2000 Marsa Brega Short 360 crash

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. 21 people died in the crash. 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.
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, which focused on aircraft maintenance and repair, 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:
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.
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), 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.
The aircraft plunged into the sea 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.
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, seven Britons and two 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. Local fishing boats also joined the search and rescue effort. Both the captain and the first officer survived the crash, but the cabin crew member did not.
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, three Indians, two Canadians, two Croatians, three Filipinos, and one person each from Tunisia and Pakistan.
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. The Swiss firm Avisto, which owned the aircraft, said that both pilots were "senior and very experienced".
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.
Investigation.
Salvage workers were deployed to the crash site to retrieve the flight data recorder (FDR) and cockpit voice recorder (CVR), and were eventually able to recover the wreckage of the Shorts 360 within nine days of the accident. The Swiss Transportation Safety Investigation Board (STSIB), British Air Accidents Investigation Branch (AAIB), and American National Transportation Safety Board (NTSB) joined with the Libyan Civil Aviation Authority (LCAA) to investigate the cause of the crash. The AAIB had offered their facility of Farnborough in Hampshire to analyse the content of the black boxes.
ATC testimony indicated that the crew had intended to make an emergency landing due to engine failure. The investigative team focused on the fuel of the aircraft, suspecting that fuel exhaustion had occurred in-flight. The investigative committee, however, ruled this out, stating that the amount of fuel on board was sufficient for the plane to reach its destination. 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.
The investigative committee noted that the flight crew had been constantly talking about the Fokker F-28 Fellowship system, a topic unrelated to their duties in the Shorts 360. The captain of the flight, who had been recently promoted and received an F-28 rating, 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 discussed the systems of the F-28 at length, lasting for the majority of the ill-fated flight. Perhaps as a result of this distraction, 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.
The weather conditions along the route were provided to the flight crew in Tripoli. Given that Libya's climate tends to be mild and not to pose a risk to aircraft, the crew did not 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.
The investigators also revealed that the single cabin crew member, the Tunisian flight attendant, did not inform the passengers that the seat cushion could be used as a flotation device. This may have contributed to 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, including how to use the seat cushions for flotation as an alternative to life jackets.
As investigators interviewed the captain, he stated that he did not 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 laws and regulations on aviation safety equipment. Avisto and Swiss-accredited representatives said that floating devices were only required for flights flying 50 miles or more from land, and that flights within 50 miles of land or where a safe water landing can be performed were not required to carry life jackets.
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.
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 ATC. The investigative committee then examined the a fuel sample from the flight, as contaminated fuel might cause an engine flame-out, but concluded that the fuel was not contaminated. Investigators then reviewed the crew's handling of the right engine after the left engine flamed-out, but there were no indications the crew mishandled the engines.
The investigation committee then turned its attention to the weather conditions at the time of the accident. They found 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 feet near a cloud base, among several other flight conditions. They then found out that the aircraft engine anti-icing systems were not engaged while the outside temperature was well below 6 degrees(C), the recommended temperature to operate anti-icing systems. The aircraft flight manual said not to rely on airframe visual icing cues before turning engine anti-ice on. It stated that the consequences of not using an engine anti-ice until build up was visible from the cockpit might result in severe engine damage.
Although the freezing altitude at the time was at 5200 feet and the aircraft was flying in temperatures of −2 degrees, the plane did not have its anti-icing system activated. The possibility of ice accumulation on the engine would have existed until the aircraft had decreased its altitude to 2000 feet or less. At that point, the ice would melt, which could possibly flood the engine, the condition which did ultimately cause the accident aircraft's engines 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, because the temperature rise was not severe enough to immediately catch the crew's attention and because they were distracted by their discussion of the Fokker F-28 system, they failed to notice the gradual increase in engine temperature.