Zone

Crash of a Boeing 737-8HG in Kozhikode: 21 killed

Date & Time: Aug 7, 2020 at 1941 LT
Type of aircraft:
Operator:
Registration:
VT-AXH
Survivors:
Yes
Schedule:
Dubai - Kozhikode
MSN:
36323/2109
YOM:
2006
Flight number:
IX1344
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
184
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
10848
Captain / Total hours on type:
4612.00
Copilot / Total flying hours:
1989
Copilot / Total hours on type:
1723
Aircraft flight hours:
43691
Aircraft flight cycles:
15309
Circumstances:
Air-India Express Limited B737-800 aircraft VT-AXH was operating a quick return flight on sector Kozhikode-Dubai-Kozhikode under ‘Vande Bharat Mission’ to repatriate passengers who were stranded overseas due to closure of airspace and flight operations owing to the Covid-19 pandemic. The aircraft departed from Kozhikode for Dubai at 10:19 IST (04:49 UTC) on 07 August 2020 and landed at Dubai at 08:11 UTC. The flight was uneventful. There was no change of crew and no defect was reported on the first sector. The aircraft departed from Dubai for Kozhikode at 10:00 UTC as flight AXB 1344 carrying 184 passengers and six crew members. AXB 1344 made two approaches for landing at Kozhikode. The aircraft carried out a missed approach on the first attempt while coming into land on runway 28. The second approach was on runway 10 and the aircraft landed at 14:10:25 UTC. The aircraft touched down approximately at 4,438 ft on 8,858 ft long runway, in light rain with tailwind component of 15 knots and a ground speed of 165 knots. The aircraft could not be stopped on the runway and this ended in runway overrun. The aircraft exited the runway 10 end at a ground speed of 84 knots and then overshot the RESA, breaking the ILS antennae and a fence before plummeting down the tabletop runway. The aircraft fell to a depth of approximately 110 ft below the runway elevation and impacted the perimeter road that runs just below the tabletop runway, at a ground speed of 41 knots and then came to an abrupt halt on the airport perimeter road just short of the perimeter wall. There was fuel leak from both the wing tanks; however, there was no postcrash fire. The aircraft was destroyed and its fuselage broke into three sections. Both engines were completely separated from the wings. The rescue operations were carried out by the ARFF crew on duty with help of Central Industrial Security Force (CISF) personnel stationed at the airport and several civilians who rushed to the crash site when the accident occurred. Upon receipt of the information about the aircraft crash the district administration immediately despatched fire tenders and ambulances to the crash site. Nineteen passengers were fatally injured and Seventy Five passengers suffered serious injuries in the accident while Ninety passengers suffered minor or no injuries. Both Pilots suffered fatal injuries while one cabin crew was seriously injured and three cabin crew received minor injuries. The rescue operation was completed at 16:45 UTC (22:15 IST).
Probable cause:
The probable cause of the accident was the non adherence to SOP by the PF, wherein, he continued an unstabilized approach and landed beyond the touchdown zone, half way down the runway, in spite of ‘Go Around’ call by PM which warranted a mandatory ‘Go Around’ and the failure of the PM to take over controls and execute a ‘Go Around’.

The following contributing factors were identitified:

The investigation team is of the opinion that the role of systemic failures as a contributory factor cannot be overlooked in this accident. A large number of similar accidents/incidents that have continued to take place, more so in AIXL, reinforce existing systemic failures within the aviation sector. These usually occur due to prevailing safety culture that give rise to errors, mistakes and violation of routine tasks performed by people operating within the system. Hence, the contributory factors enumerated below include both the immediate causes and the deeper or systemic causes.

(i) The actions and decisions of the PIC were steered by a misplaced motivation to land back at Kozhikode to operate next day morning flight AXB 1373. The unavailability of sufficient number of Captains at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirement while assigning permanent base to its Captains. There was only 01 Captain against 26 First Officers on the posted strength at Kozhikode.

(ii) The PIC had vast experience of landing at Kozhikode under similar weather conditions. This experience might have led to over confidence leading to complacency and a state of reduced conscious attention that would have seriously affected his actions, decision making as well as CRM.

(iii) The PIC was taking multiple un-prescribed anti-diabetic drugs that could have probably caused subtle cognitive deficits due to mild hypoglycaemia which probably contributed to errors in complex decision making as well as susceptibility to perceptual errors.

(iv) The possibility of visual illusions causing errors in distance and depth perception (like black hole approach and up-sloping runway) cannot be ruled out due to degraded visual cues of orientation due to low visibility and suboptimal performance of the PIC’s windshield wiper in rain.

(v) Poor CRM was a major contributory factor in this crash. As a consequence of lack of assertiveness and the steep authority gradient in the cockpit, the First Officer did not take over the controls in spite of being well aware of the grave situation. The lack of effective CRM training of AIXL resulted in poor CRM and steep cockpit gradient.

(vi) AIXL policies of upper level management have led to a lack of supervision in training, operations and safety practices, resulting in deficiencies at various levels causing repeated human error accidents in AIXL

(vii) The AIXL pilot training program lacked effectiveness and did not impart the requisite skills for performance enhancement. One of the drawbacks in training was inadequate maintenance and lack of periodic system upgrades of the simulator. Frequently recurring major snags resulted in negative training. Further, pilots were often not checked for all the mandatory flying exercises during simulator check sessions by the Examiners.

(viii) The non availability of OPT made it very difficult for the pilots to quickly calculate accurate landing data in the adverse weather conditions. The quick and accurate calculations would have helped the pilots to foresee the extremely low margin for error, enabling them to opt for other safer alternative.

(ix) The scrutiny of Tech Logs and Maintenance Record showed evidence of nonstandard practice of reporting of certain snags through verbal briefing rather than in writing. There was no entry of windshield wiper snag in the Tech log of VT-AXH. Though it could not be verified, but a verbal briefing regarding this issue is highly probable.

(x) The DATCO changed the runway in use in a hurry to accommodate the departure of AIC 425 without understanding the repercussions on recovery of AXB 1344 in tail winds on a wet runway in rain. He did not caution AXB 1344 of prevailing strong tail winds and also did not convey the updated QNH settings.

(xi) Accuracy of reported surface winds for runway 10 was affected by installation of wind sensor in contravention to the laid down criteria in CAR. This was aggravated by frequent breakdown due to poor maintenance.

