Crash of a Dassault Falcon 20C-5 in Kiel

Date & Time: Feb 15, 2006 at 1945 LT
Type of aircraft:
Operator:
Registration:
F-OVJR
Survivors:
Yes
Schedule:
Moscow - Luton
MSN:
180
YOM:
1969
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
10413
Circumstances:
En route from Moscow-Domodedovo to Luton, while cruising over Germany, the crew declared an emergency following smoke spreading in the cabin and the cockpit. The crew was cleared to divert to Kiel-Holtenau Airport. After landing by night on runway 26 which is 1,265 metres long, the aircraft was unable to stop within the remaining distance. It overran and came to rest in a ravine. All 6 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the flight attendant inadvertently set off a smoke canister intended for emergencies, causing smoke to spread in the the cabin. The crew was forced to divert to the nearest airport for an emergency landing. The following contributing factors were identified:
- The pilots failed to use the reverse thrust systems and the braking parachute after landing,
- Improper storage of emergency smoke canister in the cabin,
- Poor crew training related to the emergency equipment.

Crash of a Gulfstream GIV in Teterboro

Date & Time: Dec 1, 2004 at 1623 LT
Type of aircraft:
Operator:
Registration:
G-GMAC
Survivors:
Yes
Schedule:
Farnborough – Luton – Teterboro
MSN:
1058
YOM:
1988
Flight number:
GMA946
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
2000
Aircraft flight hours:
7452
Circumstances:
The flight was cleared for the ILS Runway 19 approach, circle-to-land on Runway 24; a 6,013-foot-long, 150-foot wide, asphalt runway. The auto throttle and autopilot were disengaged during the approach, about 800 feet agl. However, the auto throttle reengaged just prior to touchdown, about 35 feet agl. The flightcrew did not recall reengaging the auto throttle, and were not aware of the autothrottle reengagement. According to the auto throttle computers, the reengagement was commanded through one of the Engage/Disengage paddle switches located on each power lever. The target airspeed set for the auto throttle system was 138 knots. After touchdown, as the airplane decelerated below 138 knots, the auto throttle system gradually increased the power levers in an attempt to maintain the target airspeed. Without the power levers in the idle position, the ground spoilers and thrust reversers would not deploy. While the flightcrew was pulling up on the thrust reverser levers, they may not have initially provided enough aft force on the power levers (15 to 32 lbs.) to override and disconnect the auto throttle system. The flight data recorder indicated that the autothrottle system disengaged 16 seconds after the weight-on-wheels switches were activated in ground mode. As the airplane neared the end of the runway, the pilot engaged the emergency brake, and the airplane departed the right side of the runway. The autothrottle Engage/Disengage paddle switches were not equipped with switch guards. Although the autothrottle system provided an audible tone when disengaged, it did not provide a tone when engaged. The reported wind about the time of the accident was from 290 degrees at 16 knots, gusting to 25 knots, with a peak wind from 300 degrees at 32 knots.
Probable cause:
The flightcrew's inadvertent engagement of the autothrottle system, and their failure to recognize the engagement during landing, which resulted in a runway excursion. Factors were the lack of autothrottle switch guards, lack of an autothrottle engagement audible tone, and gusty winds.
Final Report:

Crash of a Short 330-200 in Paris: 1 killed

Date & Time: May 25, 2000 at 0252 LT
Type of aircraft:
Operator:
Registration:
G-SSWN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Paris - Luton
MSN:
3064
YOM:
1981
Flight number:
SSW200
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2240
Captain / Total hours on type:
1005.00
Copilot / Total flying hours:
4370
Copilot / Total hours on type:
14
Aircraft flight hours:
15215
Aircraft flight cycles:
19504
Circumstances:
The Short was departing Paris-Roissy-CDG Airport on a cargo service to Luton with two pilots on board. The crew were cleared to depart cargo stand N51 and proceed to runway 27 at 02:38. Around the same time Air Liberté Flight 8807 (an MD-83, F-GHED) also taxied to runway 27 for a flight to Madrid. At 02:44 the Charles de Gaulle ground controller asked Streamline 200 if they wished to enter runway 27 at an intermediate taxiway; the crew asked for and were granted to enter Taxiway 16. At 02:50:49 the tower controller cleared the MD-83 for takeoff: "Liberté 8807, autorisé au décollage 27, 230°, 10 à 15 kts.". The controller then immediately told the Shorts to line up and wait: "Stream Line two hundred line up runway 27 and wait, number two". As the MD-83 was travelling down the runway, the Shorts started to taxi onto the runway. At a speed of about 155 knots the left wing of MD-83 slashed through the cockpit of the Shorts plane; the MD-83 abandoned takeoff.
Probable cause:
The following findings were identified:
- Firstly, by the LOC controller’s erroneous perception of the position of the aircraft, this being reinforced by the context and the working methods, which led him to clear the Shorts to line up,
- Secondly, by the inadequacy of systematic verification procedures in ATC which made it impossible for the error to be corrected,
- Finally, by the Shorts’ crew not dispelling any doubts they had as to the position of the 'number one' aircraft before entering the runway.
Contributory factors include:
- Light pollution in the area of runway 27, which made a direct view difficult for the LOC controller,
- Difficulty for the LOC controller in accessing radar information: the ASTRE image was difficult to read and the AVISO image not displayed at his control position,
- The use of two languages for radio communications, which meant that the Shorts crew were not conscious that the MD 83 was going to take off,
- The angle between access taxiway 16 and the runway which made it impossible for the Shorts crew to perform a visual check before entering the runway,
- The lack of coordination between the SOL and LOC controllers when managing the Shorts, exacerbated by the presence of a third party whose role was not defined,
- A feedback system which was recent and still underdeveloped.
Final Report:

Crash of a Beechcraft 99 Airliner in Liège: 2 killed

Date & Time: Jun 30, 1999 at 0441 LT
Type of aircraft:
Operator:
Registration:
D-IBEX
Flight Type:
Survivors:
No
Schedule:
Luton - Frankfurt
MSN:
U-45
YOM:
1968
Flight number:
EXT114
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
En route from Luton to Frankfurt, while on a night cargo service (flight EXT114), at an altitude of 11,000 feet, the crew declared an emergency after both engines failed almost simultaneously. The crew was cleared to divert to the nearest airport that was Liège-Bierset. After being cleared to descend to FL60, the crew contacted Brussels ATC and was vectored for an approach to runway 23L. Due to the critical situation, the crew requested a straight-in approach. While descending to the airport, the aircraft crashed in a wooded area located near Seraing, about nine km southeast of the airport. The aircraft was destroyed by impact forces and a post crash fire and both pilots were killed.
Probable cause:
Both engines failed in flight due to poor maintenance. The following contributing factors were identified:
- The crew failed to follow the operator published procedures,
- There was a misunderstanding between the crew and ATC,
- Lack of visibility due to night conditions.
Final Report:

Crash of a Fokker F27 Friendship 600 in Saint Peter: 2 killed

Date & Time: Jan 12, 1999 at 1706 LT
Type of aircraft:
Operator:
Registration:
G-CHNL
Flight Type:
Survivors:
No
Schedule:
Luton - Saint Peter
MSN:
10508
YOM:
1975
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3930
Captain / Total hours on type:
750.00
Copilot / Total flying hours:
958
Copilot / Total hours on type:
317
Circumstances:
The Fokker F27 was operating on a cargo flight to Guernsey, carrying newspapers. The aircraft departed Luton at 16:14. and climbed to cruising altitude FL150/160). The descent was begun at about 60 miles from Guernsey Airport and the aircraft was vectored onto final approach by Jersey Radar. The approach checklist was actioned and the flaps were lowered to 16° just before the aircraft was turned to intercept the ILS localizer. With less than six miles to run to the threshold the commander told the first officer that he could see the runway and was content to continue the approach visually. The first officer informed ATC that they wished to continue the approach visually; they were given the appropriate clearance and control of the aircraft was then handed over to Guernsey Tower. Initially the aerodrome controller cleared the aircraft to continue the approach (there was departing traffic on the runway) and the commander called for flaps to 26° followed by the landing checklist. About one minute later the commander said "three whites" (meaning that he was aware that the aircraft was slightly high on the glide path indicated by the precision approach path indicator lights) which the first officer acknowledged. The commander then said "ok the decision is to land, speed below one four four, flaps forty". The first officer acknowledged the instruction to select flaps to 40° and announced "running". There followed a pause of about five seconds before the first officer said, "flaps forty gear and clearance you have - oops". The commander then said, in an anxious tone of voice "ok flaps twenty six" and the engines could be heard accelerating on the cockpit voice recording. There then followed a number of expletives from the commander interspersed with some loud clicks as controls or switches were operated and the sound of a warning horn which stopped before the end of the recording. On approach the aircraft had lost control, attaining a nose-high attitude. The plane stalled, clipped a house on Forest Road with its left wing and ploughed into a field short of the runway.
Probable cause:
The investigation identified the following causal factors:
(i) The aircraft was operated outside the load and balance limitations;
(ii) Loading distribution errors went undetected because the load sheet signatories did not reconcile the cargo distribution in the aircraft with the load and balance sheet;
(iii) The crew received insufficient formal training in load management.
Final Report:

Crash of a Cessna 421B Golden Eagle I off Kalundborg: 5 killed

Date & Time: Jul 29, 1986
Registration:
OY-BUS
Flight Phase:
Survivors:
No
Schedule:
Roskilde - Luton
MSN:
421B-0615
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Before takeoff from Roskilde Airport, the pilot received a weather briefing and was informed about the presence of thunderstorm activity over Denmark. All four passengers, two Directors of the Company and their wifes, were flying to London to go to an Opera. About 15 minutes into the flight, the twin engine aircraft went through clouds when it encountered severe turbulences. One of the wing tip tank detached and out of control, the aircraft entered a dive and crashed in the Great Belt off Kalundborg. The aircraft was destroyed and all five occupants were killed.
Probable cause:
In-flight loss of control due to thunderstorm activity and turbulences.

Crash of a Beechcraft C90 King Air off Copenhagen

Date & Time: Dec 26, 1983
Type of aircraft:
Registration:
G-BKID
Flight Type:
Survivors:
Yes
Schedule:
Luton - Copenhagen
MSN:
LJ-604
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Copenhagen-Kastrup following a positioning flight from Luton, both engines failed. The aircraft stalled and crashed into the sea about 4 km offshore. The pilot, sole on board, was rescued while the aircraft sank and was lost.
Probable cause:
Double engine failure on approach for unknown reasons.

Crash of a Lockheed L-1329 JetStar 6 in Luton

Date & Time: Mar 29, 1981 at 1953 LT
Type of aircraft:
Operator:
Registration:
N267L
Survivors:
Yes
Schedule:
Lagos - Hassi Messaoud - Luton
MSN:
5067
YOM:
1965
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12650
Captain / Total hours on type:
2630.00
Copilot / Total flying hours:
15000
Copilot / Total hours on type:
300
Aircraft flight hours:
4777
Circumstances:
The aircraft made a surveillance radar approach (SRA) to the Luton runway 08 at night, in conditions of low cloud and poor visibility and landed well past the touchdown zone. It then overran the end of the runway, became airborne over a 10 metre deep escarpment, struck the ground and caught fire. The seven passengers escaped from the aircraft through a hole in the fuselage and the commander exited through his direct vision (DV) window; all of them sustained relatively minor injuries. The co-pilot received severe spinal injuries and was unable to vacate the cockpit without the assistance of the rescue services. The external and cabin fires were extinguished by the aerodrome fire service who were then delayed in entering the cabin by the concentration of smoke and the lack of breathing apparatus.
Probable cause:
It was concluded that the accident was caused by the commander's action in attempting a landing from a non-precision approach without sufficient visual reference.
Final Report: