Cirrus Aviation flight C91567 was a Do 328-100 that had taken off from Berlin-Tempelhof to a scheduled service to Mannheim City. Three crew members and 24 passengers were aboard the airplane. The co-pilot was the Pilot Flying (PF) during this flight.
After an uneventful cruise flight the approach to runway 27 was carried out according to the published LOC/DME approach procedure. A few seconds prior to the touch down the co-pilot handed over the controls to the Pilot in Command (PIC).
He continued the approach. Due to an inappropriate engine power setting the main landing gear touched down for the first time after the touchdown zone and the airplane touched down for good in the last 150 m of the runway.
The crew stated that after touchdown the power levers could, at first, not be pulled into idle and therefore no thrust reverse was available. Thereupon the Emergency / Park Brake (E/P Brake) was activated.
The airplane overshot the runway and hit an earth wall about 50 m behind the end of the runway.
The accident occurred at 1745 hrs CET.
The accident was due to the airplane overshooting the runway and hitting an earth wall at the end of the runway, the non-initiation of a balked landing, the fact that the power levers could not be pulled into ground idle or reverse by the PIC (PF), the fact that the landing was not aborted after the airplane had flown across the touch-down zone, the fact that the power levers were not pulled into flight idle during the flare which both pilots did not recognise, the fact that the crew deviated from the SOPs and therefore reached their performance limit and at the end went beyond it.
The following factors contributed to the accident:
- Within in the air operator the non-precision approaches and the landings at Mannheim City were conducted with significant frequency not according to the requirements of the OM.
- The TRs and FOIs of the aircraft manufacturer were not incorporated into the OM/B or OM/D of the air operator.
- The practical training of the crew by the air operator was insufficient regarding the prevention of an erroneous operation of the power levers based on the instruction published by the aircraft manufacturer.
- The crew conducted a non-precision approach which did not comply with the air operator’s OM requirements and the AIP.
- The power lever design was not sufficiently fault tolerant.
- The existing risks caused by the problems during the use of the power levers were not recognised correctly and remedied by the responsible authorities and type certificate holders in spite of several occurrences and safety recommendations.
- The touch-down zone at Mannheim City Airfield was not marked.
- The extent and design of the safety area at the end of runway 27 was not sufficient to ensure the safety level ICAO and the German legislator require for flight operations.