(xii) The Tower Met Officer (TMO) was not available in the ATC tower at the time of the accident. The airfield was under two concurrent weather warnings and it is mandatory for the TMO to be present to update and inform the fast changing weather variations to enhance air safety. During adverse weather conditions the presence of the TMO in the ATC tower was even more critical.

(xiii) The AAI has managed to fulfil ICAO and DGCA certification requirements at Kozhikode aerodrome for certain critical areas like RESA, runway lights and approach lights. Each of these, in isolation fulfils the safety criteria however, when considered in totality, this left the aircrew of AXB 1344 with little or no margin for error. Although not directly contributory to the accident causation, availability of runway centreline lights would have certainly enhanced the spatial orientation of the PIC.

(xiv) The absence of a detailed proactive policy and clear cut guidelines by the Regulator on monitoring of Long Landings at the time of the accident was another contributory factor in such runway overrun accidents. Long Landing has been major factor in various accidents and incidents involving runway excursion since 2010 and has not been addressed in CAR Section 5, Series F, Part II.

(xv) DGCA did not comprehensively revise CAR Section 5, Series F, Part II Issue I, dated 30 Sep 99 (Rev. on 26 Jul 2017) on ‘Monitoring of DFDR/QAR/PMR Data for Accident/Incident Prevention’ to address the recommendations of the COI of 2010 AIXL Managlore Crash regarding the exceedance limits, resulting in the persisting ambiguities in this matter.

(xvi) DFDR data monitoring for prevention of accidents/incidents is done by AIXL. However 100% DFDR monitoring is not being done, in spite of the provisions laid down in the relevant CAR and repeated audit observations by DGCA. DFDR data monitoring is the most effective tool to identify exceedance and provide suitable corrective training in order to prevent runway accidents like the crash of AXB 1344. However, ATR submitted by AIXL on the said findings were accepted by DGCA year after year without ascertaining its implementation or giving due importance to its adverse implications.
Final Report:

Crash of a Boeing 777-31H in Dubai

Date & Time: Aug 3, 2016 at 1238 LT
Type of aircraft:
Operator:
Registration:
A6-EMW
Survivors:
Yes
Schedule:
Thiruvananthapuram - Dubai
MSN:
32700/434
YOM:
2003
Flight number:
EK521
Location:
Region:
Crew on board:
18
Crew fatalities:
Pax on board:
282
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7457
Captain / Total hours on type:
5123.00
Copilot / Total flying hours:
7957
Copilot / Total hours on type:
1292
Aircraft flight hours:
58169
Aircraft flight cycles:
13620
Circumstances:
On 3 August 2016, an Emirates Boeing 777-31H Aircraft, registration A6-EMW, operating a scheduled passenger flight UAE521, departed Trivandrum International Airport (VOTV), India, at 0506 UTC for a 3 hour 30 minute flight to Dubai International Airport (OMDB), the United Arab Emirates, with 282 passengers, 2 flight crew and 16 cabin crew members on board. The Commander attempted to perform a tailwind manual landing during an automatic terminal information service (ATIS) forecasted moderate windshear warning affecting all runways at OMDB. The tailwind was within the operational limitations of the Aircraft. During the landing on runway 12L at OMDB the Commander, who was the pilot flying, decided to fly a go-around, as he was unable to land the Aircraft within the runway touchdown zone. The go-around decision was based on the perception that the Aircraft would not land due to thermals and not due to a windshear encounter. For this reason, the Commander elected to fly a normal go-around and not the windshear escape maneuver. The flight crew initiated the flight crew operations manual (FCOM) Go-around and Missed Approach Procedure and the Commander pushed the TO/GA switch. As designed, because the Aircraft had touched down, the TO/GA switches became inhibited and had no effect on the autothrottle (A/T). The flight crew stated that they were not aware of the touchdown that lasted for six seconds. After becoming airborne during the go-around attempt, the Aircraft climbed to a height of 85 ft radio altitude above the runway surface. The flight crew did not observe that both thrust levers had remained at the idle position and that the engine thrust remained at idle. The Aircraft quickly sank towards the runway as the airspeed was insufficient to support the climb. As the Aircraft lost height and speed, the Commander initiated the windshear escape maneuver procedure and rapidly advanced both thrust levers. This action was too late to avoid the impact with runway 12L. Eighteen seconds after the initiation of the go-around the Aircraft impacted the runway at 0837:38 UTC and slid on its lower fuselage along the runway surface for approximately 32 seconds covering a distance of approximately 800 meters before coming to rest adjacent to taxiway Mike 13. The Aircraft remained intact during its movement along the runway protecting the occupants however, several fuselage mounted components and the No.2 engine/pylon assembly separated from the Aircraft. During the evacuation, several passenger door escape slides became unusable. Many passengers evacuated the Aircraft taking their carry-on baggage with them. Except for the Commander and the senior cabin crew member who evacuated after the center wing tank explosion, all of the other occupants evacuated via the operational escape slides in approximately 6 minutes and 40 seconds. Twenty-one passengers, one flight crewmember, and six cabin crew members sustained minor injuries. Four cabin crew members sustained serious injuries. Approximately 9 minutes and 40 seconds after the Aircraft came to rest, the center wing tank exploded which caused a large section of the right wing upper skin to be liberated. As the panel fell to the ground, it struck and fatally injured a firefighter. The Aircraft was eventually destroyed due to the subsequent fire. Following the Accident, the Operator (Emirates), the General Civil Aviation Authority (GCAA), Dubai Airports and Dubai Air Navigation Services (‘dans’) implemented several safety actions. In this Final Report, the AAIS issues safety recommendations addressed to the Operator, the GCAA, The Boeing Company, the Federal Aviation Administration (FAA), Dubai Airports, ‘dans’, and the International Civil Aviation Organization (ICAO).
Probable cause:
The Air Accident Investigation Sector determines that the causes of the Accident are:
(a) During the attempted go-around, except for the last three seconds prior to impact, both engine thrust levers, and therefore engine thrust, remained at idle. Consequently, the Aircraft’s energy state was insufficient to sustain flight.
(b) The flight crew did not effectively scan and monitor the primary flight instrumentation parameters during the landing and the attempted go-around.
(c) The flight crew were unaware that the autothrottle (A/T) had not responded to move the engine thrust levers to the TO/GA position after the Commander pushed the TO/GA switch at the initiation of the FCOM Go-around and Missed Approach Procedure.
(d) The flight crew did not take corrective action to increase engine thrust because they omitted the engine thrust verification steps of the FCOM Go-around and Missed Approach Procedure.
The Investigation determines that the following were contributory factors to the Accident:
(a) The flight crew were unable to land the Aircraft within the touchdown zone during the attempted tailwind landing because of an early flare initiation, and increased airspeed due to a shift in wind direction, which took place approximately 650 m beyond the runway threshold.
(b) When the Commander decided to fly a go-around, his perception was that the Aircraft was still airborne. In pushing the TO/GA switch, he expected that the autothrottle (A/T) would respond and automatically manage the engine thrust during the go-around.
(c) Based on the flight crew’s inaccurate situation awareness of the Aircraft state, and situational stress related to the increased workload involved in flying the go-around maneuver, they were unaware that the Aircraft’s main gear had touched down which caused the TO/GA switches to become inhibited. Additionally, the flight crew were unaware that the A/T mode had remained at ‘IDLE’ after the TO/GA switch was pushed.
(d) The flight crew reliance on automation and lack of training in flying go-arounds from close to the runway surface and with the TO/GA switches inhibited, significantly affected the flight crew performance in a critical flight situation which was different to that experienced by them during their simulated training flights.
(e) The flight crew did not monitor the flight mode annunciations (FMA) changes after the TO/GA switch was pushed because:
1. According to the Operator’s procedure, as per FCOM Flight Mode Annunciations (FMA), FMA changes are not required to be announced for landing when the aircraft is below 200 ft;
2. Callouts of FMA changes were not included in the Operator’s FCOM Go-Around and Missed Approach Procedures.
3. Callouts of FMA changes were not included in the Operator’s FCTM Go-Around and Missed Approach training.
(f) The Operator’s OM-A policy required the use of the A/T for engine thrust management for all phases of flight. This policy did not consider pilot actions that would be necessary during a go-around initiated while the A/T was armed and active and the TO/GA switches were inhibited.
(g) The FCOM Go-Around and Missed Approach Procedure did not contain steps for verbal verification callouts of engine thrust state.
(h) The Aircraft systems, as designed, did not alert the flight crew that the TO/GA switches were inhibited at the time when the Commander pushed the TO/GA switch with the A/T armed and active.
(i) The Aircraft systems, as designed, did not alert the flight crew to the inconsistency between the Aircraft configuration and the thrust setting necessary to perform a successful go-around.
(j) Air traffic control did not pass essential information about windshear reported by a preceding landing flight crew and that two flights performed go-arounds after passing over the runway threshold. The flight crew decision-making process, during the approach and landing, was deprived of this critical information.
(k) The modification of the go-around procedure by air traffic control four seconds after the Aircraft became airborne coincided with the landing gear selection to the ‘up’ position. This added to the flight crew workload as they attentively listened and the Copilot responded to the air traffic control instruction which required a change of missed approach altitude from 3,000 ft to 4,000 ft to be set. The flight crews’ concentration on their primary task of flying the Aircraft and monitoring was momentarily affected as both the FMA verification and the flight director status were missed.
Final Report:

Crash of a Boeing 737-8KN in Rostov-on-Don: 62 killed

Date & Time: Mar 19, 2016 at 0342 LT
Type of aircraft:
Operator:
Registration:
A6-FDN
Survivors:
No
Schedule:
Dubai - Rostov-on-Don
MSN:
40241/3517
YOM:
2010
Flight number:
FZ981
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
55
Pax fatalities:
Other fatalities:
Total fatalities:
62
Captain / Total flying hours:
5961
Captain / Total hours on type:
4682.00
Copilot / Total flying hours:
5767
Copilot / Total hours on type:
1100
Aircraft flight hours:
21257
Aircraft flight cycles:
9421
Circumstances:
At the overnight into 19.03.2016 the Flydubai airline flight crew, consisting of the PIC and F/O, was performing the round-trip international scheduled passenger flight FDB 981/982 on route
Dubai (OMDB) – Rostov-on-Don (URRR) – Dubai (OMDB) on the B737-8KN A6-FDN aircraft. At 18:37 on 18.03.2016 the aircraft took off from the Dubai airport. The flight had been performed in IFR. At 18:59:30 FL360 was reached. The further flight has been performed on this very FL. The descent from FL has been initiated at 22:17. Before starting the descent, the crew contacted the ATC on the Rostov-on-Don airport actual weather and the active RWY data. In progress of the glide path descent to perform landing with magnetic heading 218° (RWY22) the crew relayed the presence of “windshear” on final to the ATC (as per the aboard windshear warning system activation). At 22:42:05 from the altitude of 1080 ft (330 m) above runway level performed go-around. Further on the flight was proceeded at the holding area, first on FL080, then on FL150. At 00:23 on 19.03.2016, the crew requested descent for another approach. It was an ILS approach. The A/P was disengaged by the crew at the altitude of 2165 ft QNH (575 m QFE), and the A/T at the altitude of 1960 ft QNH (510 m QFE). . In the progress of another approach the crew made the decision to initiate go-around and at 00:40:50, from the altitude of 830 ft (253 m) above the runway level, started the maneuver. After the reach of the altitude of 3350 ft (1020 m) above the runway level the aircraft transitioned to a steep descent and at 00:41:49 impacted the ground (it collided the surface of the artificial runway at the distance of about 120 m off the RWY22 threshold) with the nose-down pitch of about 50⁰ and IAS about 340 kt (630 km/h). The aircraft disintegrated on impact and all 62 occupants were killed.
Probable cause:
The fatal air accident to the Boeing 737-8KN A6-FDN aircraft occurred during the second go around, due to an incorrect aircraft configuration and crew piloting, the subsequent loss of PIC’s situational awareness in nighttime in IMC. This resulted in a loss of control of the aircraft and its impact with the ground. The accident is classified as Loss of Control In-Flight (LOC-I) occurrence.
Most probably, the contributing factors to the accident were:
- The presence of turbulence and gusty wind with the parameters, classified as a moderate to-strong "windshear" that resulted in the need to perform two go-arounds;
- The lack of psychological readiness (not go-around minded) of the PIC to perform the second go-around as he had the dominant mindset on the landing performance exactly at the destination aerodrome, having formed out of the "emotional distress" after the first unsuccessful approach (despite the RWY had been in sight and the aircraft stabilized on the glide path, the PIC had been forced to initiate go-around due to the windshear warning activation), concern on the potential exceedance of the duty time to perform the return flight and the recommendation of the airline on the priority of landing at the destination aerodrome;
- The loss of the PIC’s leadership in the crew after the initiation of go-around and his "confusion" that led to the impossibility of the on-time transition of the flight mental mode from "approach with landing" into "go-around";
- The absence of the instructions of the maneuver type specification at the go-around callout in the aircraft manufacturer documentation and the airline OM;
- The crew’s uncoordinated actions during the second go-around: on the low weight aircraft the crew was performing the standard go-around procedure (with the retraction of landing gear and flaps), but with the maximum available thrust, consistent with the Windshear Escape Maneuver procedure that led to the generation of the substantial excessive nose-up moment and significant (up to 50 lb/23 kg) "pushing" forces on the control column to counteract it;
- The failure of the PIC within a long time to create the pitch, required to perform go around and maintain the required climb profile while piloting aircraft unbalanced in forces;
- The PIC’s insufficient knowledge and skills on the stabilizer manual trim operation, which led to the long-time (for 12 sec) continuous stabilizer nose-down trim with the subsequent substantial imbalance of the aircraft and its upset encounter with the generation of the negative G, which the crew had not been prepared to. The potential impact of the somatogravic "pitch-up illusion" on the PIC might have contributed to the long keeping the stabilizer trim switches pressed;
- The psychological incapacitation of the PIC that resulted in his total spatial disorientation, did not allow him to respond to the correct prompts of the F/O;
- The absence of the criteria of the psychological incapacitation in the airline OM, which prevented the F/O from the in-time recognition of the situation and undertaking more decisive actions;
- The possible operational tiredness of the crew: by the time of the accident the crew had been proceeding the flight for 6 hours, of which 2 hours under intense workload that implied the need to make non-standard decisions; in this context the fatal accident occurred at the worst possible time in terms of the circadian rhythms, when the human performance is severely degraded and is at its lower level along with the increase of the risk of errors.
The lack of the objective information on the HUD operation (there were no flight tests of the unit carried out into the entire range of the operational G, including the negative ones; the impossibility to reproduce the real HUD readings in the progress of the accident flight, that is the image the pilot was watching with the consideration of his posture in the seat trough the stream video or at the FFS) did not allow making conclusion on its possible impact on the flight outcome. At the same time the investigation team is of the opinion that the specific features of the HUD indication and display in conditions existed during final phase of the accident flight (severe turbulence, the aircraft upset encounter with the resulting negative G, the significant difference between the actual and the target flight path) that generally do not occur under conditions of the standard simulator sessions, could have affected the situational awareness of the PIC, having been in the highly stressed state.
Final Report:

Crash of a Boeing 747-428BCF at Bagram AFB: 7 killed

Date & Time: Apr 29, 2013 at 1527 LT
Type of aircraft:
Operator:
Registration:
N949CA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Camp Bastion - Bagram AFB - Dubaï
MSN:
25630/960
YOM:
1993
Flight number:
NCR102
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
6000
Captain / Total hours on type:
440.00
Copilot / Total flying hours:
1100
Copilot / Total hours on type:
209
Circumstances:
The aircraft crashed shortly after takeoff from Bagram Air Base, Bagram, Afghanistan. All seven crewmembers—the captain, first officer, loadmaster, augmented captain and first officer, and two mechanics—died, and the airplane was destroyed from impact forces and postcrash fire. The 14 Code of Federal Regulations Part 121 supplemental cargo flight, which was operated under a multimodal contract with the US Transportation Command, was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates. The airplane’s cargo included five mine-resistant ambush-protected (MRAP) vehicles secured onto pallets and shoring. Two vehicles were 12-ton MRAP all-terrain vehicles (M-ATVs) and three were 18-ton Cougars. The cargo represented the first time that National Airlines had attempted to transport five MRAP vehicles. These vehicles were considered a special cargo load because they could not be placed in unit load devices (ULDs) and restrained in the airplane using the locking capabilities of the airplane’s main deck cargo handling system. Instead, the vehicles were secured to centerline-loaded floating pallets and restrained to the airplane’s main deck using tie-down straps. During takeoff, the airplane immediately climbed steeply then descended in a manner consistent with an aerodynamic stall. The National Transportation Safety Board’s (NTSB) investigation found strong evidence that at least one of the MRAP vehicles (the rear M-ATV) moved aft into the tail section of the airplane, damaging hydraulic systems and horizontal stabilizer components such that it was impossible for the flight crew to regain pitch control of the airplane. The likely reason for the aft movement of the cargo was that it was not properly restrained. National Airlines’ procedures in its cargo operations manual not only omitted required, safety-critical restraint information from the airplane manufacturer (Boeing) and the manufacturer of the main deck cargo handling system (Telair, which held a supplemental type certificate [STC] for the system) but also contained incorrect and unsafe methods for restraining cargo that cannot be contained in ULDs. The procedures did not correctly specify which components in the cargo system (such as available seat tracks) were available for use as tie-down attach points, did not define individual tie-down allowable loads, and did not describe the effect of measured strap angle on the capability of the attach fittings.
Probable cause:
The NTSB determines that the probable cause of this accident was National Airlines’ inadequate procedures for restraining special cargo loads, which resulted in the loadmaster’s
improper restraint of the cargo, which moved aft and damaged hydraulic systems No . 1 and 2 and horizontal stabilizer drive mechanism components, rendering the airplane uncontrollable. Contributing to the accident was the FAA’s inadequate oversight of National Airlines’ handling of special cargo loads.
Final Report:

Crash of a McDonnell Douglas MD-83 in Kandahar

Date & Time: Jan 24, 2012 at 0828 LT
Type of aircraft:
Operator:
Registration:
EC-JJS
Survivors:
Yes
Schedule:
Dubai - Kandahar
MSN:
49793/1656
YOM:
1989
Flight number:
SWT094
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4946
Captain / Total hours on type:
3228.00
Copilot / Total flying hours:
2881
Copilot / Total hours on type:
2222
Circumstances:
On Tuesday, 24 January 2012, a McDonnell Douglas MD-83, registration EC-JJS and operated by Swiftair, took off from the Dubai Airport (United Arab Emirates) at 02:08 UTC on a scheduled flight to the Kandahar Airport (Afghanistan). Its callsign was SWT094 and there were 86 passengers (one of them a company mechanic), three flight attendants and two cockpit crew onboard. Swiftair, S.A. was operating this regularly scheduled passenger flight under an ACMI arrangement with the South African company Gryphon Airlines. The crew was picked up at its usual hotel in the emirate of Ras al-Khaimah (United Arab Emirates) at 21:00. The airplane was parked in the Ras al-Khaimah airport and had to be flown empty to the Dubai Airport. This flight departed at 00:20 UTC en route to Dubai. Once there, an agent for Gryphon Airlines gave the crew the documentation for the flight to Kandahar. They went through customs at the Dubai Airport, boarded the passengers and the cargo and refueled the airplane with enough fuel to make the return the flight, a typical practice so as to avoid refueling in Kandahar. The airplane took off from runway 30R at the Dubai Airport at 02:08 on standard instrument departure RIKET2D and climbed to flight level FL290. The first officer was the pilot flying. At 03:42, while over SERKA, they were transferred to Kabul control, which instructed them to descend to FL280. The crew reported its ISAF callsign (ISF39RT) to this ATS station, which allowed the aircraft to fly over Afghan airspace, and entered the new stipulated squawk code. Kabul Control instructed the crew to follow some radar vectors that took them to point SODAS, where they were transferred to Kandahar Control at 03:46. The crew reduced the airspeed to 250 kt above this point. Kandahar Control cleared them for an RNAV (GPS) approach to runway 05, providing a direct vector to point FALOD (the IAF), and to descend to 6,000 ft. The weather information provided on the ATIS “F” broadcast was runway in use 05, wind from 060º at 17 kt gusting to 24 kt, visibility 1,200 m, scattered clouds at 2,700 ft and broken clouds at 3,000 ft, temperature 1 ºC, dewpoint -7 ºC and QNH 30.06 in Hg (1,018 mbar). This information was practically the same as that radioed to the crew by the Kandahar control tower a few minutes before landing: wind from 060 at 15 kt gusting to 21 kt. They reached point FALOD (IAF) under cloud cover (and thus in IMC conditions). They did not exit the clouds until 1,500 ft before minimums which, for this approach, according to the associated chart, was an altitude of 3,700 ft, or 394 ft AGL. They established visual contact with the runway 500 ft above minimums and noted that they were a little right of the runway centerline. Since the captain had more operational experience at the destination airfield, he decided to take over the controls and fly the last phase of the approach maneuver. The PAPI was out of service, meaning that in final approach they only had visual references to the runway and over the ground. During short final they corrected the deviation from the runway centerline by adjusting their path from right to left. They landed at 03:58. During the flare, the crew noticed the airplane was shifting to the left, threatening to take them off the runway, as a result of which the captain applied a right roll angle. This caused the right wing tip to strike the ground before the wheels made contact with the ground. The captain regarded the maneuver as a hard landing, although the first officer thought they might have struck the runway. The autopilot was engaged until visual contact was established with the runway and the auto-throttle until the landing. On exiting the runway, the airport control tower personnel (who had witnessed the contact with the ground) ordered the crew to stop and informed them of the damage they had seen during the landing. They dispatched the emergency services (firefighters), which forced them to turn off their engines. Once it was confirmed that there was no fuel leak or damage to the wheels or brakes, they allowed the crew to restart the engines and proceed to the stand. The wing made contact with the ground some 20 m prior to the threshold, resulting in five threshold lights being destroyed by the aircraft and in damage to the aircraft’s right wing. According to the crew’s statement, the passengers were not really aware of the contact between the wing and the ground and they were subsequently disembarked normally.
Probable cause:
The accident was likely caused by the failure to observe the company's operating procedures and not executing a go-around when the approach was clearly not stabilized. Moreover, the operator lacked the authorization (and the crew the training) to carry out the RNAV (GPS) approach maneuver that was conducted at RWY 05 of the Kandahar Airport.
Contributing to the accident was:
The inoperable status of the PAPI at runway 05 of the Kandahar Airport, which was thus unable to aid the crew to establish the aircraft on the correct descent slope.
Final Report:

Crash of a Boeing 747-44AF near Dubai: 2 killed

Date & Time: Sep 3, 2010 at 1941 LT
Type of aircraft:
Operator:
Registration:
N571UP
Flight Type:
Survivors:
No
Schedule:
Hong Kong - Dubai - Cologne
MSN:
35668/1393
YOM:
2007
Flight number:
UPS006
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11410
Captain / Total hours on type:
367.00
Copilot / Total flying hours:
6130
Copilot / Total hours on type:
78
Aircraft flight hours:
9977
Aircraft flight cycles:
1764
Circumstances:
The four engine aircraft was completing a cargo flight from Hong Kong to Cologne with an intermediate stop in Dubai with two pilots on board. One minute after passing the BALUS waypoint, approaching the top of climb, as the aircraft was climbing to the selected cruise altitude of 32,000 feet, the Fire Warning Master Warning Light illuminated and the Audible Alarm [Fire Bell] sounded, warning the crew of a fire indication on the Main Deck Fire - Forward. The captain advised BAE-C that there was a fire indication on the main deck of the aircraft, informing Bahrain ATC that they needed to land as soon as possible. BAE-C advised that Doha International Airport (DOH) was at the aircraft’s 10 o’clock position 100 nm DME from the current location. The Captain elected to return to the point of departure, DXB. The crew changed the selected altitude from 32,000 feet to 28,000 feet as the aircraft changed heading back to DXB, the Auto Throttle [AT] began decreasing thrust to start the decent. The AP was manually disconnected, then reconnected , followed by the AP manually disconnecting for a short duration, the captain as handling pilot was manually flying the aircraft. Following the turn back and the activation of the fire suppression, for unknown reasons, the PACK 1 status indicated off line [PACKS 2 and 3 were off], in accordance with the fire arm switch activation. There was no corresponding discussion recorded on the CVR that the crew elected to switch off the remaining active PACK 1. As the crew followed the NNC Fire/Smoke/Fumes checklist and donned their supplemental oxygen masks, there is some cockpit confusion regarding the microphones and the intra-cockpit communication as the crew cannot hear the microphone transmissions in their respective headsets. The crew configured the aircraft for the return to DXB, the flight was in a descending turn to starboard onto the 095° reciprocal heading for DXB when the Captain requested an immediate descent to 10,000 ft. The reason for the immediate descent was never clarified in the available data. The AP was disengaged, the Captain then informed the FO that there was limited pitch control of the aircraft when flying manually. The Captain was manually making inputs to the elevators through the control column, with limited response from the aircraft. The flight was approximately 4 minutes into the emergency. The aircraft was turning and descending, the fire suppression has been initiated and there was a pitch control problem. The cockpit was filling with persistent continuous smoke and fumes and the crew had put the oxygen masks on. The penetration by smoke and fumes into the cockpit area occurred early into the emergency. The cockpit environment was overwhelmed by the volume of smoke. There are several mentions of the cockpit either filling with smoke or being continuously ‘full of smoke’, to the extent that the ability of the crew to safely operate the aircraft was impaired by the inability to view their surroundings. Due to smoke in the cockpit, from a continuous source near and contiguous with the cockpit area [probably through the supernumerary area and the ECS flight deck ducting], the crew could neither view the primary flight displays, essential communications panels or the view from the cockpit windows. The crew rest smoke detector activated at 15:15:15 and remained active for the duration of the flight. There is emergency oxygen located at the rear of the cockpit, in the supernumerary area and in the crew rest area. Due to the persistent smoke the Captain called for the opening of the smoke shutter, which stayed open for the duration of the flight. The smoke remained in the cockpit area. There was a discussion between the crew concerning inputting the DXB runway 12 Left [RWY12L] Instrument Landing System [ILS] data into the FMC. With this data in the FMC the crew can acquire the ILS for DXB RWY12L and configure the aircraft for an auto flight/auto land approach. The F.O. mentions on several occasions difficulty inputting the data based on the reduced visibility. However, the ILS was tuned to a frequency of 110.1 (The ILS frequency for DXB Runway 12L is 110.126), the Digital Flight Data Recorder [DFDR] data indicates that this was entered at 15:19:20 which correlates which the CVR discussion and timing. At approximately 15:20, during the emergency descent at around 21,000ft cabin pressure altitude, the Captain made a comment concerning the high temperature in the cockpit. This was followed almost immediately by the rapid onset of the failure of the Captain’s oxygen supply. Following the oxygen supply difficulties there was confusion regarding the location of the alternative supplementary oxygen supply location. The F.O either was not able to assist or did not know where the oxygen bottle was located; the Captain then gets out of the LH seat. This CVR excerpt indicates the following exchange between the Captain and F.O concerning the mask operation and the alternative oxygen supply bottle location. The exchange begins when the Captain’s oxygen supply stops abruptly with no other indications that the oxygen supply is low or failing. Based on the pathological information, the Captain lost consciousness due to toxic poisoning. After the Captain left the LH cockpit seat, the F.O. assumed the PF role. The F.O. remained in position as P.F. for the duration of the flight. There was no further interaction from the Captain or enquiry by the F.O as to the location of the Captain or the ability of the Captain to respond. The PF informed the BAE-C controllers that due to the limited visibility in the cockpit that it was not possible to change the radio frequency on the Audio Control Panel [ACP]. This visibility comment recurs frequently during the flight. The Bahrain East controller was communicating with the emergency aircraft via relays. Several were employed during the transition back to DXB. The aircraft was now out of effective VHF radio range with BAE-C. In order for the crew to communicate with BAE-C, BAE-C advised transiting aircraft that they would act as a communication relay between BAE-C and the emergency aircraft. BAE-C would then communicate to the UAE controllers managing the traffic in the Emirates FIR via a landline, who would then contact the destination aerodrome at Dubai, also by landline. The crew advised relay aircraft that they would stay on the Bahrain frequency as they could not see the ACP to change frequency. All of the 121.5 MHz transmissions by the PF were keyed via the VHF-R, all other radio communication with BAE-C and the relay aircraft are keyed from the VHF-L audio panel. There are several attempts by the UAE’s Area Control [EACC] to contact the flight on the guard frequency in conjunction with aircraft relaying information transmitting on the guard frequency to the accident flight. The PF of the accident flight does not appear to hear any of the transmissions from the air traffic control units or the relay aircraft on the guard frequency. Around this time, given the proximity of the aircraft to the RWY12L intermediate approach fix, Dubai ATC transmits several advisory messages to the flight on the Dubai frequencies, for example DXB ARR on 124.9 MHz advise that ‘Any runway is available’. The Runway lights for RWY30L were turned on to assist the return to DXB. The Aircraft condition inbound as the flight approached DXB for RWY12L. The computed airspeed was 350 knots, at an altitude of 9,000 feet and descending on a heading of 105° which was an interception heading for the ILS at RWY12L. The FMC was tuned for RWY12L, the PF selected the ‘Approach’ push button on the Mode Control Panel [MCP] the aircraft captures the Glide Slope (G/S). The AP did not transition into the Localizer Mode while the Localizer was armed. ATC, through the relay aircraft advised the PF, ‘you're too fast and too high can you make a 360? Further requesting the PF to perform a ‘360° turn if able’. The PF responded ‘Negative, negative, negative’ to the request. The landing gear lever was selected down at 15:38:00, followed approximately 20 seconds later by an the aural warning alarm indicating a new EICAS caution message, which based on the data is a Landing Gear Disagree Caution. At 15:38:20 the PF says: ‘I have no, uh gear’. Following the over flight of DXB, on passing north of the aerodrome abeam RWY12L. The last Radar contact before the flight passed into the zone of silence was at 15:39:03. The flight was on a heading of 89° at a speed of 320 knots , altitude 4200 feet and descending. The flight was cleared direct to Sharjah Airport (SHJ), SHJ was to the aircraft’s left at 10 nm, the SHJ runway is a parallel vector to RWY12L at DXB. The relay pilot asked the PF if it was possible to perform a left hand turn. This turn, if completed would have established the flight onto an approximate 10 mile final approach for SHJ RWY30. The flight was offered vectors to SHJ (left turn required) and accepts. The relay aircraft advised that SHJ was at 095° from the current position at 10 nm. The PF acknowledged the heading change to 095° for SHJ. For reasons undetermined the PF selected 195° degrees on the Mode Control Panel [MCP], the AP was manually disconnected at 15:40:05, the aircraft then banked to the right as the FMC captured the heading change, rolled wings level on the new heading, the throttles were then retarded, the aircraft entered a descending right hand turn at an altitude of 4000 feet, the speed gradually reduced to 240 kts. The PF made a series of pitch inputs which had a limited effect on the descent profile; the descent is arrested temporarily. There then followed a series of rapid pitch oscillations. These were not phugoid oscillations, these were commanded responses where the elevator effectiveness decreased rapidly as the airspeed decayed and the elevators could not compensate for the reduced thrust moment from the engines to maintain level flight in a steady state. This was due to the desynchronization of the control column inputs and the elevators. At this point had the aircraft remained on the current heading and descent profile it would have intercepted the terrain at or near a large urban conurbation, Dubai Silicone Oasis. The PF was in VHF communication with the relay aircraft requesting positional, speed and altitude information. From this point onwards, approximately 50 seconds elapse prior to the data ending. The effectiveness of the pitch control immediately prior to the end of the data was negligible. The control column was fully aft when the data ended, there was no corresponding elevator movement. The aircraft lost control in flight and made an uncontrolled descent into terrain.
Probable cause:
Probable causes:
- A large fire developed in palletized cargo on the main deck at or near pallet positions 4 or 5, in Fire Zone 3, consisting of consignments of mixed cargo including a significant number of lithium type batteries and other combustible materials. The fire escalated rapidly into a catastrophic uncontained fire.
- The large, uncontained cargo fire, that originated in the main cargo deck caused the cargo compartment liners to fail under combined thermal and mechanical loads.
- Heat from the fire resulted in the system/component failure or malfunction of the truss assemblies and control cables, directly affecting the control cable tension and elevator function required for the safe operation of the aircraft when in manual control.
- The uncontained cargo fire directly affected the independent critical systems necessary for crew survivability. Heat from the fire exposed the supplementary oxygen system to extreme thermal loading, sufficient to generate a failure. This resulted in the oxygen supply disruption leading to the abrupt failure of the Captain’s oxygen supply and the incapacitation of the captain.
- The progressive failure of the cargo compartment liner increased the area available for the smoke and fire penetration into the fuselage crown area.
- The rate and volume of the continuous toxic smoke, contiguous with the cockpit and supernumerary habitable area, resulted in inadequate visibility in the cockpit, obscuring the view of the primary flight displays, audio control panels and the view outside the cockpit which prevented all normal cockpit functioning.
- The shutdown of PACK 1 for unknown reasons resulted in loss of conditioned airflow to the upper deck causing the Electronic Equipment Cooling [EEC] system to reconfigure to “closed loop mode”. The absence of a positive pressure differential contributed to the hazardous quantities of smoke and fumes entering the cockpit and upper deck, simultaneously obscuring the crew’s view and creating a toxic environment.
- The fire detection methodology of detecting smoke sampling as an indicator of a fire is inadequate as pallet smoke masking can delay the time it takes for a smoke detection system to detect a fire originating within a cargo container or a pallet with a rain cover.
Contributing Factors:
- There is no regulatory FAA requirement in class E cargo compartments for active fire suppression.
- Freighter main deck class E fire suppression procedures which relay on venting airflow and depressurisation as the primary means of controlling a fire are not effective for large Class E cargo fires involving dangerous goods capable of Class D metal fire combustion.
- No risk assessment had been made for the failure of the cargo compartment liner based on the evolution of cargo logistics and associated cargo content fire threats, cargo hazards and bulk carriage of dangerous goods.
- The regulation standards for passive fire suppression do not adequately address the combined total thermal energy released by current cargo in a large cargo fire and the effect this has on the protection of critical systems.
- FAA and EASA regulatory requirements do not recognize the current total fire risk associated with pallets, pallet covers and containers as demonstrated by the NTSB/FAA testing.
- Class 9 Hazmat packing regulations do not address the total or potential fire risk that can result from lithium battery heat release during thermal runaway. Although non-bulk specification packaging is designed to contain leaks and protect the package from failure, the packaging for Class 9 does not function to contain thermal release.
- The growth rate of container and pallet fires after they become detectable by the aircraft’s smoke detection system can be extremely fast, precluding any mitigating action and resulting in an overwhelming total energy release and peak energy release rate for a standard fire load that cannot be contained.
- The course to return to Dubai required a series of complex radio communication relays due to the Pilot Flying’s inability to view and tune the radio transceivers.
- The relay communication between the Pilot Flying, relay aircraft and the various ATC stations resulted in communication confusion, incomplete and delayed communications, which contributed to the escalated workload and task saturation for the Pilot Flying.
- The Fire Main Deck non-normal checklist in the QRH was not fully completed by the crew or adhered to regarding the fire suppression flight level or land at nearest airport instruction.
- Task saturation due to smoke and multiple systems failures prevented effective use of the checklist by the crew.
- Communications between the ATCO units involved multiple stages of information exchange by landline and the destination aerodrome was not fully aware of the specific nature of the emergency, the difficulty that the Pilot Flying was experiencing or the assistance required.
- The Pilot Flying had not selected transponder code 7700, the emergency code, when radio communication with the destination aerodrome was not established.
Final Report:

Crash of a Boeing 737-800 in Mangalore: 158 killed

Date & Time: May 22, 2010 at 0605 LT
Type of aircraft:
Operator:
Registration:
VT-AXV
Survivors:
Yes
Schedule:
Dubai - Mangalore
MSN:
36333/2481
YOM:
2007
Flight number:
IX812
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
160
Pax fatalities:
Other fatalities:
Total fatalities:
158
Captain / Total flying hours:
10215
Captain / Total hours on type:
2844.00
Copilot / Total flying hours:
3620
Copilot / Total hours on type:
3319
Aircraft flight hours:
7199
Aircraft flight cycles:
2833
Circumstances:
Air India Express flight IX-811/812 is a daily round trip between Mangalore and Dubai. The outbound flight IX-811 was uneventful and landed at Dubai at 23:44 hours Local Time. The airplane was serviced and refuelled. The same flight crew operated the return leg, flight IX-812. The airplane taxied out for departure at 01:06 LT (02:36 IST). The takeoff, climb and cruise were uneventful. There was no conversation between the two pilots for about 1 hour and 40 minutes because the captain was asleep. The First Officer was making all the radio calls. The aircraft reported position at IGAMA at 05:33 hours IST and the First Officer was told to expect an ILS DME Arc approach to Mangalore. At about 130 miles from Mangalore, the First Officer requested descent clearance. This was, however, denied by the ATC Controller, who was using standard procedural control, to ensure safe separation with other air traffic. At 05:46 IST, the flight reported its position when it was at 80 DME as instructed by Mangalore Area Control. The aircraft was cleared to 7000 ft and commenced descent at 77 DME from Mangalore at 05:47 IST. The visibility reported was 6 km. Mangalore airport has a table top runway. As the AIP India states "Aerodrome located on hilltop. Valleys 200ft to 250ft immediately beyond paved surface of Runway." Owing to the surrounding terrain, Air India Express had made a special qualification requirement that only the PIC shall carry out the take off and landing. The captain on the accident flight had made a total of 16 landings in the past at this airport and the First Officer had operated as a Co-pilot on 66 flights at this airport. While the aircraft had commenced descent, there was no recorded conversation regarding the mandatory preparation for descent and landing briefing as stipulated in the SOP. After the aircraft was at about 50 miles and descending out of FL295, the conversation between the two pilots indicated that an incomplete approach briefing had been carried out. At about 25 nm from DME and descending through FL184, the Mangalore Area Controller cleared the aircraft to continue descent to 2900 ft. At this stage, the First Officer requested, if they could proceed directly to Radial 338 and join the 10 DME Arc. Throughout the descent profile and DME Arc Approach for ILS 24, the aircraft was much higher than normally expected altitudes. The aircraft was handed over by the Mangalore Area Controller to ATC Tower at 05:52 IST. The Tower controller, thereafter, asked the aircraft to report having established on 10 DME Arc for ILS Runway 24. Considering that this flight was operating in WOCL (Window Of Circadian Low), by this time the First Officer had also shown signs of tiredness. This was indicated by the sounds of yawning heard on the CVR. On having reported 10 DME Arc, the ATC Tower had asked aircraft to report when established on ILS. It appears that the captain had realized that the aircraft altitude was higher than normal and had selected Landing Gear 'DOWN' at an altitude of approximately 8,500 ft with speed brakes still deployed in Flight Detent position, so as to increase the rate of descent. As indicated by the DFDR, the aircraft continued to be high and did not follow the standard procedure of intercepting the ILS Glide Path at the correct intercept altitude. This incorrect procedure led to the aircraft being at almost twice the altitude as compared to a Standard ILS Approach. During approach, the CVR indicated that the captain had selected Flaps 40 degrees and completed the Landing Check List. At 06:03 hours IST at about 2.5 DME, the Radio Altimeter had alerted an altitude of 2500 ft. This was immediately followed by the First Officer saying "It is too high" and "Runway straight down". In reply, the captain had exclaimed "Oh my god". At this moment, the captain had disconnected the Auto Pilot and simultaneously increased the rate of descent considerably to establish on the desired approach path. At this stage, the First Officer had queried "Go around?" To this query from the First Officer, the captain had called out "Wrong loc .. ... localiser .. ... glide path". The First Officer had given a second call to the captain for "Go around" followed by "Unstabilized". However, the First Officer did not appear to take any action, to initiate a Go Around. Having acquired the runway visually and to execute a landing, it appears that the captain had increased the rate of descent to almost 4000 ft per minute. Due to this, there were numerous warnings from EGPWS for 'SINK RATE' and 'PULL UP'. On their own, the pilots did not report having established on ILS Approach. Instead, the ATC Tower had queried the same. To this call, the captain had forcefully prompted the First Officer to give a call of "Affirmative". The Tower controller gave landing clearance thereafter and also indicated "Winds calm". The aircraft was high on approach and touched down on the runway, much farther than normal. The aircraft had crossed the threshold at about 200 ft altitude with indicated speed in excess of 160 kt, as compared to 50 ft with target speed of 144 kt for the landing weight. Despite the EGPWS warnings and calls from the First Officer to go around, the captain had persisted with the approach in unstabilized conditions. Short of touchdown, there was yet another (Third) call from the First Officer, "Go around captain...We don't have runway left". However, the captain had continued with the landing and the final touchdown was about 5200 ft from the threshold of runway 24, leaving approximately 2800 ft of remaining paved surface. The captain had selected Thrust Reversers soon after touchdown. Within 6 seconds of applying brakes, the captain had initiated a 'Go Around', in contravention of Boeing SOP. The aircraft overshot the runway including the strip of 60 metres. After overshooting the runway and strip, the aircraft continued into the Runway End Safety Area (RESA) of 90 metres. Soon after which the right wing impacted the localiser antenna structure located further at 85 metres from the end of RESA. Thereafter, the aircraft hit the boundary fence and fell into a gorge.
Probable cause:
The Court of Inquiry determines that the cause of this accident was Captain's failure to discontinue the unstabilized approach and his persistence in continuing with the landing, despite three calls from the First Officer to go around and a number of warnings from the EGPWS.
Contributing Factors were:
1. In spite of availability of adequate rest period prior to the flight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia. As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgment. This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL).
2. In the absence of Mangalore Area Control Radar (MSSR), due to unserviceability, the aircraft was given descent at a shorter distance on DME as compared to the normal. However, the flight crew did not plan the descent profile properly, resulting in remaining high on approach.
3. Probably in view of ambiguity in various instructions empowering the 'copilot' to initiate a 'go around ', the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.
Final Report:

Crash of a McDonnell Douglas MD-82 in Kish Island

Date & Time: Mar 16, 2007
Type of aircraft:
Operator:
Registration:
LZ-LDD
Survivors:
Yes
Schedule:
Dubai - Kish Island
MSN:
49218/1274
YOM:
1986
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
154
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft landed hard at Kish Island Airport and was considered as damaged beyond repair. All 158 occupants escaped uninjured.

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 Douglas DC-10-30ER in Chittagong

Date & Time: Jul 1, 2005 at 0853 LT
Type of aircraft:
Operator:
Registration:
S2-ADN
Survivors:
Yes
Schedule:
Dubai - Chittagong - Dhaka
MSN:
46542
YOM:
1979
Flight number:
BG048
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
201
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Dubai on a flight to Dhaka with an intermediate stop in Chittagong, carrying 201 passengers and a crew of 15. Weather conditions at Chittagong Airport were poor with a visibility of 1,800 metres in rain, 5-7 oktas cloud at 700 feet, 3-4 oktas cloud at 1,300 feet, 0-2 oktas cloud at 2,600 feet, overcast at 8,000 feet with CB's, temporary visibility of 2 km and wind from 180 at 6 knots. On final approach, the aircraft was unstable but the captain decided to continue the descent. After touchdown on runway 23, the aircraft deviated from the centerline to the right, causing the right main gear to veer off runway. While contacting soft ground, it was torn off, causing the engine n°3 to be partially sheared off. The aircraft slid for few dozen metres before coming to rest in a grassy area along the runway. All 216 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew who failed to follow the SOP's and his failure to initiate a go-around while the aircraft was unstable on short final.