Investigation Summary
The flight was a routine employee transport service leased from the Swiss firm Avisto. During the cruise at FL070, the aircraft encountered meteorological conditions conducive to icing, with outside air temperatures around -6°C. Although the crew noticed ice forming on the windshield and activated the windshield and pitot anti-icing systems, they neglected to turn on the engine anti-icing. Cockpit Voice Recorder (CVR) data revealed the pilots were deeply engaged in a technical discussion about the Fokker F28, an aircraft also operated by the company, which distracted them from monitoring engine parameters. As the aircraft descended toward Marsa Brega, it passed through the freezing level (approximately 5,200 feet). The sudden melting of accumulated ice led to massive water ingestion in both Pratt & Whitney Canada PT6A-67R engines. The left engine flamed out first, followed shortly by the right. The crew failed to activate the engine ignition system, which could have provided continuous ignition to prevent the flameout or facilitate an immediate relight. The crew attempted to ditch the aircraft, but the impact destroyed the nose and caused the tail to detach, leading the wreckage to sink rapidly in 38 meters of water. Survival was further compromised by a lack of lifejackets and the fact that many passengers were unaware that their seat cushions were designed to be used as flotation devices.
Final Conclusions
The Libyan Civil Aviation Authority concluded the primary cause was the melting of ice formed at the engine intakes, resulting in water ingestion and subsequent double engine flameout. Contributing factors included the flight crew's failure to operate the engine anti-icing system and their engagement in a discussion not relevant to the flight, which detracted from their monitoring of the aircraft's condition.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Libyan national, aged 42.
First Officer
Libyan national, aged 49.
Systems & Failure Modes
Engine Anti-Icing
A system designed to prevent ice buildup in the engine intakes; its non-use led to ice accumulation and subsequent water ingestion.
Engine Ignition System
A system that, if activated, provides continuous ignition to prevent flameouts in heavy precipitation or icing; the crew failed to use this to attempt a relight.
GPWS
The Ground Proximity Warning System activated during the final descent after the total loss of engine power as the aircraft approached the water in an unsafe flight condition.
PT6A-67R Engines
The turboprop engines flamed out after ingesting water from melted ice accumulated during the flight.
Interesting Facts
- 01The aircraft was leased from Swiss operator Avisto Air Service.
- 02The freezing level at the time of the accident was approximately 5,200 feet.
- 03There were no lifejackets on board the aircraft.
- 04The wreckage sank to a depth of 38 meters about 5 kilometers (3.1 miles) from the coast.
- 05Both the Captain and First Officer survived the ditching.
- 06The 22 fatalities include 21 confirmed dead and one person missing, presumed dead.
- 07Due to a company shortage of first officers, the flight was operated by two captains, though one served in the First Officer role.
- 08The 41 souls on board included 16 Libyans (including 2 crew), 13 Britons, 3 Indians, 3 Filipinos, 2 Canadians, 2 Croatians, 1 Pakistani, and 1 Tunisian (crew).
Safety Actions & Advisories
Ditching Procedures Review
Investigators recommended the inclusion of correct ditching techniques in zero-flaps conditions following a total loss of power in training manuals.
Passenger Safety Briefings
Recommendations were made to ensure passengers are clearly informed of the flotation capabilities of seat cushions when lifejackets are not provided.
Known Controversies & Unanswered Questions
Absence of Lifejackets
Reference ↗The investigation highlighted a significant safety oversight: the aircraft was not equipped with lifejackets despite operating over water. This led to several drownings as passengers were unaware that seat cushions were intended for flotation.
Crew Distraction and CRM
Reference ↗The CVR revealed the crew spent a significant portion of the flight discussing the Fokker F28, a different aircraft type. This non-pertinent conversation was cited as a primary reason for their failure to notice icing conditions and engine parameter changes.