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Crash of a De Havilland Dash-8-Q402 in Yangon

Date & Time: May 8, 2019 at 1852 LT
Operator:
Registration:
S2-AGQ
Survivors:
Yes
Schedule:
Dhaka - Yangon
MSN:
4367
YOM:
2011
Flight number:
BG060
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9646
Captain / Total hours on type:
1474.00
Copilot / Total flying hours:
580
Copilot / Total hours on type:
405
Aircraft flight hours:
8115
Circumstances:
The route of the aircraft on that day was DAC-RGN-DAC. At (18:03) the Bombardier DHC-8-402 aircraft, registered (S2-AGQ) contacted Yangon control tower and at (18:16) had ILS established and reported to the Yangon control tower. Due to adverse weather, Yangon control tower asked them to execute a go-around and the aerodrome operations was closed for the aviation safety for 2 hours. When the weather condition got better, the aerodrome operations was opened. And then the DHC-8-402 aircraft, registered S2-AGQ made RNP approach because only localizer was available at that moment. While the Bombardier DHC-8-402 aircraft was and making approach to runway 21, it was a bit higher than on slope 3 degree and landed on runway 21, remaining on the ground for upwards of 7 seconds, but the aircraft ran parallel to the runway, and then it flew up in the air up to 44 ft above the ground and sank again and collided with runway 03 and slid forward out of the runway and came to a complete stop on the over-run of the runway 03. There was no fire. All gears were collapsed and fuselage was broken into three sections. All 33 occupants were evacuated, among them 20 were injured. The aircraft was destroyed.
Probable cause:
While the aircraft was unstabilized on approach, the pilot did not execute a go-around.
Final Report:

Crash of an Airbus A330-243 in Jeddah

Date & Time: May 21, 2018 at 2150 LT
Type of aircraft:
Operator:
Registration:
TC-OCH
Survivors:
Yes
Schedule:
Madinah - Dhaka
MSN:
437
YOM:
2001
Flight number:
SV3818
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
142
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Madinah-Mohammad Bin Abdulazziz Airport at 1724LT on a schedule service to Dhaka with 142 passengers and 10 crew members on board. At 1746LT, while cruising at FL370, the crew informed ATC about a malfunction of the green hydraulic system followed by a 'green hydraulic system reservoir low level' warning. The crew decided to return to Madinah but this was not possible due to deteriorating weather conditions, so it was decided to divert to Jeddah-King Abdulazziz Airport. Several attempts to lower the nose gear were unsuccessful and only both main landing gear seemed to be down. After a circuit to burn fuel, the crew was cleared to descent and expected to make a low pass over runway 16C but neither the control tower nor ground staff were able to confirm the nose gear extension. Eventually, the crew was cleared to land on runway 34R with the nose gear retracted. The aircraft landed 700 metres past the runway threshold and the nose landed 1,350 metres further, causing both engine nacelles to hit the runway surface. The airplane slid for few hundred metres and came to rest 700 metres from the runway end. All 152 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-8-Q402 Dash-8 in Kathmandu: 51 killed

Date & Time: Mar 12, 2018 at 1419 LT
Operator:
Registration:
S2-AGU
Survivors:
Yes
Schedule:
Dhaka - Kathmandu
MSN:
4041
YOM:
2001
Flight number:
BS211
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
51
Captain / Total flying hours:
5518
Captain / Total hours on type:
2824.00
Copilot / Total flying hours:
390
Copilot / Total hours on type:
240
Aircraft flight hours:
21419
Aircraft flight cycles:
28649
Circumstances:
On March 12, 2018, a US Bangla Airlines, Bombardier DHC-8-402, S2-AGU, flight number BS211 departed Hazrat Shahjalal International Airport, Dhaka, Bangladesh at 06:51 UTC on a schedule flight to Tribhuvan International Airport (TIA), Kathmandu, Nepal. The aircraft overflew part of Bangladesh and Indian airspace en-route to Nepal. At 0641, Dhaka Ground Control contacted the aircraft requesting for its Bangladesh ADC number which was recently made mandatory a few weeks ago by Bangladesh authority for all international outbound flights. The crew provided the ADC number as 2177 as provided in the Flight Plan. The Ground Controller again asked the crew if they had the ADC for Bangladesh. At 0642, PIC then contacted the Operations to confirm the Bangladesh ADC number. As per the CVR records, changes in the PIC’s vocal pitch and language used indicated that he was agitated and experiencing high levels of stress at the time while communicating with Dhaka Ground Control and airlines operations. The aircraft finally took off at 0651. As the aircraft was in a climb phase, the PIC overheard a communication between Operations and another US Bangla aircraft regarding the fuel onboard but the PIC without verifying whether the message was meant for him or not, engaged in some unnecessary conversation with the Operations staff. The Captain's vocal pitch and language used indicated that he was very much emotionally disturbed and experiencing high level of stress. The aircraft established its first contact with Kathmandu Control at 0752:04. At 0807:49 the First Officer contacted Kathmandu Control and requested for descent. Kathmandu Control gave descend clearance to FL160 with an estimated approach time of 0826 which was acknowledged by the First Officer. At 0810 the flight was handed over to Kathmandu Approach. At 0811, Kathmandu Approach instructed the aircraft to descend to 13,500 ft and hold over GURAS. The crew inserted the HOLD in the Flight Management System. At 0813:41 Kathmandu Approach further instructed the aircraft to reduce its speed and descend to 12500 ft. At 0816 Kathmandu Approach instructed the aircraft to further descend to 11500 ft., and cleared for VOR approach RWY 02 maintaining minimum approach speed. Both the crew forgot to cancel the hold on the FMS as they were engaged in some unnecessary conversation. Upon reaching GURAS, the aircraft turned left to enter the holding pattern over GURAS, it was noticed by PIC and FO and immediately PIC made correction and simultaneously this was alerted to the crew by Approach Control also. Once realizing the aircraft flying pattern and ATC clearance, the PIC immediately selected a heading of 027° which was just 5° of interception angle to intercept the desired radial of 202° inbound to KTM. The spot wind recorded was westerly at 28kt. The aircraft continued approach on heading mode and crossed radial 202° at 7 DME of KTM VOR. The aircraft then continued on the same heading of 027° and deviated to the right of the final approach course. Having deviated to the right of the final approach path, the aircraft reached about 2-3 NM North east of the KTM VOR and continued to fly further northeast. At 0827, Kathmandu Tower (TWR) alerted the crew that the landing clearance was given for RWY 02 but the aircraft was proceeding towards RWY 20. At 0829, Tower Controller asked the crew of their intention to which the PIC replied that they would be landing on RWY 02. The aircraft then made an orbit to the right. The Controller instructed the aircraft to join downwind for RWY 02 and report when sighting another Buddha Air aircraft which was already on final for RWY 02. The aircraft instead of joining downwind leg for RWY 02, continued on the orbit to the right on a westerly heading towards Northwest of RW 20. The controller instructed the aircraft to remain clear of RWY 20 and continue to hold at present position as Buddha air aircraft was landing at RW 02 (from opposite side) at that time. After the landing of Buddha Air aircraft, Tower Controller, at 08:32 UTC gave choice to BS211 to land either at RW 20 or 02 but the aircraft again made an orbit to the right, this time northwest of RWY 20. While continuing with the turn through Southeastern direction, the PIC reported that he had the runway in sight and requested tower for clearance to land. The Tower Controller cleared the aircraft to land but when the aircraft was still turning for the RWY it approached very close to the threshold for RWY 20 on a westerly heading and not aligned with the runway. At 08:33:27 UTC, spotting the aircraft maneuvering at very close proximity of the ground and not aligned with the RWY. Alarmed by the situation, the Tower Controller hurriedly cancelled the landing clearance of the aircraft by saying, "Takeoff clearance cancelled". Within the next 15-20 seconds, the aircraft pulled up in westerly direction and with very high bank angle turned left and flew over the western area of the domestic apron, continued on a southeasterly heading past the ATC Tower and further continued at a very low height, flew over the domestic southern apron area and finally attempted to align with the runway 20 to land. During this process, while the aircraft was turning inwards and momentarily headed towards the control tower, the tower controllers ducked down out of fear that the aircraft might hit the tower building. Missing the control tower, when the aircraft further turned towards the taxi track aiming for the runway through a right reversal turn, the tower controller made a transmission by saying, "BS 211, I say again...". At 08:34 UTC the aircraft touched down 1700 meters down the threshold with a bank angle of about 15 degrees and an angle of about 25 degrees with the runway axis (approximately heading Southeast) and to the left of the center line of runway 20, then veered southeast out of the runway through the inner perimeter fence along the rough down slope and finally stopped about 442 meters southeast from the first touchdown point on the runway. All four crew members (2 cockpit crew and 2 cabin crew) and 45 out of the 67 passengers onboard the aircraft were killed in the accident. Two more passengers succumbed to injury later in hospital during course of treatment. The aircraft caught fire after 6 seconds of touchdown which engulfed major portions of the aircraft.
Probable cause:
The Accident Investigation Commission determines that the probable cause of the accident is due to disorientation and a complete loss of situational awareness in the part of crewmember. Contributing to this the aircraft was offset to the proper approach path that led to maneuvers in a very dangerous and unsafe attitude to align with the runway. Landing was completed in a sheer desperation after sighting the runway, at very close proximity and very low altitude. There was no attempt made to carry out a go around, when a go around seemed possible until the last instant before touchdown on the runway.
The following contributing factors were reported:
- Improper timing of the pre-flight briefing and the commencement of the flight departure in which the operational pre-flight briefing was given in early morning but the flight departure time was around noon and there were four domestic short flights scheduled in between.
- The PIC, who was the pilot flying, seemed to be under stress due to behavior of a particular female colleague in the company and lack of sleep the preceding night.
- A very steep gradient between the crew.
- Flight crew not having practiced visual approach for runway 20 in the simulator.
- A poor CRM between the crew.

