Zone
Crash of a Douglas DC-8-62F in New York
Date & Time:
Mar 12, 1991 at 0906 LT
Registration:
N730PL
Survivors:
Yes
Schedule:
New York - Brussels
MSN:
46161
YOM:
1971
Flight number:
8C102
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
3000.00
Aircraft flight hours:
50145
Circumstances:
Before flight, the flight engineer (f/e) had calculated 'v' speeds and horizontal stabilizer trim setting for takeoff, but neither the captain nor the 1st officer (f/o) had verified them. During rotation for takeoff, the captain noted that the forced needed to pull the yoke aft was greater than normal and that the aircraft would not fly (at that speed). Subsequently, he aborted the attempted takeoff. Realizing the aircraft would not stop on the remaining runway, he elected to steer it to the right to avoid hitting traffic on a highway near the departure end. The aircraft struck ILS equipment; the landing gear collapsed and all 4 engines tore away. Subsequently, the aircraft was destroyed by fire. Investigations revealed the f/e had improperly computed the takeoff data. He had calculated the 'v' speeds and horizontal stabilizer trim setting for 242,000 lbs; however, the actual takeoff wt was 342,000 lbs. Rotation speed (Vr) for this weight was 28 knots above the speed that was used. Investigations revealed shortcomings in the operator's flightcrew training program and questionable scheduling of qualified (but marginally experienced) crew members for the accident flight.
Probable cause:
Improper preflight planning/preparation, in that the flight engineer miscalculated (misjudged) the aircraft's gross weight by 100,000 lbs and provided the captain with improper takeoff speeds; and improper supervision by the captain. Factors related to the accident were: improper trim setting provided to the captain by the flight engineer, inadequate monitoring of the performance data by the first officer, and the company management's inadequate surveillance of the operation.
Final Report:
Crash of an Embraer EMB-120RT Brasília in Bordeaux: 16 killed
Date & Time:
Dec 21, 1987 at 1510 LT
Registration:
F-GEGH
Survivors:
No
Schedule:
Brussels - Bordeaux
MSN:
120-033
YOM:
1986
Flight number:
AF1919
Crew on board:
3
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total hours on type:
101.00
Copilot / Total hours on type:
215
Aircraft flight hours:
2505
Circumstances:
Following an uneventful flight from Brussels, the crew contacted Bordeaux Approach at 15:01 and was vectored for an ILS approach to runway 23. Visibility was poor with low clouds at 100 feet and a runway visual range (RVR) of between 650 and 350 metres. Flight 1919 crossed the KERAG beacon, the initial approach fix (IAF) at an altitude of FL144, at 15:04:40. Cloud base was still around 100 feet so the crew requested to enter a holding pattern to the south of the airport. The weather conditions slightly improved during the next few minutes and Bordeaux Approach reported a cloud base at 160 feet. Flight 1919 had not reached the holding pattern yet and the pilot decided to attempt to rejoin the ILS. At 15:06:38 the flight was cleared direct to the BD beacon and to descend down to 2000 feet. At the BD beacon, the flight was cleared for final approach and instructed to contact Bordeaux Tower. The airplane had overshot the centreline and was slightly right on the glidepath. Bordeaux Tower then instructed the flight to report over the Outer Marker, which was acknowledged by the captain. After crossing the Outer Marker, the airplane was still not properly established on the ILS. The airplane descended below the glideslope with the crew hurriedly deploying flaps and landing gear. The captain did not contact Bordeaux Tower as requested. Instead he took over control of the airplane, attempting to continue the approach. Both crew members had very little time to adapt to their new roles as the airplane was descending below the glide slope. The descent continued until the aircraft struck tree tops and crashed in the Eysines forrest, about 5 km short of runway. The aircraft was totally destroyed and all 16 occupants were killed.
Probable cause:
The accident was the direct result of poorly managed aircraft trajectory.
- The lack of vigilance with respect to altitude, by one pilot and then the other, when they were in a pilot-flying situation (PF, according to the Air Littoral Operations Manual) both when the aircraft descended out of the ILS beam through 2000 feet altitude and when it descended below 220 feet, the decision height.
