AN air safety probe found that nine separate factors combined to doom a 19-year-old US turboprop aircraft as it attempted to land at Cork Airport in thick fog.
The factors ranged from a power differential between the Fairchild's two engines, poor crew decisions in challenging conditions, inadequate training and crew fatigue.
The nine key factors identified by the AAIU include:
* The approach was continued in conditions of poor visibility below those required.
* The descent was continued below the decision height without adequate visual reference.
* Uncoordinated operation of the flight and engine controls when go-around was attempted.
* Engine power-levers were retarded below the normal in-flight operational range – an action prohibited in flight.
* A power difference between the engines became significant when the engine power levers were retarded below the normal in-flight range.
* Crew tiredness and fatigue.
* Inadequate command training and checking.
* Inappropriate pairing of flight crew members.
* Inadequate operator oversight.