA1602) from Bradley International Airport to Halifax International Airport, Nova Scotia, and was to continue as MKA1602 to Zaragoza, Spain, and return to Luxembourg.

1.11 Flight Recorders

The cockpit voice recorder (CVR) was found under debris in its mounting bracket near its installed location, and it had been exposed to fire and extreme heat for an extended period. The recording tape had melted; consequently, no CVR information was available to investigators.

The flight data recorder (FDR) was found in the main cabin area forward of the wing root. The FDR suffered impact and heat damage in the crash and the tape broke in two places. The FDR contained information from the previous six flights and good data for the accident flight.

1.12.2 Wreckage Examination

A number of paper documents were recovered from the accident site and examined by TSB [Transportation Safety Board of Canada] investigators. The most significant of these was the voyage report sheet for this series of flights, which contained the MKA1601 captain's comments regarding duty time (see Section 1.18.5.3). The completed take-off data card used by the crew for the accident take-off was not found.

1.17.1.5 Crew Pressures

A significant number of MK Airlines Limited employees, particularly flight crew members, lived in southern Africa. Because of the company's business locations and route structure, employees were separated from their families for weeks at a time when on duty. With the political and social unrest in some of these areas, there was the potential for harm to come to their families when the employees were away. There were several examples cited where employees' families had experienced incidents of home invasion and/or personal attack. This was identified as a source of stress within the company.

In an effort to improve working conditions at MK Airlines Limited, the managing director had requested, some time before the accident, that the captain of MKA1602 submit a letter on behalf of the crews, listing some general concerns and suggestions of other flight crew. The letter was submitted shortly before the accident, and the company voluntarily supplied it to the TSB investigators. The letter indicated concern about recent increases in the number of pilots leaving the company and suggested that a new compensation package should be put in place to provide a more stable financial situation for flight crew members. The letter also indicated that there were not enough crews per aircraft. As well, it discussed the uncertainty of life for those living in southern Africa, indicating that the lengthy periods away from home increased stress and contributed to flight crew members looking at other employment options. The letter mentioned that inexperienced operational support personnel, combined with pressure from the Commercial Department, were causing crew scheduling difficulties.

Other company employees reported that there was a consistent shortage of B747 flight crew and they were required to spend lengthy periods away from home. To address a crew shortage in the past, the company had hired flight crew members from Argentina on contract to supplement its DC-8 operation.

1.17.3 Transport Canada

TC's Foreign Inspection Division conducted a base inspection of MK Airlines Limited operations in the United Kingdom between 15 August and 26 August 2002. The closing paragraph of the base inspection report stated that the company would be issued a Canadian Foreign Air Operators Certificate upon receipt of an acceptable corrective action plan that addressed the findings of the inspection. MK Airlines Limited submitted a corrective action plan in October 2002. On 20  December 2002, TC's Foreign Inspection Division granted MK Airlines Limited Canadian Foreign Air Operators Certificate F 10326. The Division had some concerns about issuing the certificate because of MK Airlines Limited accident history (see Section 1.18.6). However, the Division was impressed by MK Airlines Limited management, the timeliness and content of the corrective action plan, and the quality of feedback from the United Kingdom Civil Aviation Authority (CAA). Contributing to the confidence of the decision was the assessment of the Federal Aviation Administration (FAA) that the GCAA [Ghana Civil Aviation Authority] was a Category 1 regulatory authority.

1.17.4 United States Federal Aviation Administration

On 02 June 2003, the FAA granted MK Airlines Limited authority to operate in the United States by issuing Operations Specification ZM0F869F. As part of the FAA's oversight, periodic ramp inspections were conducted on MK Airlines Limited aircraft. In July 2004, MK Airlines Limited was placed on a special emphasis list. This list is issued semi-annually to identify foreign air carriers that are to be watched. The list also includes countries with a Category 1 Civil Aviation Authority, where the FAA has concerns. In September 2004, a ramp inspection of an MK Airlines Limited aircraft resulted in a decision to increase surveillance of the company's operation. A ramp inspection of an MK Airlines Limited DC-8 in the United States following the accident in Halifax identified several deficiencies, and on 29 October 2004, the FAA informed the company that its Operations Specification was cancelled; no specific reason was stated.

In December 2004, the FAA conducted a reassessment of the GCAA and, on 30  April 2005, it announced publicly that Ghana had failed to comply with ICAO [International Civil Aviation Organization] standards. As a result, Ghana's safety rating was lowered to Category 2.

1.18.1 Boeing Laptop Tool

At the time of the accident, MK Airlines Limited was using the Boeing Laptop Tool (BLT) for determining performance calculations. The BLT is a Microsoft Windows®-based software application used to calculate take-off performance data, landing performance data, and weight and balance information.

