Country
Crash of a De Havilland Dash-8-103 in Båtsfjord
Date & Time:
Jun 14, 2001 at 1608 LT
Operator:
Registration:
LN-WIS
Survivors:
Yes
Schedule:
Alta – Båtsfjord
MSN:
247
YOM:
1990
Flight number:
WF954
Crew on board:
3
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
321.00
Copilot / Total hours on type:
1000
Aircraft flight hours:
23935
Aircraft flight cycles:
29469
Circumstances:
The twin engine aircraft departed Alta Airport at 1522LT on a regular schedule service to Båtsfjord, carrying 24 passengers and a crew of three. Following an uneventful flight, the crew started a LOC/DME approach to runway 21. Shortly after passing the missed approach point, the pilot-in-command lost visual contact with the runway so the captain took over controls and continued the approach. The airplane became unstable and the crew encountered control problems due to difficulties to disengage the autopilot system. This caused the aircraft to lose height during the last segment and it landed hard, causing the right main gear to collapse upon impact. The aircraft slid for few dozen metres then veered off runway to the right and came to rest in a grassy area 23 metres to the right of the runway. All 27 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- The crew deviated from the prescribed procedure,
- The crew deviated from the company Standard Operating Procedure,
- The crew failed to comply with CRM requirements as described in the company Flight Operations Manual,
- The crew continued the approach after passing the minimum altitude without adequate visual reference with the runway,
- The crew did not consider 'go around' when passing Decision Point without adequate, visual references to the runway,
- The crew did not consider 'go around' during a landing with apparent flight control problems,
- The crew completed the landing despite the fact that the aircraft was not in a stabilised configuration,
- The non-stabilised landing with a high descent rate overloaded the right undercarriage fuse pin to a point at which it collapsed,
- The public address system did not function when used by the commander for evacuation.
- The crew deviated from the prescribed procedure,
- The crew deviated from the company Standard Operating Procedure,
- The crew failed to comply with CRM requirements as described in the company Flight Operations Manual,
- The crew continued the approach after passing the minimum altitude without adequate visual reference with the runway,
- The crew did not consider 'go around' when passing Decision Point without adequate, visual references to the runway,
- The crew did not consider 'go around' during a landing with apparent flight control problems,
- The crew completed the landing despite the fact that the aircraft was not in a stabilised configuration,
- The non-stabilised landing with a high descent rate overloaded the right undercarriage fuse pin to a point at which it collapsed,
- The public address system did not function when used by the commander for evacuation.
Final Report:
Crash of a De Havilland DHC-8-102 in Palmerston North: 4 killed
Date & Time:
Jun 9, 1995 at 0925 LT
Operator:
Registration:
ZK-NEY
Survivors:
Yes
Schedule:
Auckland - Palmerston North
MSN:
055
YOM:
1986
Flight number:
AN703
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total hours on type:
273.00
Copilot / Total hours on type:
341
Aircraft flight hours:
22154
Aircraft flight cycles:
24976
Circumstances:
At 08:17 Ansett New Zealand Flight 703 departed Auckland (AKL) as scheduled bound for Palmerston North (PMR). To the north of Palmerston North the pilots briefed themselves for a VOR/DME approach to runway 07 which was the approach they preferred. Subsequently Air Traffic Control specified the VOR/DME approach for runway 25, due to departing traffic, and the pilots re-briefed for that instrument approach. The IMC involved flying in and out of stratiform cloud, but continuous cloud prevailed during most of the approach. The aircraft was flown accurately to join the 14 nm DME arc and thence turned right and intercepted the final approach track of 250° M to the Palmerston North VOR. During the right turn, to intercept the inbound approach track, the aircraft’s power levers were retarded to 'flight idle' and shortly afterwards the first officer advised the captain ".... 12 DME looking for 4000 (feet)". The final approach track was intercepted at approximately 13 DME and 4700 feet, and the first officer advised Ohakea Control "Ansett 703" was "established inbound". Just prior to 12 miles DME the captain called "Gear down". The first officer asked him to repeat what he had said and then responded "OK selected and on profile, ten - sorry hang on 10 DME we’re looking for four thousand aren’t we so - a fraction low". The captain responded, "Check, and Flap 15". This was not acknowledged but the first officer said, "Actually no, we’re not, ten DME we’re..... (The captain whistled at this point) look at that". The captain had noticed that the right hand main gear had not locked down: "I don’t want that." and the first officer responded, "No, that’s not good is it, so she’s not locked, so Alternate Landing Gear...?" The captain acknowledged, "Alternate extension, you want to grab the QRH?" After the First Officer’s "Yes", the captain continued, "You want to whip through that one, see if we can get it out of the way before it’s too late." The captain then stated, "I’ll keep an eye on the airplane while you’re doing that." The first officer located the appropriate "Landing Gear Malfunction Alternate Gear Extension" checklist in Ansett New Zealand’s Quick Reference Handbook (QRH) and began reading it. He started with the first check on the list but the captain told him to skip through some checks. The first officer responded to this instruction and resumed reading and carrying out the necessary actions. It was the operator’s policy that all items on the QRH checklists be actioned, or proceeded through, as directed by the captain. The first officer started carrying out the checklist. The captain in between advised him to pull the Main Gear Release Handle. Then the GPWS’s audio alarm sounded. Almost five seconds later the aircraft collided with terrain. The Dash 8 collided with the upper slope of a low range of hills.
Probable cause:
The captain not ensuring the aircraft intercepted and maintained the approach profile during the conduct of the non-precision instrument approach, the captain's perseverance with his decision to get the undercarriage lowered without discontinuing the instrument approach, the captain's distraction from the primary task of flying the aircraft safely during the first officer's endeavours to correct an undercarriage malfunction, the first officer not executing a Quick Reference Handbook procedure in the correct sequence, and the shortness of the ground proximity warning system warning.
Final Report:
Crash of a De Havilland Dash-8-103 in Koh Samui: 38 killed
Date & Time:
Nov 21, 1990 at 1815 LT
Operator:
Registration:
HS-SKI
Survivors:
No
Schedule:
Bangkok - Koh Samui
MSN:
172
YOM:
1989
Flight number:
PG125
Crew on board:
5
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
38
Captain / Total hours on type:
521.00
Copilot / Total hours on type:
235
Aircraft flight hours:
3416
Aircraft flight cycles:
2998
Circumstances:
On final approach to Koh Samui Airport runway 35, the aircraft entered an area of heavy rain falls. As the crew was unable to locate the runway, the captain decided to initiate a go-around procedure. With flaps fully extended, the crew increased power and started to gain height when the aircraft rolled to the left to an angle of 75° then entered an uncontrolled descent and crashed at a speed of 147 knots about 5 km short of runway threshold. The aircraft disintegrated on impact and all 38 occupants were killed.
Probable cause:
The pilot suffered a spatial disorientation which resulted in an improper control of the aircraft. The following contributing factors were reported:
- The pilot continued the approach in bad weather conditions with limited or no visual reference with the ground.
- Both pilots attention was focused on trying to locate the runway, neglecting the standard cross checks and mutual checks on approach and failing to monitor the aircraft attitude.
- Poor crew coordination,
- Lack of teamwork,
- Poor flight monitoring that contributed to the loss of situational awareness and improper control of the aircraft.
- The pilot continued the approach in bad weather conditions with limited or no visual reference with the ground.
- Both pilots attention was focused on trying to locate the runway, neglecting the standard cross checks and mutual checks on approach and failing to monitor the aircraft attitude.
- Poor crew coordination,
- Lack of teamwork,
- Poor flight monitoring that contributed to the loss of situational awareness and improper control of the aircraft.