An investigation into the captain's behaviour showed that he had history of depression while serving in the Bangladesh Air Force in 1993 and was removed from active duty after evaluation by a psychiatrist. He was re-evaluated by a psychiatrist in January 2002 and was declared to be fit for flying. Examinations in successive annual medical checks were not focused on his previous medical condition of depression, possibly because this was not declared in the self-declaration form for annual medicals. During the flight the captain was irritable, tensed, moody, and aggressive at various times. He was smoking during the flight, contrary to company regulations. He also used foul language and abusive words in conversation with the junior female first officer. He was engaged in unnecessary conversation during the approach, at a time when sterile cockpit rules were in force. The captain seemed very unsecure about his future as he had submitted resignation from this company, though only verbally. He said he did not have any job and did not know what he was going to do for living.
Final Report:

Crash of an ATR72-212 in Cox's Bazar

Date & Time: Jul 20, 2014 at 1745 LT
Type of aircraft:
Operator:
Registration:
S2-AFN
Survivors:
Yes
Schedule:
Dhaka - Cox's Bazar
MSN:
379
YOM:
1993
Flight number:
4H501
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Dhaka, the crew initiated the approach to Cox's Bazar in poor weather conditions due to heavy rain falls. After touchdown, the nose gear collapsed. The airplane slid on its nose for few dozen metres before coming to rest in the middle of the runway that was blocked for almost 22 hours. All 48 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of an ATR72-500 in Dhaka

Date & Time: Apr 30, 2012 at 0851 LT
Type of aircraft:
Operator:
Registration:
60314
Flight Type:
Survivors:
Yes
Schedule:
Bangkok - Dhaka
MSN:
881
YOM:
2009
Flight number:
KAT304
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Dhaka-Hazrat Shahjalal Airport, the twin engine aircraft deviated to the right and veered off runway. It collided with an embankment, lost its undercarriage and came to rest against a concrete wall. All 15 occupants were rescued, among them two passengers were slightly injured.

Ground fire of a Boeing 747-357 in Dhaka

Date & Time: Mar 25, 2008 at 0827 LT
Type of aircraft:
Operator:
Registration:
TF-ARS
Survivors:
Yes
Schedule:
Madinah - Dhaka
MSN:
22996/586
YOM:
1983
Flight number:
SV810
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
307
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18137
Captain / Total hours on type:
5637.00
Copilot / Total flying hours:
7161
Copilot / Total hours on type:
261
Aircraft flight hours:
99327
Aircraft flight cycles:
18779
Circumstances:
TF-ARS (B747-300) was on a scheduled flight from Medina (Saudi Arabia) to Dhaka (Bangladesh), flight number SVA810. The flight crew consisted of a commander, copilot and a flight engineer. The cabin crew consisted of 15 crew members including one senior cabin attendant. Additionally to the cabin crew, one “off duty” cabin crew member was in the cabin. According to the commander, the flight from Medina and the landing at Dhaka was uneventful. During the landing roll, approximately 50 seconds after touchdown, the flight crew received a call from the tower controller where the tower controller inquired whether the aircraft was under control. The flight crew responded to the call by stating that the aircraft was completely under control and asked what the problem seemed to be. The controller then informed the flight crew that fire was observed at the right wing area. At this point the Aerodrome Fire Operator had already activated the fire fighters as well as the rescue team. As soon as the controller had informed the flight crew about the fire, the flight crew received a No. 3 engine fire alarm. The co-pilot immediately discharged the first engine fire bottle and the flight crew requested firefighter assistance and shut down all engines. The co-pilot waited 20 seconds until the second fire bottle was discharged. At this time the commander called the senior cabin attendant to the flight deck using the public address system (PA). This command was followed by a command to the cabin crew to remain seated. The commander informed the senior cabin attendant of the situation and instructed him to evaluate the situation and to evacuate the passengers if necessary. The senior cabin attendant went back down to the main deck and saw the smoke and the fire through the windows. He then commanded the cabin crew as well as passengers, by using a megaphone, to evacuate the aircraft. The cabin attendant at location L2 (see figure 6-7, page 21) had already operated the emergency exit and started evacuating the passengers. Cabin attendants at locations L1 and R2 (see figure 6-7, page 21) also operated their respective emergency exits. After realizing that smoke and fire were at the right hand side, the emergency exit at R2 was blocked by one of the cabin attendants. All passengers managed to evacuate without serious injuries and the fire department at Zia International Airport managed to extinguish the fire successfully. The damage to the aircraft was later evaluated as beyond economical repair.
Probable cause:
When TF-ARS was decelerating after landing on runway 14 at Zia International Airport, fuel leak at engine No. 3 resulted in a fire within the strut. The cause of the fire was that fuel was leaking through the flexible half coupling to the hot surface of the engine. The fuel leak was because the O-ring and retaining rings were not properly assembled within the coupling and one retaining ring was missing. The IAAIB considers unclear instructions in the aircraft maintenance manual (AMM) to be a contributing factor of the incorrect installation. Another incorrect installation was also found at the flexible half coupling at the front spar for engine No. 1. However there were no signs of a fuel leak in that area, most likely due to the fact that both the retaining rings and the O-ring were within the coupling even though they were incorrectly placed. During the investigation, it was not possible to determine the quantity of the fuel leak. However it is likely that the draining system within the strut of engine No. 3 could not manage the fuel leak. According to the manufacturer, the intention of the draining system is to drain drips or small running leaks. Furthermore the drain was clogged by debris, but IAAIB believes that this was a result of the fire. Two out of six suitable emergency exits on the left side were used (L1 and L2) to evacuate most of the passengers during the emergency evacuation. The reason for not opening doors at location L3, L4 and L5 initially was most likely due to the fact that the commander ordered the cabin crew to remain seated prior to the emergency evacuation. The cabin crew members at locations L3 to L5 most likely did not hear the emergency evacuation command from the senior cabin crew member as he was only using a megaphone. Furthermore these exits were not opened later since the passengers moved aggressively to the opened exits, L1 and L2. The reason for not opening emergency exit UDL at the upper deck was evaluated by the crew to be too risky for the passengers. The flight crew discharged both fire bottles for engine No. 3 without managing to extinguish the fire. The flight crew did not discharge fire bottles on other engines. According to the passenger evacuation checklist (see Appendix 2), the crew should discharge all fire bottles before evacuation.
Findings as to causes and contributing factors:
- Incorrect assembly of the flexible half coupling at the front spar of engine No. 3.
- Retaining ring missing in flexible half coupling at the front spar engine No. 3.
- Lock wire fastened in such a way that the coupling nut might rotate slightly.
Findings as to risk:
- Unclear command made to the cabin crew to start emergency evacuation.
- Cabin crew did not open all suitable emergency exits.
- Flight crew did not follow company’s procedure regarding evacuation.
Other findings:
- Retaining rings and O-ring incorrectly inserted in the flexible half coupling on engine No. 1.
- Pliers used to tighten or loosen the coupling nuts, even though maintenance manual instructs to only hand tight the nuts.
Final Report:

Crash of an Airbus A310 in Dubai

Date & Time: Mar 12, 2007 at 0630 LT
Type of aircraft:
Operator:
Registration:
S2-ADE
Flight Phase:
Survivors:
Yes
Schedule:
London - Dubai - Dhaka
MSN:
698
YOM:
1996
Flight number:
BG006
Location:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
236
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from Dubai Intl Airport runway 12L, after V1 speed, the crew heard a loud bang then noticed severe vibrations when the nose gear collapsed. The captain abandoned the takeoff procedure and initiated an emergency braking manoeuvre. The aircraft slid on its nose for few hundred metres and came to rest just before the end of the runway, slightly to the left of the centerline. All 250 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Failure of the nose gear during the takeoff roll after it impacted a half wheel rim which was broken off during the takeoff from a previous aircraft.

Crash of a Fokker F28 Fellowship 4000 in Sylhet

Date & Time: Oct 8, 2004 at 0915 LT
Type of aircraft:
Operator:
Registration:
S2-ACH
Survivors:
Yes
Schedule:
Dhaka - Sylhet
MSN:
11172
YOM:
1981
Flight number:
BG601
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
79
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The flight from Dhaka to Sylhet was delayed for few hours due to poor weather conditions at destination with limited visibility, heavy rain falls, low ceiling and strong winds. Following an uneventful flight, the aircraft landed too far down a wet runway. Unable to stop within the remaining distance, it overran and came to rest in a drainage ditch. 30 passengers were slightly injured while all other occupants escaped unhurt. Both pilots were seriously injured as the cockpit was trapped against an earth wall.
Probable cause:
It was determined that the crew failed to refer to the PAPI's and following a wrong approach configuration, the aircraft landed too far down the runway, reducing the landing distance available. The following contributing factors were reported:
- The ILS system was not properly calibrated, causing the aircraft to land about 900 feet past the runway threshold,
- The aircraft was too high on approach,
- The aircraft' speed at touchdown was 20 knots above the reference speed,
- The braking action was considered as low because the runway surface was wet,
- Aquaplaning,
- The crew failed to initiate a go-around procedure.

Crash of a Boeing 707-3J6C in Dhaka

Date & Time: Jul 11, 2003 at 0638 LT
Type of aircraft:
Operator:
Registration:
5X-AMW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dhaka - Amman
MSN:
20723
YOM:
1974
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 14 at Dhaka-Zia Ul-Haq Airport, the crew encountered an unexpected situation and the captain decided to abandon the takeoff procedure. Unable to stop within the remaining distance (runway 14 is 3,200 metres long), the aircraft overran, lost its undercarriage and came to rest 450 metres further. All five crew members escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Fokker F28 Fellowship 4000 in Sylhet

Date & Time: Dec 22, 1997 at 2236 LT
Type of aircraft:
Operator:
Registration:
S2-ACJ
Survivors:
Yes
Schedule:
Dhaka - Sylhet
MSN:
11180
YOM:
1981
Flight number:
BG609
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
85
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Sylhet Airport, the crew encountered foggy conditions. Due to poor visibility, the crew was unable to establish a visual contact with the approach and runway lights so the decision was taken to initiate a go-around procedure. Few minutes later, a second attempt to land was abandoned for the same reason. The captain insisted and elected to make another approach. On final, the aircraft descended below the MDA and struck the ground 3 km short of runway threshold. On impact, the undercarriage were torn off and the aircraft came to rest in a waterlogged area, broken in two. All 89 occupants were rescued, among them 50 were slightly injured.
Probable cause:
Controlled flight into terrain after the crew continued the descent below MDA without visual contact with the ground until the aircraft impacted terrain.