Crash of a Boeing 737-2K9 in Douala: 71 killed

Date & Time: Dec 3, 1995 at 2244 LT
Type of aircraft:
Operator:
Registration:
TJ-CBE
Survivors:
Yes
Schedule:
Cotonou – Douala
MSN:
23386
YOM:
1985
Flight number:
UY3701
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
71
Pax fatalities:
Other fatalities:
Total fatalities:
71
Captain / Total flying hours:
7990
Captain / Total hours on type:
5923.00
Copilot / Total flying hours:
5850
Copilot / Total hours on type:
4317
Aircraft flight hours:
18746
Aircraft flight cycles:
23233
Circumstances:
While on a night approach to Douala Airport, at a distance of 3,5 NM, the crew was cleared to land on runway 30. At this time, the aircraft initiated a slight climb and about 15 seconds later, the copilot informed ATC about technical problems. Three seconds later, the aircraft rolled to the left, struck trees and crashed in a mangrove located about 1,700 metres south of runway 30, bursting into flames. Three passengers and two crew members (the copilot and a stewardess) were seriously injured while 71 other occupants were killed.
Probable cause:
The accident resulted from a loss of control of the aircraft during an attempted go-around made during the touchdown maneuver on landing, with degraded performance.
The following factors contributed to the accident:
- The detachment by structural fatigue of a blade from the first stage of the compressor on engine n°1 which led to a loss of power, and
- A destabilization of the trajectory during landing and the late or slow execution of the go-around procedure in an unidentified single-engine configuration which resulted in an irreversible loss of speed.
Final Report:

Crash of a Boeing 737-2A8 in New Delhi

Date & Time: Dec 2, 1995 at 1253 LT
Type of aircraft:
Operator:
Registration:
VT-ECS
Survivors:
Yes
Schedule:
Bombay – Jaipur – New Delhi
MSN:
20963
YOM:
1974
Flight number:
IC492
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
102
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6088
Circumstances:
Following a wrong approach configuration, the aircraft landed too far down the runway, about 600 metres from the runway end. Unable to stop within the remaining distance, the aircraft overran, struck a concrete wall (45 cm high) and came to rest 450 metres further. All 108 occupants were evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The injudicious and imprudent decision of the Pilot-in-Command to hastily complete the flight in the inadequate time available before the notified closure of Delhi airport for a VVIP flight,
- The dangerously unstabilised approach made by the Pilot-in-Command, primarily due to his failure to decelerate the aircraft in time,
- The failure of the First Officer to call out significant deviations from the stipulated approach parameters,
- The failure of the Pilot-in-Command to carry out a missed approach in spite of his approach being grossly unstabilised,
- The inadvertent omission of the Pilot-in-Command to arm the speed brake before landing,
- Touch-down of the aircraft at excessive speed and too far down the runway,
- Failure of the First Officer and Pilot-in-Command to monitor the automatic deployment of the speed brake, and failure of the Pilot-in-Command to deploy it manually,
- Impact of the aircraft with an 18-inch high cement-concrete cable duct in the kutcha ground beyond the over-run area,
- The pilot disregard of procedures, regulations and instructions.
Final Report:

Crash of a Boeing 737-2F9 in Kaduna: 11 killed

Date & Time: Nov 13, 1995 at 0853 LT
Type of aircraft:
Operator:
Registration:
5N-AUA
Survivors:
Yes
Schedule:
Yola – Jos – Kaduna – Lagos
MSN:
22985
YOM:
1982
Flight number:
WT357
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
11
Aircraft flight hours:
22375
Aircraft flight cycles:
27567
Circumstances:
Nigeria Airways flight WT357 departed Yola (YOL) at 07:00 en route to Lagos (LOS). Intermediate stops were planned at Jos (JOS) and Kaduna (KAD). The Boeing 737 landed at Jos at 07:40 and departed fifty minutes later. The flight to Kaduna was uneventful. Kaduna ATC gave the aircraft an inbound clearance with no delay for a locator approach to runway 05. Though, the initial landing clearance was for runway 05, the captain requested to land on runway 23. He was reminded by the controller that the wind was from 090 magnetic, but he still insisted on using the 23 approach. At 08:42, the aircraft commenced its initial descent at 48 miles on the ILS/DME to 4,500 ft. At 08:49 UTC, it was cleared to 3,500 ft at 10 miles out and was later descended to 500 ft. The aircraft turned left from the track 310 to align with runway 23 and the aircraft was still in the turn when the threshold was sighted just 1.5 miles to the left of the aircraft. The first officer asked the captain "Can you make it to land from that position?". The observer in the jump seat also suggested going on the downwind, presumably to re-position the aircraft for landing on runway 05. There was no response at all from the captain and the approach was continued for runway 23. The left turn was very steep and it took the aircraft to the left of the runway centreline and a right correction was applied. The observer shouted "Watch the wing" as the wings could have struck the ground on the final approach. By this time, the aircraft crossed the threshold with the flying pilot still struggling to maintain directional control for runway centreline alignment. The aircraft touched down 7820 feet down the runway, leaving just 2020 ft (615.85 m) of runway length. The captain was reported to have used 1.8 and 1.6 EPR on the reversers. When a runway overrun became inevitable, the captain turned the aircraft to the left with the intention to take advantage of the last rapid exit intersection to avoid the runway end lights. At this juncture, the aircraft entered an uncontrollable skid. The right wing hit the ground, thus rupturing the fuel tanks and a huge fire erupted. The aircraft was destroyed by the fire.
Probable cause:
The probable cause of the accident is the continuation of a highly unstabilized approach when the option of a missed approach could have been taken. The contributing factor was the turn off at 76 knots into the high speed intersection when an overrun into the extended runway end should have been maintained.

Crash of a Boeing 737-2H6 on Mt San Vicente: 65 killed

Date & Time: Aug 9, 1995 at 2014 LT
Type of aircraft:
Operator:
Registration:
N125GU
Survivors:
No
Site:
Schedule:
Miami – Guatemala City – San Salvador – Managua – San José
MSN:
23849
YOM:
1987
Flight number:
GU901
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
58
Pax fatalities:
Other fatalities:
Total fatalities:
65
Captain / Total flying hours:
9828
Copilot / Total flying hours:
4696
Aircraft flight hours:
16645
Aircraft flight cycles:
20323
Circumstances:
Following an uneventful flight from Guatemala City, the crew was cleared to start the descent to San Salvador-Comalapa Airport but encountered poor visibility due to the night and heavy rain falls. In thunderstorm activity, the crew was cleared to modify his route while descending to the airport. After being cleared to descend to 5,000 feet, the GPWS alarm sounded. The captain applied full power when the aircraft struck trees and crashed in a dense wooded area located on the Mt San Vicente (Chichontepec Volcano - 2,181 metres high), about 25 km northeast from runway 25 threshold. The aircraft disintegrated on impact and all 65 occupants were killed.
Probable cause:
The probable cause of the accident was the flight crew's lack of situational awareness in relation to the 7,159 foot obstruction, the flight crew's decision to descend below the MSA while deviating from a published transition or approach, and the ambiguity of position information between both the flight crew and the air traffic controller which resulted in the controller's issuance of an altitude assignment that did not provide terrain clearance. Contributing to the accident was the failure of the First Officer to direct his concern of reported positions to the Captain in a more direct and assertive manner and the failure of the controller to recognize the aircraft's reported position relative to obstructions and give appropriate instructions/warnings. An ineffective CRM program at Aviateca also contributed to the accident.
Final Report:

Crash of a Boeing 737-2A1 in São Paulo

Date & Time: Feb 2, 1995 at 0008 LT
Type of aircraft:
Operator:
Registration:
PP-SMV
Survivors:
Yes
Schedule:
São Paulo – Buenos Aires
MSN:
20968
YOM:
1974
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
121
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
6500.00
Copilot / Total flying hours:
4500
Copilot / Total hours on type:
2500
Circumstances:
Following a night takeoff from São Paulo-Guarulhos Airport, en route to Buenos Aires, the captain informed ATC about technical problems and was cleared to return for an emergency landing. The aircraft landed at a speed of 185 knots with flaps down to 15° on wet runway 09L. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest 200 metres further. All 128 occupants were evacuated safely, among them two passengers were slightly injured. The aircraft was written off.
Probable cause:
It was determined that the n°3 leading edge flap actuator attachment fitting on the wing front spar had fractured due to corrosion. The actuator came away and caused the failure of some hydraulic lines and damage to the thrust control cables. Some 1981 Boeing Service Bulletins had not been complied with. One of these included the replacement of the aluminium leading edge flap actuator attachment fitting with a steel one; this had not been done. The following contributing factors were reported:
- Excessive workload on approach and landing due to the emergency situation,
- Poor approach planning,
- Lack of visibility due to the night,
- Poor crew coordination,
- Poor crew resources management,
- The crew forgot to lower the flaps electrically on approach, causing the speed to be 32 knots in excess,
- Poor aircraft maintenance and supervision,
- Failures in the supervision of the Company's operating sector.
Final Report:

Crash of a Boeing 737-281 in Yogyakarta

Date & Time: Jan 16, 1995 at 1930 LT
Type of aircraft:
Operator:
Registration:
PK-JHF
Survivors:
Yes
Schedule:
Jakarta – Yogyakarta – Denpasar
MSN:
20508/287
YOM:
1971
Flight number:
SG416
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on wet runway 09, the aircraft was unable to stop within the remaining distance. It overran, lost its nose gear and came to rest 100 metres further. All 58 occupants escaped uninjured while the aircraft was damaged beyond repair. A thunderstorm just passed over Yogyakarta Airport before the flight SG416 arrived from Jakarta and the approach was completed in a 30° flaps down configuration. Apparently, the braking action was poor.

Crash of a Boeing 737-298C in Kinshasa

Date & Time: Jan 2, 1995
Type of aircraft:
Operator:
Registration:
9Q-CNI
Survivors:
Yes
MSN:
20793
YOM:
1973
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Kinshasa-N'Djili Airport was completed in poor weather conditions. For unknown reasons, the aircraft landed hard and nose first. Upon impact, the nose gear collapsed and the aircraft came to rest. There were no casualties but the aircraft was damaged beyond repair.