- Inadequate coordination of tasks between the two pilots who formed the flight crew, neither of which had performed important tasks related to this function, such as monitoring and reporting ILS or altitude deviations, while in a nonpilot-flying situation (PNF, according to the same manual).
- The lack of vigilance with respect to altitude, by one pilot and then the other, when they were in a pilot-flying situation (PF, according to the Air Littoral Operations Manual) both when the aircraft descended out of the ILS beam through 2000 feet altitude and when it descended below 220 feet, the decision height.
- Inadequate coordination of tasks between the two pilots who formed the flight crew, neither of which had performed important tasks related to this function, such as monitoring and reporting ILS or altitude deviations, while in a nonpilot-flying situation (PNF, according to the same manual).
Final Report:
Crash of a Cessna 421C Golden Eagle III in Hamburg: 2 killed
Date & Time:
Jan 29, 1986 at 2200 LT
Registration:
D-IEEP
Survivors:
No
Schedule:
Hamburg - Brussels
MSN:
421C-1060
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from runway 15, while climbing to a height of about 800 feet, the twin engine entered an uncontrolled descent and crashed in a grassy area located past the runway end. The aircraft was destroyed and both occupants were killed.
Crash of a Boeing 707-329 in Brussels
Date & Time:
Mar 29, 1981 at 0940 LT
Registration:
OO-SJA
Survivors:
Yes
Schedule:
Brussels - Tenerife
MSN:
17623/78
YOM:
1959
Flight number:
SLR1915
Crew on board:
7
Crew fatalities:
Pax on board:
110
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
64462
Circumstances:
The four engine airplane departed Brussels-Zavantem Airport runway 02 at 0929LT on a charter flight to Tenerife-Sur Reina Sofia with 110 passengers and a crew of seven on board. While climbing to an altitude of 7,000 feet, the engine n°3 exploded and caught fire. The crew declared an emergency and was cleared to return for a landing on runway 25L. After the fire was contained and while completing a last turn on final, the airplane was approaching too fast and overshot so the pilot decided to land on runway 25R. After touchdown, reversers on engine n°1 and 4 were activated and the crew initiated an emergency braking procedure. Nevertheless, the captain considered the remaining distance as insufficient and decided to steer the aircraft to the left of the runway where it came to rest. All 117 occupants were quickly rescued and the aircraft was damaged beyond repair.
Probable cause:
It was determined that the explosion of the engine n°3 was the consequence of the disintegration of a blade located on the 10th stage of the compressor due to fatigue cracks. The following contributing factors were reported:
- Approach completed with one engine inoperative,
- The total weight of the aircraft was above the max allowable weight upon landing,
- The approach speed was too high,
- The crew failed to use the brakes properly.
- Approach completed with one engine inoperative,
- The total weight of the aircraft was above the max allowable weight upon landing,
- The approach speed was too high,
- The crew failed to use the brakes properly.
Crash of a Boeing 707-329 in Tenerife
Date & Time:
Feb 15, 1978 at 1313 LT
Registration:
OO-SJE
Survivors:
Yes
Schedule:
Brussels - Tenerife
MSN:
17627
YOM:
1960
Crew on board:
9
Crew fatalities:
Pax on board:
189
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
56787
Circumstances:
The airplane was completing a charter flight from Brussels to Tenerife, carrying 189 passengers and a crew of nine on behalf of Sebelair. On approach to Tenerife-Norte-Los Rodeos Airport, the crew informed ATC about technical problems as he was unable to lower the nose gear. The landing was completed on runway 12/30 with the nose gear retracted and the airplane slid for a distance of 1,200 meters before coming to rest in flames. All 198 occupants were evacuated, four passengers were slightly injured. The aircraft was destroyed by fire.
Crash of a Hawker-Siddeley HS.121 Trident 1C in London: 118 killed
Date & Time:
Jun 18, 1972 at 1711 LT
Registration:
G-ARPI
Survivors:
No
Schedule:
London - Brussels
MSN:
2109
YOM:
1964
Flight number:
BE548
Crew on board:
9
Crew fatalities:
Pax on board:
109
Pax fatalities:
Other fatalities:
Total fatalities:
118
Captain / Total hours on type:
4000.00
Copilot / Total hours on type:
750
Circumstances:
Following a normal takeoff roll on runway 28R, the aircraft rotated 42 seconds after brakes were released and lifted off 2 seconds later at 145 knots IAS. At 63 seconds the autopilot was engaged 355 feet above the runway at 170 knots IAS; the IAS speed lock was selected shortly thereafter. At 74 seconds the aircraft started a 20° banked turn to port towards the Epsom Non-Directional Beacon (NDB). At 83 seconds the captain reported 'Climbing as cleared'. He was then instructed to change frequency and contact London Air Traffic Control Centre. At 93 seconds the noise-abatement procedure was initiated. On the assumption that the captain was the handling pilot, this would involve the second officer selecting the flaps fully up and operating the thrust levers to reduce power to the pre-calculated figure. At 100 seconds the captain called 'Passing 1500' and at 103 seconds the aircraft was cleared to climb to Flight Level 60. This message was acknowledged by the captain at 108 seconds with the terse call 'up to 60'. This was the last message received from the flight. At second 114 when the airspeed was 162 knots and the altitude 1,772 feet, the droop lever was selected up putting the aircraft into the area of the stall as the droop started to move. At second 116 the stick-pusher stall recovery device operated, causing the autopilot automatically to disengage and the nose of the aircraft to pitch down and the stick-push to cease as the incidence decreased. Since the elevator trim would stay at its position on autopilot disengagement which at that speed with the droop up would be - the incidence then increased causing a second stick-push at second 124 and a third at second 127. At second 128 the stall recovery system was manually inhibited by pulling the lever. The aircraft then pitched up rapidly, losing speed and height, entering very soon afterwards the true aerodynamic stall and then a deep stall from which at that height no recovery was possible. Impact was at second 150 in a field next to the A30 motorway. The aircraft was totally destroyed and none of the 118 occupants survived the crash.
Probable cause:
The immediate causes of the accident were these:
- A failure by Captain Key to achieve and maintain adequate speed after noise-abatement procedures,
- Retraction of the droops at some 60 knots below the proper speed causing the aircraft to enter the stall regime and the stick-shaker and pusher to operate,
- Failure by the crew to monitor the speed errors and to observe the movement of the droop lever,
- Failure by the crew to diagnose the reason for the stick-shaker operation and the concomitant warnings,
- The dumping by the crew of the stall recovery system.
The underlying causes were these:
- The abnormal heart condition of Captain Key leading to lack of concentration and impaired judgment sufficient to account for his toleration of the speed errors and to his retraction of, or order to retract, the droops in mistake for the flaps,
- Some distraction, the nature of which is uncertain, possibly due to the presence of Captain Collins as a passenger on the flight deck, which caused S/O Ticehurst's attention to wander from his monitoring duties,
- Lack of training directed at the possibility of 'subtle' pilot incapacitation,
- Lack of experience of S/O Keighley,
- Lack of knowledge in the crew of the possibility or implication of a change of configuration stall,
- Lack of knowledge on the part of the crew that a stick-shaker and push might be experienced almost simultaneously and of the probable cause of such an event,
- Lack of any mechanism to prevent retraction of the droops at too low a speed after flap-retraction.
- A failure by Captain Key to achieve and maintain adequate speed after noise-abatement procedures,
- Retraction of the droops at some 60 knots below the proper speed causing the aircraft to enter the stall regime and the stick-shaker and pusher to operate,
- Failure by the crew to monitor the speed errors and to observe the movement of the droop lever,
- Failure by the crew to diagnose the reason for the stick-shaker operation and the concomitant warnings,
- The dumping by the crew of the stall recovery system.
The underlying causes were these:
- The abnormal heart condition of Captain Key leading to lack of concentration and impaired judgment sufficient to account for his toleration of the speed errors and to his retraction of, or order to retract, the droops in mistake for the flaps,
- Some distraction, the nature of which is uncertain, possibly due to the presence of Captain Collins as a passenger on the flight deck, which caused S/O Ticehurst's attention to wander from his monitoring duties,
- Lack of training directed at the possibility of 'subtle' pilot incapacitation,
- Lack of experience of S/O Keighley,
- Lack of knowledge in the crew of the possibility or implication of a change of configuration stall,
- Lack of knowledge on the part of the crew that a stick-shaker and push might be experienced almost simultaneously and of the probable cause of such an event,
- Lack of any mechanism to prevent retraction of the droops at too low a speed after flap-retraction.
