Crash of a Boeing 747-258F in Amsterdam: 47 killed

Date & Time: Oct 4, 1992 at 1835 LT
Type of aircraft:
Operator:
Registration:
4X-AXG
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
New York - Amsterdam - Tel Aviv
MSN:
21737
YOM:
1979
Flight number:
LY1862
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
47
Captain / Total flying hours:
25000
Captain / Total hours on type:
9500.00
Copilot / Total flying hours:
4288
Copilot / Total hours on type:
612
Aircraft flight hours:
45746
Aircraft flight cycles:
10107
Circumstances:
The aircraft was on a flight from John F . Kennedy International Airport, New York, to Ben Gurion International Airport, Tel Aviv, with an intermediate stop at Schiphol Airport for a crew change and cargo processing. The aircraft arrived in Amsterdam at 13:40 and was scheduled for departure at 16:30 but received an air traffic control slot time of 17:20 for departure. The maintenance transit check was carried out. The aircraft was refuelled with 74,200 litres of Jet A1 fuel, making the total amount of fuel on board of 72 metric tons. The four people on board the aircraft at take off were the captain, copilot, flight engineer, and one non-revenue passenger. There was a total of 114.7 metric tons of cargo on board of which 6.5 metric tons were considered low grade dangerous goods. The flightcrew involved in the accident had arrived at Schiphol Airport on a previous El Al flight and had 20 hours crew rest prior to the beginning of their crew duty. The air traffic situation at Schiphol Airport prior to the departure of EI Al 1862 was not extraordinary, according to ATC witnesses. Two runways were in use, 01L for take off and 06 for landing. There was moderate inbound traffic for runway 06, a moderate number of departures from 01L and several VFR flights over the northern part of the city of Amsterdam. From the beginning of El Al 1862's emergency declaration, air traffic services for the flight were provided by Amsterdam Radar on 124.87, Schiphol Approach on 121.2, Schiphol Arrival on 118.4 and indirectly by Schiphol Tower. The captain requested clearance for push back at 17:04. The aircraft taxied out at 17:14. The copilot was to be the pilot flying (PF), and the captain was to be the pilot not flying (PNF). The takeoff roll on runway 01L started at 17:21, with a takeoff gross weight of 338.3 metric tons, and the aircraft followed the Pampus departure as cleared by ATC. The performance limited maximum takeoff gross weight for the prevailing conditions of the flight was 359.3 metric tons. No anomalies were evident during the initial climb until 17:27.30, as the aircraft was passing through an altitude of about 6,500 feet. The flight data recorder revealed that the n°3 and 4 engines and their pylons departed the right wing at this time. The copilot then transmitted the emergency call, "El Al 1862, mayday, mayday, we have an emergency". The aircraft turned to the right, and according to witnesses on the ground, started dumping fuel immediately. The Amsterdam Radar controller confirmed the emergency call and immediately cleared the area of other traffic. At 17:28.06 the controller, not knowing the reason for the emergency call, asked the crew if they wanted to return to Schiphol Airport. After the acknowledgement by the crew of their intention to return to the airport they were instructed to turn to heading 260 and were informed about their position relative to Schiphol Airport. At 17:28.17 the crew reported a fire on engine n°3 and subsequently they indicated loss of thrust on engines n°3 and 4. Witnesses heard one or more banging sounds and saw a dark plume of smoke trailing the aircraft. Some witnesses saw objects fall. Other witnesses also saw fire on the right wing which eventually disappeared. When the aircraft turned right two vapour trails were seen to emerge from the wingtips. At 17:28.57, El Al 1862 was informed that runway 06 was in use and the wind was 040° at 21 knots. The flight crew however requested runway 27 for landing. ATC then asked the crew if they could switch radio frequency to Schiphol Approach Control on 121.2 megahertz. The crew immediately switched frequency to Approach Control. Subsequently the flightcrew was instructed to switch to Schiphol Arrival on 118.4 megahertz. Because the aircraft was only 7 miles from the airport and still flying at an altitude of 5,000 feet, a straight in approach was not feasible and the crew was instructed to turn right to heading 360 and descend to 2,000 feet. The crew was again informed about the wind (by then 050° at 22 knots). About one minute later at 17:31.17 the controller asked what distance they required to touchdown. Shortly thereafter, the controller asked for the number of track miles the flight crew required for an approach. The crew stated that they needed "12 miles final for landing". Together with this reply to ATC, the call "Flaps 1" could be heard as background conversation in the cockpit. ATC instructed El Al 1862 to turn right to heading 100. During the turn the controller asked for the status of the aircraft and was informed : "n°3 and 4 are out and we have problems with the flaps". The airplane had turned through heading 100 and was maintaining heading 120. No corrective action was taken by the controller. The aircraft maintained an airspeed of 260 knots and was in a gradual descent. El Al 1862 was cleared for the approach and directed to turn right to heading 270 to intercept the final approach course. The airplane was then at an altitude of about 4,000 feet, with a ground speed of approximately 260 knots and on heading 120. The position was 3 nautical miles north of the centreline of runway 27 at a distance of about 11 miles projected on the extended centreline of runway 27. According to the radar plot, it took about thirty seconds before the aircraft actually changed heading. When it became apparent that the airplane was going to overshoot the localizer, the controller informed the crew accordingly and directed the aircraft to turn further to heading 290 in an attempt to intercept the final approach again but now from the south. Twenty seconds later a new heading instruction to 310 was given, along with descent clearance to 1,500 feet. The flightcrew acknowledged this instruction at 17:35.03 and added, "and we have a controlling problem". Approximately 25 seconds later the copilot called, "Going down 1862, going down ". In the first part of this transmission commands from the captain to raise all the flaps and to lower the landing gear could be heard. During the middle part of this transmission a sound was heard, and in the final part of the transmission another sound was audible. These sounds were later analyzed and determined to be the stick shaker and the ground proximity warning system respectively. The airplane crashed at 17:35.42 into an eleven-floor apartment building in the Bijlmermeer, a suburb of Amsterdam, approximately 13 km east of Schiphol Airport. The impact was centred at the apex of two connected and angled blocks of apartments and fragments of the aircraft and the buildings were scattered over an area approximately 400 meters wide and 600 meters long. Firefighting and rescue operations started shortly after the crash. The aircraft was destroyed by the impact and the resulting fire. The accident occurred during dusk. All four occupants as well as 43 people on the ground were killed. 26 other people on the ground were injured, 11 of them seriously.
Probable cause:
The design and certification of the B 747 pylon was found to be inadequate to provide the required level of safety. Furthermore the system to ensure structural integrity by inspection failed. This ultimately caused - probably initiated by fatigue in the inboard midspar fuse-pin - the n°3 pylon and engine to separate from the wing in such a way that the n°4 pylon and engine were torn off, part of the leading edge of the wing was damaged and the use of several systems was lost or limited. This subsequently left the flight crew with very limited control of the airplane. Because of the marginal controllability a safe landing became highly improbable, if not virtually impossible.
Final Report:

Crash of a Boeing 747-2R7F near Wanli: 5 killed

Date & Time: Dec 29, 1991 at 1505 LT
Type of aircraft:
Operator:
Registration:
B-198
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Taipei - Anchorage
MSN:
22390
YOM:
1980
Flight number:
CI358
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
45868
Aircraft flight cycles:
9094
Circumstances:
Four minutes after takeoff from Taipei-Chiang Kai Shek Airport, while climbing to an altitude of 5,000 feet, the crew contacted ATC and declared an emergency after the engine n°3 separated from the right wing. The crew was instructed first to maintain FL050 and to initiate a left turn but the captain replied this was not possible so he was eventually cleared to turn to the right. Two minutes later, the aircraft entered an uncontrolled descent and crashed on the slope of Mt Wuzu located near Wanli, about 20 km northeast of Taipei. The aircraft disintegrated on impact and all five crew members were killed. The accident occurred six minutes after takeoff.
Probable cause:
It was determined that the engine n°3 detached during initial climb following the rupture of its pylon due to the presence of fatigue cracks. After the engine n°3 detached, it struck the engine n°4 that separated as well. In such conditions, the crew was unable to maintain a safe control of the aircraft. Last A-check maintenance programme was completed last December 21. It was also reported that a misunderstanding occurred between pilots and ATC who misunderstood which engine was lost, thinking that the emergency situation was reporting to a loss of engine n°2.

Crash of a Boeing 747-237B in New Delhi

Date & Time: May 7, 1990 at 0917 LT
Type of aircraft:
Operator:
Registration:
VT-EBO
Survivors:
Yes
Schedule:
London - New Delhi - Bombay
MSN:
20558
YOM:
1972
Flight number:
AI132
Country:
Region:
Crew on board:
20
Crew fatalities:
Pax on board:
195
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8026
Circumstances:
After touchdown at New Delhi-Indira Gandhi Airport following an uneventful flight from London-Heathrow Airport, the crew started the braking procedure and activated the thrust reversers when the pylon of the engine n°1 failed. The engine partially detached, causing a fuel line to rupture and the fuel to ignite. The aircraft was stopped after a course of almost 3 km and all 215 occupants were evacuated safely. The fire was extinguished but the aircraft was damaged beyond repair.
Probable cause:
The accident was caused due to the migration of the improperly installed diagonal-brace aft fuse-pin of the No.1 engine from its fitting which substantially reduced the load carrying capability of the engine fittings resulting in failure of the upper-link forward fuse pin due to excessive loads on account of probably improper landing leading to a partial separation of engine and fire.

Crash of a Boeing 747-249F in Puchong: 4 killed

Date & Time: Feb 19, 1989 at 0636 LT
Type of aircraft:
Operator:
Registration:
N807FT
Flight Type:
Survivors:
No
Site:
Schedule:
Singapore - Kuala Lumpur
MSN:
21828
YOM:
1979
Flight number:
FT066
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Aircraft flight hours:
34000
Aircraft flight cycles:
9000
Circumstances:
The aircraft was completing a cargo flight from Singapore-Changi Airport, carrying a load of textiles, computer softwares and mail as well as four crew members. Following a direct route to Kayell for an NDB approach to runway 33, the crew was cleared to 'descend two four zero zero' (2,400 feet), which was interpreted by the crew as 'to 400'. The crew continued the descent, passed below the minimum descent altitude of 2,400 feet when the aircraft struck trees and crashed on the slope of a wooded terrain located near the village of Puchong, about 14 km from the airport. The aircraft was totally destroyed and all four crew members were killed.
Probable cause:
The following findings were reported:
- The GPWS alarm sounded in the cockpit but the crew failed to respond appropriately,
- The crew failed to adhere to the published approach procedures and approach checklist,
- Poor crew coordination,
- Lack of visibility,
- Non-standard phraseology used by ATC, causing the crew to misinterpret instructions.

Crash of a Boeing 747-244B in the Indian Ocean: 159 killed

Date & Time: Nov 28, 1987 at 0407 LT
Type of aircraft:
Operator:
Registration:
ZS-SAS
Flight Phase:
Survivors:
No
Schedule:
Taipei – Port Louis – Johannesburg
MSN:
22171
YOM:
1980
Flight number:
SA295
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
140
Pax fatalities:
Other fatalities:
Total fatalities:
159
Captain / Total flying hours:
13843
Captain / Total hours on type:
3884.00
Copilot / Total flying hours:
7362
Copilot / Total hours on type:
4096
Aircraft flight hours:
26743
Aircraft flight cycles:
4877
Circumstances:
On November 27th 1987 flight SA295 was scheduled to depart from Taipei's Chiang Kai Shek Airport at 13:00 UTC for Mauritius' Plaisance Airport and Johannesburg, South Africa on a scheduled international air transport service. Due to adverse weather and the late arrival of a connecting flight the departure time was delayed and the airplane took off at 14:23 UTC with 149000 kg of fuel, 43225 kg of baggage and cargo, 140 passengers and a crew comprising 5 flight crew members and 14 cabin crew members. The calculated flight time was 10 hours 14 minutes. The take-off was normal. At 14:56 UTC the crew communicated with Hong Kong Radar and thereafter routine position reports were given to the flight information centres (FICs) at Hong Kong, Bangkok, Kuala Lumpur, Colombo, Cocos Islands and Mauritius. At 15:55 a routine report was made to the Operator's base at Johannesburg. The information given was that the airplane had taken off from Taipei at 14:23, was flying at FL310 and that the arrival time at Mauritius was estimated as 00:35 UTC. At about 22:30 the pilot called Mauritius FIC, using HF radio, and advised that the aircraft had been at position 070° East at 22:29 at FL350 and that the time at position 065° East was estimated as 23:12. At 23:13 the position report of 065° East at FL350 was given to Mauritius FIC. The estimated time of arrival (ETA) over position 060° East was given as 23:58. About 23:45 the master fire warning alarm sounded on the flight deck. Somebody, probably the pilot, inquired where the warning had come from and received the reply that it had come from the main deck cargo. The pilot then asked that the check list be read. Some 30 seconds later somebody on the flight deck uttered an oath. The pilot called Mauritius Approach Control at 23:49 and said that they had a smoke problem and were doing an emergency descent to FL140. The approach controller gave clearance for the descent and the pilot asked that the fire services be alerted. The controller asked if full emergency services were required to which the pilot replied in the affirmative. At 23:51 the approach controller asked the pilot for his actual position. The pilot replied: "Now we have lost a lot of electrics, we haven't got anything on the aircraft now". At 23:52 the approach controller asked for an ETA at Plaisance and was given the time of 00:30. At 23:52:50 the pilot made an inadvertent transmission when he said to the senior flight engineer: "Hey Joe, shut down the oxygen left". From this time until 00:01:34 there was a period of silence lasting 8 minutes and 44 seconds. From 00:01:34 until 00:02:14 the pilot inadvertently transmitted instructions, apparently to the senior flight engineer, in an excited tone of voice. Most of the phrases are unintelligible. At 00:02:43 the pilot gave a distance report as 65 nautical miles. This was understood by the approach controller to be the distance to the airport. In fact it was the distance to the next waypoint, Xagal. The distance to the airport at that point was approximately 145 nautical miles. At 00:02:50 the approach controller recleared the flight to FL50 and at 00:03:00 gave information on the actual weather conditions at Plaisance Airport, which the pilot acknowledged. When the approach controller asked the pilot at 00:03: 43 which runway he intended to use he replied one three but was corrected when the controller asked him to confirm one four. At 00:03:56 the controller cleared the flight for a direct approach to the Flic-en-Flac (FF) non-directional beacon and requested the pilot to report on approaching FL50. At 00:04:02 the pilot said: "Kay". From 00:08:00 to 00:30:00 the approach controller called the aircraft repeatedly but there was no reply. The aircraft crashed into the Indian Ocean at a position determined to be about 134 nautical miles North-East of Plaisance Airport. The accident occurred at night, in darkness, at about 00:07 UTC. The local time was 04:07. Within a few days drifting pieces of wreckage were found, but it took until January 28th, 1988 for the main wreckage field to be found on the Ocean floor, at a depth of 4400 meters. The cockpit voice recorder was recovered on 6 January 1989.
Probable cause:
Despite intensive investigation the Board was unable to find or conclude that fireworks or any other illegal cargo were carried in the aircraft. The accident followed an uncontrollable fire in the forward right pallet on the main deck cargo compartment. The aircraft crashed into the sea at high speed following a loss of control consequent on the fire.
Fire of an unknown origin had possibly:
1) incapacitated the crew;
2) caused disorientation of the crew due to thick smoke;
3) caused crew distraction;
4) weakened the aircraft structure, causing an in-flight break-up.;
5) burned through several control cables;
6) caused loss of control due to deformation of the aircraft fuselage.
Final Report:

Crash of a Boeing 747-228B in Rio de Janeiro

Date & Time: Dec 2, 1985 at 0634 LT
Type of aircraft:
Operator:
Registration:
F-GCBC
Survivors:
Yes
Schedule:
Paris – Rio de Janeiro – Buenos Aires – Santiago de Chile
MSN:
22427
YOM:
1980
Flight number:
AF091
Country:
Crew on board:
17
Crew fatalities:
Pax on board:
265
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16139
Captain / Total hours on type:
979.00
Copilot / Total flying hours:
6148
Copilot / Total hours on type:
513
Aircraft flight hours:
22762
Circumstances:
Air France flight 091 was involved in runway excursion accident at Rio de Janeiro-Galeão International Airport, Brazil. The aircraft, a Boeing 747-200, took off from Paris-Charles de Gaulle Airport, France at 21:30 UTC on a flight to Santiago, Chile with en route stops at Rio de Janeiro and Buenos Aires, Argentina. The flight to Rio de Janeiro took about eleven hours and was uneventful. At 08:34 UTC the aircraft touched down on runway 14, 400 meters from the threshold. After reversers were set, the aircraft deviated from the runway heading and at 2,000 meters from the threshold it veered off the right side of the runway. The aircraft ran over the grass for 765 meters, until passing over a drainage ditch and the load apron concrete step, where the landing gears folded aft with the left wing gear completely separating. On the load apron concrete the aircraft spun around for 275 meters until stopping, after the left outboard wing section struck an illumination stand. For a few seconds engines 2, 3 and 4 kept running at maximum reverse thrust, while engine number one run operated at full forward thrust. After the engines were shut down, the passengers evacuated using three of the aircraft's left hand side escape slides. The fire that started on the area near engines number 2 and 3 was extinguished by the airport fire fighters. It appeared that the n°1 engine throttle cable had broken, making it impossible for the flight crew to control engine power. The engine had accelerated to an unusually high level of (forward) thrust (above takeoff power).
Probable cause:
The following findings were reported:
(1) Human Factor:
Physiological Aspect - The crewmembers physical conditions (fatigue) might have contributed to their delay in perceiving the engine failure and to the inadequate reactions during the emergency.
(2) Material Factor:
a) The hydraulic pump ripple of the CF6-50E engine caused considerable vibration on the pulley support region, which worked as a dynamic source to produce cable oscillation and relative movement between cable and pulley.
b) Pulley bracket design deficiency, possibly related to the reduced contact area between cable and pulley, allowing for the wearing of these components in the presence of abrasive agents, in association with the vibration on that area, knowing that there is localized contact between both (at the same points) in an almost permanent way (93% of the engine operating time in cruise range).
c) The tests performed by the Manufacturer confirmed the existing relative movement between cable and pulley, even after the introduction of modifications.
(3) Maintenance Deficiency:
a) The use of an aluminum pulley, not authorized by the manufacturer as a substitution to the recommended phenolic pulley, made possible the formation of the abrasive agent (alumina).
b) The inadequate fixation of the pulley bracket due to the use, by the operator, of a screw of insufficient length for an additional washer, left loose the support side brace, allowing for the increase of the relative movement. already existing at that region, between cable and pulley.
(4) Flight Manual Deficiency:
a) The B747 AFM instructions allow the pilot flying to apply reverse thrust before knowing the effective transit of reversers.
b) The B747 AFM has no instruction regarding a failure of reverser deployment associated with an engine runaway forward thrust. The lack of instructions on this specific kind of abnormality, contributed to the crew not noticing that the failure had occurred.
(5) Training Requirement Deficiency:
a) The lack of simulator training requirement for this type of emergency contributed to the control loss.
(6) Crewmember Factor due to Operational Error:
a) The captain did not observe the AFM instructions about the reverse levers and manual brake use.
b) The FIE did not observe the AFM instructions about the correct engine instrument monitoring during the reverse operation.
Final Report:

Crash of a Boeing 747SR-46 on Mt Osutaka: 520 killed

Date & Time: Aug 12, 1985 at 1856 LT
Type of aircraft:
Operator:
Registration:
JA8119
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Tokyo - Osaka
MSN:
20783
YOM:
1974
Flight number:
JL123
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
509
Pax fatalities:
Other fatalities:
Total fatalities:
520
Captain / Total flying hours:
12423
Captain / Total hours on type:
4842.00
Copilot / Total flying hours:
3963
Copilot / Total hours on type:
2665
Aircraft flight hours:
25030
Aircraft flight cycles:
18835
Circumstances:
JA8119 was a Japan Air Lines Boeing 747SR, a short range variant of the Boeing 747 Series 100. The was aircraft specifically configured for domestic flights with a high density seating arrangement. On June 2, 1978 the aircraft operated on a flight to Osaka (ITM). It floated after touchdown and on the second touchdown the tail struck the runway. The aircraft sustained substantial damage to the rear underside of the fuselage. The rear pressure bulkhead was cracked as well. The aircraft was repaired by Boeing. Engineers replaced the lower part of the rear fuselage and a portion of the lower half of the bulkhead. Seven years later, on August 12, 1985, JA8119 had completed four domestic flights when it landed at Tokyo-Haneda (HND) at 17:17. The next flight was to be flight 123 to Osaka (ITM). The aircraft took off from Tokyo-Haneda at 18:12. Twelve minutes later, while climbing through 23900 feet at a speed of 300 knots, an unusual vibration occurred. An impact force raised the nose of the aircraft and control problems were experienced. A decompression had occurred and the crew got indications of problems with the R5 door. In fact, the rear pressure bulkhead had ruptured, causing serious damage to the rear of the plane. A portion of its vertical fin, measuring 5 m together with the section of the tail cone containing the auxiliary power unit (APU) were ripped off the plane. Due to the damage, the hydraulic pressure dropped and ailerons, elevators and yaw damper became inoperative. Controlling the plane was very difficult as the airplane experienced dutch rolls and phugoid oscillations (unusual movement in which altitude and speed change significantly in a 20-100 seconds cycle without change of angle of attack). The aircraft started to descend to 6600 feet while the crew tried to control the aircraft by using engine thrust. Upon reaching 6600 feet the airspeed had dropped to 108 knots. The aircraft then climbed with a 39 degree pitch-up to a maximum of approx. 13400 feet and started to descend again. At 18:56 JAL123 finally brushed against a tree covered ridge, continued and struck the Osutaka Ridge, bursting into flames. A stewardess, one female passenger and two little girl survived while 520 other occupants were killed.
Probable cause:
It is estimated that this accident was caused by deterioration of flying quality and loss of primary flight control functions due to rupture of the aft pressure bulkhead of the aircraft, and the subsequent ruptures of a part of the fuselage tail, vertical fin and hydraulic flight control systems. The reason why the aft pressure bulkhead was ruptured in flight is estimated to be that the strength of the said bulkhead was reduced due to fatigue cracks propagating at the spliced portion of the bulkhead's webs to the extent that it became unable to endure the cabin pressure in flight at that time. The initiation and propagation of the fatigue cracks are attributable to the improper repairs of the said bulkhead conducted in 1978, and it is estimated that the fatigue cracks having not be found in the later maintenance inspection is contributive to their propagation leading to the rupture of the said bulkhead.
Final Report: