Crash of a Douglas DC-10-30CF in Faro: 56 killed

Date & Time: Dec 21, 1992 at 0833 LT
Type of aircraft:
Operator:
Registration:
PH-MBN
Survivors:
Yes
Schedule:
Amsterdam - Faro
MSN:
46924
YOM:
1975
Flight number:
MP495
Location:
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
327
Pax fatalities:
Other fatalities:
Total fatalities:
56
Captain / Total flying hours:
14441
Captain / Total hours on type:
1497.00
Copilot / Total flying hours:
2288
Copilot / Total hours on type:
1787
Aircraft flight hours:
61543
Aircraft flight cycles:
14615
Circumstances:
At 0552LT, the aircraft departed Amsterdam-Schiphol Airport on a charter flight to Faro. The flight had been delayed for 40 minutes due to n°2 engine reverser problems. After a flight of 2 hours and 17 minutes, the crew was cleared to descend to FL070. Shortly afterwards Faro Approach Control provided the crew with the following weather: wind 15°/18 knots; 2,500 metres visibility, thunderstorms with 3/8 clouds at 500 feet, 7/8 clouds at 2,300 feet and 1/8 cumulonimbus at 2,500 feet, OAT 16° C. Clearance to descend to 1,220 metres was given at 0820LT, followed by a clearance to 915 metres and 650 metres 4, respectively 6 minutes later. At 0829LT the crew were informed that the runway was flooded. At an altitude of 303 metres and at a speed of 140 knots, the aircraft became unstable and at 177 metres the first officer switched the autopilot from CMD (command mode) to CWS (control-wheel steering). One minute later it was switched from CWS to manual and the airspeed began falling below approach reference speed. About 3-4 seconds short of touchdown, elevator was pulled to pitch up and engine power was increased. When the n°3 and 5 spoilers extended, the aircraft banked to the right to an angle of 25°. The right main gear struck the the runway surface with a rate of descent of 900 feet per minute and at a speed of 126 knots. With a nose up attitude of 8,79° and a roll angle of 5,62°, the aircraft touched down with a positive acceleration of 1,95 g. Upon impact, the right wing separated while the aircraft slid down the runway and came to rest 1,100 metres from the runway 11 threshold and 100 metres to the right of the centreline, bursting into flames. Two crew members and 54 passengers were killed while 284 other occupants were evacuated, among them 106 were seriously injured.
Probable cause:
The high rate of descent in the final phase of the approach and the landing made on the right landing gear, which exceeded the structural limitations of the aircraft.; The crosswind, which exceeded the aircrafts limits and which occurred in the final phase of the approach and during landing. The combination of both factors determined stresses which exceeded the structural limitations of the aircraft. Contributing factors were: The instability of the approach; the premature power reduction, and the sustaining of this condition, probably due to crew action; the incorrect wind information delivered by Approach Control; the absence of an approach light system; the incorrect evaluation by the crew of the runway conditions; CWS mode being switched off at approx. 80ft RA, causing the aircraft to be in manual control in a critical phase of the landing; the delayed action of the crew in increasing power; the degradation of the lift coefficient due to heavy showers. The Netherlands Aviation Safety Board commented that the probable cause should read: "a sudden and unexpected wind variation in direction and speed (windshear) in the final stage of the approach. Subsequently a high rate of descent and an extreme lateral displacement developed, causing a hard landing on the right-hand main gear, which in combination with a considerable crab angle exceeded the aircraft structural limitations. Contributing factors: From the forecast and the prevailing weather the crew of MP495 did not expect the existence of windshear phenomena.; The premature large power reduction and sustained flight idle thrust, most probable due to crew action.; CWS mode being disengaged at approx. 80ft RA, causing the aircraft to be in manual control at a critical stage in the landing phase.
Final Report:

Crash of a Piper PA-31T Cheyenne II in Horta: 4 killed

Date & Time: Jun 5, 1990 at 1802 LT
Type of aircraft:
Operator:
Registration:
F-GJPL
Survivors:
No
Schedule:
Ponta Delgada - Horta
MSN:
31-8120029
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
8590
Aircraft flight hours:
1663
Circumstances:
The twin engine airplane departed Ponta Delgada Airport at 1449LT on a survey flight over the Atlantic ocean to trace shoals of tuna, carrying two passengers, one observer and one pilot. At 1751LT, the mission was over and the pilot was cleared to descend to Horta Airport. On final approach to runway 29, after being cleared to land, the aircraft entered a right turn then lost height and crashed 600 meters to the right of the runway 29 extended centerline. The aircraft was totally destroyed and all four occupants were killed.
Probable cause:
It is believed that the loss of control following an unexpected right turn on short final was the consequence of a temporary disability of the pilot who probably suffered an aortic rupture. Nevertheless, the following hypothesis were not ruled out: asphyxia to carbon monoxide, convulsion or a heart attack.
Final Report:

Crash of a Boeing 707-331B in Santa Maria: 144 killed

Date & Time: Feb 8, 1989 at 1408 LT
Type of aircraft:
Operator:
Registration:
N7231T
Survivors:
No
Schedule:
Bergame - Santa Maria - Punta Cana
MSN:
19572
YOM:
1968
Flight number:
IDN1851
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
137
Pax fatalities:
Other fatalities:
Total fatalities:
144
Aircraft flight hours:
44755
Aircraft flight cycles:
12589
Circumstances:
Independent Air flight IDN1851, a Boeing 707, departed Bergamo, Italy (BGY) at 10:04 UTC for a flight to Punta Cana, Dominican Republic (PUJ) via Santa Maria, Azores (SMA). At 13:56:47 Santa Maria Tower cleared the flight to descend to 3000 feet for a runway 19 ILS approach: "Independent Air one eight five one roger reclear to three thousand feet on QNH one zero two seven and runway will be one niner." In that transmission, the trainee controller had transmitted an incorrect QNH that was 9 hPa too high. The actual QNH was 1018.7 hPa. After a brief pause the message resumed at 13:56:59: "expect ILS approach runway one niner report reaching three thousand." This transmission was not recorded on the voice recorder of Flight 1851, probably because the first officer keyed his mike and read back: "We’re recleared to 2,000 feet and ah ... ." The first officer paused from 13:57:02 to 13:57:04, then unkeyed the mike momentarily. This transmission was not recorded on the ATS tapes. In the cockpit, the first officer questioned aloud the QNH value, but the captain agreed that the first officer had correctly understood the controller. After being cleared for the ILS approach the crew failed to accomplish an approach briefing, which would have included a review of the approach plate and minimum safe altitude. If the approach plate had been properly studied, they would have noticed that the minimum safe altitude was 3,000 feet and not 2,000 feet, as it had been understood, and they would have noticed the existence and elevation of Pico Alto. At 14:06, the flight was 7.5 nm from the point of impact, and beginning to level at 2,000 feet (610 meters) in light turbulence at 250 KIAS. At 14:07, the flight was over Santa Barbara and entering clouds at approximately 700 feet (213 meters) AGL in heavy turbulence at 223 KIAS. At 14:07:52, the captain said, "Can’t keep this SOB thing straight up and down". At approximately 14:08, the radio altimeter began to whine, followed by the GPWS alarm as the aircraft began to climb because of turbulence, but there was no reaction on the part of the flight crew. At 14:08:12, the aircraft was level when it impacted a mountain ridge of Pico Alto. It collided with a rock wall on the side of a road at the mountain top at an altitude of approximately 1,795 feet (547 meters) AMSL.
Probable cause:
The Board of Inquiry understands that the accident was due to the non-observance by the crew of established operating procedures, which led to the deliberate descent of the aircraft to 2000ft in violation the minimum sector altitude of 3,000 feet, published in the appropriate aeronautical charts and cleared by the Santa Maria Aerodrome Control Tower.
Other factors:
1) Transmission by the Santa Maria Aerodrome Control Tower of a QNH value 9 hPa higher than the actual value, which put the aircraft at an actual altitude 240 feet below that indicated on board,
2) Deficient communications technique on the part of the co-pilot, who started reading back the Tower's clearance to descend to 3000ft before the Tower completed its transmission, causing a communications overlap,
3) Violation by the Aerodrome Control Tower of established procedures by not requiring a complete read back of the descent clearance,
4) Non-adherence by the crew to the operating procedures published in the appropriate company manuals, namely with respect to cockpit discipline, approach briefing , repeating aloud descent clearances, and informal conversations in the cockpit below 10,000 feet,
5) General crew apathy in dealing with the mistakes they made relating to the minimum sector altitude, which was known by at least one of the crew members, and to the ground proximity alarms,
6) Non-adherence to standard phraseology both by the crew and by Air Traffic Control in some of the air-ground communications,
7) Limited experience of the crew, especially the co-pilot, in international flights,
8) Deficient crew training, namely concerning the GPWS as it did not include emergency manoeuvres to avoid collision into terrain,
9) Use of a route which was not authorized in the AIP Portugal,
10) The operational flight plan, whose final destination was not the SMA beacon, was not developed in accordance with the AIP Portugal.

Crash of a Learjet 23 in Lisbon

Date & Time: Jan 30, 1989
Type of aircraft:
Operator:
Registration:
F-GDAV
Flight Type:
Survivors:
Yes
Schedule:
Paris - Lisbon
MSN:
23-017
YOM:
1965
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the twin engine aircraft belly landed at Lisbon-Portela de Sacavém Airport and slid for few dozen meters before coming to rest. Both pilots were uninjured while the aircraft was damaged beyond repair.

Crash of a Lockheed C-130E Hercules in Lajes

Date & Time: Apr 15, 1984
Type of aircraft:
Operator:
Registration:
64-0539
Flight Type:
Survivors:
Yes
Schedule:
Lajes - Lajes
MSN:
4029
YOM:
1965
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crash on landing in Lajes in the following circumstances, according to the following testimony:
I was the Maintenance Job Controller on duty when the day this occurred. The incident aircraft had declared an inflight emergency (IFE) for (if I recall correctly) #3 engine shutdown. In any case it was right wing engine that was out of service. Fire trucks were standing by as this was SOP for IFEs. The aircraft came in from south to north. On landing roll the crew reversed all three operating engines instead of only the running symmetrical engines of each wing. Having twice the reverse thrust action exerted on the left wing caused the aircraft to yaw left and depart the runway. After going through the perimeter fence off to the left of the runway, it rode up some rock walls and nearly impacted two dwellings on the other side before coming to rest. The left wing caught on fire. In pictures that are available you can see where one of the propellers that departed on impact sliced a hole in the fuselage just in front of the red prop plane of rotation line on the left hand side. Fortunately, because the fire trucks were already lined up on the runway, the fire was extinguished quickly. The only injury to the aircrew was a broken finger. Some side notes. The aircraft was carrying the produce flown in weekly for the commissary on base, No big deal in the scope of things but fruits and veggies were in short supply unless you went local. Also, in one of those oddities of life that made it all the more surreal, the Line Chief had said over the maintenance radio just before it landed, “I hope he remembers to reverse only one and four when he lands.” The next words I heard from him were, “We have a 130 in the dirt!” “We have a 130 on fire!” You just can’t make that stuff up. It was almost prescient. The aircraft was eventually mated with the cockpit section of C-130 that was written off due to a hard landing in Germany. They flew that in on a C-5 with replacement wings etc. Robbins Depot Maintenance came in and bolted it all together. It eventually flew out on a onetime flight to the depot in Italy.
Thanks to Bill Hewett, maintenance controller on duty when it occurred.

Crash of a Britten-Norman BN-2A Islander in Serra de Monchique

Date & Time: Nov 6, 1982
Type of aircraft:
Operator:
Registration:
CS-AJO
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Cascais – Portimão
MSN:
125
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route from Cascais to Portimão, the pilot encountered poor weather conditions when the airplane lost height and crashed on a hill located in Serra de Monchique. All four occupants were rescued.

Crash of a Beechcraft C90 King Air off Azores Islands

Date & Time: Mar 10, 1982
Type of aircraft:
Registration:
N6272C
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
LJ-1025
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was forced to ditch the aircraft off the Azores Islands following in-flight technical problems. The pilot was rescued while the airplane sank and was lost.

Crash of a Cessna 421A Golden Eagle I in Lisbon: 7 killed

Date & Time: Dec 4, 1980 at 2016 LT
Type of aircraft:
Operator:
Registration:
YV-314P
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Lisbon - Porto
MSN:
421A-0040
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
1613
Captain / Total hours on type:
42.00
Copilot / Total flying hours:
744
Aircraft flight hours:
1500
Circumstances:
The twin engine airplane, chartered by the Portuguese Government, was engaged in a special flight from Lisbon to Porto, carrying various members of the Portuguese Government. Shortly after takeoff from Lisbon-Portela de Sacavém Airport, while climbing by night, the twin engine airplane lost height and crashed onto several houses located in the district of Camarate. The aircraft was totally destroyed and all seven occupants were killed. There were no casualties on ground.
Occupants:
Mr. Francisco Sa Carneiro, Prime Minister,
Mrs. Francisco Sa Carneiro,
Mr. Amaro da Costa, Minister of Defence,
Mrs. Amaro da Costa,
One Chief of Cabinet and two pilots.
Probable cause:
The loss of control during initial climb was the consequence of the combination of the following factors:
- Poor flight preparation on part of the crew,
- Inadvertent shutdown of the left engine during initial climb for unknown reasons,
- The left propeller was not feathered, causing high drag,
- The flaps were not deployed in the correct position for takeoff,
- The CofG was off limits,
- Negligences of those responsible for planning and safety in the air transport of important figures of State, in an aircraft of foreign registration whose maintenance status was not previously maintained rated,
- Crew fatigue,
- Crew psychic stress accumulation.
Final Report:

Crash of a Consolidated PBY-6A Catalina off Alverca: 1 killed

Date & Time: Jun 28, 1979
Type of aircraft:
Registration:
N101CS
Survivors:
Yes
MSN:
2141
YOM:
1944
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The seaplane christened 'La Calypso volante' was returning to Lisbon following a scientific mission. Off Alverca, the seaplane landed hard on the Tagus, causing the left wing to separate and the left engine to struck the cockpit. The pilot Philippe Cousteau, son of the French explorer Jacques-Yves Cousteau, was killed. Seven other occupants were injured.
Probable cause:
The exact cause of the accident could not be determined. However, it is believed that the speed upon landing was slightly too high.

Crash of a Casa 212 Aviocar 100 on Terceira Island: 3 killed

Date & Time: Jul 5, 1978
Type of aircraft:
Operator:
Registration:
6518
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Lajes - Lajes
MSN:
50
YOM:
1976
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
While flying in marginal weather conditions, the airplane struck the slope of a mountain located in the Serra de Santa Bárbara National Forest, on the west side of Terceira Island. All three crew members were killed.