Crash of a Short 360-200 off Sint Maarten: 2 killed

Date & Time: Oct 29, 2014 at 1840 LT
Type of aircraft:
Operator:
Registration:
N380MQ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sint Maarten - San Juan
MSN:
3702
YOM:
1986
Flight number:
SKZ7101
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5318
Captain / Total hours on type:
361.00
Copilot / Total flying hours:
1040
Copilot / Total hours on type:
510
Aircraft flight hours:
25061
Aircraft flight cycles:
32824
Circumstances:
On October 29, 2014, at about 1840 Atlantic Standard Time, a Shorts SD3-60, United States registered N380MQ was destroyed when it crashed into the sea shortly after takeoff from Runway 28 at Princess Juliana International Airport, Sint Maarten, Dutch Antilles, Kingdom of the Netherlands. The two crewmembers on board sustained fatal injuries. The aircraft was operated by SkyWay Enterprises Inc. on a scheduled FedEx contract cargo flight to Luis Munoz Marin International Airport, San Juan, Puerto Rico. At 1839 local, Juliana Tower cleared the aircraft for takeoff Runway 28 - maintain heading 230 until passing 4000 feet. At 1840 local, Tower observed the aircraft descending visually and the radar target and data block disappeared. There were no distress calls. Night conditions and rain prevailed at the time of the accident. Coast Guard search crews discovered aircraft debris close to the shoreline about 1 ½ hours later. The Sint Maarten Civil Aviation Authority initiated an investigation in accordance with ICAO Annex 13. Local investigation authority personnel were joined by Accredited Representatives and advisors from the following states: the USA (NTSB/FAA), United Kingdom (AAIB and Shorts Brothers PLC), and Canada (TSB, TC, PWC). Organization of the investigation included the following groups: Operations, Accident Site and Wreckage, Powerplants, Aircraft Maintenance, Air Traffic Services, Meteorology, and GPS Study. The operator made available personnel for interviews but deferred to participate in the groups. Flight recorders were not installed nor required on this cargo configured aircraft. The original FDR and CVR were removed following conversion to cargo only operations. A handheld GPS recovered from submerged wreckage was successfully downloaded. Data revealed the aircraft past the departure runway threshold on takeoff and attained a maximum GPS recorded altitude of 433 feet at 119 knots groundspeed at 18:39:30. The two remaining data points were over the sea and recorded decreasing altitude and increasing airspeed. The wreckage was recovered from the sea and examined by technical experts. Assessment of the evidence concluded there were no airframe or engine malfunctions that would have affected the airworthiness of the aircraft. The experts concluded that the aircraft struck the sea while under normal engine operation. Operations and human performance investigators evaluated the evidence and analyzed extensive interviews. The investigation concluded that the aircraft departed from the expected flight path in an unusual attitude. The pilot flying most likely experienced a somatographic illusion as a result of a stressful takeoff and acceleration from flap retraction. The pilot’s reaction to pitch down while initiating a required heading change led to an extreme unusual attitude. Circumstances indicate the pilot monitoring did not perceive/respond/intervene to correct the flight path and recover from the unusual attitude. The aircraft exceeded the normal maneuvering parameters, the crew experienced a loss of control, and lacking adequate altitude for recovery, the aircraft crashed into the sea.
Probable cause:
The investigation believes the PF experienced a loss of control while initiating a turn to the required departure heading after take-off. Flap retraction and its associated acceleration combined to set in motion a somatogravic illusion for the PF. The PF’s reaction to pitch down while initiating a turn most likely led to an extreme unusual attitude and the subsequent crash. PM awareness to the imminent loss of control and any attempt to intervene could not be determined. Evidence show that Crew resource management (CRM) performance was insufficient to avoid the crash. Contributing factors to the loss of control were environmental conditions including departure from an unfamiliar runway with loss of visual references (black hole), night and rain with gusting winds.
Final Report:

Crash of a Let L-410UVP in Shabunda

Date & Time: Oct 25, 2014 at 1416 LT
Type of aircraft:
Operator:
Registration:
9Q-COT
Flight Type:
Survivors:
Yes
Schedule:
Bukavu – Shabunda
MSN:
83 10 23
YOM:
1983
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
7325.00
Copilot / Total flying hours:
3300
Aircraft flight hours:
7187
Aircraft flight cycles:
8265
Circumstances:
The twin engine aircraft departed Bukavu-Kavumu Airport at 1341LT on a 40-minute cargo flight to Shabunda, carrying two pilots and a load of 1,500 kilos of various goods. On final approach to Shabunda Airport, at a height of 300 feet, the right engine lost power. The crew attempted an emergency landing when the aircraft stalled and crashed in palm trees located 3,7 km short of runway. The aircraft was destroyed by impact forces and both pilots were seriously injured.
Probable cause:
On final approach, the right engine lost power, causing the aircraft to stall because the speed dropped. Investigations were unable to determine the exact cause of the loss of power because the aircraft was totally destroyed. Nevertheless, the crew was unable to expect a stall recovery because the stall occurred at an insufficient height.
Final Report:

Crash of a Fokker F27 Friendship 500 near Kogatende: 3 killed

Date & Time: Aug 31, 2014 at 1945 LT
Type of aircraft:
Registration:
5Y-SXP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mwanza - Nairobi
MSN:
10681
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft departed Mwanza Airport at 1926LT on a cargo flight Nairobi. While passing FL169, the aircraft entered an uncontrolled descent. It passed FL146 at an excessive speed of 430 knots and eventually crashed in an open field located near Kogatende. The wreckage was found the following morning. The aircraft disintegrated on impact and all three occupants were killed.

Crash of an Antonov AN-12BK in Tamanrasset: 7 killed

Date & Time: Aug 30, 2014 at 0244 LT
Type of aircraft:
Operator:
Registration:
UR-DWF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Glasgow – Ghardaïa – Tamanrasset – Malabo
MSN:
8 3 458 02
YOM:
1968
Flight number:
UKL4061
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The four engine aircraft was performing a cargo flight from Glasgow-Prestwick to Malabo, Equatorial Guinea, with intermediate stops in Ghardaïa and Tamanrasset. On board were seven crew members and a load consisting of oil equipment. About three minutes after takeoff from Tamanrasset-Aguenar-Hadj Bey Akhamok Airport, radio contact was lost when the aircraft crashed in a mountainous terrain located some 15 km south of the airport. The wreckage was found few hours later. The aircraft was destroyed by impact forces and a post crash fire and all seven crew members (six Ukrainians and one Russian) were killed.

Crash of a Let L-410UVP near Mulume Munene: 4 killed

Date & Time: Aug 23, 2014 at 1355 LT
Type of aircraft:
Operator:
Registration:
9Q-CXB
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bukavu - Kama
MSN:
82 09 25
YOM:
1982
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed Bukavu-Kavumu Airport at 1342LT on a cargo flight to Kama, carrying two pilots, two passengers and a load of 1,500 kilos of books. Some 10 minutes later, the crew changed his frequency and no further contact was established. As the aircraft failed to arrive in Kama, Maniema Province, SAR operations were initiated. The crew of two helicopters from the same operator spotted the burnt wreckage two days later, in the region of Mulume Munene, some 30 km southwest of Bukavu. The aircraft was destroyed by impact forces and a post crash fire and all four occupants were killed.
Probable cause:
It is believed that the crew lost control of the aircraft following an engine failure in flight for unknown reasons.

