Crash of a Douglas DC-9-31 in Monrovia

Date & Time: Jul 26, 1995
Type of aircraft:
Operator:
Registration:
5N-BBA
Survivors:
Yes
Schedule:
Kano – Lagos – Accra – Monrovia
MSN:
47217
YOM:
1968
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Monrovia-James Spriggs Payne Airport was completed in poor weather conditions with a visibility limited due to heavy rain falls. On final, the aircraft struck the ground short of runway threshold, causing the undercarriage to be torn off. The aircraft slid on its belly for about 500 metres before coming to rest on the runway. All 91 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
In poor weather conditions, the crew continued the approach below the minimum safe altitude until the aircraft impacted terrain short of runway threshold. The lack of visibility caused by the heavy rain falls remains a contributing factor, but the crew should have made the decision to initiate a go-around procedure since the landing was obviously missed.

Ground explosion of a Douglas DC-9-32 in Atlanta

Date & Time: Jun 8, 1995 at 1908 LT
Type of aircraft:
Operator:
Registration:
N908VJ
Flight Phase:
Survivors:
Yes
Schedule:
Atlanta - Miami
MSN:
47321
YOM:
1969
Flight number:
VJA597
Crew on board:
5
Crew fatalities:
Pax on board:
57
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9500
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
3800
Copilot / Total hours on type:
552
Aircraft flight hours:
63000
Circumstances:
As ValuJet Flight 597 began its takeoff roll, a 'loud Bang' was heard by the occupants, the right engine fire warning light illuminated, the crew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered evacuation of the airplane. A flight attendant (F/A) received serious puncture wounds from shrapnel and thermal injuries; another F/A and 5 passengers received minor injuries. Investigation revealed that an uncontained failure of the right engine had occurred due to fatigue failure of its 7th stage high compressor disc. The fatigue originated at a stress redistribution hole in the disc. Analysis of fatigue striation measurements indicated that the fatigue crack had originated before the disc was last overhauled at a repair station (Turk Hava Yollari) in 1991, but was not detected. Also, investigation of the repair station revealed evidence concerning a lack of adequate recordkeeping and a failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures.
Probable cause:
Failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disc, thus allowing the detectable crack to grow to a length at which the disc ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate record keeping system and the failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident.
Final Report:

Crash of a Douglas DC-9-14 in María La Baja: 51 killed

Date & Time: Jan 11, 1995 at 1938 LT
Type of aircraft:
Operator:
Registration:
HK-3839X
Flight Phase:
Survivors:
Yes
Schedule:
Bogotá – Cartagena – San Andres – Panama City – Cali – Bogotá
MSN:
45742/26
YOM:
1966
Flight number:
RS256
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
51
Captain / Total flying hours:
10924
Captain / Total hours on type:
4605.00
Copilot / Total flying hours:
4229
Copilot / Total hours on type:
3952
Aircraft flight hours:
65084
Aircraft flight cycles:
69716
Circumstances:
The aircraft departed Bogotá-El Dorado Airport at 1843LT with a delay of six hours because of technical problems with the electrical systems. At 1934LT, after being cleared to start the descent to Cartagena-Rafael Núñez Airport, the crew descended from FL190 to FL080 when radar contact was lost. Four minutes later, the pilot of a Cessna 208 operated by Aerocorales informed ARTCC about a plane descending vertically and crashing in a marshy field located near María La Baja. The wreckage was found about 40 km southeast of Cartagena Airport. The aircraft disintegrated on impact and among the debris, a nine year old girl was found alive, all 51 other occupants have been killed.
Probable cause:
It was determined that the loss of control occurred after the pilot-in-command suffered a loss of situational awareness. Contributing to the loss of Vertical Situational Awareness, was the failure of the altimeter Number one during the descent, the lack of light in the altimeter Number two, the ineffectiveness of the Altitude Alert due to the failure of the altimeter Number one, the lack of radar service in the area, the complacency of the command crew because of good weather conditions, flight training that may not have been authorized by the company, the failure of the ground proximity warning system (GPWS), or lack of crew reaction time to respond to this alarm.
Final Report:

Crash of a Douglas DC-9-31 in Monrovia

Date & Time: Aug 18, 1994 at 1058 LT
Type of aircraft:
Operator:
Registration:
5N-BBE
Survivors:
Yes
Schedule:
Banjul – Freetown – Monrovia – Accra – Lagos
MSN:
45872
YOM:
1968
Flight number:
ADK018
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
62484
Circumstances:
The aircraft departed Banjul, Gambia, on an international scheduled service to Lagos with intermediate stops in Freetown, Monrovia and Accra. The approach to Monrovia-James Spriggs Payne Airport runway 23 was completed in poor weather conditions with heavy rain falls. On final, at a distance of 4 km from the runway threshold, the captain confirmed that visual contact with the runway was established and continued the approach. At an excessive speed, the airplane passed over the runway threshold at a height of 150 feet and landed too far down the runway, about 3,000 feet past its threshold. On a wet runway surface, despite full brakes and reverse thrusts were deployed, the aircraft could not be stopped within the remaining distance. It overran at a speed of 80 knots and came to rest 120 metres further, bursting into flames. All 85 occupants were rescued, among them few were slightly injured. The aircraft was destroyed by fire.
Probable cause:
Wrong approach configuration on part of the crew who completed the approach at an excessive speed and well above the glide, causing the aircraft to land too far down runway 23 which is 1,800 metres long. Poor braking action due to wet runway surface was considered as a contributing factor as well as the fact that the crew failed to initiate a go-around procedure as the landing maneuver was obviously missed.

Crash of a Douglas DC-9-31 in Charlotte: 37 killed

Date & Time: Jul 2, 1994 at 1843 LT
Type of aircraft:
Operator:
Registration:
N954VJ
Survivors:
Yes
Site:
Schedule:
Columbia - Charlotte
MSN:
47590
YOM:
1973
Flight number:
US1016
Crew on board:
5
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
37
Captain / Total flying hours:
8065
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
12980
Copilot / Total hours on type:
3180
Aircraft flight hours:
53917
Aircraft flight cycles:
63147
Circumstances:
USAir Flight 1016 was a domestic flight from Columbia (CAE) to Charlotte (CLT). The DC-9 departed the gate on schedule at 18:10. The first officer was performing the duties of the flying pilot. The weather information provided to the flightcrew from USAir dispatch indicated that the conditions at Charlotte were similar to those encountered when the crew had departed there approximately one hour earlier. The only noted exception was the report of scattered thunderstorms in the area. Flight 1016 was airborne at 18:23 for the planned 35 minute flight. At 18:27, the captain of flight 1016 made initial contact with the Charlotte Terminal Radar Approach Control (TRACON) controller and advised that the flight was at 12,000 feet mean sea level (msl). The controller replied "USAir ten sixteen ... expect runway one eight right." Shortly afterward the controller issued a clearance to the flightcrew to descend to 10,000 feet. At 18:29, the first officer commented "there's more rain than I thought there was ... it's startin ...pretty good a minute ago ... now it's held up." On their airborne weather radar the crew observed two cells, one located south and the second located east of the airport. The captain said "looks like that's [rain] setting just off the edge of the airport." One minute later, the captain contacted the controller and said "We're showing uh little buildup here it uh looks like it's sitting on the radial, we'd like to go about five degrees to the left to the ..." The controller replied "How far ahead are you looking ten sixteen?" The captain responded "About fifteen miles." The controller then replied "I'm going to turn you before you get there I'm going to turn you at about five miles northbound." The captain acknowledged the transmission, and, at 18:33, the controller directed the crew to turn the aircraft to a heading of three six zero. One minute later the flightcrew was issued a clearance to descend to 6,000 feet, and shortly thereafter contacted the Final Radar West controller. At 18:35 the Final Radar West controller transmitted "USAir ten sixteen ... maintain four thousand runway one eight right.'' The captain acknowledged the radio transmission and then stated to the first officer "approach brief." The first officer responded "visual back up ILS." Following the first officer's response, the controller issued a clearance to flight 1016 to "...turn ten degrees right descend and maintain two thousand three hundred vectors visual approach runway one eight right.'' At 18:36, the Final Radar West controller radioed flight 1016 and said "I'll tell you what USAir ten sixteen they got some rain just south of the field might be a little bit coming off north just expect the ILS now amend your altitude maintain three thousand." At 18:37, the controller instructed flight 1016 to ''turn right heading zero niner zero." At 18:38, the controller said "USAir ten sixteen turn right heading one seven zero four from SOPHE [the outer marker for runway 18R ILS] ... cross SOPHE at or above three thousand cleared ILS one eight right approach." As they were maneuvering the airplane from the base leg of the visual approach to final, both crew members had visual contact with the airport. The captain then contacted Charlotte Tower. The controller said "USAir ten sixteen ... runway one eight right cleared to land following an F-K one hundred short final, previous arrival reported a smooth ride all the way down the final." The pilot of the Fokker 100 in front also reported a "smooth ride". About 18:36, a special weather observation was recorded, which included: ... measured [cloud] ceiling 4,500 feet broken, visibility 6 miles, thunderstorm, light rain shower, haze, the temperature was 88 degrees Fahrenheit, the dewpoint was 67 degrees Fahrenheit, the wind was from 110 degrees at 16 knots .... This information was not broadcast until 1843; thus, the crew of flight 1016 did not receive the new ATIS. At 18:40, the Tower controller said "USAir ten sixteen the wind is showing one zero zero at one nine." This was followed a short time later by the controller saying "USAir ten sixteen wind now one one zero at two one." Then the Tower controller radioed a wind shear warning "windshear alert northeast boundary wind one nine zero at one three.'' On finals the DC-9 entered an area of rainfall and at 18:41:58, the first officer commented "there's, ooh, ten knots right there." This was followed by the captain saying "OK, you're plus twenty [knots] ... take it around, go to the right." A go around was initiated. The Tower controller noticed Flight 1016 going around "USAir ten sixteen understand you're on the go sir, fly runway heading, climb and maintain three thousand." The first officer initially rotated the airplane to the proper 15 degrees nose-up attitude during the missed approach. However, the thrust was set below the standard go-around EPR limit of 1.93, and the pitch attitude was reduced to 5 degrees nose down before the flightcrew recognized the dangerous situation. When the flaps were in transition from 40 to 15 degrees (about a 12-second cycle), the airplane encountered windshear. Although the DC-9 was equipped with an on-board windshear warning system, it did not activate for unknown reasons. The airplane stalled and impacted the ground at 18:42:35. Investigation revealed that the headwind encountered by flight 1016 during the approach between 18:40:40 and 18:42:00 was between 10 and 20 knots. The initial wind component, a headwind, increased from approximately 30 knots at 18:42:00 to 35 knots at 18:42:15. The maximum calculated headwind occurred at 18:42:17, and was calculated at about 39 knots. The airplane struck the ground after transitioning from a headwind of approximately 35 knots, at 18:42:21, to a tailwind of 26 knots (a change of 61 knots), over a 14 second period.
Probable cause:
The board determines that the probable cause of the accident was:
- The flight crew's decision to continue an approach into severe convective activity that was conducive to a microburst,
- The flight crew's failure to recognize a windshear situation in a timely manner,
- The flight crew's failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear,
- The lack of real-time adverse weather and windshear hazard information dissemination from air traffic control, all of which led to an encounter with and failure to escape from a microburst-induced windshear that was produced by a rapidly developing thunderstorm located at the approach end of runway 18R.
The following contributing factors were reported:
- The lack of air traffic control procedures that would have required the controller to display and issue ASR-9 radar weather information to the pilots of flight 1016,
- The Charlotte tower supervisor's failure to properly advise and ensure that all controllers were aware of and reporting the reduction in visibility and the RVR value information, and the low level windshear alerts that had occurred in multiple quadrants,
- The inadequate remedial actions by USAir to ensure adherence to standard operating procedures,
- The inadequate software logic in the airplane's windshear warning system that did not provide an alert upon entry into the windshear.
Final Report:

Crash of a Douglas DC-9-32 in Vigo

Date & Time: Mar 21, 1994 at 0917 LT
Type of aircraft:
Operator:
Registration:
EC-CLE
Survivors:
Yes
Schedule:
Madrid - Vigo
MSN:
47678
YOM:
1975
Flight number:
AO260
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
110
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
38224
Aircraft flight cycles:
41155
Circumstances:
On final approach to Vigo Airport runway 20, the crew encountered foggy conditions with a visibility limited to 1,500 metres. The aircraft descended below the glide and the left main gear struck an element of the approach light system located 100 metres short of runway threshold. The aircraft then landed 50 metres short of runway, causing both main landing gear to collapse. The aircraft slid on its belly for about 580 metres before coming to rest, bursting into flames. All 116 occupants were rescued, among them 21 were injured. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the flying crew who led the aircraft descending below the glide in limited visibility conditions. The crew's attention was focused on the visual contact with the runway and the pilots ignored the alarms that was sounding in the cockpit.

Crash of a Douglas DC-9-32 in Ciudad Bolívar

Date & Time: Jul 19, 1993
Type of aircraft:
Operator:
Registration:
YV-613C
Survivors:
Yes
MSN:
47104
YOM:
1967
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
60
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Ciudad Bolívar Airport was completed in poor weather conditions with limited visibility due to heavy rain falls. On short final, about 4,800 metres short of runway 06 threshold, the aircraft was too high on the glide and the captain decided to make a correction. After touchdown, the crew initiated the braking procedure but the aircraft was unable to stop within the remaining distance. It overran the wet runway (1,737 metres long) and came to rest 150 metres further. All 65 occupants were evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew who continued the descent too high on the glide. It was reported that the landing speed was slightly above Vref at 123 knots and the aircraft suffered aquaplaning as the runway surface was wet.

Crash of a Douglas DC-9-32 in Denpasar

Date & Time: Jun 21, 1993 at 1125 LT
Type of aircraft:
Operator:
Registration:
PK-GNT
Survivors:
Yes
Schedule:
Yogyakarta - Denpasar
MSN:
47790/907
YOM:
1979
Flight number:
GA630
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
72
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Denpasar-I Gusti Ngurah Rai Airport, Bali, the aircraft was too high on the glide. The captain made an overcorrection, causing the aircraft to approach the runway with a high rate of descent. In a nose-up attitude, the aircraft struck the runway surface with a positive acceleration of 5 g. After landing, the crew completed the deceleration and braking procedure, vacated the runway and rolled to the gate where all occupants disembarked safely. A complete inspection of the aircraft by technicians revealed that it suffered major fuselage damages and was later declared as damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the flying crew.