Zone
Crash of a Learjet 25D off Naiguatá: 5 killed
Date & Time:
Aug 19, 2017 at 0016 LT
Registration:
YV3191
Survivors:
No
Schedule:
Maiquetía – Barcelona
MSN:
25-368
YOM:
1984
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The airplane departed Maiquetía-Símon Bolívar Airport at 0011LT for a 35 minutes flight to Barcelona. About five minutes after takeoff, while cruising at an altitude of 23,000 feet, the aircraft went out of control and plunged into the sea few km off Naiguatá, State of Vargas. It appeared the aircraft disintegrated on impact and few debris were found the following morning floating on water. All five occupants were killed.
Crash of an Airbus A320-211 near Prads-Haute-Bléone: 150 killed
Date & Time:
Mar 24, 2015 at 1041 LT
Operator:
Registration:
D-AIPX
Survivors:
No
Schedule:
Barcelona – Düsseldorf
MSN:
147
YOM:
1990
Flight number:
4U9525
Crew on board:
6
Crew fatalities:
Pax on board:
144
Pax fatalities:
Other fatalities:
Total fatalities:
150
Captain / Total hours on type:
3811.00
Copilot / Total hours on type:
540
Aircraft flight hours:
58313
Aircraft flight cycles:
46748
Circumstances:
The aircraft left Barcelona at 1000LT on a scheduled flight to Düsseldorf (flight 4U9525/GWI18G). At 1032LT, one minute after reaching its assigned cruising altitude of 38,000 feet near Toulon (level off), the aircraft started to lose altitude and continued a straight in descent during nine minutes, until it reached the altitude of 6,800 feet. It was later confirmed that no distress call was sent by the crew. Radar contact was lost at a height of 6,800 feet at 1041LT when the aircraft hit a mountain slope located near Prads-Haute-Bléone, northeast of Digne-les-Bains. At the time of the accident, weather conditions were considered as good with no storm activity, reasonable wind component and no turbulence. The crash site was reached by first rescuers in the afternoon and the aircraft disintegrated on impact. None of the 150 occupants survived the crash. The second black box (DFDR) was found on April 2, nine days after the accident.
Probable cause:
The collision with the ground was due to the deliberate and planned action of the copilot who decided to commit suicide while alone in the cockpit. The process for medical certification of pilots, in particular self-reporting in case of decrease in medical fitness between two periodic medical evaluations, did not succeed in preventing the copilot, who was experiencing mental disorder with psychotic symptoms, from exercising the privilege of his licence. The following factors may have contributed to the failure of this principle:
-The copilot’s probable fear of losing his ability to fly as a professional pilot if he had reported his decrease in medical fitness to an AME,
-The potential financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly,
- The lack of clear guidelines in German regulations on when a threat to public safety outweighs the requirements of medical confidentiality.
Security requirements led to cockpit doors designed to resist forcible intrusion by unauthorized persons. This made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps.
-The copilot’s probable fear of losing his ability to fly as a professional pilot if he had reported his decrease in medical fitness to an AME,
-The potential financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly,
- The lack of clear guidelines in German regulations on when a threat to public safety outweighs the requirements of medical confidentiality.
Security requirements led to cockpit doors designed to resist forcible intrusion by unauthorized persons. This made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps.
Final Report:
Crash of a Boeing 737-3Y0 in Kaliningrad
Date & Time:
Oct 1, 2008 at 2318 LT
Operator:
Registration:
EI-DON
Survivors:
Yes
Schedule:
Barcelona - Kaliningrad
MSN:
23812/1511
YOM:
1988
Flight number:
KNI794
Crew on board:
6
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
1258.00
Copilot / Total hours on type:
1010
Aircraft flight hours:
48514
Aircraft flight cycles:
39949
Circumstances:
The accident aircraft Boeing 737-3Y0 EI-DON, was operated by KD Avia on a flight from Kaliningrad, Russia to Barcelona, Spain and return. Flight KD793 to Barcelona was uneventful. The return flight, KD794, departed at 16:18 with 138 passengers and six crew members on board. The copilot was Pilot Flying, the captain was Pilot Monitoring. The en route part of the flight was uneventful. As the flight was descending to Kaliningrad at night in heavy rains and with gusty crosswind. During the descent flaps were first selected at 1° and thereafter to 5°. As the flaps were transitioning to this position, a flap asymmetry warning caught the attention of the crew. At 19:00 hours the captain took over control and selected flaps to 2°, the position at which there was no asymmetry warning. The crew then contacted the controller at Kaliningrad and reported that they had flap problems. As the descent was continued, the copilot performed the necessary calculations for a landing with flaps at 2°. At 19:09 the cabin crew was warned to prepare for a high-speed landing. Using the QRH to work the flap issue, the co-pilot activated the 'flap inhibit' and 'gear inhibit' switches. This "incorrect" action effectively disconnected the ground-proximity warning system (GPWS). At 19:11 it was established that the landing speed would be Vref +30, leading to a planned landing speed of 161 knots. At 19:14 the Landing Gear Warning Horn sounded due to the combination of power and flaps setting with the fact that the landing gear had not been selected down. This warning was cancelled by the crew. When the engine power was reduced to idle, the Landing Gear Warning Horn sounded again. This time the crew did not pay attention to the warning and continued to land. The airplane performed a gear up landing, sliding for 1440 m before coming to rest on the runway. The flap asymmetry issue was caused by a faulty Flap Position Transmitter. The flaps had extended to the commanded position, but the system incorrectly detected an asymmetry issue. This issue had occurred previously on EI-DON. The sensor had been replaced prior to departure from Kaliningrad that same day.
Probable cause:
The crash was caused by aircraft landing with not extended landing gear that resulted in aircraft structure and engines damage and it was caused by combination of the following adverse factors:
- Erroneous deactivation of GPWS gear warning (voice) system that was caused by failure to perform QRH recommendations on flaps warning deactivation during their asymmetrical extension;
- Presence of QRH manual on board of Boeing-737-300 EI-DON aircraft containing in Additional Deferred Item clause of Trailing Edge Flap Asymmetry chapter recommendation to the crew which are not specialized for the board configuration;
- Violation of the "Crew operating procedure of Boeing-737-300 aircraft" and non-compliance with QRH recommendations («LANDING CHECKLIST» section) with the result that the crew did not extend landing gear and did not monitor their position;
- Stereotyping on actuation of Landing Gear Warning Horn aural warning during approach as a result of which the crew deactivated it repeatedly without monitoring of landing gear position;
- Inadequate coordination of the crew resulted in lack of monitoring of compliance with FCOM and QRH requirements at occurrence and development of abnormal situation;
Appropriate safety recommendations based on the investigation results were developed.
Following this accident, both pilots lost their licence and KD Avia's AOC was revoked by Russian authorities in September 2009. The same month, KD Avia bankrupted.
- Erroneous deactivation of GPWS gear warning (voice) system that was caused by failure to perform QRH recommendations on flaps warning deactivation during their asymmetrical extension;
- Presence of QRH manual on board of Boeing-737-300 EI-DON aircraft containing in Additional Deferred Item clause of Trailing Edge Flap Asymmetry chapter recommendation to the crew which are not specialized for the board configuration;
- Violation of the "Crew operating procedure of Boeing-737-300 aircraft" and non-compliance with QRH recommendations («LANDING CHECKLIST» section) with the result that the crew did not extend landing gear and did not monitor their position;
- Stereotyping on actuation of Landing Gear Warning Horn aural warning during approach as a result of which the crew deactivated it repeatedly without monitoring of landing gear position;
- Inadequate coordination of the crew resulted in lack of monitoring of compliance with FCOM and QRH requirements at occurrence and development of abnormal situation;
Appropriate safety recommendations based on the investigation results were developed.
Following this accident, both pilots lost their licence and KD Avia's AOC was revoked by Russian authorities in September 2009. The same month, KD Avia bankrupted.
Final Report:
Crash of a BAe 125-3A in Barcelona
Date & Time:
Jun 26, 2006 at 0958 LT
Registration:
N125GK
Survivors:
Yes
Schedule:
Caracas - Barcelona
MSN:
25127
YOM:
1967
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Caracas-Maíquetia-Simón Bolívar Airport, the crew complete the approach to Barcelona-General José Antonio Anzoátegui Airport. The airplane landed normally and after a course of about 100 metres, both main gears collapsed. The aircraft skidded on runway and eventually came to rest, bursting into flames. All 8 occupants escaped uninjured while the aircraft was damaged beyond repair.
