2000 Marsa Brega Short 360 crash

Marsa Brega Short 360 crash

A Short 360 similar to the aircraft involved in the crash
Accident
Date	13 January 2000 (2000-01-13)
Summary	Ditching caused by icing
Site	Mediterranean Sea, 5km off Marsa Brega, Libya
Aircraft
Aircraft type	Short 360
Operator	Avisto
Registration	HB-AAM
Flight origin	Tripoli International Airport, Tripoli, Libya
Destination	Marsa Brega Airport, Marsa Brega, Libya
Passengers	38
Crew	3
Fatalities	21
Injuries	17 (11 seriously injured)
Missing	1 (presumed dead)
Survivors	19

The 2000 Marsa Brega Short 360 crash occurred on 13 January 2000 when a fully loaded Swiss-registered Short 360 leased by Avisto ditched into the sea near Marsa Brega in Libya. The aircraft was chartered by Sirte Oil Company to transport oil workers to the city. It was carrying 41 people (38 passengers and three crew). Most of the passengers were foreigners. As both engines failed in mid-flight, the crew chose to ditch the aircraft. The crash claimed the lives of 21 people. An official investigation concluded that the de-icing device on the aircraft was not activated. The aircraft flew into an adverse weather condition and an icing condition occurred in mid-flight. The ice melted and flooded the engine, causing both engines to fail. The Libyan Civil Aviation Authority also blamed the pilots for conducting conversation unrelated to the flight.^[1]

Flight

The aircraft took off from Tripoli International Airport at 09:29 UTC with two flight crew, one cabin crew and 38 passengers to Marsa Brega, a city known for its oil refinery. The aircraft was leased from Avisto Air Service, a firm based in Zurich, Switzerland that focused on aircraft maintenance and repair,^[2] to Sirte Oil Company. The crew had noticed a fuel imbalance prior to the flight, making a log entry and cross-feeding fuel before the flight. The aircraft started its descent at 11:25 UTC. At 11:36 UTC the left engine flamed out. The Captain then told the First Officer: "We just had an engine failure". The First Officer then stated that the oil pressure decreased. The Captain then ordered the first officer to raise the landing gear and flaps, then asked him to confirm if they just had an engine failure. He later ordered to shut down the engine:^[1]

• 11:36:58 Captain  : "We just had an engine failure"
• 11:37:00 First Officer: "You are not kidding"
• 11:37:01 First Officer: "Oil pressure going low"
• 11:37:03 Captain  : "Power"
• 11:37:04 First Officer: "OK"
• 11:37:05 Captain  : "Ok, power on the right engine"
• 11:37:11 First Officer: "OK, checked"
• 11:37:12 (Warning sound)
• 11:37:21 Captain  : "OK gears &, flaps are up"
• 11:37:23 First Officer: "Yes"
• 11:37:25 Captain  : "Confirm left engine failure"
• 11:37:26 First Officer: "Confirmed"
• 11:37:27 Captain  : "Shut down left engine"

After the First Officer shut down the left engine, the right engine flamed out. The Captain then told the First Officer that they had lost both engines. The Captain then ordered the First Officer to contact Marsa Brega for an emergency landing.^[1]

• 11:37:29 Captain  : "Oh, Oh, Oh my god!"
• 11:37:33 First Officer : "What happened?"
• 11:37:35 Captain  : "Both failures, two engine failures!"
• 11:37:39 Captain  : "Just call Marsa Brega!"

The crew then contacted Marsa Brega Tower, requesting an emergency landing. The Captain asked the First Officer to restart the engine. As they prepared for an emergency landing (ditching),^[3] multiple warnings sounded in the cockpit. The Captain then ordered the First Officer to open the emergency hatch. The ATC asked the crew to confirm the emergency. As the First Officer confirmed the emergency, the aircraft impacted water.^[1]

• 11:38:30 First Officer : "Oh Lord! (Ya Rab!)"
• 11:38:32 ATC  : "Confirm emergency"
• 11:38:34 First Officer : "Emergency!" (Fi Albahr!)
• 11:38:34 (Sound of impact and end of recording)

The aircraft plunged into the sea 5 kilometres (3.1 mi) off of Marsa Brega. The front part of the aircraft was totally destroyed. The tail of the aircraft detached from the fuselage on impact, in a 10° nose up position. As the aircraft began to sink, water started to fill into the cabin. One British survivor escaped after kicking out an aircraft window as the aircraft began to sink.^[4]

Search and rescue team were immediately deployed by authorities. At least 19 people were rescued and evacuated from the sea. Among them were 10 Libyans, 7 Britons and 2 Indians. The rescue effort was hampered by bad weather. Swiss Transportation Ministry spokesman Hugo Schiltenhelm received reports that 15 people had died in the crash.^[5] Local fishing boats also joined the search and rescue effort. During the night of 13 January, at least 5 Briton and 2 Filipino were still missing. Embassies were trying to contact relatives about the crash. Both the Captain and the First Officer survived the crash, however the cabin crew didn't survive.^[6]

Passengers and crew

At least 38 passengers and 3 crew were on board the flight, including three children and one infant. The British ambassador in Tripoli, Richard Dalton, confirmed that there were 13 Britons on board, 5 of whom were killed in the crash. Other nationalities on board included 14 Libyans, 3 Indians, 2 Canadians, 2 Croatians, 3 Filipinos, and one person each from Tunisia and Pakistan.^[7]

Nationality	Passengers	Crew	Total
Canada	2	0	2
Croatia	2	0	2
India	3	0	3
Libya	14	2	16
Pakistan	1	0	1
Philippines	3	0	3
Tunisia	0	1	1
United Kingdom	13	0	13
Total	38	3	41

The captain was a 42-year-old Libyan citizen with total flying experience of 8,814 hours, of which 3,840 hours were on the Shorts 360. The first officer was a 49-year-old Libyan citizen with total flying experience of 10,422 hours, of which 1,950 were on the type.^[1] The Swiss firm Avisto, who owned the aircraft, claimed that both pilots were "senior and very experienced".^[6]

Aircraft

The aircraft involved in the crash was a Shorts 360, a commuter turbo-prop airliner that was manufactured in Belfast, United Kingdom. The aircraft was registered in Switzerland as HB-AAM. The Shorts 360 has a good safety record as a commuter aircraft. The aircraft had 7,138 flying hours. It was equipped with two engines from Pratt & Whitney Canada and two propellers from Hartzell Propeller.^[1]

Investigation

Salvage workers were deployed onto the crash site to retrieve the black box of the flight. The FDR and the CVR were eventually found. The wreckage of the Shorts 360 was recovered nine days after the accident. The STSIB,^[8] British AAIB^[9] and American NTSB joined with the Libyan LCAA to investigate the cause of the crash. The British AAIB had offered their facility of Farnborough in Hampshire to analyse the content of the black boxes.^[1]

Early reports suggest that the aircraft had an engine failure in mid flight. This was confirmed by the ATC testimony, stating that the aircraft had intended to make an emergency landing due to failure on its engines. The investigative team focused on the fuel of the aircraft, suspecting that fuel exhaustion had occurred in-flight.^[10] v The investigative committee, however, ruled it out, stating that the fuel was sufficient. This observation was reinforced by local fishermen who had joined the search and rescue effort who stated that fuel was leaking from the aircraft wreckage.

An analysis made by the investigative committee noted that the flight crew were constantly talking about the Fokker F-28 Fellowship system; a topic unrelated to their duties. The Captain of the flight had been recently promoted and had received an F-28 rating. He had been planning to move to piloting the Fokker F-28. The first officer had already been promoted to the Fokker 28. Both members of the flight crew then began discussing the system of the F-28. This discussion was long and took the majority of the flight. Perhaps as a result of this banter, the flight crew failed to notice that ice had accumulated on the windshield of the aircraft. When the ice was eventually noticed, the flight crew activated the ice detection and anti-icing for the pitot static and the windshield of the aircraft. They failed, however, to activate the engine intake anti-icing system.^[1]

The weather condition along the route was provided to them in Tripoli. Given that the climate in Libya is typically "not dangerous" for flying throughout the year and no significant weather events frequently occurred, the crew didn't pay much attention to the weather report. The Captain of the flight, who survived the crash, told investigators that the weather report was not available and stated that weather reports in other Libyan airports were not correct.^[1]

The investigators also revealed that the one and only cabin crew member, the Tunisian crew, didn't inform the passengers that the seat cushion could be used as a flotation device. This may have been the cause of the high number of drownings among the deceased. One of the main duties of the cabin crew member is to brief passengers about safety equipment on board. The passengers could have used the seat cushions for flotation as an alternative to life jackets.^[1]

As investigators interviewed the Captain, he stated that he didn't know that the seat cushions could be used as flotation devices even though he had previously received information about it. At this point, investigators began to worry and started to review the Swiss air law on aviation safety equipment. Avisto and Switzerland accredited representatives said that floating device are only required for flights flying at 50 miles or more from the land and revealed that it was not required if the flight was flying at 50 miles or less, or landing is over water and a safe landing can be performed.^[1]

Although the aircraft was not equipped with life jackets, the safety instruction card located on the back of each seat instructed passengers to use life jackets in case of ditching. "LIFE JACKET UNDER YOUR SEAT" was also clearly written.^[1]

Both engines were taken to the United Kingdom for analysis. Three specialists from the engine manufacturer were involved in the investigation. Their analysis concluded that there was no mechanical failure or metal failure on the engine, despite reports of engine failure by survivors, the crew members, and the ATC worker. The investigative committee then examined the a fuel sample from the flight, as contaminated fuel might cause an engine flameout. The investigation concluded that the fuel was uncontaminated.^[1]

Investigators then thought that the crew may have mishandled the right engine after the left engine flamed out. There were no indications, however, that the crew mishandled the engines.^[1]

The investigation committee then noticed that the aircraft had flown directly into a storm. According to the flight manual, the crew should have activated the aircraft's anti-icing system each time the aircraft entered mists, fogs, clouds, rain, snow, hail, or when flying at 500 ft near cloud base among several other flight conditions. They then found out that the aircraft was not de-iced while the outside temperature was well below 6 degrees(C). The aircraft flight manual said not to rely on airframe visual icing cues before turning engine anti-ice on. It states that the consequences of not using an engine anti-ice until build up was visible from the cockpit might result in severe engine damage.^[1]

Even though the freezing altitude at the time was at 5200 ft and engine intake icing is expected when the outside temperature is 6 degrees or below, the aircraft was flying in outside temperature of -2 degree without its anti-icing system activated. The possibility of ice accumulation on the engine would have existed until the aircraft had decreased its altitude to 2.000 ft or less. At that point, the ice would melt which could have possibly flooded the engine, the condition which caused the engine to flame out. This scenario may have been avoided if the ignitors on the operating engine were put on after the first engine flame out. The operating engine would have produced power until a safe landing could be performed. If ice accumulation had occurred on the engine, the instrument panel would have informed the pilot that there was a rise in engine temperature. While this is something the flight crew should have noticed, they failed to identify this warning. The investigation stated that they didn't notice the rise of engine temperature because they were so busy discussing the Fokker F-28 system. The temperature rise itself was not significant enough to catch the crew's attention.^[1]

See also

• Air Florida Flight 90
• Air Algerie Flight 5017

References

External links

• Accident description, Aviation Safety Network
• CVR transcript of the flight, Tailstrike.com