Aviation safety investigations & reports

Engine over-torque event - Bombardier, DHC-8-315, VH-SBI, 22 km north-east of Devonport Airport, 8 March 2011

Investigation number:
AO-2011-038
Status: Completed
Investigation completed

Summary

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On 8 March 2011, an Eastern Australia Airlines operated (the operator) Bombardier Inc. DHC-8-315 aircraft, registered VH-SBI, departed Melbourne, Victoria on a scheduled passenger service to Devonport, Tasmania.

On arrival at Devonport, a runway 24 area navigation global navigation satellite system (RNAV (GNSS)) approach was commenced. The crew did not become visual with the runway at the minima due to the prevailing weather conditions and a missed approach was conducted. The aircraft was climbed to 3,100 ft and a holding pattern conducted.

A second approach was commenced, during which time, the aircraft's speed decayed. The pilot in command (PIC) made two airspeed advisory calls and the copilot responded immediately by increasing power on each occasion. The two power applications failed to accelerate the aircraft and the crew observed the airspeed reduce to 107 kts. The PIC called assertively for more power to be applied and the copilot immediately responded by applying power. During the recovery, the aircraft's engines were over-torqued to 120% for about 2 seconds. The operator and engine manufacturer transient over-torque limits were not exceeded.

A second missed approach was conducted and the flight was diverted to Launceston, Tasmania where the aircraft landed without further incident.

In response to this incident, and a stickshaker warning event involving a Eastern Australian Airlines Bombardier Inc. DHC-8-315 aircraft on 1 March 2011 (ATSB investigation AO-2011-036), the operator issued a safety alert stating that the primary consideration for pilots is to maintain an awareness of the aircraft's speed, altitude and position; and controlling its flight path.

Download Final Report
[Download  PDF: 4.28MB]
 
 
 
General details
Date: 08 March 2011   Investigation status: Completed  
Time: 2030 ESuT    
Location   (show map): 22 km north-east of Devonport Airport   Investigation type: Occurrence Investigation  
State: Tasmania   Occurrence type: Control - Other  
Release date: 12 September 2011   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Bombardier Inc  
Aircraft model DHC-8  
Aircraft registration VH-SBI  
Serial number 605  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  
Destination Devonport, Tas.  
Last update 14 November 2018