Crash of a Lockheed C-130E Hercules at Chaklala-Nur Khan AFB

Date & Time: Nov 9, 2018 at 1438 LT
Type of aircraft:
Operator:
Registration:
4180
Flight Type:
Survivors:
Yes
Schedule:
Chaklala - Chaklala
MSN:
4180
YOM:
1966
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a training mission at Chaklala-Nur Khan AFB in Islamabad. Upon touchdown, a tyre burst. Control was lost and the airplane veered off runway to the right and collided with a concrete wall before coming to rest, burstin into flames. All nine occupants escaped uninjured while the aircraft was destroyed by a post crash fire. It is believed that the landing was hard.

Crash of a PZL-Mielec AN-2R near Arkhangelsk

Date & Time: Nov 8, 2018 at 1054 LT
Type of aircraft:
Operator:
Registration:
RA-84674
Flight Phase:
Survivors:
Yes
Schedule:
Arkhangelsk – Soyana – Dolgoshchel’e – Mezen
MSN:
1G191-52
YOM:
1981
Flight number:
9135
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4742
Captain / Total hours on type:
4336.00
Copilot / Total flying hours:
969
Copilot / Total hours on type:
761
Aircraft flight hours:
13509
Aircraft flight cycles:
20389
Circumstances:
The single engine airplane departed Arkhangelsk-Vaskovo Airport on a flight to Mezen with intermediate stops in Soyana and Dolgoshchel’e, carrying 12 passengers (11 adults and one child) and two pilots. En route, weather conditions deteriorated with drizzle. The crew reduced his altitude from 400 to 300 metres when frost formed on the windshield. The captain decided to return to Arkhangelsk but the aircraft' speed dropped from 170 to 120 km/h. Unable to maintain the speed and altitude, the crew attempted an emergency landing when the aircraft collided with trees and crashed in a wooded area located about 50 km northeast of Arkhangelsk-Talaghy Airport. All 14 occupants were rescued, among them two passengers were injured. The aircraft was destroyed.
Probable cause:
The accident with the An-2 RA-84674 aircraft occurred during a forced landing in the forest, the need for which was due to the impossibility of continuing the flight due to the effect of icing on the aerodynamic and traction characteristics of the aircraft (the inability to maintain altitude and speed even with the takeoff engine operating mode). The contributing factor, most likely, was the decision of the crew to climb over 150 m from the ground level, where the presence of stratus clouds and icing was predicted.
Final Report:

Crash of a Boeing 737 MAX 8 off Jakarta: 189 killed

Date & Time: Oct 29, 2018 at 0631 LT
Type of aircraft:
Operator:
Registration:
PK-LQP
Flight Phase:
Survivors:
No
Schedule:
Jakarta - Pangkal Pinang
MSN:
43000
YOM:
2018
Flight number:
JT610
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
181
Pax fatalities:
Other fatalities:
Total fatalities:
189
Captain / Total flying hours:
6028
Captain / Total hours on type:
5176.00
Copilot / Total flying hours:
5174
Copilot / Total hours on type:
4286
Aircraft flight hours:
895
Aircraft flight cycles:
443
Circumstances:
The aircraft departed runway 25L at Jakarta-Soekarno-Hatta Airport at 0621LT bound for Pangkal Pinang, carrying 181 passengers and 8 crew members. The crew was cleared to climb but apparently encountered technical problems and was unable to reach a higher altitude than 5,375 feet. At this time, the flight shows erratic speed and altitude values. The pilot declared an emergency and elected to return to Jakarta when control was lost while at an altitude of 3,650 feet and at a speed of 345 knots. The airplane entered a dive and crashed 12 minutes after takeoff into the Kerawang Sea, about 63 km northeast from its departure point. The airplane disintegrated on impact and few debris were already recovered but unfortunately no survivors. It has been reported that the aircraft suffered various technical issues during the previous flight on Sunday night but was released for service on Monday morning. Brand new, the airplane was delivered to Lion Air last August 18. At the time of the accident, weather conditions were considered as good. The Cockpit Voice Recorder (CVR) was found on 14 January 2019. In the initial stages of the investigation, it was found that there is a potential for repeated automatic nose down trim commands of the horizontal stabilizer when the flight control system on a Boeing 737 MAX aircraft receives an erroneously high single AOA sensor input. Such a specific condition could among others potentially result in the stick shaker activating on the affected side and IAS, ALT and/or AOA DISAGREE alerts. The logic behind the automatic nose down trim lies in the aircraft's MCAS (Maneuvering Characteristics Augmentation System) that was introduced by Boeing on the MAX series aircraft. This feature was added to prevent the aircraft from entering a stall under specific conditions. On November 6, 2018, Boeing issued an Operations Manual Bulletin (OMB) directing operators to existing flight crew procedures to address circumstances where there is erroneous input from an AOA sensor. On November 7, the FAA issued an emergency Airworthiness Directive requiring "revising certificate limitations and operating procedures of the airplane flight manual (AFM) to provide the flight crew with runaway horizontal stabilizer trim procedures to follow under certain conditions.
Probable cause:
Contributing factors defines as actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the
consequences of the accident or incident. The presentation is based on chronological order and not to show the degree of contribution.
1. During the design and certification of the Boeing 737-8 (MAX), assumptions were made about flight crew response to malfunctions which, even though consistent with current industry guidelines, turned out to be incorrect.
2. Based on the incorrect assumptions about flight crew response and an incomplete review of associated multiple flight deck effects, MCAS’s reliance on a single sensor was deemed appropriate and met all certification requirements.
3. MCAS was designed to rely on a single AOA sensor, making it vulnerable to erroneous input from that sensor.
4. The absence of guidance on MCAS or more detailed use of trim in the flight manuals and in flight crew training, made it more difficult for flight crews to properly respond to uncommanded MCAS.
5. The AOA DISAGREE alert was not correctly enabled during Boeing 737-8 (MAX) development. As a result, it did not appear during flight with the mis-calibrated AOA sensor, could not be documented by the flight crew and was therefore not available to help maintenance identify the mis-calibrated AOA sensor.
6. The replacement AOA sensor that was installed on the accident aircraft had been mis-calibrated during an earlier repair. This mis-calibration was not detected during the repair.
7. The investigation could not determine that the installation test of the AOA sensor was performed properly. The mis-calibration was not detected.
8. Lack of documentation in the aircraft flight and maintenance log about the continuous stick shaker and use of the Runaway Stabilizer NNC meant that information was not available to the maintenance crew in Jakarta nor was it available to the accident crew, making it more difficult for each to take the appropriate actions.
9. The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and performance in manual handling, NNC execution, and flight crew communication, leading to ineffective CRM application and workload management. These performances had previously been identified during training and reappeared during the accident flight.
Final Report:

Crash of a Sukhoi Superjet 100-95B in Yakutsk

Date & Time: Oct 10, 2018 at 0321 LT
Type of aircraft:
Operator:
Registration:
RA-89011
Survivors:
Yes
Schedule:
Ulan-Ude - Yakutsk
MSN:
95019
YOM:
2012
Flight number:
SYL414
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
87
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13125
Captain / Total hours on type:
1080.00
Copilot / Total flying hours:
3200
Copilot / Total hours on type:
1300
Aircraft flight hours:
8115
Aircraft flight cycles:
3320
Circumstances:
Following an uneventful flight from Ulan-Ude, the crew initiated the approach to Yakutsk-Platon Oyunsky Intl Airport Runway 23L. Due to work in progress, the runway 05R threshold was displaced by 1,150 metres, reducing the landing distance to 2,248 metres for the runway 23L on which the touchdown zone lighting system was unserviceable. On approach, the crew was informed by ATC that the friction coefficient was 0,45. The crew completed the landing on runway 23L with a slight tailwind component of 4 knots and started the braking procedure. Unable to stop within the remaining distance, the aircraft overran, entered the construction area and collided with the junction of a concrete section under reconstruction, causing both main landing gear to collapse (the left main gear was torn off). The aircraft slid for another 250 metres before coming to rest. All 92 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The cause of the aviation accident with the RRJ 95B RA-89011 aircraft when landing at night with one deactivated thrust reverser was the transfer to the crew of incorrect information about the value of the friction coefficient, which led to the landing on an icy runway, the average normative friction coefficient which was less than 0.3, which did not allow landing in accordance with current regulations. This led to a significant increase in landing distance, rolling the aircraft out of the runway and collision with the junction of the reconstructed section of the runway with a height of about 0.4 m, which led to the destruction of the main landing gear supports and damage to the engines with fuel leakage without causing a fire.
The contributing factors were the following:
- Absence of a connecting ramp (which was not envisaged by the reconstruction project) between the current and the part of the runway being reconstructed;
- inefficiency of the SMS of Yakutsk Airport JSC in terms of identification and control of risks associated with the possibility of ice formation at the runway, and insufficient control over the implementation of the SMS by aviation authorities;
- erroneous determination of the Xc value at the last measurement;
- inefficiency of ice removal procedure during runway cleaning due to lack of chemical reagents for ice removal and/or thermal machines at the airfield;
- lack of information from the RRJ-95LR-100 RA 89038 aircraft crew about actual rolling out of the runway, which was an aviation incident and was subject to investigation;
- failure by airport and ATC officials to take appropriate action after receiving the RRJ-95LR-100 RA-89038 low friction report from the aircraft crew.
Final Report:

Crash of an Ilyushin II-20M off Latakia: 15 killed

Date & Time: Sep 17, 2018 at 2207 LT
Type of aircraft:
Operator:
Registration:
RF-93610
Flight Phase:
Survivors:
No
Schedule:
Hmeimim - Hmeimim
MSN:
173 0115 04
YOM:
1973
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
The four engine aircraft departed Hmeimim AFB located southeast of Latakia at 2031LT on a maritime patrol and reconnaissance mission over the Mediterranean Sea. About an one hour and a half later, while returning to its base, the airplane was hit by a S-200 surface-to-air missile shot by the Syrian ground forces. At the time of the accident, four Israel F-16 fighters were involved in a ground attack onto several infrastructures located in the region of Latakia. Out of control, the airplane crashed into the Mediterranean Sea some 35 km west of Latakia. The following morning, Russian Authorities confirmed the loss of the aircraft that was inadvertently shot down by the Syrian Army forces and that all 15 crew members were killed.
Probable cause:
Shot down by a Syrian S-200 surface-to-air missile.

Crash of a Boeing 737-8AS in Sochi

Date & Time: Sep 1, 2018 at 0258 LT
Type of aircraft:
Operator:
Registration:
VQ-BJI
Survivors:
Yes
Schedule:
Moscow - Sochi
MSN:
29937/1238
YOM:
2002
Flight number:
UT579
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13995
Captain / Total hours on type:
6391.00
Copilot / Total flying hours:
12277
Copilot / Total hours on type:
5147
Aircraft flight hours:
45745
Aircraft flight cycles:
23434
Circumstances:
On 31.08.2018 Boeing 737-800 VQ-BJI operated by UTAir Airlines conducted the scheduled flight UT 579 from Moscow (Vnukovo airport) to Sochi (Adler airport). During the preflight briefing (at 19:50) the crew was provided with the necessary weather information. At 20:15, the crew had passed the medical examination at Vnukovo airport mobile RWY medical unit. The Daily Check line maintenance (DY) was done on 30.08.2018 at Vnukovo airport by UTG aviation services, ZAO; job card # 11465742. The A/C takeoff weight was 68680 kg and the MAC was 26.46 %, that was within the AFM limitations for the actual conditions. At 21:33 the takeoff from Vnukovo airport was performed. The flight along he prescribed route was performed on FL350 in auto mode and without any issues. The F/O acted as the pilot flying (PF). When approaching the Sochi aerodrome traffic control area, the flight crew was provided by the aerodrome approach control with the approach and descending conditions, as well as with the weather conditions near the aerodrome. After descending to the height specified by Sochi Approach, the pilot contacted Sochi Radar, waited for the weather that met his minimum and was cleared for landing. In course of the first approach to landing (from the altitude about 30 m) when RVR got down because of heavy showers, the PIC took controls and performed the go-around. In course of the second approach, the crew performed the landing but failed to keep the airplane within the RWY. The airplane had landed at about 1285 m from the RWY threshold, overrun the threshold, broke through the aerodrome fencing, and came to rest in Mzymta river bed. This ended with the fire outbreak of fuel leaking from the damaged LH wing fuel tank. The crew performed the passenger evacuation. The aerodrome alert measures were taken and the fire was brought under control. Eighteen occupants were injured while all other occupants were unhurt. The aircraft was damaged beyond repair.
Probable cause:
The aircraft overrun, destroying and damage by fire were caused by the following factors:
- repeated disregarding of the windshear warnings which when entered a horizontal windshear (changing from the head wind to tail one) at low altitude resulted in landing at distance of 1285 m from the RWY threshold (overrunning the landing zone by 385 m) with the increased IAS and tail wind;
- landing to the runway, when its normative friction coefficient was less than 0.3 that according to the regulations in force, did not allow to land.
The factors contributed the accident:
- the crew violation of the AFM and Operator's OM requirements in regards to the actions required a forecasted or actual wind shear warning;
- use of the automatic flight mode (autopilot, autothrottle) in the flight under the windshear conditions which resulted in the aircraft being unstable (excess thrust) when turning to the manual control;
- lack of prevention measures taken by the Operator when the previous cases of poor crew response to windshear warning were found;
- insufficient crew training in regards to CRM and TEM that did not allow to identify committed mistakes and/or violations in good time;
- the crew members' high psychoemotional state caused by inconsistency between the actual landing conditions and the received training as well as the psychological limit which was determined by the individual psychological constitution of each member;
- insufficient braking both in auto and manual mode during the aircraft rollout caused by the insufficient tyre-to-ground friction aiming to achieve the specified rate of braking. Most probably the insufficient tyre-to-ground friction was caused by the significant amount of water on the RWY surface;
- the aerodrome services' noncompliance of Sochi International Aerodrome Manual requirements related to the RWY after heavy showers inspection which resulted in the crew provision of wrong normative friction coefficients. In obtaining of the increased overrun speed of about ≈75 kt (≈140 km/h) the later setting of engines into reverse mode was contributed (the engines were set into reverse mode 16 s later than the aircraft landed at distance of about ≈200 m from the runway end).
Final Report:

Crash of a Boeing 737-85C in Manila

Date & Time: Aug 16, 2018 at 2355 LT
Type of aircraft:
Operator:
Registration:
B-5498
Survivors:
Yes
Schedule:
Xiamen – Manila
MSN:
37574/3160
YOM:
2010
Flight number:
MF8667
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On August 16, 2018, about 1555UTC/2355H local time, a Boeing 737-800 type of aircraft with Registry No. B-5498 operating as flight CXA 8667 sustained substantial damage following a runway excursion after second approach while landing on Runway 24 of Ninoy Aquino International Airport (NAIA), Manila, Philippines. The flight was a scheduled commercial passenger from Xiamen, China and operated by Xiamen Airlines. The one hundred fifty-seven (157) passengers and two (2) pilots together with the five (5) cabin crew and one air security officer did not sustain any injuries while the aircraft was substantially damaged. An instrument flight rules flight plan was filed. Instrument Meteorological Conditions (IMC) prevailed at the time of the accident. During the first approach, the Captain who was the pilot flying aborted the landing at 30 feet Radio Altitude (RA) due to insufficient visual reference. A second approach was considered and carried out after briefing the First Officer (FO) of the possibility of another aborted landing should the flight encounter similar conditions. The briefing included a diversion to their planned alternate airfield. The flight was “stabilized” on the second approach with flaps set at 30 degrees landing position, all landing gears extended and speed brake lever appropriately set in the ARM position. On passing 1,002 feet Radio Altitude (RA), the autopilot was disengaged; followed by the disengagement of the auto-throttle, three (3) seconds later. The ILS localizer lateral path and Glide slope vertical path were accurately tracked and no deviations were recorded. The “reference” landing speed for flaps 30 for the expected aircraft gross weight at the time of landing was 145 knots and a target speed of 150 knots was set on the Mode Control Panel (MCP). The vertical descent rate recorded during the approach was commensurate with the recommended descent rate for the profile angle and ground speed; and was maintained throughout the approach passing through the Decision Altitude (DA) of 375 feet down to 50 feet radio altitude (RA). As the aircraft passed over the threshold, the localizer deviation was established around zero dot but indicated the airplane began to drift to the left of the centerline followed by the First Officer (FO) making a call out of “Go-Around” but was answered by the Captain “No”. The throttle levers for both engines were started to be reduced to idle position at 30 feet RA and became fully idle while passing five (5) feet RA. At this point, the aircraft was in de-crab position prior to flare. At 13 feet RA, the aircraft was rolling left and continuously drifting left of the runway center line. At 10 feet RA another call for go-around was made by the FO but was again answered by the Captain with “No” and “It’s Okay”. At this point, computed airspeed was approximately 6 knots above MCP selected speed and RA was approaching zero feet. Just prior to touchdown, computed airspeed decreased by 4 knots and the airplane touched down at 151 knots (VREF+6). The wind was recorded at 274.7 degrees at 8.5 knots. Data from the aircraft’s flight data recorder showed that the aircraft touched down almost on both main gears, to the left of the runway centerline, about 741 meters from the threshold of runway 24. Deployment of the speed brakes was recorded and auto brakes engagement was also recorded. The auto brakes subsequently disengaged but the cause was undetermined. Upon touchdown, the aircraft continued on its left-wards trajectory while the aircraft heading was held almost constant at 241 degrees. After the aircraft departed the left edge of the runway, all landing gears collided with several concrete electric junction boxes that were erected parallel outside the confines of the runway pavement. The aircraft was travelling at about 147 knots as it exited the paved surface of the runway and came to rest at approximately 1,500 meters from the threshold of Runway 24, with a geographical position of 14°30’23.7” N; 121°0’59.1” E and a heading of 120 degrees. Throughout the above sequence of events from touchdown until the aircraft came to a full stop, the CVR recorded 2 more calls of “GO-AROUND” made by the FO. Throughout the landing sequence, the thrust reversers for both engines were not deployed. Throttle Lever Position (TLP) were recorded and there was no evidence of reverse thrust being selected or deployment of reversers. After the aircraft came to a complete stop, the pilots carried out all memory items and the refence items in the evacuation non-normal checklist, which includes extending the flaps to a 40 degrees position. The aircraft suffered total loss of communication and a failure in passenger address system possibly due to the damage caused by the nose gear collapsing rearwards and damaging the equipment in the E/E compartment or the E-buss wires connecting the Very High Frequency (VHF) 1 radio directly to the battery was broken. The Captain then directed the FO to go out of the cockpit to announce the emergency evacuation. The cabin crew started the evacuation of the passengers utilizing the emergency slides of the left and right forward doors. There were no reported injuries sustained by the passengers, cabin crew, flight crew or the security officer.
Probable cause:
Primary causal factors:
a. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference.
- The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline.
- The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation.
b. The Captain failed to apply sound CRM practices.
- The Captain did not heed to the First Officer call for a Go-Around.
Contributory factors:
a. Failure to apply appropriate TEM strategies. Failure of the Flight Crew to discuss and apply appropriate Threat and Error Management (TEM) strategies for the following:
- Inclement weather.
- Cross wind conditions during approach to land.
- Possibility of low-level wind shear.
- NOTAM information on unserviceable runway lights.
b. Inadequate Company Policy on Go-Around:
- Company’s Standard Operation Procedures were less than adequate in terms of providing guidance to the flight crew for call out of "Go-Around" during landing phase of the flight.
c. Runway strip inconsistent with CAAP MOS for Aerodrome and ICAO Annex 14:
- The uneven surface and concrete obstacles contributed to the damage sustained by the aircraft.
Final Report:

Crash of a Pacific Aerospace PAC 750XL near Oksibil: 8 killed

Date & Time: Aug 11, 2018 at 1420 LT
Operator:
Registration:
PK-HVQ
Survivors:
Yes
Site:
Schedule:
Tanah Merah – Oksibil
MSN:
144
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
13665
Captain / Total hours on type:
1468.00
Aircraft flight hours:
4574
Aircraft flight cycles:
5227
Circumstances:
On 11 August 2018, a PAC 750XL aircraft registered PK-HVQ was being operated by PT. Marta Buana Abadi (Dimonim Air) on unscheduled passenger flight from Tanah Merah to Oksibil. At the day of the occurrence the meteorological condition at Oksibil was below the requirement of Visual Flight Rule (VFR) weather minima and did not improve. Being aware that some flights had performed flight to Tanah Merah to Oksibil and returned, the pilot decided to fly to Oksibil. At 1342 LT, on daylight condition the PK-HVQ aircraft departed from Tanah Merah to Oksibil, on board the aircraft were one pilot, one observer pilot and 7 passengers. According to the passenger and cargo manifest, the total weight of passenger and the baggage were 473 kg. Prior to the departure, there was no record or report of aircraft system malfunction. At 1411 LT, the PK-HVQ pilot made initial contact to Oksibil Tower controller and reported that the aircraft was maintaining altitude of 7,000 feet over and the estimate time arrival at Oksibil would be 0520 UTC (1420 LT). The Oksibil Tower controller advised the pilot of the latest meteorological condition that the visibility was 1 up to 2 km and most of the area were covered by cloud. At 1416 LT, the pilot reported that the aircraft position was over Oksibil Aiport and the Oksibil Tower controller instructed the pilot to continue the flight to the final runway 11 and to report when the runway had in sight. The Oksibil Tower controller and pilots of other aircraft called the pilot but no reply. On the following day, the aircraft was found on a ridge of mountain about 3.8 Nm north west of Oksibil on bearing 331° with elevation about 6,800 feet. Eight occupants were fatally injured and one occupant was seriously injured.
Probable cause:
The KNKT concluded the contributing factors as follows:
- The VFR weather minimum requirement that was not implemented properly most likely had made the pilot did not have a clear visual to the surrounding area.
- Considering that the Pilot in Command (PIC) had lack knowledge of the terrain surrounding the Oksibil area, and the absence of voice alert from the TAWS when the aircraft flying close to terrain, resulted in the PIC did not have adequate awareness to the surrounding terrain while flying into clouds and continued to fly below the terrain height until the aircraft impacted the terrain.
Final Report: