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Investigation Blames Pilot Error For Smartwings Engine Shutdown Incident
The Czech Civil Aviation Authority (CAA) has released the final report on an accident that occurred on Aug. 22, 2019, involving a Smartwings Boeing 737-800 aircraft — registration OK-TVO — that had an engine shutdown in flight while it was flying from Samos, Greece to Prague, Czech Republic operating flight QS1125.
The report released by the Accident Investigation Unit of the Czech Aviation Authority (UZPLN), published only in Czech, concludes that “the probable cause of the serious incident was following the loss of a propulsion unit a faulty decision-making process by the aircraft commander that did not comply with the Quick Reference Handbook (QRH) and Flight Crew Training Manual (FCTM),” Aviation Herald reported.
The fuel pump was already running dry before the flight during which the incident occurred, according to the Defect Logbook, and once the left side engine failed, the crew failed to follow mandatory procedures and land at the closest suitable airport. Instead, the report says, they proceeded to descend from 36,000 feet to 24,000 feet and continue the flight for further 2 hours and 20 minutes and land at their scheduled destination at Ruzyne International Airport in Prague.
Short-Term Follow Up By Police
Immediately following the incident, the Prague Police opened a formal investigation for a possible offense of reckless endangerment, Czechjournal.cz reported. This investigation led to a criminal procedure initiated on Nov. 27, 2019, by the District Prosecution Office in Prague for suspicion of committing a crime of endangering the public due to negligence.
The investigation could not rely on the cockpit voice recorder as it had already been overwritten by a subsequent flight, but investigators were able to download the data from the flight data recorder.
It has been ascertained that the engine failure happened while the aircraft was at 36,000 feet, at which point the crew reported a “maintenance issue” to Air Traffic Control without declaring an emergency. After unsuccessfully trying to restart the engine twice, the captain pinpointed Prague as the closest airport and reported the engine failure and declaring “PAN” — a radio term meant to signify an emergency — only when in contact with Prague Air Traffic Control. The UZPLN investigation noted there were three other suitable diversion airports closer than Prague that could and should have been selected for a diversion.
The aircraft landed in Prague with 2,340 kilograms of fuel, which would have not been enough to divert from Prague to their alternate airport as defined by the flight plan had something gone wrong that would have prevented a landing in Prague. That, in turn, would have forced them to declare an emergency — in this case, a more urgent “mayday” call.
In September 2019, a Smartwings internal investigation had concluded that the incident was caused by a crew error. The captain was removed from his position of head of flight operations but continued to fly for Smartwings, maintaining his instructor privileges.
Smartwings is a Czech low-cost airline founded in 1997 operating a fleet of 35 Boeing 737 aircraft — including -700, -800, -900ER and MAX 8 variants — to 65 destinations, many of them seasonal and located in vacation destinations in the Mediterranean area and in the Middle East.
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