Crash of an Avro RJ100 in London-City

Date & Time: Feb 13, 2009 at 2040 LT
Type of aircraft:
Operator:
Registration:
G-BXAR
Survivors:
Yes
Schedule:
Amsterdam - London-City
MSN:
E3298
YOM:
1997
Flight number:
BA8456
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4730
Captain / Total hours on type:
2402.00
Circumstances:
Following a normal touchdown, the fracture of the nose landing gear main fitting allowed the nose gear to collapse rearwards and penetrate the lower fuselage, causing significant damage to the equipment bay and the battery to become disconnected. The penetration of the fuselage allowed smoke and fumes produced by the consequent release of hydraulic fluid to enter the cockpit and passenger cabin. With the battery disconnected and after the engines were shut down, all power to the aircraft PA systems was lost and the remote cockpit door release mechanism became inoperative. No pre-accident defects were identified with the manual cockpit door release mechanism or the PA system.
Probable cause:
The nose landing gear main fitting failed following the formation of multiple fatigue cracks within the upper section of the inner bore, originating at the base of machining grooves in the bore surface. These had formed because the improved surface finish, introduced by SB 146-32-150, had not been properly embodied at previous overhaul by Messier Services Inc, despite their overhaul records showing its incorporation. The operator had been in full compliance with the Service Bulletin relating to regular inspection of the main fitting, and embodiment of SB 146-32-150 at overhaul removed the requirement for these inspections by the operator.
Final Report:

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 Douglas C-47B-35-DK in Southend

Date & Time: Jun 3, 1971 at 1325 LT
Operator:
Registration:
PH-MOA
Survivors:
Yes
Schedule:
Southend – Amsterdam
MSN:
16605/33353
YOM:
1945
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4663
Captain / Total hours on type:
1750.00
Copilot / Total flying hours:
3247
Copilot / Total hours on type:
230
Aircraft flight hours:
6372
Circumstances:
The aircraft was engaged in a charter flight from Southend to Amsterdam, carrying 32 supporters of the Ajax football team back to The Netherlands. Following a fall in manifold pressure and the discovery of an oil leak in the starboard engine soon after a night takeoff, the pilot decided to return to Southend Airport for an emergency landing. In order to avoid an overshoot, he positioned the flaps to a 15° angle for the landing which resulted in a higher than normal airspeed at touchdown. The aircraft touched down about half-way down the runway in use, overran the paved area and collided with an earth bank. Of the 32 passengers and four crew on board, two passengers were injured. The aircraft was damaged beyond repair.
Probable cause:
The accident was due to a late touchdown and inappropriate use of the flaps. Insufficient braking efficiency resulted in a higher speed of overrun than would have otherwise occurred. The following factors were reported:
- The documentation of the aircraft was not in order,
- The number of persons on board was in excess of the number for which seating capacity and safety belts were provided, and the aircraft weight at take-off was 335 kg in excess of the authorised maximum,
- Following an engine failure in the air, the aircraft made an emergency landing at Southend Airport at a weight 560 kg in excess of its regulated landing weight,
- The approach and landing was made with 15° of flap extended, full flap was not used,
- Touchdown occurred approximately half way down the runway,
- The aircraft wheels brakes were worn to the extent that their efficiency would have been impaired and oil may have reduced the grip of the starboard tyre,
- The aircraft overran the paved area and collided with an earth bank on the aerodrome boundary.
Final Report:

Crash of a Convair CV-240-4 in Amsterdam: 2 killed

Date & Time: May 25, 1953 at 1530 LT
Type of aircraft:
Operator:
Registration:
PH-TEI
Flight Phase:
Survivors:
Yes
Schedule:
Amsterdam – Paris
MSN:
125
YOM:
1949
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
7104
Circumstances:
After a run of 700 meters on runway 05, the captain started to rotate. During the initial climb, at a height of approximately 50 to 60 feet and at a speed of 233 km/h, the pilot-in-command retracted the flaps when the aircraft lost height and stalled. The pilot closed the throttles and belly landed the airplane on the remaining runway. The aircraft slid for 200 meters, overran, crossed a road where it struck two standing girls before coming to rest near a drainage ditch, broken in two. All 34 occupants were evacuated safely while two girls aged 16 and 4 were killed. The aircraft was destroyed.
Probable cause:
The exact cause of the accident could not be determined with certainty. During the extensive technical investigation no facts were found to be true for a technical failure of any part of the aircraft before the accident. The damping of the cable tensioners did not fully meet the specifications however, the Board considered that this could hardly have affected steerability. The ascent was somewhat flatter than normal and possibly created the rapid execution of the commands "flaps up" and "first power reduction" provide a greater condition steering movement required than the captain was used to. That need not be serious as long as the captain retained the confidence he had could bring back the plane in ascending flight. All in all, the investigation did not provide a clear cause for the captain Of course it is important that one of the conclusions of the Council was that “On the basis of the foregoing, the Board, together with the preliminary investigator, is of the opinion that in this case does not warrant the application of any sanction against the person is present.

Crash of a Douglas C-47A-25-DK into the North Sea: 7 killed

Date & Time: Feb 2, 1950 at 0539 LT
Operator:
Registration:
PH-TEU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Amsterdam – London
MSN:
13396
YOM:
1944
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft left Amsterdam-Schiphol Airport at 0525LT on a cargo flight to London. Fourteen minutes later, it went out of control and dove into the North Sea, about 66 km west of the Dutch coast. All seven crew members were killed. According to the testimony of a Danish boat's captain, an engine was on fire when the aircraft came down.

Crash of an Avro 652 Anson I in Amsterdam

Date & Time: Aug 14, 1949
Type of aircraft:
Operator:
Registration:
OO-SRA
Flight Type:
Survivors:
Yes
Schedule:
Stavanger – Groningen
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a cargo flight from Stavanger to Groningen with a load of lobsters. On approach to Groningen-Eelde Airport, the crew encountered communication problems and was unable to locate the airport due to foggy conditions. The pilot then decided to divert to Amsterdam-Schiphol Airport. But on approach to the capital city, the crew encountered poor weather conditions as well and was forced to abandon the approach. A second attempt to land was abandoned as well and the pilot made a go around. During the third approach, he tried to descent under the cloud layer when the airplane hit the ground, lost its undercarriage, hit a caravan and came to rest on a drainage ditch. Both occupants were unhurt while the aircraft was damaged beyond repair. It was reported there were 15 liters of fuel remaining in the tanks at the time of the accident.

Crash of a Beechcraft D18S in Amsterdam: 5 killed

Date & Time: Apr 26, 1949
Type of aircraft:
Operator:
Registration:
PH-UDI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Amsterdam - Amsterdam
MSN:
A-0426
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew consisting of one instructor and four pilots under supervision was completing a local training mission in Amsterdam-Schiphol Airport. In flight, the crew voluntarily shot down an engine and continued the instruction program on one engine only. Few seconds later, the operative engine failed. The aircraft stalled and crashed in flames on the bank of a canal. The aircraft was destroyed by a post crash fire and all five crew members were killed.
Probable cause:
Engine failure.

Crash of a Lockheed L-049-46-25 Constellation in Prestwick: 40 killed

Date & Time: Oct 20, 1948 at 2332 LT
Operator:
Registration:
PH-TEN
Survivors:
No
Schedule:
Amsterdam – Prestwick – Gander – New York
MSN:
2083
YOM:
1947
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
30
Pax fatalities:
Other fatalities:
Total fatalities:
40
Circumstances:
The descent to Prestwick Airport was completed by night. On final approach to runway 32, the captain encountered strong winds and decided to start a go around and to follow a holding pattern. He later obtained the permission to start an approach to runway 26. On final, the four engine aircraft christened 'Nijmegen' went into few patches of fog when the pilot said on the frequency: 'we hit something, try to get height'. Shortly later, the aircraft crashed in flames in a field located 5 km short of the runway threshold. A passenger was seriously injured while 39 other occupants were killed. The only survivor died from his injuries few hours later.
Probable cause:
It was determined that:
- When the pilot started his landing maneuver for runway 26 of Prestwick Airport the weather conditions were already below the limits for this maneuver but that from the weather forecasts received this could not be known to him and that this could not be personally judged at the time.
- That, although the landing on runway 26 under the weather conditions, as far as these were known to the pilot, required the greatest caution, the pilot could not be blamed for having commenced that landing procedure.
- That flying too long on the downwind-leg of runway 26 caused the accident.
- That, if no unknown circumstances contributed to the extension of the flight on the downwind-leg of runway 26, the extension was due to the delayed action of the pilot after he lost visual approach.
- That it was not impossible that a stronger wind that the pilot accounted for contributed to the extension of the flight on the downwind-leg of runway 26.
- That the possibility of other circumstances as mentioned under 4 could not be ruled out, but that no data was available which could give cause for the supposition that they contributed to the extension of the flight at a low altitude on the downwind-leg of runway 26.

Crash of a Douglas DC-6 in Northwood: 32 killed

Date & Time: Jul 4, 1948 at 1503 LT
Type of aircraft:
Operator:
Registration:
SE-BDA
Survivors:
No
Schedule:
Stockholm – Amsterdam – Northolt
MSN:
43119
YOM:
1948
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
25
Pax fatalities:
Other fatalities:
Total fatalities:
32
Circumstances:
The four engine aircraft christened 'Agnar Viking' was approaching RAF Northolt when the crew encountered low visibility due to poor weather conditions. After being cleared by ATC to descent to 2,500 feet, the crew was unable to locate the airport and decided to return to Amsterdam-Schiphol Airport. Few minutes later, while climbing to an altitude of 3,000 feet, the aircraft collided with a Royal Air Force Avro 685 York C.1 registered MW248. This second aircraft was completing a flight from Malta-Luqa with four passengers and a crew of three. Following the collision, both aircraft went out of control, dove into the ground and crashed in a wooded area located in Northwood, about 4 miles north of RAF Northolt. Both aircraft were destroyed and all 39 people were killed.
Probable cause:
The cause of the loss must in all probability be found in the field of human fallibility on the part of those responsible for the control of the aircraft from the ground or the flight of the aircraft in the air. Investigators found that the separation of 500 feet in force in the Northolt area, provided an inadequate margin of safety and recommended that it should be increased to 1,000 feet for the Metropolitan Control Zone. The report also discussed the standard setting for altimeters (known as QFF) that had been introduced in May 1948 for aircraft above 1,500 feet within control zones, and that any error in setting the barometric pressure of one millibar gave an error of 28 feet.

Crash of a Douglas C-47A-5-DK in Leeuwarden

Date & Time: Dec 27, 1947 at 1240 LT
Operator:
Registration:
PH-TCV
Survivors:
Yes
Schedule:
Amsterdam – Leeuwarden – Groningen
MSN:
12309
YOM:
1944
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While approaching Leeuwarden, the crew encountered poor weather conditions with heavy rain falls and a cloud base at 100 meters. Unable to locate the airport, the captain decided to make a go around and increased engine power. Shortly later, while flying over the city of Leeuwarden, the aircraft hit with its left wing the church of Saint Bonifatius which is 70 meters high. Three meters of the left wing were sheared off. The captain reduced his altitude in an attempt to make an emergency landing and completed a belly landing in a field. The aircraft skidded for several yards and hit three successive ditches before coming to rest with both propellers sheared off. All 15 occupants were unhurt while the aircraft was damaged beyond repair.