Crash of a Fokker 50 in Nairobi: 4 killed

Date & Time: Jul 2, 2014 at 0417 LT
Type of aircraft:
Operator:
Registration:
5Y-CET
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nairobi - Mogadishu
MSN:
20262
YOM:
26
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
14531
Captain / Total hours on type:
6821.00
Copilot / Total flying hours:
823
Copilot / Total hours on type:
513
Aircraft flight hours:
27342
Aircraft flight cycles:
26358
Circumstances:
On 2 July 2014, about 01.14 UTC, 5Y-CET, a Fokker F50, an international cargo flight, operated by Skyward International, crashed shortly after takeoff from Jomo Kenyatta International Airport (JKIA), Nairobi, Kenya (JKIA). Instrument Meteorological Conditions prevailed at the time and the airplane was on an instrument flight plan. The four crewmembers were fatally injured. The airplane was destroyed and consumed by post-crash fire. The destination of the flight was Aden Adee International Airport, Mogadishu, Somalia. The airplane was repositioned from its home base at Wilson Airport in Nairobi, the day before. The accident captain (CAPT) and another first officer conducted the repositioning flight. (see Aircraft Information). At JKIA, the airplane was loaded with cargo in preparation for the accident flight. The accident crew consisted of the Capt and FO in addition to a maintenance engineer and loadmaster. According to air traffic control (ATC), the flight plan was filed for duration of 2.5 hours at an altitude of 19,000 feet along with 5 hours of fuel aboard. Based on flight recorder data, the Capt was the pilot-flying and the FO was the pilot-monitoring. The accident flight was reconstructed using data from air traffic control and flight recorder information. According to FDR data, engine start occurred at at 01.50.20. At about 01.10.59 the flight made initial contact with JKIA air traffic control tower and after routine communication, including the confirmation of the number of person and fuel endurance, the flight was cleared for takeoff at 0112.30. At 01.11.58, both engines accelerated to a high power setting with engine no. 1 stabilizing at 78% torque, 100% propeller speed and engine 2 stabilizing at 80% torque, 99% propeller speed. About six seconds later, the Capt indicates “power is set”. About 2 seconds afterwards the Capt indicated “the auto-feather is off, left” and then 5 seconds later, the FO calls out “seven eighty” (?). About 16 seconds after initial engine acceleration was applied, the first of a series of three chimes audio alerts occurred, and continued at 1 second interval throughout the CVR recording. Immediately after the initial chimes, the Capt said “you see” and “how much is that?”. The FO responded “okay niner”. The Capt then asked “it has gotten to?” The FO replied “thirty four thirty ninety two” and shortly afterward “the left one is thirty”. About 24 seconds after initial engine acceleration, engine 1 torque climbs over a period of 2 seconds to a recorded value of 119.9%, the maximum value the recorder is capable of recording. Simultaneously Engine 1 propeller speed falls from 100% to 57%. Other engine shaft speeds remain at approximately their original high power values. Airspeed at the point this change occurs was less than 30 knots. During this period, the FO called out “one twenty two now [pause] torque”. The Capt responded “it is rising eh? The FO then noted “torque one twenty six now”. About 31 seconds after initial engine acceleration, the FO called out “okay speed alive sixty”. About a second later the Capt asked “do we reduce or”? The FO responded “we can just cut”. The Capt inquired “do we abort or continue?” The FO responded, “okay one one twelve and nine four point three” and then “okay one sixteen [pause] ninety four.” The Capt acknowledged “yeah okay” About 47 seconds after initial engine acceleration, the Capt said twice “did I reduce it?”and the FO responded sequentially “yeah” and “okay”] About 52 seconds after initial engine acceleration, the Capt asked “how is it now?” and the FO replied “yeah one oh two [pause] ninety four”. About 7 seconds later the FO called out “okay, one sixteen ninety four”. About 1 minute after initial engine acceleration, the Capt inquired “Is it really going?” The FO replied “one oh one, ninety five”. The Capt acknowledged and shortly afterward he queried “is it going really, is the aircraft really moving”. The FO responded “okay, one oh one, ninety five”. About 4 seconds later, the Capt indicated “it is not giving power” About 1 minute 9 seconds after the initial engine acceleration the FO called out “okay speed has now reached about hundred”. The Capt responded “oh yeah” and immediately afterward the FO called out “okay one eleven, ninety five”. About 1 minute 18 seconds after the initial engine acceleration, the FO indicated “hundred now”. The Capt acknowledged. About 1 minute 26 seconds after the initial engine acceleration, the FO called out “V one V R rotate” About 1 minute 33 seconds after the initial engine acceleration a transition of the airplane from ground to air mode is recorded and the pressure altitude begins to climb along with the Capt immediately afterward expressing two exclamations. Following the transition to air mode there were 51 seconds of flight recorder data before the recording ended. During this time and over a period of about 3 seconds, the FO calls out “positive rate of climb” and the Capt responded “gear up”. About 3 second later, the Capt expressed “it doesn’t have power [pause] it’s on one side.” About 6 seconds afterward, the FO said “we can also turn back”. About 3 seconds later the first of seven “don’t sink” (GPWS aural warning alerts) begins over a period of 23 seconds. After the second GPWS alert the Capt queried “ok, we’re ok?” After the third GPWS alert, the FO said “we can turn back” and the Capt immediately responded “let’s just go”. The FO replied “okay”. After the fifth GPWS alert, the Capt indicated “and this one is showing one fourteen” and then queried? “we can turn back?”. About 2 seconds later, the FO called out “okay speed is one hundred” and the Capt responded “but this one has nothing” About 1 second later and about the time of the sixth GPW alert, JKIA control tower radioed “five yankee charlie echo tango contact radar one two three decimal three. Good morning.” After the seventh GPWS alert the recording ended about 13 seconds later. During this time, the controller called the aircraft again. The Capt expressed “tell him [pause] tell him we have no power”. The last CVR data indicates the FO radioed, “ah tower charlie echo” and the transmission abruptly ended along with simultaneous sounds of distress. According to FDR data, about 15 seconds after the airplane transitioned from ground to air mode the recorded altitude peaked about 5060 feet and accompanied by a maximum airspeed of 100 knots. Along with a variation of airspeed between 90 knots and 100 knots for the remainder of the recording, during the following 20 seconds the altitude decreased to about 5000 feet and then increased to 5050 feet over the next 10 seconds where it remained until the recording ended at 1.14.27. Witness Accounts (Air Traffic Controller Civilians). The aircraft crashed during the hours of darkness at geographical coordinates of 01° 17’16”S, 36° 57’5”E.
Probable cause:
The probable cause of the accident was the decision by the crew to conduct the flight with a known mechanical problem and their failure to abort or reject the takeoff after receiving twenty seven cautions.
The following findings were identified:
- A three chime alert occurred during the positioning flight from HKNW to HKJK,
- Crew continued with the flight with a known fault,
- No evidence that remedial maintenance action was taken after landing from that flight prior to the event flight,
- No evidence of the anomaly being captured in the aircraft technical log,
- At least one of the occupants during the event flight, possibly the PIC, had been present during the positioning flight and thus was aware of the three chime alert that had occurred then,
- Twenty seven sound of three chime alert event occurred during the take off roll on the accident flight,
- The aforementioned alert occurred well before V1,
- The left engine exhibited high torque values (in excess of 120%) while the left propeller speed was reduced to the range between 45% to 55% rpm for most of the flight,
- Crew continued with take of roll and subsequent rotation despite the twenty seven chime alert,
- When airborne, crew contemplated turning back but eventually elected to continue with the flight,
- Cargo weight exceeded what was indicated in the load sheet 36,
- There was no evidence of any maintenance having been conducted on the aircraft since its Certificate of Airworthiness issue two months previously (9th May 2014).
Final Report:

Crash of a Douglas DC-3C near San Vincente del Caguán: 5 killed

Date & Time: May 8, 2014 at 1202 LT
Type of aircraft:
Operator:
Registration:
HK-4700
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Villavicencio – Florencia
MSN:
9700
YOM:
1943
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10233
Captain / Total hours on type:
9950.00
Copilot / Total flying hours:
4417
Copilot / Total hours on type:
3812
Aircraft flight hours:
27771
Circumstances:
The aircraft departed Villavicencio on a cargo flight to Florencia, carrying three passengers, two pilots and a load consisting of 2,540 kg of various goods. While cruising under VFR mode at an altitude of 6,500 feet, weather conditions worsened and the crew attempted to modify his route when the aircraft impacted ground and crashed in a wooded and mountainous area located some 45 km north of San Vincente del Caguán, near Uribe. The aircraft was destroyed by impact forces and all five occupants were killed.
Probable cause:
It was determined that the accident was the consequence of a controlled flight into terrain. The crew failed to evaluate properly the risks and the danger of poor weather conditions and decided to perform the flight in VFR mode. While cruising in IMC and failing to check the minimum prescribed altitude, the crew suffered a loss of situational awareness, causing the aircraft to hit he mountainous terrain.
Final Report:

Crash of a Boeing 737-476SF in East Midlands

Date & Time: Apr 29, 2014 at 0228 LT
Type of aircraft:
Operator:
Registration:
EI-STD
Flight Type:
Survivors:
Yes
Schedule:
Paris-Roissy-Charles de Gaulle – East Midlands
MSN:
24433/1881
YOM:
1990
Flight number:
ABR1748
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4279
Captain / Total hours on type:
377.00
Copilot / Total flying hours:
3900
Circumstances:
The aircraft was scheduled to operate three commercial air transport (cargo) sectors: from Athens to Bergamo, then to Paris Charles de Gaulle, and finally East Midlands. The aircraft’s flap load relief system was inoperative, which meant that the maximum flap position to be used in flight was 30, rather than 40º. This defect had been deferred in the aircraft’s technical log and it had no effect on the landing of the aircraft. Otherwise, the aircraft was fully serviceable. The co-pilot completed the pre-flight external inspection of the aircraft in good light, and found nothing amiss. The departure from Athens was uneventful, but a combination of factors affecting Bergamo (including poor weather, absence of precision approach aids, and work in progress affecting the available landing distance) led the crew to decide to route directly to Paris, where a normal landing was carried out. The aircraft departed Paris for East Midlands at 0040 hrs, loaded with 10 tonnes of freight, 8 tonnes of fuel (the minimum required was 5.6 tonnes), and with the co-pilot as Pilot Flying. Once established in the cruise, the flight crew obtained the latest ATIS information from East Midlands, which stated that Runway 27 was in use, although there was a slight tailwind, and Low Visibility Procedures (LVPs) were in force. They planned to exchange control at about FL100 in the descent, for the commander to carry out a Category III autoland. However, as they neared their destination, the weather improved, LVPs were cancelled, and the flight crew re-briefed for an autopilot approach, followed by a manual landing, to be carried out by the co-pilot. The landing was to be with Flap 30, Autobrake 2, and idle reverse thrust. The final ATIS transmission which the flight crew noted before landing stated that the wind was 130/05 kt, visibility was 3,000 metres in mist, and the cloud was broken at 600 ft aal. The commander of EI-STD established radio contact with the tower controller, and the aircraft was cleared to land; the surface wind was transmitted as 090/05 kt. The touchdown was unremarkable, and the autobrake functioned normally, while the co-pilot applied idle reverse thrust on the engines. As the aircraft’s speed reduced through approximately 60 kt, the co-pilot handed control to the commander, who then made a brake pedal application to disengage the autobrake system. However, the system remained engaged, so he made a second, more positive, brake application. The aircraft “shuddered” and rolled slightly left-wing-low as the lower part of the left main landing gear detached. The commander used the steering tiller to try to keep the aircraft tracking straight along the runway centreline, but it came to a halt slightly off the centreline, resting on its right main landing gear, the remains of the left main landing gear leg, and the left engine lower cowl. The co-pilot saw some smoke drift past the aircraft as it came to a halt. The co-pilot made a transmission to the tower controller, reporting that the aircraft was in difficulties, after which the co-pilot of another aircraft (which was taxiing from its parking position along the parallel taxiway) made a transmission referring to smoke from the 737’s landing gear. The commander of EI-STD had reached the conclusion that one of the main landing gear legs had failed, but as a result of the other pilot’s transmission, he was also concerned that the aircraft might be on fire. The commander immediately moved both engine start levers to the cut-off positions, shutting down the engines. Three RFFS vehicles had by now arrived at the adjacent taxiway intersection, and their presence there prompted the commander to consider that the aircraft was not on fire (he believed that if it were, the vehicles would have adopted positions closer by and begun to apply fire-fighting media). The RFFS vehicles then moved closer to the aircraft and fire-fighters placed a ladder against door L1, which the co-pilot had opened. Having spoken to fire-fighters while standing in the entrance vestibule, the commander returned to the flight deck and switched off the battery. The flight crew were assisted from the aircraft and fire-fighters applied foam around the landing gear and engine to make the area safe. The commander had taken the Notoc2 with him from the aircraft, and informed fire-fighters of the dangerous goods on board the aircraft.
Probable cause:
The damage to the flap system, fuselage, and MLG equipment was attributable to the detachment of the left MLG axle, wheel and brake assembly. The damage to the MLG outer cylinder, engine and nacelle was as result of the aircraft settling and sliding along the runway. The left MLG axle assembly detached from the inner cylinder due to the momentary increase in bending load during the transition from auto to manual braking. The failure was as a result of stress corrosion cracking and fatigue weakening the high strength steel substrate at a point approximately 75 mm above the axle. It is likely that some degree of heat damage was sustained by the inner cylinder during the overhaul process, as indicated by the presence of chicken wire cracking within the chrome plating over the majority of its surface. However, this was not severe enough to have damaged the steel substrate and therefore may have been coincidental. Although the risk of heat damage occurring during complex landing gear plating and refinishing processes is well understood and therefore mitigated by the manufacturers and overhaul agencies, damage during the most recent refinishing process cannot be discounted. The origin of the failure was an area of intense, but very localized heating, which damaged the chrome protection and changed the metallurgy; ie the formation of martensite within the steel substrate. This resulted in a surface corrosion pit, which, along with the metallurgical change, led to stress corrosion cracking, fatigue propagation and the eventual failure of the inner cylinder under normal loading.
Final Report:

Crash of a Fokker 50 in Guriceel

Date & Time: Apr 20, 2014
Type of aircraft:
Operator:
Registration:
5Y-VVJ
Flight Type:
Survivors:
Yes
Schedule:
Nairobi – Guriceel
MSN:
20133
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Nairobi-Wilson Airport on a cargo flight to Guriceel, carrying two pilots and a load of six tons of khat. After landing, the crew encountered difficulties to stop the airplane within the remaining distance. The aircraft overran and came to rest with its left wing partially torn off. Both pilots evacuated safely and the aircraft was damaged beyond repair.

Crash of a Boeing 737-3B7(SF) in Honiara

Date & Time: Jan 26, 2014 at 1259 LT
Type of aircraft:
Operator:
Registration:
ZK-TLC
Flight Type:
Survivors:
Yes
Schedule:
Brisbane – Honiara
MSN:
23705/1497
YOM:
1988
Flight number:
PAQ523
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Brisbane, the crew completed the approach and landing at Honiara-Henderson Airport. After touchdown on runway 24, the right main gear collapsed and punctured the right wing. The aircraft veered slightly to the right and came to a halt on the runway. All three occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The failure of the right main gear was the consequence of an inappropriate rework (ie, machining and re-threading) of the tee-bolt fitting and the associated installation of a reduced size nut and washer, during the last overhaul in 2004.