Paris-Roissy-CDG | Bureau of Aircraft Accidents Archives

Crash of a Douglas DC-10-30 in Niger: 170 killed

Date & Time: Sep 19, 1989 at 1359 LT

Type of aircraft:

Douglas DC-10

Operator:

Registration:

N54629

Flight Phase:

Flight

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Desert

Schedule:

Brazzaville – N’Djamena – Paris

MSN:

46852

YOM:

1973

Flight number:

UT772

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

156

Pax fatalities:

Other fatalities:

Total fatalities:

170

Captain / Total flying hours:

11039

Captain / Total hours on type:

2723.00

Copilot / Total flying hours:

8357

Copilot / Total hours on type:

754

Aircraft flight hours:

60267

Aircraft flight cycles:

14777

Circumstances:

The DC-10 departed N'Djamena Airport at 1313LT bound for Paris-Roissy-Charles de Gaulle Airport. Forty-six minutes later, while cruising at an altitude of 35,000 feet over Niger, the aircraft disappeared from radar screens and the crew did not send any distress call. It was quickly understood that the aircraft exploded in mid-air and crashed somewhere in the desert. SAR operations were initiated and the wreckage was found a day later in the Ténéré Desert, about 650 km north of N'Djamena, northeast from the Termit Mountain Range. Debris scattered on 100 km2 and none of the 170 occupants survived the crash.

Probable cause:

It was determined that the accident was the aircraft was destroyed by an explosion. The following findings were reported:
- The destruction was due to an explosive charge placed in a container located in position 13R in the forward cargo hold.
- The bomb was formed of pentrite, namely an explosive composed with a powerful and very sensitive crystalline nitric ester.
- The Investigation Commission assert that the most plausible hypothesis is that the explosive charge was inside baggage loaded at Brazzaville Airport.
- Observations made shortly after the accident on Brazzaville Airport made it clear that, at that time, the airport security measures in force were not in accordance with the ICAO standards and recommended practices (Annex 17 to the Convention on International Civil Aviation and Civil Aviation Security Manual (DOC 8973)).

Final Report:

Crash of a Boeing 747-228B in Rio de Janeiro

Date & Time: Dec 2, 1985 at 0634 LT

Type of aircraft:

Boeing 747-200

Operator:

Registration:

F-GCBC

Flight Phase:

Landing (descent or approach)

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Airport (less than 10 km from airport)

Schedule:

Paris – Rio de Janeiro – Buenos Aires – Santiago de Chile

MSN:

22427

YOM:

1980

Flight number:

AF091

Location:

Rio de Janeiro-Galeão

Rio de Janeiro

Country:

Brazil

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

265

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

16139

Captain / Total hours on type:

979.00

Copilot / Total flying hours:

6148

Copilot / Total hours on type:

513

Aircraft flight hours:

22762

Circumstances:

Air France flight 091 was involved in runway excursion accident at Rio de Janeiro-Galeão International Airport, Brazil. The aircraft, a Boeing 747-200, took off from Paris-Charles de Gaulle Airport, France at 21:30 UTC on a flight to Santiago, Chile with en route stops at Rio de Janeiro and Buenos Aires, Argentina. The flight to Rio de Janeiro took about eleven hours and was uneventful. At 08:34 UTC the aircraft touched down on runway 14, 400 meters from the threshold. After reversers were set, the aircraft deviated from the runway heading and at 2,000 meters from the threshold it veered off the right side of the runway. The aircraft ran over the grass for 765 meters, until passing over a drainage ditch and the load apron concrete step, where the landing gears folded aft with the left wing gear completely separating. On the load apron concrete the aircraft spun around for 275 meters until stopping, after the left outboard wing section struck an illumination stand. For a few seconds engines 2, 3 and 4 kept running at maximum reverse thrust, while engine number one run operated at full forward thrust. After the engines were shut down, the passengers evacuated using three of the aircraft's left hand side escape slides. The fire that started on the area near engines number 2 and 3 was extinguished by the airport fire fighters. It appeared that the n°1 engine throttle cable had broken, making it impossible for the flight crew to control engine power. The engine had accelerated to an unusually high level of (forward) thrust (above takeoff power).

Probable cause:

The following findings were reported:
(1) Human Factor:
Physiological Aspect - The crewmembers physical conditions (fatigue) might have contributed to their delay in perceiving the engine failure and to the inadequate reactions during the emergency.
(2) Material Factor:
a) The hydraulic pump ripple of the CF6-50E engine caused considerable vibration on the pulley support region, which worked as a dynamic source to produce cable oscillation and relative movement between cable and pulley.
b) Pulley bracket design deficiency, possibly related to the reduced contact area between cable and pulley, allowing for the wearing of these components in the presence of abrasive agents, in association with the vibration on that area, knowing that there is localized contact between both (at the same points) in an almost permanent way (93% of the engine operating time in cruise range).
c) The tests performed by the Manufacturer confirmed the existing relative movement between cable and pulley, even after the introduction of modifications.
(3) Maintenance Deficiency:
a) The use of an aluminum pulley, not authorized by the manufacturer as a substitution to the recommended phenolic pulley, made possible the formation of the abrasive agent (alumina).
b) The inadequate fixation of the pulley bracket due to the use, by the operator, of a screw of insufficient length for an additional washer, left loose the support side brace, allowing for the increase of the relative movement. already existing at that region, between cable and pulley.
(4) Flight Manual Deficiency:
a) The B747 AFM instructions allow the pilot flying to apply reverse thrust before knowing the effective transit of reversers.
b) The B747 AFM has no instruction regarding a failure of reverser deployment associated with an engine runaway forward thrust. The lack of instructions on this specific kind of abnormality, contributed to the crew not noticing that the failure had occurred.
(5) Training Requirement Deficiency:
a) The lack of simulator training requirement for this type of emergency contributed to the control loss.
(6) Crewmember Factor due to Operational Error:
a) The captain did not observe the AFM instructions about the reverse levers and manual brake use.
b) The FIE did not observe the AFM instructions about the correct engine instrument monitoring during the reverse operation.

Final Report:

Crash of a Boeing 747-283B in Madrid: 181 killed

Date & Time: Nov 27, 1983 at 0106 LT

Type of aircraft:

Boeing 747-200

Operator:

Registration:

HK-2910

Flight Phase:

Landing (descent or approach)

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Airport (less than 10 km from airport)

Schedule:

Frankfurt – Paris – Madrid – Caracas – Bogotá

MSN:

21381

YOM:

1977

Flight number:

AV011

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

173

Pax fatalities:

Other fatalities:

Total fatalities:

181

Captain / Total flying hours:

23215

Captain / Total hours on type:

2432.00

Copilot / Total flying hours:

4384

Copilot / Total hours on type:

875

Aircraft flight hours:

20811

Aircraft flight cycles:

5800

Circumstances:

Following an uneventful flight from Paris-Roissy-CDG Airport, the crew was cleared to descent to Madrid-Barajas Airport runway 33. Once the altitude of 9,000 feet reached on descent, the crew was cleared to continue. At 0103LT, he was cleared to land on runway 33 and should complete a turn to the right. Following several errors on approach, the crew initiated a right turn prior to pass over the VOR, causing the aircraft to descent below the MDA. At an altitude of 2,247 feet and at a speed of 142 knots, the right main gear struck the top of a hill. Upon impact, the right main gear and the engine n°4 were torn off. Three seconds later, while in a 4,9° nose-up attitude, at a speed of 135 knots, the aircraft struck the top of a second hill. Then, six seconds later, the right wing struck the ground. The aircraft overturned and crashed upside down, bursting into flames. The wreckage was found 12 km from the runway threshold in an olive plantation. Eleven passengers (among them four members of the same family, father, mother and both children) were injured while 181 other occupants were killed, among them the Peruvian writer Manuel Scorza.

Probable cause:

Following a series of omissions and navigation errors on descent, the crew adopted a wrong approach configuration, causing the aircraft to descend below the MDA without proper visual contact with the runway until initial and final impact with the ground. The following contributing factors were reported:
_ Inaccurate navigation by the crew, which placed them in an incorrect position for initiating the approach manoeuvre,
- Failure of the crew to take corrective action after the GPWS alarm sounded in the cockpit,
- Poor crew coordination,
- Crew fatigue,
- Lack of ATC assistance during the last portion of the flight,
- Misinterpretation of ATC instructions on part of the flying crew,
- Lack of visibility due to the night.