The weight and balance data were supplied by and built into the software by MK Airlines Limited, and Boeing provided training to the MK Airlines Limited software administrator. The MK Airlines Limited BLT software administrator was responsible for setting up the weight and balance page for each specific aircraft and for supplying the airport database for the BLT.

1.18.1.2 MK Airlines Limited Crew Training on Boeing Laptop Tool

The BLT was then given to the B747 Training Department instructors to begin training crews in its use. Information on the BLT was distributed to flight crews in the form of newsletters and notices to flight crews.

On 09 February 2004, the MK Airlines Limited B747 chief training pilot issued a Notice to Flight Crew to the B747 flight crew (including loadmasters) on the subject of the BLT. It stated the following:

Please find attached the Performance section and relevant QRH pages. Please take the time to study these for when the BLT program is put onto the onboard computers.

Most of the MK Airlines Limited flight crew members did not receive any formal training on the BLT, and there was no method to evaluate and record if individuals had become competent using the BLT by the end of the self-study training period. Company Training Department and management personnel were aware that some pilots were not comfortable using personal computers. No additional general computer training was offered to the flight crews.

1.18.1.3 Performance Data from the Boeing Laptop Tool

When the BLT software is opened, the introduction page presents the user for calculating take-off performance data the maximum take-off power using JT9D-7Q engine performance, identified by the aircraft registration (9G-MKJ). Once the screen of the appropriate power rating is selected, the user inputs the airport and atmospheric data. The user then selects the "calculate" button and the BLT will indicate the maximum take-off weight for that runway and the EPR [engine pressure ratio] setting for maximum thrust for that power rating. The performance data also include the aircraft weight on which the data were based. The user then transfers the appropriate data to a take-off data card.

1.18.5.1 MK Airlines Limited Rest, Duty and Flight Time Schemes

Revision 003 to the MK Airlines Limited OM [Operations Manual], Part A, Section 7, effective 11 February 2000, stated that the maximum allowable duty period for a heavy crew was 20 hours, with a maximum of 16 flight hours, conforming to both the 1995 and 2002 version of the GCARs [Ghana Civil Aviation Regulations]. Revision 003 defined a heavy crew as two captains, two co-pilots and two flight engineers. However, Section 4.1, Crew Composition, of the OM defined a heavy crew as three pilots and two flight engineers, in contradiction to Section 7. The actual practice was to use three pilots, not four.

Revision 011 to the OM, amending the flight and duty time scheme, became effective on 23 September 2002 and was the scheme in effect at the time of the accident. In this revision, the maximum duty time for a heavy crew flying one to four sectors was increased to 24 hours, with a maximum of 18 flight hours. As well, the definition for a heavy crew was revised to include three pilots and two flight engineers. The company indicated that the reduction in pilots was to reflect consistency with Section 4.1 of the OM and the normal company practice. The amendment was sent to all manual holders, including the GCAA. The GCAA could not find any record of having received the amendment. MK Airlines Limited's own electronic records indicated that the GCAA had received the amendment.

1.18.5.3 MKA1602 Crew Duty Time

The MKA1602 crew was scheduled for a 24.5-hour duty day. MK Airlines Limited was in contravention of its OM by planning a flight to exceed 24 hours; similarly, the flight crew was in contravention by accepting a flight planned to exceed the maximum allowable duty period. At the time of the accident, the flight crew (captains, first officer, and flight engineers) had been on duty for almost 19 hours. However, due to the delays that had been experienced at Luxembourg-Findel Airport and Bradley International Airport, the crew would likely have been on duty for approximately 30 hours at their final destination of Luxembourg-Findel Airport, had the remaining flights continued uneventfully. Hotel and telephone records at Luxembourg indicated that some crew members might have been awake since early in the morning. According to the voyage reports, the loadmaster and ground engineer had been on duty for 45.5 hours.

The MK Airlines Limited OM stated, "all flights are planned in accordance with the limitations of the company's approved rest, duty and flight time schemes." Review of the planned duty periods for all the previous MKA1601/MKA1602 flights indicated that approximately 71 per cent of the flights had been planned in excess of 24 hours, averaging 24.37 hours. Company management personnel stated that they were unaware that this was occurring. The GCAA also had not detected these exceedences during its oversight of the company.

The MK Airlines Limited OM also stated, "flights may exceed the prescribed flight/duty limitations due to unforeseen circumstances" and "the company should also monitor these unplanned exceedences on a seasonal quarterly basis and not allow more than 25 per cent of the routes flown for that quarterly season to be exceeded, which will require a re-planning of crewing for that particular route/flight pattern." Review of the actual duty periods flown on the MKA1601/MKA1602 route indicated that they exceeded 24 hours 95 per cent of the time, averaging 26.85 hours. Company management was aware that exceedences were occurring. These exceedences were also not detected by the GCAA during its oversight of the company.

The MKA1601 captain wrote the following on the company voyage report:

According to our brief the duty period required to complete this flight is 24 hrs 30 min. In terms of Part A (7) the max duty period is 24 hrs. The crew were called out to operate starting this duty period at 1200Z only to finally depart at 1600Z. Can anything be done to correct the constant delays experienced in LUX for the Bradley run?

 1.18.5.5 Fatigue Management

Under the flight and duty time scheme in use by MK Airlines Limited, three pilots were required in a heavy crew working a maximum 24-hour duty period. The heavy crew would usually consist of one captain and two first officers, or two captains and one first officer.

MK Airlines Limited ground engineers and loadmasters were not subject to any duty time restrictions because there were no company rules, labour laws or aviation regulations pertaining to duty time that applied to them. It was determined that there were times when they could spend up to seven days on board an aircraft.

In addition, the ground engineer had some days where he was performing line maintenance duties at the maintenance facilities in Luxembourg and Johannesburg, South Africa. Individuals performing ground engineer and loadmaster tasks are regarded as important members of the crew who could easily contribute adversely to an accident through a fatigue-induced error.

1.18.6 Previous MK Airlines Limited Accidents and Incidents

The MKA1602 accident was the fourth major accident the airline had experienced since 1992. The three previous accidents occurred in Nigeria, and very little information was available with respect to the first two occurrences. [http://aviation-safety.net/database/record.php?id=19920215-0 & http://aviation-safety.net/database/record.php?id=19961217-2]

The Federal Republic of Nigeria, Ministry of Aviation, produced a Civil Aviation Accident Report (FMA/AIPB/389) for the company's third accident in Port Harcourt, with one fatality. [http://aviation-safety.net/database/record.php?id=20011127-0] A review of the report and information obtained from other sources indicated that the pilot flying was following a non-standard autopilot approach, tracking a localizer radial inbound and descending using vertical speed mode; MK Airlines Limited company policy was to not use the autopilot below 2000 feet agl. There were other indications of non-adherence to procedures, including the failure to make appropriate calls between the pilot flying and pilot not flying. A lack of situational awareness due to poor cockpit coordination was apparent, and there was a problem interpreting the visual references on the approach.

1.18.7 Managing the Risks of an Organization

During MK Airlines Limited expansion, the management was actively working on improving the company's infrastructure; however, during this same period, there were examples of insufficient management staff, inadequate supervision, routine shortcuts, and procedural non adherences that were taken by employees and supervisors when it was necessary to meet operational demands. Four major accidents in the company history are strong indicators of inadequate protection.

Analysis

2.4.1 MK Airlines Limited Expansion

The addition of B747 aircraft [since MK Airlines’ first B747 acquisition in 1999] added significantly to the Training Department's challenge of meeting the demand for qualified flight crews. At the same time, flight crew turnover was increasing as individuals found more attractive employment elsewhere. Also, the company's policy of recruiting from southern Africa limited the pool of new potential crew members. All these factors contributed to a shortage of flight crew required to meet the flying or production demand. This shortage of flight crews increased the potential for increased fatigue and stress among the personnel.

2.4.2 Rest, Duty and Flight Time 

Although the OM stated that flights would not be planned beyond 24 hours, the Crewing Department at MK Airlines Limited routinely scheduled flights in excess of that limit. There was no effective program in place to monitor how frequently these planning exceedences occurred, nor was there a program to detect and monitor exceedences beyond the planned duty days. In the absence of adequate company corrective action regarding these exceedences, crews developed risk mitigation strategies that included napping in flight and while on the ground to accommodate the longer scheduled duty days. This routine non-adherence to the OM contributed to an environment where some employees and company management felt that it was acceptable to deviate from company policy and/or procedures when it was considered necessary to complete a flight or a series of flights.

Examination of the occurrence crew's work/rest/sleep and duty history indicated that the operating crew would have been at their lowest levels of performance because of fatigue at, or shortly after, their arrival in Halifax. This state of fatigue would have made them susceptible to taking procedural shortcuts and reduced their situational awareness.

2.4.3 MK Airlines Limited Company Risk Management

MK Airlines Limited flight crews often flew into airports with poor facilities, experienced frequent delays and equipment malfunctions, and were scheduled for lengthy duty periods, often with limited on-board rest facilities. Many of the crews, supervisors and managers were accustomed to difficulty, hardship, and overcoming challenges.

Acceptance of non-adherence to company direction and procedures by managers was often tacitly accepted in the belief that it did not generate an unacceptable risk. Although three previous accidents should have been significant risk indicators for the company, there was an overall acceptance that the commercial growth was being managed adequately in terms of risk. Shortcuts (non-adherence to procedures) had become a habitual part of routine work practices.

2.4.4 Company Oversight of Operations

The company OM, which had been approved by the GCAA, contained a description of how the company was to conduct flight operations safely and within the regulations. Many areas of the OM were incomplete, out of date or inadequate. Moreover, the Operations Manager was over tasked to a point where adequate supervision and management of day-to-day flight operations was not always possible.

2.4.5 Company Introduction of the Boeing Laptop Tool

The BLT was introduced by MK Airlines Limited without direction, assistance or approval from the GCAA. Although advisory and guidance references of the FAA and Joint Aviation Authority were used, the introduction was without adequate training and evaluation. The crew reference material was self-study and there was little direct training provided. It is unknown if the user(s) of the BLT in this occurrence was fully conversant with the software, in particular this feature.

2.5 Regulatory Oversight of MK Airlines Limited

In general, the safety oversight the GCAA conducted on MK Airlines Limited was limited. The GCAA's oversight effectiveness was adversely affected by the necessity to maintain a greater amount of scrutiny on another Ghana-registered airline, even though the following significant risk indicators were present at MK Airlines Limited:

§                  the company had had three previous accidents;

§                  it had been in a continuous period of growth for some time; and

§                  there had been deficiencies noted related to non-adherence to OM policy and SOPs [standard operating procedures]
       
 identified.

In general, the regulatory oversight of MK Airlines Limited by the GCAA was not adequate to detect serious non-conformances to flight and duty times, or ongoing non-adherence to company directions and procedures.

2.6 Halifax Take-off Performance Data

Without a CVR [cockpit voice recorder whose information was unavailable to investigators due to long and extreme heat exposure] , it was difficult to determine the exact reasons the flight crew used a low EPR setting and a low rotation speed.

The BLT was most likely the source used for the take-off data. Consequently, it is most likely that the performance data error came from the misuse or misunderstanding of the BLT.

2.7 Failure to Recognize Inadequate Take-off Performance

In this accident, the take-off was attempted using a thrust setting and take-off speeds significantly lower than those required to become safely airborne. Once the take-off began, the flight crew did not recognize that the aircraft's performance was significantly less than the scheduled performance, until they reached a point where their response was insufficient to avert the accident.

2.8 Summary

The take-off data card was most likely completed using performance data from the BLT. The data for the Halifax take-off of the flight data recorder was nearly identical to that of the Bradley take-off [2.51 hours prior to the Halifax take-off], indicating that the Bradley take-off weight was used to generate the performance data in Halifax. The user subsequently selected the "calculate" button of the BLT, which resulted in the generation of take-off performance data containing incorrect speeds and thrust setting for Halifax. The flight crew used the incorrect speeds and thrust setting during the take-off attempt; however, the settings were too low, especially the thrust setting, to enable the aircraft to take off safely.

Factors that likely contributed to the incorrect take-off data being generated and then not being detected before the take-off attempt were flight crew fatigue, non-adherence to procedures, inadequate training on the BLT, and personal stresses. Once the take-off had commenced, the crew's situational awareness likely was not sufficient to allow them to detect the inadequate acceleration before it was too late to take off safely.

Conclusions

The Bradley take-off weight was likely used to generate the Halifax take-off performance data, which resulted in incorrect V speeds and thrust setting being transcribed to the take-off data card.
The incorrect V speeds and thrust setting were too low to enable the aircraft to take off safely for the actual weight of the aircraft.
It is likely that the flight crew member who used the Boeing Laptop Tool (BLT) to generate take-off performance data did not recognize that the data were incorrect for the planned take-off weight in Halifax. It is most likely that the crew did not adhere to the operator's procedures for an independent check of the take-off data card.
Crew fatigue likely increased the probability of error during calculation of the take off performance data, and degraded the flight crew's ability to detect the error.
The company did not have a formal training and testing program on the BLT, and it is likely that the user of the BLT in this occurrence was not fully conversant with the software.

The company increase of the maximum flight duty time for a heavy crew from 20 to 24 hours increased the potential for fatigue.
Regulatory oversight of MK Airlines Limited by the Ghana Civil Aviation Authority (GCAA) was not adequate to detect serious non-conformances to flight and duty times, nor ongoing non-adherence to company directions and procedures.
Company planning and execution of very long flight crew duty periods substantially increased the potential for fatigue.
There were no regulations or company rules governing maximum duty periods for loadmasters and ground engineers, resulting in increased potential for fatigue induced errors.