Final Report:
Ground accident of a Douglas DC-3C in Amsterdam
Date & Time:
May 9, 1970
Registration:
OO-AUX
Survivors:
Yes
Schedule:
Amsterdam - Brussels
MSN:
43088
YOM:
1947
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Without clearance, the copilot released the brakes and began to taxi when the right propeller struck a ground power unit. The airplane was immediately stopped. There were no casualties but the airplane was later considered as damaged beyond repair.
Probable cause:
Pilot error.
Crash of a Boeing 707-329C in Lagos: 7 killed
Date & Time:
Jul 13, 1968 at 0400 LT
Registration:
OO-SJK
Survivors:
No
Schedule:
Brussels - Lagos
MSN:
19211
YOM:
1966
Flight number:
SN712
Crew on board:
5
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Flight SN712 was a non-scheduled international cargo flight from Brussels direct to Lagos on behalf of the Federal Government of Nigeria with 34 994 kg of cargo on board. No passengers were being carried. A flight plan was filed for a flight of 6 hours 9 minutes and the total endurance of the aircraft was stated as 8 hours 20 minutes. The designated alternate was Kano. The aircraft took off from Brussels at 2152 hours GMT on 12 July 1968 and routine radio reports were received during the en route phase of the flight. At 0325 hours R/T contact was made with Lagos approach control. The R/T transmissions with the aircraft have been identified as being almost certainly the voice of the co-pilot indicating that he was doing the R/T rhile the pilot-in-command was flying the aircraft. The aircraft gave an ETA at Lagos of 0355 hours and reported that it was at flight Level (FL) 330. A request was then made for the latest Lagos weather and the reply included the following information: wind: 210°/3 kt; visibility: 16 km; cloud: 5/8 stratocumulus 270 m, 7/8 altostratus 2 400 m, temporary thunderstorms, 118 cumulonimbus 2 000 ft; QNH: 1012 mb; temperature 24°. At 0327 hours the aircraft reported an ETA overhead Ibadan NDB of 0344 hours in response to a request for this information from Lagos. One minute later it reported that the Ibadan NDB did not appear to be operating. At 0336 the aircraft requested descent clearance. It was cleared to Lagos at FL60 and commenced the descent from FL330 at that time. Three minutes later the aircraft reported passing Ibadan and descending through FL275 but since it had reported earlier that the Ibadan NDB seemed not to be radiating it is not known how the position was determined. In reply Lagos approach stated that there was no delay in the approach and that the runway in use was 19. At 0341 hours, when the aircraft was about 50 miles north of. Lagos, it was recleared to 2 200 ft on a QNH of 1012 mb - and told to report field in sight. The flight recorder readout shows that shortly after this interchange the descent was interrupted while the speed decreased to a figure corresponding to the recommended maximum for landing gear extension and this speed was not exceeded for the remainder of the flight. Close study of the flight recording shows subsequent irregularity indicating that the automatic pilot was most probably disengaged at this stage of the flight. Subsequent to the speed reduction the rate of descent was re-established to approximately 2 000 ft/min and at 0350 hours the aircraft passed one mile to the east of Lagos airport whilst on a southerly heading at an altitude of 15 000 ft. The aircraft was heard flying over the airport at this time. The flight recorder indicates that a procedure turn was made to the south of the airport in the vicinity of the city of Lagos and at its conclusion there was a second interruption in the descent following which the airspeed remained below the maximum for 25° of flap. At 0354 hours the aircraft passed over the airport northbound at an altitude of 9 000 ft maintaining the average rate of descent of 2 000 ft/min for a further 2 1/2 minutes. At 0356 hours a procedure turn was commenced at an altitude of about 5 000 ft during which the rate of descent was reduced to 1 500 ft/min. The track of the aircraft between its passage over the airport northbound and the commencement of the final procedure turn is almost coincident with the outbound track of the published VOR approach procedure. At 0357 hours Lagos approach control was informed by the aircraft that it was in the procedure turn and requested to give the wind conditions. In reply control stated that the wind was calm and this was acknowledged. Shortly afterwards approach control instructed the aircraft to report runway in sight and this was also acknowledged. On completion of the procedure turn at an altitude of 1 400 ft (a height above the airport of 1268 ft) the airspeed was reduced from 190 kt to a little less than 160 kt and the rate of descent was reduced to 900 ft/min. The heading was stabilized on 197° M and at 0359 hours the aircraft asked for the runway lights to be put on maximum brightness. Approach control replied that the runway lights were on low intensity non-variable. A transmitter switch was then heard but there was no subsequent message from the aircraft before it crashed about 8 1/2 miles north of the airport approximately on the extended centre line of the runway. All the occupants were killed and the aircraft caught fire immediately and was burnt out. All seven occupants were killed.
