Crash of an Airbus A300B4-230F in Recife

Date & Time: Oct 21, 2016 at 0630 LT
Type of aircraft:
Operator:
Registration:
PR-STN
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Recife
MSN:
236
YOM:
1983
Flight number:
STR9302
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11180
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
7300
Copilot / Total hours on type:
800
Circumstances:
Following an uneventful cargo service from São Paulo-Guarulhos Airport, the crew initiated the descent to Recife-Guararapes Airport. On final approach to runway 18, after the aircraft had been configured for landing, at an altitude of 500 feet, the crew was cleared to land. After touchdown, the thrust lever for the left engine was pushed to maximum takeoff power while the thrust lever for the right engine was simultaneously brang to the idle position then to reverse. This asymetric configuration caused the aircraft to veer to the right and control was lost. The airplane veered off runway to the right and, while contacting soft grounf, the nose gear collapsed. The airplane came to rest to the right of the runway and was damaged beyond repair. All four occupants evacuated safely.
Probable cause:
Contributing factors.
- Control skills - undetermined
Inadequate use of aircraft controls, particularly as regards the mode of operation of the Autothrottle in use and the non-reduction of the IDLE power levers at touch down, may have led to a conflict between pilots when performing the landing and the automation logic active during approach. In addition, the use of only one reverse (on the right engine) and placing the left throttle lever at maximum takeoff power resulted in an asymmetric thrust that contributed to the loss of control on the ground.
- Attitude - undetermined
The adoption of practices different from the aircraft manual denoted an attitude of noncompliance with the procedures provided, which contributed to put the equipment in an unexpected condition: non-automatic opening of ground spoilers and asymmetric thrust of the engines. These factors required additional pilot intervention (hand control), which may have made it difficult to manage the circumstances that followed the touch and led to the runway excursion.
- Crew Resource Management - a contributor
The involvement of the PM in commanding the aircraft during the events leading up to the runway excursion to the detriment of its primary responsibility, which would be to monitor systems and assist the PF in conducting the flight, characterized an inefficiency in harnessing the human resources available for the airplane operation. Thus, the improper management of the tasks assigned to each crewmember and the non-observance of the CRM principles delayed the identification of the root cause of the aircraft abnormal behavior.
- Organizational culture - a contributor
The reliance on the crew's technical capacity, based on their previous aviation experience, has fostered an informal organizational environment. This informality contributed to the adoption of practices that differed from the anticipated procedures regarding the management and operation of the aircraft. This not compliance with the procedures highlights a lack of safety culture, as lessons learnt from previous similar accidents (such as those in Irkutsk and Congonhas involving landing using only one reverse and pushing the thrust levers forward), have apparently not been taken into account at the airline level.
- Piloting judgment - undetermined
The habit of not reducing the throttle lever to the IDLE position when passing at 20ft diverged from the procedures contained in the aircraft-operating manual and prevented the automatic opening of ground spoilers. It is possible that the consequences of this adaptation of the procedure related to the operation of the airplane were not adequately evaluated, which made it difficult to understand and manage the condition experienced.
- Perception - a contributor
Failure to perceive the position of the left lever denoted a lowering of the crew's situational awareness, as it apparently only realized the real cause of the aircraft yaw when the runway excursion was already underway.
- Decision-making process - a contributor
An inaccurate assessment of the causes that would justify the behavior of the aircraft during the landing resulted in a delay in the application of the necessary power reduction procedure, that is, repositioning the left engine power lever.
Final Report:

Crash of a Boeing 737-347 in Wamena

Date & Time: Sep 13, 2016 at 0733 LT
Type of aircraft:
Operator:
Registration:
PK-YSY
Flight Type:
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
23597/1287
YOM:
1986
Flight number:
TGN7321
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23823
Captain / Total hours on type:
9627.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
480
Aircraft flight hours:
59420
Aircraft flight cycles:
48637
Circumstances:
On 13 September 2016, a Boeing 737-300 Freighter, registered PK-YSY was being operated by PT. Trigana Air Service on a scheduled cargo flight from Sentani Airport, Jayapura (WAJJ) to Wamena Airport, Wamena (WAVV), Papua, Indonesia. Approximately 2130 UTC, during the flight preparation, the pilot received weather information which stated that on the right base runway 15 of Wamena Airport, on the area of Mount Pikei, low cloud was observed with the cloud base was increasing from 200 to 1000 feet and the visibility was 3 km. At 2145 UTC, the aircraft departed Sentani Airport with flight number IL 7321 and cruised at altitude 18,000 feet. On board the aircraft was two pilots and one Flight Operation Officer (FOO) acted as loadmaster. The aircraft carried 14,913 kg of cargo. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). There was no reported or recorded aircraft system abnormality during the flight until the time of occurrence. After passing point MALIO, the aircraft started to descend. The pilot observed the weather met the criteria of Visual Meteorological Condition (VMC). The pilots able to identify another Trigana flight from Sentani to Wamena in front of them. While passing altitude 13,500 feet, approximately over PASS VALLEY, the Wamena Tower controller instructed the pilot to report position over JIWIKA. When the aircraft position was over point JIWIKA, the Wamena Tower controller informed to the pilot that the flight was on sequence number three for landing and instructed the pilot to make orbit over point X, which located at 8 Nm from runway 15. The pilot made two orbits over Point X to make adequate separation with the aircraft ahead prior to received approach clearance. About 7,000 feet (about 2,000 feet above airport elevation), the pilot could not identify visual checkpoint mount PIKEI and attempted to identify a church which was a check point of right base runway 15. The pilot felt that the aircraft position was on right side of runway centerline. About 6,200 feet (about 1,000 feet above airport elevation), the PF reduced the rate of descend and continued the approach. The PM informed to the PF that runway was not in sight and advised to go around. The PF was confident that the aircraft could be landed safely as the aircraft ahead had landed. Approximately 5,600 feet altitude (about 500 feet above airport elevation) and about 2 Nm from runway threshold the PF was able to see the runway and increased the rate of descend. The pilot noticed that the Enhanced Ground Proximity Warning System (EGPWS) aural warning “SINK RATE” active and the PF reduced the rate of descend. While the aircraft passing threshold, the pilot felt the aircraft sunk and touched down at approximately 125 meters from the beginning runway 15. The Flight Data Recorder recorded the vertical acceleration was 3.25 g on touchdown at 2230 UTC. Both of main landings gear collapsed. The left main landing gear detached and found on runway. The engine and lower fuselage contacted to the runway surface. The aircraft veer to the right and stopped approximately 1,890 meters from the beginning of the runway 15. No one was injured on this occurrence and the aircraft had substantially damage. Both pilots and the load master evacuated the aircraft via the forward left main cargo door used a rope.
Probable cause:
Refer to the previous aircraft that was landed safely, the pilot confidence that a safe landing could be made and disregarding several conditions required for go around.
Final Report:

Crash of a Boeing 737-476 in Bergamo

Date & Time: Aug 5, 2016 at 0407 LT
Type of aircraft:
Operator:
Registration:
HA-FAX
Flight Type:
Survivors:
Yes
Schedule:
Paris-Roissy-CDG - Bergamo
MSN:
24437/2162
YOM:
1991
Flight number:
QY7332
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9787
Captain / Total hours on type:
2254.00
Copilot / Total flying hours:
343
Copilot / Total hours on type:
86
Aircraft flight hours:
65332
Circumstances:
The aircraft departed Paris-Roissy-Charles de Gaulle Airport at 0254LT on a cargo flight (service QY7332) to Bergamo on behalf of DHL Airways. Upon arrival at Bergamo-Orio al Serio Airport, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and strong wind. The aircraft crossed the runway threshold at a speed of 156 knots and landed 18 seconds later, 2,000 metres pas the runway threshold. Unable to stop within the remaining distance (runway 28 is 2,807 metres long), the aircraft overran, went through the perimeter fence, lost its undercarriage and both engines and eventually stopped in a motorway, some 520 metres pas the runway end. Both crew members evacuated safely and the aircraft was destroyed.
Probable cause:
The causes of the accident are mainly due to the human factor. In particular, the accident was caused by the runway overrun during the landing phase, caused by a loss of situational awareness relating to the position of the aircraft with respect to the runway itself. This loss of situational awareness on the part of the crew caused a delay in contact with the runway, which occurred, at a still high speed, in a position too far to allow the aircraft to stop within the remaining distance.
Contributing to the dynamics of the event:
- The commander's prior decision not to carry out a go-around procedure (this decision is of crucial importance in the chain of events that characterized the accident),
- Inadequate maintenance of flight parameters in the final phase of landing,
- Failure of the crew to disconnect the autothrottle prior to landing,
- Poor lighting conditions with the presence of storm cells and heavy rain falls at the time of the event (environmental factor), which may have contributed to the loss of situation awareness,
- The attention paid by the crew during the final phase of the flight, where both pilots were intent to acquire external visual references and did not realize that the aircraft crossed over the runway at high speed for 18 seconds before touchdown,
- The lack of assertiveness of the first officer in questioning the commander's decisions.
Finally, it cannot be excluded that a condition of tiredness and fatigue may have contributed to the accident, even if not perceived by the crew, which may have influenced the cognitive processes, in particular those of the captain, interfering with his correct decision making process.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Canaima: 2 killed

Date & Time: Aug 1, 2016 at 0730 LT
Operator:
Registration:
YV607T
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
La Paragua – Canaima
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was performing a cargo flight from La Paragua to Canaima. While descending to Canaima in the early morning, the crew encountered an unexpected situation and was forced to attempt an emergency landing. The airplane crashed some 34 km northeast of the intended destination, bursting into flames. The aircraft was destroyed by a post crash fire and both occupants were killed.
Crew:
Johnny Ramirez, pilot,
José Angel Soto Zapata, copilot.

Crash of a Cessna 208B Grand Caravan EX in Lolat

Date & Time: Jun 14, 2016 at 0758 LT
Type of aircraft:
Operator:
Registration:
PK-RCK
Flight Type:
Survivors:
Yes
Schedule:
Wamena – Lolat
MSN:
208B-5149
YOM:
2014
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
53
Circumstances:
The single engine airplane departed Wamena Airport at 0739LT on a cargo flight to Lolat, carrying two passengers, one pilot and a load of building materials for a total weight of 1,190 kilos. On short final to Lolat Airfield, the aircraft impacted the roof of a wooded house and crashed, bursting into flames. All three occupants of the airplane evacuated safely while three people in the house were injured. The aircraft was totally destroyed by a post crash fire.

Crash of a McDonnell Douglas MD-11F in Seoul

Date & Time: Jun 6, 2016 at 2243 LT
Type of aircraft:
Operator:
Registration:
N277UP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Seoul - Anchorage
MSN:
48578/588
YOM:
1995
Flight number:
UPS061
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7769
Captain / Total hours on type:
6152.00
Copilot / Total flying hours:
4236
Copilot / Total hours on type:
3491
Aircraft flight hours:
63195
Aircraft flight cycles:
11344
Circumstances:
The crew started the takeoff procedure from runway 33L at Seoul-Incheon Airport and reached V1 speed after a course of 6,413 feet. At a speed of 182 knots, the crew heard a noise corresponding to the failure of both tires n°9 and 10 located on the central landing gear. The captain decided to abandon the takeoff procedure and initiated an emergency braking maneuver. Unable to stop within the remaining distance of 4,635 feet (in relation with the total weight of 629,600 lbs), the airplane overran. While contacting a grassy area, the nose gear collapsed then the airplane struck various equipment of the localizer antenna and came to rest 485 meters past the runway end. All four crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The decision of the crew to abandon the takeoff procedure at a speed slightly above V1 due to the failure of both tyres n°9 & 10 located on the central landing gear. The aircraft then overran due to the combination of the following factors:
- Limited time and information available to the crew to evaluate the situation,
- Dynamic instability of the central landing gear caused by both tyres' failure,
- Decrease of 48% of the braking performances due to the rupture of a hydraulic pipe located on the primary braking system.
Final Report:

Crash of an Antonov AN-12B in Camp Dwyer: 7 killed

Date & Time: May 18, 2016 at 1407 LT
Type of aircraft:
Operator:
Registration:
4K-AZ25
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Camp Dwyer – Mary – Baku
MSN:
3 3 412 09
YOM:
1963
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
22628
Captain / Total hours on type:
3953.00
Copilot / Total flying hours:
4625
Copilot / Total hours on type:
836
Aircraft flight hours:
19828
Aircraft flight cycles:
9107
Circumstances:
On May 18, 2016 the crew of An-12B 4K-AZ25 aircraft operated by Silk Way Airlines including the Captain, First Officer, navigator, flight mechanic, flight radio operator and loadmaster was planned to fly via route Baku (Azerbaijan) - Bagram (Afghanistan) - Dwyer (Afghanistan) - Mary (Turkmenistan) - Baku. There were also two maintenance mechanics and an engineer on board the a/c. The preliminary training of the crew was conducted on 29.12.2015 by the Chief Navigator of Silk Way Airlines. The pre-flight briefing was conducted on 18.05.2016 by a captain-instructor and a navigator-instructor. The following has been determined so far. According to the information available at the moment the flight to Dwyer aerodrome was conducted in an acceptable way. At 09:11:27 the crew started up the engines at Dwyer aerodrome, Engine #2 was the last to be started up at 09:47:37. Before the takeoff the Captain distributed the duties within the crew, nominating the FO as the PF, and himself as PM. After the engine startup the crew initiated taxiing to perform takeoff with heading 229°. The concrete RWY of Dwyer aerodrome is measured 2439 m by 37 m. The a/c TOW and CG were within the AFM limitations. In the course of the takeoff, at 09:57:56 the flight mechanic reported an increase in MGT of Engine #3 above the acceptable level: "Engine #3, look, engine temperature over six hundred, over seven hundred", which was confirmed by the FO: "Yes, it's getting temperature" while the Captain asked to be more attentive. According to the crew reports the takeoff was performed with Flaps 15. As the checklist was being read, the Captain ordered to lock the propellers. After the Captain's order to lock the propellers a slight increase in torque-measuring device values was recorded on Engine #1 and #4, and in 17 seconds also Engine #2, which indirectly implies that propellers #1, #2 and #4 were at stops. There is no evidence that propeller of Engine #3 was locked. At 09:59:42 the crew initiated the takeoff. Before the takeoff the ATC advised the crew on the wind direction and speed on the RWY: 280° 14 knots (7 m/sec) gusting 26 knots (13 m/sec). Thus it was quartering headwind and the headwind component might have been 5 to 9 m/sec. While performing takeoff the crew first increased thrust on Engines #1 and #4 and then on Engine #2 after 10 seconds. The thrust of the three engines was about 50 kg/sq.cm as per torque indicator (lower than takeoff mode). The third engine was still operating in the ground idle mode, though the CVR did not record any crew callouts concerning Engine #3 operation parameters. Based on the CCTV system of Dwyer aerodrome the takeoff roll was initiated almost from the RWY threshold and was conducted to the left of the RWY centerline. No significant deviations from the takeoff course during the takeoff roll were recorded. During the takeoff roll the rudder was deflected left close to extreme. Probably the pilots were also applying differential control on Engine #2 to decrease the right torque moment. At 10:00:14 at approximately 120 km/h IAS the "Engine #3 negative thrust" signal was started to be recorded and was recorded on up to the end of the record. At that time the a/c was about 430 m away from the start of the takeoff roll. At 10:00:42 Engines #1 and #4 thrust was increased up to 63 kg/sq.cm as per torque indicator (consistent with takeoff mode for the actual flight conditions). At that time the IAS was about 150 km/h Engine #2 thrust was increased up to the same value only 23 seconds later at about 200 km/h IAS. At that time the a/c was about 840 m away from the RWY end. Engine #3 was still operating in ground idle mode. Approximately 260 m before the RWY end at a speed of 220 km/h IAS (maximum speed reached) the FDR recorded the start of nose up input on the control column. The a/c did not lift off After rolling all along the RWY the a/c overran the RWY onto the ground at a speed of 220 km/h While moving on the ground the aircraft sustained significant damage, which led to post-crash fire that destroyed most of the aircraft structures. Out of the nine persons on board seven were killed and two were seriously injured and taken to hospital.
Final Report:

Crash of a Douglas DC-3C in Puerto Gaitán

Date & Time: Apr 6, 2016 at 0625 LT
Type of aircraft:
Operator:
Registration:
HK-2663
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Puerto Gaitán – Villavicencio
MSN:
10210
YOM:
1945
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4058
Copilot / Total flying hours:
7934
Aircraft flight hours:
23291
Circumstances:
Shortly after takeoff from Puerto Gaitán Airport Runway 04, while on a cargo flight to Villavicencio, the left engine exploded and caught fire. As the aircraft was losing speed and height, the crew attempted an emergency landing when the aircraft crash landed in an open field located 2,6 km southwest from the airport, bursting into flames. All three crew members escaped with minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
Failure of the left engine following the detachment of the head of a cylinder shortly after takeoff. Deficiencies in maintenance processes contributed to this situation. The crew failed to follow the emergency procedures when the left engine caught fire and exploded, reducing the power on the right engine. In such conditions, the aircraft was unable to maintain a safe altitude and the crew was forced to attempt an emergency landing.
Final Report:

Crash of an Antonov AN-26B off Cox's Bazar: 3 killed

Date & Time: Mar 9, 2016 at 0905 LT
Type of aircraft:
Operator:
Registration:
S2-AGZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cox’s Bazar – Jessore
MSN:
134 08
YOM:
1984
Flight number:
21
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
13315
Captain / Total hours on type:
6896.00
Copilot / Total flying hours:
1438
Copilot / Total hours on type:
1195
Aircraft flight hours:
16379
Aircraft flight cycles:
17299
Circumstances:
On March 9, 2016 one AN -26B aircraft belonging to True Aviation Ltd was operating a schedule cargo flight from a small domestic airport (Cox’s Bazar-VGCB) in southern Bangladesh to another domestic airport (Jessore -VGJR) in western Bangladesh, The cargo was Shrimp fries. As per the General Declaration the total cargo quantity was 802 boxes weighing 4800 kg. The airline had filled a flight plan keeping the ETD blank. The flight plan routing was CB W4 CTG W5 JSR at FL 100. All the documents except the load sheet were found properly signed and are in the possession of AAIT. According to ATC controller’s statement and recorded tape the aircraft requested for startup clearance at 0258z. As per the recordings with ATC the controller passed the visibility information of Jessore Airport as 3km. The aircraft started engines and requested for taxi. The aircraft was cleared to taxi to Runway 35 via taxiway S. The aircraft requested for takeoff clearance and was cleared for Take Off at 0305z. Immediately after airborne the pilot reported engine failure without mentioning initially which engine had failed but later confirming failure of the left engine and requested for immediate return back to Cox’s Bazar airport. He was advised by ATC to call left hand down wind. But the control tower spotted the aircraft making a right hand down wind at a very low altitude. All emergency services were made standby from the ATC. The aircraft called final and requested for landing clearance. For reasons so far unknown the aircraft made a low level Go Around. The controller in the tower saw the aircraft flying at about 400 to 500 feet. The surviving Flight Navigator also confirmed this in his statement. The ATC advised the captain to call left hand down wind. But there was no response from the crew. The ATC repeatedly kept calling the aircraft but there was no response from the crew and total communication was lost. At time 0332z the airport authority came to know through other means that the aircraft had crashed approximately 03km west of the airport.
Probable cause:
The accident was the consequence of the combination of the following factors:
a) Failure to initiate a rejected take off during take off roll following the indication of engine failure;
b) Failure to adhere to the company SOP following the detection of the engine failure during take off;
c) Considering the poor visibility at Cox’s Bazar Airport, diverting to the alternate airfield Chittagong Airport located only 50 nm away that has the provision for full ILS approach facility. This could have helped the crew in carrying out a proper one engine out precision approach landing;
d) The aircraft flew at a speed much lower than the clean configuration speed. The aircraft flew at 225 km/h in clean configuration whereas the minimum clean configuration speed is 290 km/hr.
e) As per the FDR data the aircraft stalled while making a turn towards the side of the failed engine at a very low altitude.
Final Report:

Crash of a Canadair Regional Jet CRJ-200PF near Akkajaure Lake: 2 killed

Date & Time: Jan 8, 2016 at 0020 LT
Operator:
Registration:
SE-DUX
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Oslo – Tromsø
MSN:
7010
YOM:
1993
Flight number:
SWN294
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3365
Captain / Total hours on type:
2208.00
Copilot / Total flying hours:
3232
Copilot / Total hours on type:
1064
Aircraft flight hours:
38601
Aircraft flight cycles:
31036
Circumstances:
The flight was uneventful until the start of the event, which occurred during the approach briefing in level flight at FL 330. The event started at 00:19:20 hrs during darkness without moonlight, clouds or turbulence. The lack of external visual references meant that the pilots were totally dependent on their instruments which, inter alia consisted of three independent attitude indicators. According to recorded data and simulations a very fast increase in pitch was displayed on the left attitude indicator. The pilot in command, who was the pilot flying and seated in the left seat exclaimed a strong expression. The displayed pitch change meant that the pilot in command was subjected to a surprise effect and a degradation of spatial orientation The autopilot was, most probably, disconnected automatically, a “cavalry charge” aural warning and a single chime was heard, the latter most likely as a result of miscompare between the left and right pilots’ flying displays (PFD). Both elevators moved towards nose down and nose down stabilizer trim was gradually activated from the left control wheel trim switch. The airplane started to descend, the angle of attack and G-loads became negative. Both pilots exclaimed strong expressions and the co-pilot said “come up”. About 13 seconds after the start of the event the crew were presented with two contradictory attitude indicators with red chevrons pointing in opposite directions. At the same time none of the instruments displayed any comparator caution due to the PFDs declutter function in unusual attitude. Bank angle warnings were heard and the maximum operating speed and Mach number were exceeded 17 seconds after the start of the event, which activated the overspeed warning. The speed continued to increase, a distress call was transmitted and acknowledged by the air traffic control and the engine thrust was reduced to flight idle. The crew was active during the entire event. The dialogue between the pilots consisted mainly of different perceptions regarding turn directions. They also expressed the need to climb. At this stage, the pilots were probably subjected to spatial disorientation. The aircraft collided with the ground one minute and twenty seconds after the initial height loss. The two pilots were fatally injured and the airplane was destroyed.
Probable cause:
The erroneous attitude indication on PFD 1 was caused by a malfunction of the Inertial Reference Unit (IRU 1). The pitch and roll comparator indications of the PFDs were removed when the attitude indicators displayed unusual attitudes. In the simulator, in which the crew had trained, the corresponding indications were not removed. During the event the pilots initially became communicatively isolated from each other. The current flight operational system lacked essential elements which are necessary. In this occurrence a system for efficient communication was not in place. SHK considers that a general system of initial standard calls for the handling of abnormal and emergency procedures and also for unusual and unexpected situations should be incorporated in commercial aviation. The accident was caused by insufficient operational prerequisites for the management of a failure in a redundant system.
Contributing factors were:
- The absence of an effective system for communication in abnormal and emergency situations,
- The flight instrument system provided insufficient guidance about malfunctions that occurred,
- The initial maneuver that resulted in negative G-loads probably affected the pilots' ability to manage the situation in a rational manner.
Final Report: