The Black Hole Business Model: The crash of Manx2 flight 7100

Manx2 flight 7100 lies upside down after crashing in Cork, Ireland. (Alchetron)

On the 10th of February 2011, an Irish commuter plane operating a regular flight between Belfast and Cork suddenly flipped over and crashed while attempting a go-around in bad weather. The plane skidded off the runway upside down, killing 6 of the 12 people on board — a major air disaster for Ireland, which has a stellar safety record. But as investigators tried to piece together the circumstances leading up to the accident, they began to uncover a convoluted network of sketchy companies behind the “airline” and its operations. In fact, there didn’t seem to be an airline at all; instead, there was some kind of Frankenstein’s monster made up of separate entities each agreeing to manage some aspect of the operation. It became clear that with such a diffusion of responsibility, safety had fallen by the wayside. Regulatory violations were rampant in areas ranging from flight duty time limits to company organization to pilot training. The scale of the mess was staggering. How could such a dangerous airline go unnoticed by the authorities? And was this “black hole” business model somehow connected to the crash?

EC-ITP, the aircraft involved in the accident. (AAIU)

Manx2 flight 7100 was a regularly scheduled international commuter flight from Belfast, Northern Ireland, to Cork, Ireland. Manx2.com offered a handful of short flights to destinations in the UK, Ireland, and its operational base on the Isle of Man using a mixed fleet of small commercial airplanes with fewer than 20 seats. Among them was a Fairchild SA-227 Metro III, a twin turboprop commuter plane commonly known as the Metroliner. It was this plane that arrived in Belfast on the morning of the 10th of February 2011 to operate flight 7100 to Cork.

Scheduled to fly the route that day were Captain Jordi Sola Lopez, from Spain, and First Officer Andrew Cantle, from England. Lopez had only about 1,800 flying hours total, low for a captain, and had in fact been flying as captain without supervision for only four days. Cantle was even less experienced, with only 539 total hours; he had been hired barely more than a week earlier and had just come out of training. In fact, he had not yet completed all of the line checks required by law and was supposed to be flying with a training captain, but the airline had nevertheless started scheduling him on regular flights with regular crews.

Route of flight 7100. (Google)

In Belfast, ten passengers waited at the gate to board flight 7100 to Cork. However, there was an unexpected delay: because the plane was used to run cargo flights for Royal Mail during the night, the pilots had to reinstall the passenger seats before the first flight of the day, and this took longer than expected. Because the airline had no baggage handler in Belfast, First Officer Cantle was also tasked with loading the passengers’ bags onto the plane, although he lacked the proper certification to do this.

Once the plane was ready, the passengers boarded, and Cantle gave the pre-flight safety briefing because the plane was too small to carry a flight attendant. At 8:10 a.m., the flight finally took off from Belfast, its pilots planning to arrive in Cork after one hour. However, weather conditions in Cork at that moment were below the minimums allowed for landing and were expected to stay that way for some time. The pilots were using an outdated weather forecast from earlier that morning and never requested an updated weather report while on the ground in Belfast, leaving them unaware of just how bad the conditions were. Because conditions at the destination were below the minimum at the time of departure, they were supposed to file a flight plan listing two alternate airports, but they didn’t do this.

By the time flight 7100 made contact with Cork, fog had enveloped the airport, reducing visibility below the 550 meters required for a Metroliner to land. Hoping that this was a temporary situation and that conditions would improve, Lopez and Cantle decided to try to approach runway 17 anyway. With visibility below the minimum, regulations prohibited them from continuing beyond the outer marker (the last radio beacon on the approach course) if conditions did not improve. However, the pilots either were unaware of the rule or chose to disregard it, and they continued the descent beyond the outer marker in an attempt to catch sight of the runway.

At 9:03, flight 7100 reached its decision height of 200 feet — the point at which the pilots were obligated to perform a go-around and abandon the approach if they could not see the runway. However, Lopez and Cantle continued descending straight through this altitude. Still unable to see the runway, Cantle — who was the pilot flying — initiated a go-around at a height of only 101 feet, while Lopez informed air traffic control that flight 7100 was making a missed approach.

After climbing out and circling back away from the airport, Lopez asked air traffic control for permission to approach runway 35 — the same runway but from the opposite direction — hoping that with the sun at their backs, visibility would be better. This didn’t change the fact that visibility was still well below the minimum, but once again, Lopez and Cantle continued past the outer marker and descended through the decision height. After descending to just 91 feet without catching sight of the runway, Cantle again initiated a go-around, and flight 7100 abandoned its second landing attempt.

An excerpt from the ATC transcript covering the period before and after the first go-around. Note that flight 7100 is using the callsign “Flightavia 400C.” (AAIU)

By now, it was becoming clear that landing in Cork might be impossible. Lopez decided that they should enter a holding pattern and wait to see if conditions improved before deciding whether to divert. While holding above Cork, the pilots discussed possible alternate airports. They requested the weather conditions in Waterford, their only designated alternate, but the controller informed them that visibility there was also below minima. The same was true in Shannon, and Dublin was marginal. Only in Kerry were conditions clear. Some minutes into the hold, First Officer Cantle suggested that they divert to Kerry, but before Lopez could respond, another pilot requested weather information for Cork, and the controller provided a slightly improved visibility figure. After overhearing this conversation, the pilots of flight 7100 believed that conditions might be improving and resolved to make one last attempt to land.

Southern Ireland with Cork Airport and alternates considered by the flight crew. (Google)

After visibility further increased to 500 meters, just shy of the minimum, Lopez and Cantle began the third approach at 9:40 a.m. A third approach is rather unusual — due to a high rate of accidents on the third approach, many airlines have limited flights to two approaches before requiring a diversion, but there is no regulatory limit on the number of approaches that may be carried out. Under pressure to keep the schedule and get the passengers to their destination, the pilots of flight 7100 decided to take the risk.

As the Metroliner descended toward the airport, visibility improved above the minimum, and it seemed like there might be some hope of landing. But the fog soon thickened again, and visibility on runway 17 dropped back below 550 meters. Nevertheless, Lopez and Cantle continued the approach.

Throughout the flight they had been dealing with an annoying mechanical problem with the plane’s right engine. Due to an improperly manufactured sensor, the right engine’s fuel flow regulator was receiving temperature information that was 57˚C too cold. One of several manifestations of this problem was that the right engine produced about 5% more torque than the left engine; and consequently, its propeller was spinning about 5% slower at any given power setting. This in turn affected the thrust output of the propeller, which is a function of rotation speed and blade pitch. In order to balance the amount of thrust produced by the two engines, the throttle levers had to be left in a slightly staggered position at all times. As Lopez and Cantle struggled to find the runway on their final landing attempt, this was yet another problem that they had to keep in mind.

The pressure/temperature sensors from the two engines. Can you spot the differences? [Note: airplane engines are traditionally numbered from left to right.] (AAIU)

During the approach, Lopez decided that he would ease Cantle’s workload by taking over control of the throttle levers. This was very much a non-standard maneuver, and for good reason: the pilot flying the plane should always be controlling the throttles in order to improve his or her reactions to the movement of the aircraft. Cantle was therefore left out of the loop when Lopez made a critical piloting error: while attempting to reduce thrust to modify their descent rate, he pulled the throttles back to below the flight idle position. “Flight idle” is the lowest power setting used during flight, in which the engines deliver little to no forward thrust. Below this is a zone called the “beta range,” which lies between forward thrust and reverse thrust. Unlike jet aircraft, reverse thrust on a propeller plane is not a separate system; instead, reverse thrust exists on the same input spectrum as forward thrust, because both thrust direction and magnitude are controlled by the blade pitch. Therefore, reverse thrust — used only for braking or reversing on the ground — is activated by moving the throttle levers back past flight idle, through the beta range, and into the full reverse position. When Lopez moved the throttles back, the right throttle rested in the flight idle detent as he intended, but the staggered left throttle (which had been left on a lower power setting than the right throttle due to the thrust mismatch) went past this point and into the beta range, causing it to produce a small amount of negative thrust. Over a period of several seconds, the reversed left engine caused the plane to bank forty degrees to the left.

Data from the last 20 seconds of the flight. At point 2, note how the torque output of the left [no. 1] engine goes negative, and the aircraft rolls to the left up until point 4. (AAIU)

As the left bank increased, Lopez uttered an exclamation of surprise and called out, “Go around!” As Cantle pulled up to climb, Lopez shoved the throttle levers forward to go-around power, in the process forgetting to keep them in the staggered position. When the throttle levers were left in the same power setting, the left engine generated more thrust than the faulty right engine, so the left wing began to rise, rotating the plane level. But after that, it kept going, raising the left wing further and causing the plane to bank back to the right! Within seconds, the Metroliner rolled over ninety degrees to the right, catching the pilots completely by surprise. Before they could react to the upset, the plane lost altitude and struck the runway right wing down, shredding the wingtip as the aircraft rolled inverted. Flight 7100 crashed to earth upside down and slid off the runway onto the grass, ripping open the front half of the plane and sending a wall of mud plowing backward through the cabin. After a few terrifying seconds, the plane came to a stop on its roof, its forward fuselage crumpled like an accordion into the ground.

Animation of the crash. (Mayday)

In the control tower, an alarm suddenly sounded as specialized equipment detected a signal from the plane’s emergency locator beacon. Controllers attempted to contact flight 7100, but there was no response, confirming that the plane must have crashed. The crash alarm was activated and fire trucks rushed to the scene, discovering the plane lying upside down off the side of runway 17 with its engines on fire. After quickly dousing the flames, firefighters set about the difficult task of rescuing the passengers still trapped inside. All the doors had been crumpled on impact and could not be opened, so rescuers had to cut their way in through the baggage compartment. Upon entering the cabin, they found that several passengers seated in the back of the plane had survived the crash, and they were pulled to safety. To reach some of the survivors further to the front, where the cabin had been crushed down to the top of the seat backs, firefighters had to cut out each row of seats to move forward and free people from the tangled wreckage. But after six passengers had been pulled alive from the plane, a massive plug of mud and grass blocked further progress, and it was clear that no one else could have survived.

Rescue workers respond to the scene of the crash. (BBC)

In all, six of the twelve people on board were killed in the crash, including both pilots. All the victims had been seated in the front of the plane and died instantly when the forward fuselage crumpled. Although the crash might seem small compared to the disasters that periodically plaster the front pages of newspapers, Ireland had not had a fatal commercial airline accident since 1968, making this the worst crash on Irish soil in more than 40 years. Accordingly, Ireland’s Air Accident Investigation Unit (AAIU) launched one of the largest investigations in its modern history in order to uncover the cause.

Inside the cabin after the crash. (AAIU)

After analyzing the flight data and cockpit conversations, it became apparent that the proximate cause of the crash was a loss of control due to asymmetric thrust, which in a moment of extremely high workload the pilots failed to counter. When he accidentally decelerated the left engine into the beta range, Lopez caught himself by surprise; the ensuing go-around was therefore performed with the aircraft in an unusual attitude while very close to the ground, and in the pressure of the moment, he forgot to keep the throttles staggered. Because he was not receiving feedback from the throttles, Cantle didn’t realize what was happening until too late, and the plane impacted the runway.

Aerial view of the crash site. (AAIU)

However, the events in the last seconds of the flight made up only part of the story. An analysis of all three of flight 7100’s attempted approaches revealed some troubling issues. First of all, none of the approaches were legal, because when visibility is below the minimum the approach cannot be continued past the outer marker. The pilots also descended below decision height on every approach. And interviews with surviving passengers revealed that the pilots had to reinstall the seats into the aircraft and load the baggage by themselves. Both of these tasks required licenses that neither pilot had, and the loading procedure was supposed to be approved by a competent authority, which had not occurred. On this one short flight, so many rules had been broken that investigators had to ask: what was wrong with this airline?

First responders continue to survey the scene after the survivors have been removed. (Aviation Safety Network)

It didn’t take much digging for investigators to discover that Manx2 wasn’t actually an airline at all. It simply sold seats on flights using planes belonging to several other companies, who allowed Manx2 to use its branding and livery on their aircraft. The airplane itself was owned by a Spanish bank, which had leased it to a Spanish company called Linéas Aéreas de Andalucia (or Air Lada for short). Air Lada had in turn sub-leased the aircraft to another Spanish airline called Flightline S.L., which held the Air Operator Certificate (AOC) under which the flights were conducted. Air Lada, considered the owner of the plane, had a contract with Manx2 to use the aircraft, even though it was operated by Flightline; there was in fact no communication between Flightline and Manx2 at all. The pilots were employed by Air Lada but were trained by Flightline and their point of contact worked for Manx2. Maintenance was provided by another Spanish company which had a contract with Flightline, but in practice the maintenance bills were sent directly to Air Lada. During the night, the plane flew cargo for the Royal Mail, for which Air Lada had a separate contract with a UK company called Air Charter Services. Air Charter Services held the AOC for those flights, which were conducted without the involvement of Flightline or Manx2. Air Lada, as it turned out, was also not an airline because it lacked an Air Operator Certificate; rather, it was a regular company that owned aircraft, which it leased out to actual airlines that carried out the operations described in contracts signed between Air Lada and various third parties. There was in fact no airline in the traditional sense; rather, there was a bizarre amalgamation of several companies that each carried out part of the duties of a real airline, like some kind of Frankenstein’s monster made out of scraps from the bottom of the corporate barrel.

A handy chart: how the “airline” was owned and operated. (Own work)

Looking into the history of this arrangement, investigators found that the role of the Operator had previously been held by a different Spanish airline called Eurocontinental Air, but after a series of incidents in the UK, Spain’s State Aviation Safety Agency (AESA) had revoked this company’s AOC. To carry out the contract with Manx2, Air Lada replaced Eurocontinental Air with Flightline S.L., but kept using the same planes and some of the same crews. For passengers who thought they were flying with an airline called Manx2, it would not have appeared as though anything changed. In fact, the UK’s Civil Aviation Authority had previously become concerned that Manx2 was branding itself as an airline, and ordered it to include a disclaimer on its website listing the actual airlines for which it acted as the ticket seller.

Promotional material for the 2010 launch of a new Manx2.com service between Galway and Belfast featured Melissa Magee dressed as a “Manx cat” while advertising the route. (Galway Advertiser)

Despite all its cost-cutting measures, records revealed that Air Lada was in financial stress well before the crash. The company had been struggling to pay for repairs to another Metroliner that had been damaged in a hard landing, and it was unable to give pilots their paychecks on time. This was a clear red flag that the company was in trouble, and sure enough, the longer investigators looked, the more violations they found.

A crane lifts the wreckage in preparation for transport off airport. (Reuters)

Besides the infractions already listed, numerous other violations were discovered. Flightline was required to provide a “data frame layout” which would help investigators decode the information on the flight data recorder; however, it was unable to produce one. The identification stickers on the propeller blades contained serial numbers that didn’t match the ones printed on the blades themselves. Maintenance defects were not being reported in the aircraft’s technical log book, possibly because Air Lada and Flightline had no maintenance outstations in the British Isles capable of dealing with them. Such an outstation, equipped with personnel and equipment, was also required in order to convert the plane between passenger and cargo configurations, but the pilots were doing this themselves. Regulations required airlines to avoid pairing new commanders with inexperienced first officers, but Flightline did not appear to have considered this whatsoever (and in fact pairing Lopez with Cantle was highly questionable). Flightline thought a different copilot was involved in the accident and was unaware of a mid-week roster change, even though as the AOC holder it was supposed to be responsible for crew rosters. Flightline’s own training manual specified a minimum of 10 hours of crew resource management training for commanders, but Lopez had only received 2.5 hours. Lopez’s final check ride before being promoted to captain was supposed to last two hours and include four landings, but it actually lasted only 40 minutes with two landings, not enough time to determine whether he was fit for command. First Officer Cantle had not finished all of his line checks and was not supposed to be flying without an instructor captain. And flight duty time limits were being violated constantly — just in the four days before the crash, Lopez had twice been asked to start work before his legally mandated rest period was over, and during that same period Cantle once exceeded the maximum time on duty by more than two hours, including an entire flight that was carried out illegally.

Another view of the wreckage removal process. (Irish Examiner)

In such an environment, it was obvious that an accident or serious incident was inevitable. Overworked, tired, and missing required training, the pilots were unprepared for basic aspects of the job. They weren’t getting paid on time, and they were flying in weather conditions much worse than those encountered during their training in Spain. They hadn’t been getting enough sleep and were likely suffering from fatigue, causing impaired decision-making and reduced situational awareness. And they were under pressure from higher-ups to keep flights on schedule; in fact, the contract between Air Lada and Manx2 included penalties if flights were late or if an aircraft had to be removed from service. All of these factors came to a head on a risky third approach in bad weather, a situation that was already so dangerous that many airlines avoided it altogether. If anything, it was surprising that a crash didn’t happen earlier.

Note the open baggage compartment door, through which firefighters managed to gain access to the interior. (Bureau of Aircraft Accidents Archives)

Investigators now had to ask: how could such widespread violation of regulations go undetected by the appropriate authorities? Because the plane was owned and operated by Spanish companies, oversight responsibility lay with Spain’s AESA. But Irish investigators discovered that the AESA was totally unaware of the existence of the Air Lada-Flightline-Manx2 operation in the British Isles. The AESA knew that Flightline was operating two sub-leased Fairchild Metroliners, but did not know what it was using them for. It knew nothing of the contract between Air Lada and Manx2 because Air Lada was not technically an airline and was therefore not under its purview. However, in practice the flights in the British Isles were scheduled and overseen by Air Lada, while Flightline exercised little to no control over day-to-day operations, in particular the night flights for Royal Mail; therefore, because Air Lada was the company which had the aircraft at its continuous disposal, it was legally the operator. However, Air Lada held no Air Operator Certificate, putting the entire UK-Ireland-Isle of Man operation in contravention of regulations. Air Lada was effectively using a loophole of questionable legality to operate air carrier services without a license and without any regulatory oversight.

Third view of the wreckage recovery. (TheJournal.ie)

Regardless of Air Lada’s legal shenanigans, the AESA did oversee Flightline S.L. and should have caught on to its inability to properly carry out the operation in the British Isles. However, when Flightline added the two Air Lada Metroliners to its fleet in 2010, the AESA approved the expansion without checking whether the company was capable of properly operating, maintaining, and overseeing an increase in fleet size. Regular checks of Flightline’s maintenance and flight operations failed to uncover the fact that the Metroliners were operating out of a remote base in the Isle of Man. The AESA’s Irish and British counterparts did not have the right under European Union law to exercise oversight authority of an airline registered in a different EU member state, so there was nothing they could do to discover the scope of the problem either.

View of the foward section, which was completely crushed. (Aviation Accidents Database)

By the time the investigation concluded, the AAIU had pieced together a picture of a convoluted air carrier operation that often skirted and sometimes outright broke the law. This led to two inexperienced and improperly trained crewmembers being paired together on a flight in bad weather with a plane that had a significant maintenance defect, resulting in the accident. Air Lada and Manx2 had effectively figured out how to fly passengers without the requisite licenses, without being beholden to safety regulations, and without getting caught. Clearly something needed to be done to prevent this from ever happening again.

As a result of their findings, Irish investigators recommended that the European Union establish clearly defined penalties for operators that violate flight duty time limits, provide a standardized syllabus for command training for new captains, and restrict ticket sellers from exercising operational control over accredited airlines with which they have contracts. Also as a result of the findings, the Spanish AESA banned Flightline from operating the Fairchild Metroliner, and ordered it and several other “problem airlines” to comply with a laundry list of urgent safety changes or face revocation of their air operator certificates. Flightline ultimately demonstrated enough improvement to satisfy the AESA; however, the operation under the Manx2 branding ceased. Manx2 went out of business in 2012 and its assets were bought out by another company that rebranded it as Citywing. (What happened to Air Lada, and whether they ever faced justice, is unclear.)

Another view of wreckage recovery. (The Irish Times)

The story of Manx2 flight 7100 is a cautionary tale for regulators, airlines, and passengers alike. Regardless of the temptation to skirt the rules, they exist for a reason, and non-compliance can and will result in preventable tragedies. Regulators must keep a careful eye on small, cash-strapped airlines that are likely to pull the sort of illegal cost-saving schemes used by Air Lada, Flightline, and Manx2. And passengers can exercise a certain level of scrutiny themselves: when booking flights on small planes with small airlines, it pays to research whether the airline is really an airline at all. When you fly, you effectively trust a company with your life, and if that company is using the black hole business model, it might be better to pass them by.

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Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.