Probable cause:
The accident was caused by the aircraft descending below its minimum safe altitude for reasons that have not been determined. The following findings were reported:
- The aircraft made an almost continuous descent from FL275 to the point of impact without an intermediate report being made of either its height or position between "passing IB beacon" and a point "on procedure turn" north of Lagos airport,
- The approach to land was made at night without ILS glide slope or marker beacon guidance,
- There was an absence of instructions regarding the monitoring of the altitude by the pilot not flying the aircraft and the cross checking of altimeters during an approach.
- The aircraft made an almost continuous descent from FL275 to the point of impact without an intermediate report being made of either its height or position between "passing IB beacon" and a point "on procedure turn" north of Lagos airport,
- The approach to land was made at night without ILS glide slope or marker beacon guidance,
- There was an absence of instructions regarding the monitoring of the altitude by the pilot not flying the aircraft and the cross checking of altimeters during an approach.
Final Report:
Crash of a Douglas DC-6B in Milan: 4 killed
Date & Time:
Feb 18, 1966 at 0304 LT
Registration:
OO-ABG
Survivors:
No
Schedule:
Brusssels - Milan
MSN:
43829/351
YOM:
1953
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total hours on type:
1619.00
Copilot / Total hours on type:
21
Circumstances:
The aircraft had taken off from Brussels at 0010 hours GMT on 18 February 1966 on a cargo flight to Milan-Malpensa, Italy, to transport 214 calves. The flight was routine until the aircraft arrived over the Saronno VOR/NDB at 0148 hours. It was then cleared by Milan ACC to fly directly to the Malpensa radio beacon with a 6 000 ft "clearance limit" and to contact Malpensa APP directly. The aircraft was duly transferred to this latter unit at 0150 hours. At 0153 hours the aircraft was over NDB Malpensa at 6 000 feet and was cleared by Malpensa APP to carry out a STANDARD/ILS (SIA) approach procedure to runway 35R. The aircraft was also provided with complete meteorological data for Malpensa Airport; runway visibility was given as 250 m. The aircraft left the 6 000 ft level at 0153:20 hours outbound on track 1550 as specified in AIP/ITALY MAP/050/1. At 0157:33 hours the pilot reported on approach inbound (352°) at 4 000 feet. At 0159:49 hours the Malpensa airport PAR controller provided the pilot with the current parameters: distance 7 NM/on track/ on the glide path. At 0200:44 hours the pilot reported 2 000 ft at the outer marker. It was cleared by Malpensa APP to land on runway 35R and instructed to report runway in sight. The ground/air/ground communications log indicates that the approach procedure was being carried out correctly and at 0202:50 hours the radar controller informed the pilot that he was over the approach end of the runway. This was the last contact between the aircraft and the control services. The aircraft had actually carried out a night-time final approach phase procedure in extremely critical visibility conditions because of fog, and in such conditions it had crossed the threshold of runway 35R deviating about 8° to the right in relation to the runway centre line; it then continued alongside the runway for about 2 400 m and struck the top of a group of trees beyond which it crashed to the ground approximately 3 000 m from the runway threshold and 435 m from its centre line. The aircraft caught fire following fuel spillage after impact with the ground. All the occupants were killed and the cargo was destroyed.
Probable cause:
The Commission attributed the accident to the following causes:
(1) Failure of the pilot to comply with the Company's "minima";
(2) Subsequent belated decision to execute the missed approach procedure.
(1) Failure of the pilot to comply with the Company's "minima";
(2) Subsequent belated decision to execute the missed approach procedure.
Final Report: