Crash of a Boeing 737-81Q at Jacksonville NAS

Date & Time: May 3, 2019 at 2142 LT
Type of aircraft:
Operator:
Registration:
N732MA
Survivors:
Yes
Schedule:
Guantánamo Bay - Jacksonville
MSN:
30618/830
YOM:
2001
Flight number:
LL293
Crew on board:
7
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
2204.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
18
Aircraft flight hours:
38928
Aircraft flight cycles:
15610
Circumstances:
According to both pilots, the takeoff, climb, and cruise portions of the flight were uneventful. The No. 1 (left) thrust reverser was not operational and deferred for the flight in accordance with the airplane’s minimum equipment list. The captain was the pilot flying for the accident flight, and the first officer was the pilot monitoring. The captain was also performing check airman duties for the first officer who was in the process of completing operating experience training. During the approach to Jacksonville Naval Air Station (NIP), the flight crew had two runway change discussions with air traffic controllers due to reported weather conditions (moderate to heavy precipitation) near the field; the pilots ultimately executed the area navigation GPS approach to runway 10, which was ungrooved and had a displaced threshold 997 ft from the threshold, leaving an available landing distance of 8,006 ft. As the airplane descended through 1,390 ft mean sea level (msl), the pilots configured it for landing with the flaps set at 30º and the landing gear extended; however, the speedbrake handle was not placed in the armed position as specified in the Landing checklist. At an altitude of about 1,100 ft msl and 2.8 nm from the runway, the airplane was slightly above the glidepath, and its airspeed was on target. Over the next minute, the indicated airspeed increased to 170 knots (17 knots above the target approach speed), and groundspeed reached 180 knots, including an estimated 7-knot tailwind. At an altitude of about 680 ft msl and 1.6 nm from the threshold, the airplane deviated further above the 3° glidepath such that the precision approach path indicator (PAPI) lights would have appeared to the flight crew as four white lights and would retain that appearance throughout the rest of the approach. Eight seconds before touchdown, multiple enhanced ground proximity warning system alerts announced “sink rate” as the airplane’s descent rate peaked at 1,580 fpm. The airplane crossed the displaced threshold 120 ft above the runway (the PAPI glidepath crosses the displaced threshold about 54 ft above the runway) and 17 knots above the target approach speed, with a groundspeed of 180 knots and a rate of descent about 1,450 ft per minute (fpm). The airplane touched down about 1,580 ft beyond the displaced threshold, which was 80 ft beyond the designated touchdown zone as specified in the operator’s standard operating procedures (SOP). After touchdown, the captain deployed the No. 2 engine thrust reverser and began braking; he later reported, however, that he did not feel the aircraft decelerate and increased the brake pressure. The speedbrakes deployed about 4 seconds after touchdown, most likely triggered by the movement of the right throttle into the idle reverse thrust detent after main gear tire spinup. The automatic deployment of the speedbrakes was likely delayed by about 3 seconds compared to the automatic deployment that could have been obtained by arming the speedbrakes before landing. The airplane crossed the end of the runway about 55 ft right of the centerline and impacted a seawall 90 ft to the right of the centerline, 9,170 ft beyond the displaced threshold, and 1,164 ft beyond the departure end of runway 10. After the airplane came to rest in St. Johns River, the flight crew began an emergency evacuation.
Probable cause:
An extreme loss of braking friction due to heavy rain and the water depth on the ungrooved runway, which resulted in viscous hydroplaning. Contributing to the accident was the operator’s inadequate guidance for evaluating runway braking conditions and conducting en route landing distance assessments.
Contributing to the continuation of an unstabilized approach were
1) the captain’s plan continuation bias and increased workload due to the weather and performing check airman duties and
2) the first officer’s lack of experience.
Final Report:

Crash of a Douglas DC-8-61F at Guantánamo Bay NAS

Date & Time: Aug 18, 1993 at 1656 LT
Type of aircraft:
Operator:
Registration:
N814CK
Flight Type:
Survivors:
Yes
Schedule:
Norfolk – Guantánamo Bay
MSN:
46127
YOM:
1969
Flight number:
CB808
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20727
Captain / Total hours on type:
1527.00
Copilot / Total flying hours:
15350
Copilot / Total hours on type:
492
Aircraft flight hours:
43947
Aircraft flight cycles:
18829
Circumstances:
Flight 808 took off from Norfolk at 14:13 for a cargo flight to Guantánamo Bay. The flight and arrival into the Guantánamo terminal area was uneventful. At 16:34, while the flight was descending from FL320, radio contact was established with the Guantánamo radar controller. The radar controller instructed flight 808 to maintain VFR 12 miles off the Cuban coast and report at East Point. The runway in use was runway 10. The flight crew then requested a runway 28 approach, but changed this back to a runway 10 approach a couple of minutes later. Clearance was given at 16:46 with wind reported at 200°/7 knots. The runway 10 threshold was located 0,75 mile East of Cuban airspace, designated by a strobe light, mounted on a Marine Corps guard tower, located at the corner of the Cuban border and the shoreline. On the day of the accident, the strobe light was not operational (both controller and flight crew were not aware of this). The aircraft was approached from the south and was making a right turn for runway 10 with an increasing angle of bank in order to align with the runway. At 200-300 feet agl the wings started to rock towards wings level and the nose pitched up. The right wing appeared to stall, the aircraft rolled to 90deg. angle of bank and the nose pitched down. The aircraft then struck level terrain 1400 feet west of the approach end of the runway and 200 feet north of the extended centreline.
Probable cause:
The impaired judgement, decision-making, and flying abilities of the captain and flight crew due to the effects of fatigue; the captain's failure to properly assess the conditions for landing and maintaining vigilant situational awareness of the airplane while manoeuvring onto final approach; his failure to prevent the loss of airspeed and avoid a stall while in the steep bank turn; and his failure to execute immediate action to recover from a stall. Additional factors contributing to the cause were the inadequacy of the flight and duty time regulations applied to 14 CFR, Part 121, Supplemental Air Carrier, international operations, and the circumstances that resulted in the extended flight/duty hours and fatigue of the flight crew members. Also contributing were the inadequate crew resource management training and the inadequate training and guidance by American International Airways, Inc., to the flight crew for operations at special airports such as Guantanamo Bay; and the Navy's failure to provide a system that would assure that local tower controller was aware of the inoperative strobe light so as to provide the flight crew with such information.
Final Report:

Crash of a Convair C-131F Samaritan off Jacksonville NAS: 14 killed

Date & Time: Apr 30, 1983 at 1209 LT
Type of aircraft:
Operator:
Registration:
141010
Flight Type:
Survivors:
Yes
Schedule:
Jacksonville – Guantánamo
MSN:
293
YOM:
1955
Crew on board:
6
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
After takeoff from Jacksonville-Towers Field NAS, while climbing, the left engine failed. The crew declared an emergency and was cleared to return. On final approach, the airplane crashed in the St Johns River about 125 yards short off shore. The aircraft came to rest in shallow waters and was destroyed. A passenger was rescued while 14 other occupants were killed.
Probable cause:
Failure of the left engine during initial climb or unknown reasons.

Crash of a Lockheed PV-1 Ventura off Guantanamo Bay: 2 killed

Date & Time: Apr 27, 1979 at 0116 LT
Type of aircraft:
Registration:
N544B
Flight Phase:
Flight Type:
Survivors:
No
MSN:
5267
YOM:
1943
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2720
Circumstances:
The twin engine airplane departed Fort Lauderdale in the evening on a flight to the Dominican Republic. En route, while cruising by night, the crew informed ATC about the failure of all instruments. He apparently attempted to ditch the aircraft when it crashed into the sea about 20 nautical miles off Guantanamo Bay. Few debris were found floating on water and both occupants were killed.
Probable cause:
The crew became lost/disoriented following a fuel exhaustion and electrical failure during normal cruise. The following findings were reported:
- Fuel exhaustion,
- Electrical failure,
- Navigation instruments out,
- Ditched in international waters 20 NM south of Cuba,
- Debris recovered.
Final Report:

Crash of a Boeing C-135B-BN Stratolifter in Guantánamo Bay: 7 killed

Date & Time: Oct 23, 1962
Type of aircraft:
Operator:
Registration:
62-4136
Flight Type:
Survivors:
No
Schedule:
McGuire - Guantánamo Bay
MSN:
18476
YOM:
3
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Aircraft flight hours:
150
Circumstances:
On final approach to Guantánamo Bay NAS, the aircraft was too low. One of the wing struck the ground 1,000 feet short of runway 09 threshold. Out of control, the aircraft crashed in flames, killing all seven crew members.

Crash of a Rockwell Aero Commander 560 in Guantánamo Bay

Date & Time: Aug 16, 1958
Registration:
128
Flight Type:
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances near Guantánamo Bay. Used by the Transport Squadron.

Crash of a Lockheed P2V-5 Neptune into the Caribbean Sea: 11 killed

Date & Time: Sep 26, 1955
Type of aircraft:
Operator:
Registration:
131442
Flight Phase:
Survivors:
No
Schedule:
Guantánamo Bay - Guantánamo Bay
MSN:
426-5323
Flight number:
Snowcloud Five
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft left Guantánamo Bay NAS in Cuba on a meteorological mission consisting of investigations of the hurricane 'Janet' that was classified in cat 4 and approaching Jamaica from the south. While penetrating the eye of the hurricane at an altitude of about 700 feet, the airplane went out of control and crashed into the sea, some 480 km southwest of the Jamaican coast. SAR operations were conducted but eventually suspended after few days as no trace of the aircraft nor the eleven occupants was found. There were nine crew members and two journalists on board.

Crash of a Douglas JD-1 Invader off Guantanamo Bay NAS: 2 killed

Date & Time: May 22, 1954
Type of aircraft:
Operator:
Registration:
77153
Flight Phase:
Survivors:
No
Schedule:
Guantanamo Bay - Guantanamo Bay
MSN:
77153
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Crashed in unknown circumstances into the sea about 21 miles off Guantanamo Bay NAS. Both crew members were killed.

Crash of a Consolidated PBY-5A Catalina into the Caribbean Sea: 16 killed

Date & Time: Apr 6, 1944
Type of aircraft:
Operator:
Registration:
08044
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Juan – Guantánamo
MSN:
863
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
En route from San Juan to the Guantánamo NAS, crew encountered engine problems and elected to ditch the aircraft that crashed into the Caribbean Sea. Fifteen occupants were missing, one was killed and fourteen others were rescued. No trace of the missing crew was ever found.
Probable cause:
Fuel exhaustion.