DALLAS — Lithuanian aviation authorities have released an interim report into the Swiftair (WT) Boeing 737-400SF crash on November 25, 2024, while on approach to Vilnius Airport (VNO). The report identifies cockpit errors and system mismanagement as the principal culprits in the accident.
The aircraft was performing a cargo flight for the European Air Transport Leipzig (QY), a DHL (D0) subsidiary, when it crashed during the final approach, killing the captain and seriously injuring the first officer and two passengers.
The Lithuania Republic Ministry of Justice’s Transport Accident and Incident Investigation Division report identifies telling moments in the flight when miscommunications, procedural slippages, and configuration fallibilities multiplied into a tragic outcome.
Flight Information, Timeline of Events
The Boeing 737-400SF took off from Leipzig—Halle Airport (LEJ) at 02:08 UTC (03:08 local time) on a scheduled cargo flight bound for Vilnius. The first part of the flight was uneventful. However, at 03:01 UTC, a chain of procedural and technical mistakes started to unravel during the approach phase:
- 03:01—The approach briefing begins and includes the descent checklist, which is completed five minutes later. More specifically, the landing data step is omitted.
- 03:09—The captain, who is the pilot monitoring (PM), makes an unsuccessful call to the Vilnius Area Control Center (ACC).
- 03:10—The captain successfully established contact with Vilnius ACC after coordination with the first officer.
- 03:12—Both pilots discuss activating the anti-icing system; however, as later verified during the investigation, both anti-ice switches are in the OFF position.
- 03:17—One of the pilots accidentally turns off both the electric and engine-driven hydraulic pumps of Hydraulic System B. This cuts off hydraulic pressure to vital flight control components, such as the flaps. A warning light comes on, and the autopilot subsequently disconnects with an audible alarm that the crew mutes.
- 03:22—The approach checklist is complete, but the landing checklist is omitted. The first officer asks if anti-ice was being used, and the captain accidentally acknowledges it.
- 03:24–03:26—The pilot flying calls for “Flaps 5,” but FDR data indicates that the flaps are not extended.
- 03:26—The gear is lowered, and “Flaps 15” is called, but the captain warns that the approach speed is still too high.
- 03:27—The crew attempts to switch to the local tower frequency, but minutes before impact, they are no longer on either frequency.
- 03:27:56—The Captain notices the flaps remain retracted. Indicating an impending aerodynamic stall. EGPWS gives multiple alerts: “Sink Rate” and “Pull Up”.
- 03:28:01—A go-around is initiated, and the autothrottle increases thrust.
- 03:28:07—EGPWS sounds “Too low, terrain” alert.
- 03:28:08—The aircraft hits the terrain, killing the captain and seriously injuring three others on the plane.
Identified the Key Contributing Factors
- Deactivation of Hydraulic System B:
One of the biggest mistakes was the accidental deactivation of Hydraulic System B which severed hydraulic pressure to key flight control systems such as flaps that aid in landing that severely limited the aircraft’s landing configuration and deceleration capability. The flaps never extended, remaining fully retracted throughout the final approach phase.
- Anti-Ice System Mismanagement:
The crew did not activate the anti-ice systems despite knowing the potential weather conditions. Later on, investigators established that both the wing and engine anti-ice switches were in the OFF position. The omission might have negatively impacted the aircraft’s aerodynamic performance.
- Communication Errors
Communication breakdowns compounded cockpit confusion. Though unsuccessful in reaching Vilnius ACC, the crew eventually established contact but later attempted to switch to the tower frequency, stymied by a series of mistakes. During the final approach, the aircraft did not contact either approach or tower controllers.
Victims, Damage, Regulation
The captain was pronounced dead on the scene. The co-pilot and two passengers were seriously injured. Investigators have not yet interviewed the first officer due to his medical condition. Miraculously, even though the aircraft hit the buildings near the airport, no one on the ground was injured.
The interim report also confirmed that the aircraft was operated and maintained to European Union Aviation Safety Agency (EASA) standards and that no findings indicated mechanical failure before the pilot-induced errors.
Next Steps
The team will continue the investigation, focusing on crew training, ensuring procedural compliance, and operating aircraft systems. A report detailing the findings is expected to be published later this year.
Preliminary findings emphasize the necessity of maintaining checklist discipline, systems awareness, and effective communication throughout all phases of flight, particularly during demanding approaches.
The featured image shows EC-MFE, the aircraft involved in the accident.
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