The Irish Air Accident Investigation Unit (AAIU) is taking aim at “systemic deficiencies at the operational, organizational and regulatory levels” for European airlines in its final report into the fatal February 2011 crash of a Manx2 Metro III with 10 passengers.

The turboprop aircraft was attempting to land in dense fog at Cork after a scheduled flight from Belfast City.

The AAIU has issued 11 recommendations, in part targeting cross-border airline operations after what officials say was the “most challenging” of the 500 investigations in the unit's 20-year history. The Metro III pilots were making a third landing attempt at Cork in fog when they lost control during an attempted go-around and crashed near the runway. Both pilots and four passengers were killed. Six passengers survived, including four with serious injuries.

While the probable cause—loss of control during an attempted go-around initiated below the 200 ft. decision height for a Category 1 instrument approach—was not surpising given the number of landing attempts, the lack of operational control and lapses in oversight of the non-traditional Manx2 “airline” were eye-opening.

Based in Isle of Man, Manx2 was selling tickets for UK, Irish and Isle of Man scheduled service on an aircraft owned by a Spanish bank and leased to a Spanish company, Air Lada, that did not have an air operator certificate (AOC). Air Lada, however, subleased the Metro to another Spanish company, Flightline, that did have an AOC.

Investigators say Manx2 had an arrangement with Air Lada to supply aircraft and crews for its scheduled flights, but had neither a contract nor communications with Flightline. “Some of the operational responsibility of the operator as AOC holder, including operational control, were being inappropriately exercised by the owner and ticket seller,” says the AAIU. Manx2 was running passenger flights through four operators with AOCs—Flightline, a German operator, a Czech operator and a UK operator—all “under the ticket seller's brand name and livery,” says the AAIU final report. All the operations were legal under rules governing passenger aircraft with 19 or fewer seats.

Four recommendations to the European Commission include a call to review flight and duty time rules and the role of ticket sellers, restricting the businesses from exercising operational control. The assessment will not include Manx2 as the company went out of business in December 2012.

The AAIU also wants Spanish regulators, who said they had no knowledge of Flightline's remote operation in the UK and Ireland, to review policy regarding continuing oversight of air carriers conducting remote operations. The three recommendations to the European Aviation Safety Agency include consideration of the number of successive instrument approaches that should be allowed at an airport. Flightline, which still operates in the region, received two recommendations regarding its operational and training policies.

Post-accident analysis showed the Manx2 pilots to be ill-fit for the flight, both in terms of fatigue and pairing. The captain, who had been upgraded from co-pilot only four days earlier, was not “fully rested,” says the AAIU. The co-pilot, who was the “pilot-flying” on the accident flight, had not completed his initial line check and had exceeded European flight and duty time limits by 2.5 hr. A survey of all seven pilots in Flightline's Manx2 operation revealed additional duty time and rest exceedences, including one pilot's duty time of more than 20 hr.

On the accident flight, the pilots requested two Category 1 instrument approaches at Cork despite ceiling and visibility below the capabilities of the aircraft and crew. On both approaches, the co-pilot descended to approximately 100 ft. before initiating a go-around. The crew then requested a holding pattern to wait for visibility to improve. In the hold, visibility reports from Cork showed some improvement and the pilots initiated another approach. Once again, the visibility was below minimums with the co-pilot flying. However at 200 ft., the captain took the throttles, reducing the levers below idle into the negative thrust, or beta, range, an option that is only allowed on the ground for turning but may have been used in this case for a rapid descent to the runway. A defective sensor in the left engine spurred a surge in negative thrust on that engine, causing a 40 deg. roll to the left. The pilots then initiated a full-power go-around, which likely caused an uncontrollable roll rate to the right due to asymmetrical thrust and drag. c