Serious incident Saab 340B G-LGNM,
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ASN Wikibase Occurrence # 179440
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Date:Friday 3 October 2014
Type:Silhouette image of generic SF34 model; specific model in this crash may look slightly different    
Saab 340B
Registration: G-LGNM
MSN: 340B-187
Year of manufacture:1990
Engine model:General Electric CO GE CT7-9B
Fatalities:Fatalities: 0 / Occupants: 28
Aircraft damage: None
Category:Serious incident
Location:between Aberdeen and Sumburgh -   United Kingdom
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Aberdeen-Dyce Airport (ABZ/EGPD)
Destination airport:Sumburgh Airport, Shetland Islands (LSI/EGPB)
Investigating agency: AAIB
Confidence Rating: Accident investigation report completed and information captured
The aircraft was operating a scheduled passenger service from Aberdeen to Sumburgh.
On departure from Aberdeen at 09:00 hrs UTC, for the second flight to Sumburgh, there was a strong south-south-westerly airstream and severe mountain waves were forecast between FL40 and FL280.
The planned cruising level was FL150 and ATC approved a climb to FL130. Close to FL65, the aircraft entered cloud and the crew switched on the engine anti-icing systems, together with the wing and stabiliser de-icing boots. Above FL110, the rate of climb reduced. A small amount of ice had formed around the windscreen wipers but the commander initially assessed that the reduced rate of climb was due to downdraughts caused by mountain wave effect.
Ice was seen to accrete on the propeller spinners, and propeller de-icing was selected to norm when the outside air temperature reached -5ºC. No propeller vibration was apparent and no ice from the propellers was heard to strike the fuselage. The commander, who was pilot flying, used the autopilot’s vertical speed (VS) mode and reduced the Indicated Air Speed (IAS) from more than 160 KIAS, the normal minimum speed for climbing in icing, to 145 KIAS, which was the appropriate V-ERICING speed for use in exiting icing conditions. The half-bank mode and IAS (hold) mode were engaged and the aircraft continued to climb at 145 KIAS. The commander realised the aircraft was being affected by ice, as well as by mountain wave effect, but was confident that it was close to the cloud tops and would climb above the icing level.
The pilots later recalled that the indicated rate of climb varied from a maximum of about 800 ft/min to a slightly negative rate. Climb power was maintained and the propeller rpm were also kept at the normal setting of 1,230 rpm. The co-pilot later stated that he realised that the power and propeller rpm should have been increased when the speed was reduced below 160 KIAS, in accordance with standard operating procedures (SOPs), but he had not suggested this at the time. Approximately 3/4 inch of ice could be seen on the windscreen wipers, while the de-icing boots on the wing appeared to clear any ice that formed on them.
The aircraft reached FL130 at 09:25 hrs but it only accelerated to 164 KIAS, rather than the expected 180 KIAS or greater. The commander’s reaction was to climb the aircraft another 100 ft, then descend back to FL130 using VS mode. This was not a manoeuvre the commander had previously employed, but he had seen it used by another pilot. Before commencing it, he and the co-pilot had a brief discussion about what was intended. The commander thought that the angle of attack (AOA) and drag would reduce during descent and the aircraft would accelerate. Instead, during the short climb, the IAS reduced quickly towards 150 KIAS and did not increase in the descent.
On regaining FL130, the autopilot remained engaged and the active vertical mode was ALTS which is the altitude hold mode displayed when the aircraft is maintaining a pre-selected altitude. The pilots believed they were experiencing moderate icing and should descend to FL110 to increase airspeed. After ATC had approved the descent, the commander commented that the ice conditions were more than moderate and that the airframe was accumulating a lot of ice. FL110 was entered in the altitude pre-selector and the commander selected a rate of descent of 1,000 ft/min, using VS mode.
The commander noticed that, despite the selected rate of descent, the aircraft’s pitch attitude remained high (around 5º nose-up) and he increased the selected rate to 2,500 ft/min. The airframe then started to vibrate and the commander said "feel that, that’s a stall... i think... icing stall". Approximately 10 seconds after the vibration started, at 09:28:49 hrs, the aural stall warning sounded for approximately one second, the stick shaker operated and the autopilot disengaged.
The commander took manual control and pitched the aircraft to 2º nose-down. He later reported that a little more force than usual had been required to lower the nose of the aircraft but it then responded normally as the speed increased to greater than 190 KIAS. The vibration ceased and the aircraft seemed to be in trim, without any pitch trim adjustment by the commander. The autopilot was re-engaged approximately 9 seconds after disconnection and, shortly afterwards, an elevator mis-trim annunciation was displayed on both Electronic Attitude Director Indicators (EADIs). It was acknowledged by the crew and cleared within a few seconds.
The flight was continued to its original destination, without climbing again, and without further incident.

G-LGNM probably encountered both severe icing conditions and mountain wave effect while climbing. The crew reduced the airspeed to VCLEAN+15, for optimum climb performance, but the propeller rpm and power were not increased to MCP. The co-pilot perceived that the command gradient between himself and the commander was too steep for him to feel comfortable advocating such a procedure, even though he believed it appropriate.
After levelling-off, airspeed initially increased before reducing back towards VCLEAN+15, a speed that was only intended for use when climbing out of icing conditions, and in combination with MCP. It was apparent that the aircraft’s performance was being impaired by ice and it would have been appropriate to set MCP, as well as disengage the autopilot.
Pre-stall buffet was experienced and the recovery was delayed until after the stall warner had activated. Not all the stall recovery vital actions were implemented, although control was regained before a wing drop developed, as had happened in previous Saab 340 stall events.
The manufacturer is reviewing the guidance in the AFM and AOM, relating to flying the Saab 340B in icing conditions, and the operator has updated its advice to crews on the same subject.

Accident investigation:
Investigating agency: AAIB
Report number: EW/G2014/10/04
Status: Investigation completed
Duration: 11 months
Download report: Final report


History of this aircraft

Other occurrences involving this aircraft
12 April 1999 N347BE Business Express 0 Boston-Logan International Airport, MA (BOS) sub
24 September 2015 G-LGNM Loganair 0 near Kirkwall non

Revision history:

10-Sep-2015 09:21 harro Added
04-Oct-2015 03:30 Dr. John Smith Updated [Source, Embed code]
10-Oct-2015 16:30 Aerossurance Updated [Operator]

Corrections or additions? ... Edit this accident description

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