Crash of a McDonnell Douglas MD-11F in Tokyo: 2 killed

Date & Time: Mar 23, 2009 at 0649 LT
Type of aircraft:
Operator:
Registration:
N526FE
Flight Type:
Survivors:
No
Schedule:
Guangzhou - Tokyo
MSN:
48600/560
YOM:
1993
Flight number:
FDX080
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8132
Captain / Total hours on type:
3648.00
Copilot / Total flying hours:
5248
Copilot / Total hours on type:
879
Aircraft flight hours:
40767
Aircraft flight cycles:
7131
Circumstances:
Aircraft bounced repeatedly during landing on Runway 34L at Narita International Airport. During the course of bouncing, its left wing was broken and separated from the fuselage attaching point and the airplane caught fire. The airplane rolled over to the left being engulfed in flames, swerved off the runway to the left and came to rest inverted in a grass area. The Pilot in Command (PIC) and the First Officer (FO) were on board the airplane, and both of them suffered fatal injuries. The airplane was destroyed and the post-crash fire consumed most parts.
Probable cause:
In this accident, when the airplane landed on Runway 34L at Narita International Airport, it fell into porpoising. It is highly probable that the left wing fractured as the load transferred from the left MLG to the left wing structure on the third touchdown surpassed the design limit (ultimate load). It is highly probable that a fire broke out as the fuel spillage from the left wing caught fire, and the airplane swerved left off the runway rolling to the left and came to rest inverted on the grass area. The direct causes which the airplane fell into the porpoise phenomenon are as follows:
a. Large nose-down elevator input at the first touchdown resulted in a rapid nose down motion during the first bounce, followed by the second touchdown on the NLG with negative pitch attitude. Then the pitch angle rapidly increased by the ground reaction force, causing the larger second bounce, and
b. The PF‘s large elevator input in an attempt to control the airplane without thrust during the second bounce. In addition, the indirect causes are as follows:
a. Fluctuating airspeed, pitch attitude due to gusty wind resulted in an approach with a large sink rate,
b. Late flare with large nose-up elevator input resulted in the first bounce and
c. Large pitch attitude change during the bounce possibly made it difficult for the crewmembers to judge airplane pitch attitude and airplane height relative to the ground (MLG height above the runway).
d. The PM‘s advice, override and takeover were not conducted adequately. It is somewhat likely that, if the fuse pin in the MLG support structure had failed and the MLG had been separated in the overload condition in which the vertical load is the primary component, the damage to the fuel tanks would have been reduced to prevent the fire from developing rapidly. It is probable that the fuse pin did not fail because the failure mode was not assumed under an overload condition in which the vertical load is the primary component due to the interpretation of the requirement at the time of type certification for the MD-11 series airplanes.
Final Report:

Crash of a Boeing 747-251B in Agana

Date & Time: Aug 19, 2005 at 1418 LT
Type of aircraft:
Operator:
Registration:
N627US
Survivors:
Yes
Schedule:
Tokyo - Agana
MSN:
21709
YOM:
1979
Flight number:
NW074
Country:
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
324
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7850
Captain / Total hours on type:
7850.00
Copilot / Total flying hours:
9100
Copilot / Total hours on type:
8695
Aircraft flight hours:
95270
Circumstances:
During the initial approach, the red GEAR annunciator light above the gear lever illuminated, and the landing gear warning horn sounded after the gear handle was selected down and the flaps were selected to 25 degrees. During the go-around, the captain asked the second officer (SO), "what do you have for the gear lights?" The SO responded, "four here." When all gear are down and locked on the Boeing 747-200, the landing gear indication module located on the SO’s instrument panel has five green lights: one nose gear light above four main landing gear lights. The crew then read through the "Red Gear Light Remains On (After Gear Extension)" emergency/abnormal procedure from the cockpit operations manual to troubleshoot the problem. Although the checklist twice presented in boldface type that five lights must be present for the gear to be considered down and locked, the crew did not verbalize the phrase either time. The captain did not directly request a count, and the SO did not verbally confirm, the number of gear down annunciator lights that were illuminated; instead, the flight crew made only general comments regarding the gear, such as "all gear," "all green," or "got 'em all." Because the crew believed that all of the gear annunciator lights were illuminated, they considered all gear down and locked and decided not to recycle the landing gear or attempt to extend any of the gear via the alternate systems before attempting a second approach. During all communications with air traffic control, the flight crew did not specify the nature of the problem that they were troubleshooting. Although the checklist did not authorize a low flyby, if the flight crewmembers had verbalized that they had a gear warning, the controller most likely would have been able to notify the crew of the nose gear position before the point at which a go-around was no longer safe. Multiple gear cycles were conducted after the accident, and the nose gear extended each time with all nose gear door and downlock indications correctly displayed on the landing gear indication module. Post accident examination of the nose gear door actuator found that one of the two lock keys was installed 180 degrees backward. Although this improper configuration could prevent proper extension of the nose gear, the actuator had been installed on the accident airplane since 2001 after the actuator was overhauled by the operator. No anomalies were found with the landing gear indication module, the nose gear-operated door sequence valve, and the nose/body landing gear selector valve.
Probable cause:
The flight crews' failure to verify that the number of landing gear annunciations on the second officer’s panel was consistent with the number specified in the abnormal/emergency procedures checklist, which led to a landing with the nose gear retracted.
Final Report:

Crash of a Gulfstream GII near Keningau: 12 killed

Date & Time: Sep 4, 1991 at 1411 LT
Type of aircraft:
Operator:
Registration:
N204C
Survivors:
No
Site:
Schedule:
Tokyo - Kota Kinabalu - Jakarta
MSN:
143
YOM:
1974
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The aircraft departed Tokyo-Narita Airport on a flight to Jakarta with a fuel stop at Kota Kinabalu Airport, carrying nine passengers and three crew members, among them four corporate members of the Conoco Group that leased the aircraft from DuPont de Nemours. Following an uneventful flight from Tokyo, the crew started the descent to Kota Kinabalu after being cleared to 10,000 then 5,000 feet. ATC instructed the crew to follow a route to the south (180°) and after passing VJN VOR at 4,000 feet, the crew could expect a clearance for an approach to runway 02. While descending to 4,000 feet, the aircraft disappeared from radar screens after it struck the slope of a mountain located in the Crocker Mountain Range, about 9 km northwest of Keningau and 57 km south of Kota Kinabalu Airport. The aircraft was destroyed upon impact and all 12 occupants were killed.
Probable cause:
The accident was the consequence of a series of error and omissions on part of the flying crew, resulting in a controlled flight into terrain.
The following contributing factors were reported:
- The pilots did not slow the aircraft to approach speed when directed by ATC (Event69). This error put the aircraft over VJN VOR/DME approximately 15 minutes earlier than ATC expected. The average ground speed inbound to the VOR/DME, between Event65 (DME 37 nmi) and Event104 (DME 0.0 nmi), was 400 knots.
- The pilots did not descend according to the published descent profile for their arrival sector. If the pilots had done this the aircraft would have been at 4,000 feet altitude over the VJN VOR/DME and in position for the initial approach segment for a VOR/DME approach procedure.
- The CVR recording indicates the pilots did not consider any published approach other than the ILS approach. Nevertheless, the pilots did not specifically request the ILS approach.
- The radiotelephone communication methods used by copilot Johnston were sloppy and not compliant with ICAO standards. Specifically, Johnston indicated to ATC he understood and would comply with the ATC directive to descend over the VJN VOR/DME to 9,500 feet. He did this by repeating (part of) the directive at Event118 suggesting to ATC he understood the directive and would comply.
- The pilots did not ask for clarification on the ATC directive to “descend south of the airfield” and put the aircraft on a heading 180o. The aircraft ground track suggested by Frank Petersen in his deposition and in his report titled “REPORT OF INVESTIGATION INTO THE ACCIDENT INVOLVING N204C” (April 24, 1992) has the aircraft flying outbound from the VJN VOR/DME on the 180° radial. This ground track can not be correct since it would put the aircraft 3 nmi east of the crash site at the time the pilots initiated the right turn. The 3 nmi distance could not have been covered in the 25 seconds between initiating the right turn and the impact. (At 230 knots it would take over 46 seconds to cover this distance.) Furthermore, the aircraft would have crashed before it did into the mountains along the 180° radial from the VJN VOR/DME.
- The cockpit conversation at Event179 indicates both pilots saw high terrain 52 seconds before impact. At this time the aircraft was less than 1 nmi from eye-level hills at 4,000 feet and less than 1.7 nmi from a peak at 4,875 feet. The pilots should have realized they were violating IFR approach procedures. (At this time of day the cloud cover near these hills would have been broken with cloud bases above 4,000 feet.) The pilots made no comment to ATC about the terrain or the cloud conditions.
Source: DuPont GII N204C Crash by Roger K. Parsons - Seagull Publishing, Houston, TX
Final Report:

Crash of a Boeing 707-331C in Tokyo

Date & Time: Oct 23, 1981 at 0019 LT
Type of aircraft:
Operator:
Registration:
OD-AGT
Flight Type:
Survivors:
Yes
Schedule:
Tokyo - Bangkok
MSN:
19213/613
YOM:
1967
Flight number:
MV332
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
270.00
Copilot / Total flying hours:
2461
Copilot / Total hours on type:
2262
Aircraft flight hours:
37873
Aircraft flight cycles:
8346
Circumstances:
After takeoff from Tokyo-Narita Airport while on a cargo flight to Bangkok, the crew reported technical problems with the engine n°3 after the n°6 carbon seal was worn, causing a loss of lubrication. The crew was cleared to return for an emergency landing but weather conditions were marginal and the visibility was limited. Following an approach to runway 16, the airplane was too high and passed over the threshold at a height of 500 feet. The crew continued the descent and the aircraft landed 1,700 meters past the runway threshold and bounced. After reverse thrust was applied on engine n°1, 2 and 4, the airplane veered off runway and struck a manhole, causing the nose gear to collapse. The airplane came to rest and was damaged beyond repair while all three crew members were uninjured. At the time of the accident, wind was from 210 to 350°, 11 knots gusting to 34 knots, visibility 2,200 meters, RVR 900 meters for runway 16 with heavy rain falls and fog.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Unfavorable weather conditions,
- Wrong runway selection according to wind component and weather,
- Wrong approach configuration,
- The crew failed to initiate a go-around,
- The crew misunderstood ATC instructions.
Final Report:

Crash of a Boeing 707-323C in the Pacific Ocean: 6 killed

Date & Time: Jan 30, 1979 at 2100 LT
Type of aircraft:
Operator:
Registration:
PP-VLU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Tokyo – Los Angeles – Lima – Rio de Janeiro
MSN:
19235
YOM:
1961
Flight number:
RG967
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
23000
Circumstances:
The four engine airplane departed Tokyo-Narita Airport at 2023LT on a cargo flight to Rio de Janeiro with intermediate stops in Los Angeles and Lima. There were six crew members on board as well as 53 paintings by Manabu Mabe, returning from a Tokyo exhibition, valued at US$1.24 million. At 2045LT, the last radio transmission was recorded with ATC and about 15 minutes later, while in cruising altitude, the airplane disappeared from the radar screens. SAR operations were immediately initiated by Japanese and American Authorities but eventually suspended after several days as no trace of the aircraft nor the six occupants was found. The captain, Gilberto Araújo da Silva, was flying the Varig Boeing 707 that crashed while approaching Paris-Orly Airport on July 11, 1973.
Probable cause:
Due to lack of evidences as the wreckage was not found, the exact cause of the accident could not be determined. However, it was reported that the crew did not send any distress call and it is believed that the accident may have been caused by a sudden and accidental decompression of the cabin.