Crash of a Boeing 737-200 in Coventry: 5 killed

Date & Time: Dec 21, 1994 at 0953 LT
Type of aircraft:
Operator:
Registration:
7T-VEE
Flight Type:
Survivors:
No
Schedule:
Algiers - Amsterdam - Coventry
MSN:
20758
YOM:
1973
Flight number:
AH702P
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10686
Captain / Total hours on type:
2187.00
Copilot / Total flying hours:
2858
Copilot / Total hours on type:
2055
Aircraft flight hours:
45633
Circumstances:
The Boeing 737, named "Oasis" was owned and operated by Air Algerie and had been leased by Phoenix Aviation in order to operate a series of live animal export flights from the UK to France and the Netherlands. On December 21, at 06:42 the plane departed from Amsterdam for a flight to Coventry. Weather at Coventry worsened and when arriving near Coventry, the RVR for runway 23 was 700 metres. The aircraft was not able to receive the Coventry runway 23 ILS as its dual navigation receiver system was not to an updated 40 channel ILS standard, so an SRA approach was flown. The radar guidance was completed at 0,5 miles from touchdown; the commander decided to discontinue the approach and execute a go-around. A holding pattern was then taken up at 07:44. When holding, the RVR further reduced to 600 m and the flight diverted to East Midlands to wait on the ground for weather improvement. The aircraft landed there at 08:08. At around 09:00 weather conditions improved to 1200 m visibility and an overcast cloud base at 600 feet. The flight departed East Midlands at 09:38 and climbed to FL40. Approaching Coventry, the crew received radar vectors for a runway 23 approach. After some initial confusion about the heading (the controller wanted the crew to turn left for 010°, while the crew understood 100°) the turn was continued to 260° and the SRA approach started at 12 miles from touchdown. The aircraft descended below the Minimum Descent Height (MDH) for the approach procedure and collided with an 86 feet high (291 feet ams) electricity transmission tower (pylon) which was situated on the extended centreline of the runway, some 1.1 miles from the threshold. The collision caused major damage to the inboard high lift devices on the left wing and the left engine. The consequent loss of lift on the left wing and the thrust asymmetry, caused the aircraft to roll uncontrollably to the left. When passing through a wings vertical attitude, the left wingtip impacted the gable end of a house. The aircraft continued rolling to an inverted attitude and impacted the ground in an area of woodland close to the edge of the housing conurbation. An intense fire ensued.
Probable cause:
The following factors were reported:
- The flight crew allowed the aircraft to descend significantly below the normal approach glide path during a Surveillance Radar Approach to runway 23 at Coventry Airport, in conditions of patchy lifting fog. The descent was continued below the promulgated Minimum Descent Height without the appropriate visual reference to the approach lighting or the runway threshold.
- The standard company operating procedure of cross-checking altimeter height indications during the approach was not observed and the appropriate Minimum Descent Height was not called by the non handling pilot.
- The performance of the flight crew was impaired by the effects of tiredness, having completed over 10 hours of flight duty through the night during five flight sectors which included a total of six approaches to land.
Final Report:

Ground accident of a Boeing 737-2C0 in Houston

Date & Time: Nov 26, 1994 at 1102 LT
Type of aircraft:
Operator:
Registration:
N11244
Flight Phase:
Survivors:
Yes
MSN:
20073
YOM:
1969
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two technicians took over the airplane from the main Continental maintenance hangar to the gate 41. While approaching the gate, the right wing of the B737 collided with the left wing of a Continental Airlines Boeing 737-300 that was towed from the next gate. While the second B737 was slightly damaged, the right wing of the B737 registered was partially sheared off. There were no casualties but the aircraft was damaged beyond repair.
Probable cause:
Failure of maintenance personnel to follow the taxi checklist resulting in the hydraulic pumps not being turned on.

Crash of a Boeing 737-2R4C in New Delhi: 5 killed

Date & Time: Mar 8, 1994 at 1454 LT
Type of aircraft:
Operator:
Registration:
VT-SIA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
New Delhi - New Delhi
MSN:
21763
YOM:
1979
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7263
Captain / Total hours on type:
2821.00
Copilot / Total flying hours:
556
Copilot / Total hours on type:
166
Aircraft flight hours:
25947
Aircraft flight cycles:
2861
Circumstances:
The aircraft was engaged in a local training flight at New Delhi-Indira Gandhi Airport, carrying one instructor and three trainee pilots. Five circuits and landings were completed uneventfully and during the sixth touch-and-go exercice, after take off from runway 28, the aircraft took a left turn and crashed on the international apron. The aircraft collided with an Aeroflot Ilyushin II-86 registered RA-86119 that was parked on the apron, bay n°45. Both aircraft were destroyed by fire. All four crew members on board the Boeing 737 were killed as well as four people on board the II-86 and one on the ground.
Probable cause:
Loss of control after rotation due to application of wrong rudder by trainee pilot during engine failure exercice. The instructor did not guard/block the rudder control and give clear commands as instructor so as to obviate the application of wrong rudder control by the trainee pilot.
Final Report:

Crash of a Boeing 737-2H6 in Managua

Date & Time: Jul 18, 1993 at 1930 LT
Type of aircraft:
Operator:
Registration:
N401SH
Survivors:
Yes
Schedule:
Tegucigalpa - Managua - San José
MSN:
20584
YOM:
1972
Flight number:
SH415
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
88
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Managua-Augusto Cesar Sandino Airport was completed in poor weather conditions with limited visibility due to thunderstorm activity and heavy rain falls. On short final, the captain got distracted by lightning striking the ground to the right of the airplane. Then the aircraft landed nose first, causing it to be partially torn off. The aircraft bounced, veered off runway to the right and came to rest 45 metres to the right of the runway. All 94 occupants evacuated safely, except a crew member who was seriously injured.

Crash of a Boeing 737-2A8 in Aurangabad: 55 killed

Date & Time: Apr 26, 1993 at 1306 LT
Type of aircraft:
Operator:
Registration:
VT-ECQ
Flight Phase:
Survivors:
Yes
Schedule:
New Delhi – Jaipur – Udaipur – Aurangabad – Bombay
MSN:
20961
YOM:
1974
Flight number:
IC491
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
112
Pax fatalities:
Other fatalities:
Total fatalities:
55
Captain / Total flying hours:
4963
Captain / Total hours on type:
1720.00
Copilot / Total flying hours:
1172
Copilot / Total hours on type:
921
Aircraft flight hours:
43886
Circumstances:
Indian Airlines Boeing 737 aircraft VT-ECQ was operating scheduled flight IC491 from Delhi to Jaipur, Udaipur, Aurangabad and Bombay. The flight from Delhi to Aurangabad was uneventful. The aircraft took-off from Aurangabad with 118 persons on board. Aircraft lifted up almost at the end of runway and impacted heavily with a lorry carrying pressed cotton bales running from North to South on a highway at a distance of about 410 feet from the end of runway. The aircraft left main landing gear, left engine bottom cowling and thrust reverser impacted the left side of the truck at a height of nearly seven feet from the level of the road. Thereafter the aircraft hit the high tension electric wires nearly 3 kms North-East of the runway and hit the ground. In all 55 persons received fatal injuries. The aircraft was destroyed due to post impact fire.
Probable cause:
The probable cause of accident has been attributed to :
- Pilots' error in initiating late rotation and following wrong rotation technique, and
- Failure of the NAA to regulate the mobile traffic on the Beed road during the flight hours.
Final Report:

Crash of a Boeing 737-287C in San Luis

Date & Time: Nov 20, 1992 at 2110 LT
Type of aircraft:
Operator:
Registration:
LV-JNE
Flight Phase:
Survivors:
Yes
Schedule:
San Luis - Buenos Aires
MSN:
20408
YOM:
1970
Flight number:
AR8524
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
107
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The landing at San Luis Airport was relatively heavy so the copilot requested ground personnel to check the undercarriage before departure, and nothing abnormal was reported. During the takeoff roll, just before the aircraft reached V1 speed, the tyre n°4 burst while the tyre n°3 lost pressure. The captain decided to abort the takeoff maneuver and initiated an emergency braking procedure. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest 125 metres further, bursting into flames. All 113 occupants evacuated safely while the aircraft was destroyed by a post crash fire. It was reported the aircraft landed hard at San Luis Airport at 2046LT and took off at 2110LT, giving a gap of 24 minutes between landing and takeoff.
Probable cause:
Aborted takeoff and subsequent overran and destruction of the aircraft following the failure of both tyres on the right main gear during takeoff. The following contributing factors were reported:
- The flight schedule with reduced time scales and short 'stopover' failed to allow the necessary cooling of wheels and brakes, giving rise to the deflation and subsequent destruction of the tyre n°4 and the explosion and destruction of the tyre n°3,
- Limited braking action on the landing gear assembly,
- Partial knowledge and ignorance of the times and procedures for cooling the wheels by the pilots,
- Delay in the departure of the flight, with respect to the scheduled time,
- Difficulty in appreciating at San Luis Airport during a night takeoff, visual references of runway,
- Lack of concern during the takeoff abort on part of the pilots.
Final Report:

Crash of a Boeing 737-2A1C in Cruzeiro do Sul: 3 killed

Date & Time: Jun 22, 1992 at 0605 LT
Type of aircraft:
Operator:
Registration:
PP-SND
Flight Type:
Survivors:
No
Schedule:
Rio Branco - Cruzeiro do Sul
MSN:
21188
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4581
Captain / Total hours on type:
3081.00
Copilot / Total flying hours:
2437
Copilot / Total hours on type:
337
Aircraft flight hours:
31980
Circumstances:
While descending to Cruzeiro do Sul Airport by night and good weather conditions, the crew encountered problems with the intermittent activation of a warning light in the instrument panel, warning them of a fire in the cargo compartment. On final approach, the aircraft struck trees and crashed in a dense wooded area located in hilly terrain. The wreckage was found 15 km from runway 10 threshold and all three occupants were killed.
Probable cause:
The following findings were reported:
a. Human Factor
(1) Physiological Aspect
- There was no evidence of this aspect contributing to the occurrence of the accident.
(2) Psychological Aspect - Contributed
- The psychological aspect contributed through the generation of a high level of anxiety to perform the landing and in the diversion of the focus of attention during the approach manoeuvres to land.
- The psychological aspect was influenced by the activation of the smoke alarm which generated an increase in the workload on board.
b. Material Factor
- There were no indications that this factor contributed to the accident.
c. Operational Factor
(1) Deficient Instruction
- Although the instruction was carried out in accordance with what the standards recommend, the failures that contributed to the accident are characteristic of lack of experience in facing abnormalities simultaneously with the maintenance of flight control. Such failures could be avoided with more adequate simulator instructions and training involving the cockpit management aspects.
(2) Poor Maintenance - Undetermined .
- It was not possible to determine the cause of the activation of the 'Aft Cargo Smoke' alarm and whether the maintenance services contributed to this occurrence.
(3) Deficient Cockpit Coordination
- Inadequate performance of the duties assigned to each crew member. The procedures foreseen for the execution of descent by instrument have been modified and some have been deleted depending on the appearance of a complicator element (smoke alarm).
(4) Influence of the environment
- The dark night contributed to the creation of the 'black hole' phenomenon, or 'background figure', making it difficult to perceive external references for a possible identification of the vertical distance of the aircraft from the ground.
(5) Deficient Oversight
- The supervision, at cockpit level, contributed to the accident by the inadequate management of the resources available for the flight in the cockpit.
- Company level supervision contributed to the accident by not identifying the need for cockpit management training and providing it to the crew involved.
- Supervision, at company level, was also inadequate when climbing to the same mission, two pilots unfamiliar with the airplane to be used and in night operation.
(6) Other Operational Aspects
- The failure to comply with several 'Callouts', the non-use of the radio altimeter and the inadequate use of the 'altitude alert', as an aid to the accomplishment of the descent procedure, contributed to the occurrence of the accident.
Final Report:

Crash of a Boeing 737-204 near Tucutí: 47 killed

Date & Time: Jun 6, 1992 at 2100 LT
Type of aircraft:
Operator:
Registration:
HP-1205CMP
Flight Phase:
Survivors:
No
Schedule:
Miami – Panama City – Cali
MSN:
22059
YOM:
1979
Flight number:
CM201
Location:
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
47
Aircraft flight hours:
45946
Aircraft flight cycles:
17845
Circumstances:
The airplane departed Panama City-Tocumen Airport runway 21L at 2036LT bound for Cali, Colombia. While cruising at FL250, the crew was informed about poor weather conditions 30-50 miles ahead. Shortly later, there was an intermittent failure of the main attitude indicator due to a short circuit. This was not noticed by the flight crew, who attempted to adjust the aircraft attitude based on the false information from the attitude indicator. They lost control of the aircraft which entered a steep descent and started to disintegrate at FL100, and impacting the ground 80° nose down. The wreckage was found in the jungle about 13 km southwest of Tucití. All 47 occupants were killed.
Probable cause:
The following findings were reported:
- Loss of control of the aircraft because the flight crew followed false information from an attitude indicator that operated intermittently.
- Lack of visible horizon during cruise flight due to night and approaching bad weather.
- Insufficient cross-checking between the primary and emergency (standby) attitude indicators to identify intermittent attitude errors and to select a reliable source of (correct) attitude information.
- Non-standard cabin configurations between aircraft in the fleet of the company, which required the crew to determine how to set the switches based on the aircraft was being operated at the time.
- Incomplete ground crew training simulator, as it did not present 'differences between aircraft' and 'crew resource management' in sufficient detail to give the crew knowledge to overcome intermittent attitude indicator errors and to maintain control of the aircraft.