Crash of a Learjet 35A in Chicago: 2 killed

Date & Time: Jan 5, 2010 at 1327 LT
Type of aircraft:
Operator:
Registration:
N720RA
Flight Type:
Survivors:
No
Schedule:
Pontiac - Chicago
MSN:
156
YOM:
1977
Flight number:
RAX988
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7000
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
2400
Aircraft flight hours:
15734
Circumstances:
The flight was scheduled to pick up cargo at the destination airport and then deliver it to another location. During the descent and 14 minutes before the accident, the airplane encountered a layer of moderate rime ice. The captain, who was the pilot flying, and the first officer, who was the monitoring pilot, made multiple statements which were consistent with their awareness and presence of airframe icing. After obtaining visual flight rules conditions, the flight crew canceled the instrument flight rules clearance and continued with a right, circling approach to the runway. While turning into the base leg of the traffic pattern, and 45 seconds prior to the accident, the captain called for full flaps and the engine power levers were adjusted several times between 50 and 95 percent. In addition, the captain inquired about the autopilot and fuel balance. In response, the first officer stated that he did not think that the spoilerons were working. Shortly thereafter, the first officer gave the command to add full engine power and the airplane impacted terrain. There was no evidence of flight crew impairment or fatigue in the final 30 minutes of the flight. The cockpit voice recorder showed multiple instances during the flight in which the airplane was below 10,000 feet mean sea level that the crew was engaged in discussions that were not consistent with a sterile cockpit environment, for example a lengthy discussion about Class B airspeeds, which may have led to a relaxed and casual cockpit atmosphere. In addition, the flight crew appears to have conducted checklists in a generally informal manner. As the flight was conducted by a Part 135 operator, it would be expected that both pilots were versed with the importance of sterile cockpit rules and the importance of adhering to procedures, including demonstrating checklist discipline. For approximately the last 24 seconds of flight, both pilots were likely focusing their attention on activities to identify and understand the reason for the airplane's roll handling difficulties, as noted by the captain's comment related to the fuel balance. These events, culminating in the first officer's urgent command to add full power, suggested that neither pilot detected the airplane's decaying energy state before it reached a critical level for the conditions it encountered. Light bulb filament examination revealed that aileron augmentation system and stall warning lights illuminated in the cockpit. No mechanical anomalies were found to substantiate a failure in the aileron augmentation system. No additional mechanical or system anomalies were noted with the airplane. A performance study, limited by available data, could not confirm the airplane's movements relative to an aileron augmentation system or spoileron problem. The level of airframe icing and its possible effect on the airplane at the time of the accident could not be determined.
Probable cause:
A loss of control for undetermined reasons.
Final Report:

Crash of an Antonov AN-12B in Heglig

Date & Time: Jan 4, 2010 at 0910 LT
Type of aircraft:
Operator:
Registration:
ST-AQQ
Flight Type:
Survivors:
Yes
Schedule:
Khartoum – Heglig
MSN:
9 3 465 04
YOM:
1969
Flight number:
MGG100
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7050
Captain / Total hours on type:
6000.00
Copilot / Total flying hours:
10038
Copilot / Total hours on type:
7050
Aircraft flight hours:
36190
Circumstances:
The four engine aircraft departed Khartoum Airport at 0738LT on a cargo flight to Heglig, carrying four crew members and a load consisting of 13 tons of various goods. On final approach to Heglig Airport, the aircraft was too low. It collided with obstacles and a concrete block located 16 metres short of runway threshold and housing an element of the approach light system. The aircraft bounced, nosed down and landed nose first 52 metres further. After a course of 183 metres, a tyre on the right main gear burst. The captain instructed the flight engineer to activate the reverse thrust systems but the flight engineer did not check the power levers. The aircraft veered off runway to the left, lost its left main gear and came to rest. All four occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration, causing the aircraft to land short of runway.
The following factors were identified:
- The flight engineer unlocked props I, II, III at throttle position < 20 degrees UPRT and No IV engine at 40 degrees UPRT,
- Unrectification of nose wheel and main landing gear crack as recommended by the manufacturer.

Crash of a Boeing 727-231F in Kinshasa

Date & Time: Jan 2, 2010
Type of aircraft:
Operator:
Registration:
9Q-CAA
Flight Type:
Survivors:
Yes
MSN:
21986/1580
YOM:
1980
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Kinshasa-N'Djili Airport, the crew encountered poor weather conditions with limited visibility due to heavy rain falls. After touchdown on runway 06, the aircraft passed through standing water when control was lost. It veered off runway to the right, lost its undercarriage and came to rest in a grassy area. All four occupants escaped uninjured while the aircraft was damaged beyond repair.

Ground accident of a Boeing 727-222F in São Paulo

Date & Time: Dec 1, 2009 at 0130 LT
Type of aircraft:
Operator:
Registration:
PR-MTK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Brasília – São Paulo
MSN:
20037/701
YOM:
1969
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful night cargo flight from Brasília, the aircraft landed at São Paulo-Guarulhos Airport. While taxiing, the aircraft hit airport equipment while approaching its stand. The aircraft was severely damaged on its nose and cockpit area. All three occupants escaped uninjured while the aircraft was damaged beyond repair. The encountered brakes problems.

Crash of a McDonnell Douglas MD-11F in Shanghai: 3 killed

Date & Time: Nov 28, 2009 at 0814 LT
Type of aircraft:
Operator:
Registration:
Z-BAV
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Shanghai - Bishkek
MSN:
48408/457
YOM:
1990
Flight number:
SMJ324
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The three engine aircraft departed Shanghai-Pudong Airport on a cargo flight to Bishkek, carrying various goods and seven crew members. During the takeoff roll from runway 35L, the pilot-in-command initiated the rotation but the aircraft did not lift off properly with had a negative vario. It overran the runway and eventually crashed in an open field. Three crew were killed while four others were injured. The aircraft was totally destroyed.
Probable cause:
The crew did not properly operate the thrust levers so that the engines did not reach take off thrust. The aircraft had not reached Vr at the end of the runway and could not get airborne. According to the design criteria of the MD11 the crew needs to push at least two thrust levers to beyond 60 degrees, which will trigger autothrust to leave "CLAMP" mode and adjust the thrust to reach the target setting for takeoff, the servo motors would push the thrust levers forward in that case. During the accident departure the pilot in the left seat did not advance the thrust levers to more than 60 degrees, hence the server motors did not work although autothrust was engaged but remained in CLAMP mode and thus did not adjust the thrust to reach takeoff settings. The crew members perceived something was wrong. Audibly the engine sound was weak, visibibly the speed of the aircraft was low, tactically the pressure on the back of the seat was weaker than normal. Somebody within the crew, possibly on the observer seats, suggested the aircraft may be a bit heavy. The T/O THRUST page never appeared (it appears if autothrust is engaged and changes from CLAMP to Thrust Limit setting. Under normal circumstances with autothrust being engaged a click sound will occur as soon as the thrust levers reach the takeoff thrust position. A hand held on the thrust levers will feel the lever moving forward, however, the crew entirely lost situational awareness. None of the anomalies described in this paragraph prompted the crews members' attention. When the aircraft approached the end of the runway several options were available: reject takeoff and close the throttles, continue takeoff and push the throttle to the forward mechanical stop, continue takeoff and immediately rotate. The observer called "rotate", the captain rotated the aircraft. This shows the crew recognized the abnormal situation but did not identify the error (thrust levers not in takeoff position) in a hurry but reacted instinctively only. As the aircraft had not yet reached Vr, the aircraft could not get airborne when rotated. As verified in simulator verification the decision to rotate was the wrong decision. The simulator verification showed, that had the crew pushed the thrust levers into maximum thrust when they recognized the abnormal situation, they would have safely taken the aircraft airborne 670 meters before the end of the runway. The verification also proved, that had the crew rejected takeoff at that point, the aircraft would have stopped before the end of the runway. The crew did not follow standard operating procedures for managing thrust on takeoff. The crew operations manual stipulates that the left seat pilot advances the thrust levers to EPR 1.1 or 70% N1 (depending on engine type), informs the right seat pilot to connect autothrust. The pilot flying subsequently pushes the thrust levers forward and verifies they are moving forward on servos, the pilot monitoring verifies autothrust is working as expected and reaches takeoff thrust settings. In this case the left seat pilot not only did not continue to push the thrust levers forward, but also called out "thrust set" without reason as he did not verify the takeoff thrust setting had been achieved. It is not possible to subdivide the various violations of procedures and regulations. The crew had worked 16 hours during the previous sector. In addition, one crew member needed to travel for 11 hours from Europe to reach the point of departure of the previous sector (Nairobi Kenya), two crew members need to travel for 19 hours from America to the point of departure of the previous sector. These factors caused fatigue to all crew members. The co-pilot was 61 years of age, pathological examination showed he was suffering from hypertension and cardiovascular atherosclerosis. His physical strength and basic health may have affected the tolerance towards fatigue. All crew members underwent changes across multiple time zones in three days. Although being in the period of awakeness in their biological rhythm cycle, the cycle was already in a trough period causing increased fatigue. The captain had flown the Airbus A340 for 300 hours in the last 6 months, which has an entirely different autothrust handling, e.g. the thrust levers do not move with power changes in automatic thrust, which may have caused the captain to ignore the MD-11 thrust levers. The co-pilot in the right hand seat had been MD-11 captain for about 7 years but had not flown the MD-11 for a year. Both were operating their first flight for the occurrence company. The two pilots on the observer seats had both 0 flight hours in the last 6 months. The co-pilot (right hand seat) was pilot flying for the accident sector. The captain thus was responsible for the thrust management and thrust lever movement according to company manual. A surviving observer told the investigation in post accident interviews that the captain was filling out forms and failed to monitor the aircraft and first officer's actions during this critical phase of flight. There are significant design weaknesses in the MD-11 throttle, the self checks for errors as well as degree of automation is not high.
Source: Aviation Herald/Simon Hradecky

Crash of a Cessna 208B Grand Caravan in Windhoek: 3 killed

Date & Time: Nov 15, 2009 at 0658 LT
Type of aircraft:
Operator:
Registration:
ZS-OTU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Windhoek – Ondjiva – Lubango – Luanda
MSN:
208B-0513
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
671
Captain / Total hours on type:
206.00
Aircraft flight hours:
12469
Circumstances:
On 15 November 2009, at about 0458Z, and aircraft a Cessna Caravan 208B, with a pilot and three passengers on board, took off from Eros Airport for a flight to Ondjiva, Lubango and Luanda. On board the aircraft were a substantial amount of cargo, which included building materials, meat, paints, bottles of wine etc. which was placed between and on top of the seats as well as in the cargo-pod. The cargo inside the cabin area was not secured. Shortly after takeoff from runway 19, the aircraft turned to the right and then pitched nose up. According to the passenger who survived, the aircraft entered into a left spin shortly after the nose pitched up and second later impacted with terrain, coming to rest facing the direction it took off from. The pilot and two passengers were fatally injured during the accident. One of the passengers survived the accident and was admitted to a local hospital with s spinal injury. The pilot-in-command was a holder of a commercial pilot licence. His medical certificate was valid with restrictions (to wear corrective lenses). Fine weather was reported during the time of the accident with surface wind of 180° at 8 knots.
Probable cause:
The investigations revealed that during this operation the aircraft's take-off weight was exceeded by 629 pounds. The aircraft failed to maintain flying speed and stalled shortly after takeoff, rendering ground impact inevitable.
The following contributing factors were identified:
- This was the pilot's first flight from Eros Airport therefore being unfamiliar with the airport and the environmental phenomena's associated with it (especially taking off from runway 19),
- The pilot made one fundamental error in his weight calculation that he used the incorrect aircraft empty weight,
- The cargo that was in the cabin was packed between and underneath and on top of the seats and was not secured,
- The aircraft took off from runway 19, which was an upslope runway,
- Taking off from runway 19 the terrain kept rising with mountains straight ahead as well as to the left and right,
- The pilot retracted the flaps shortly after rotation, which resulted in an attitude change and performance (aircraft lost altitude), which should be regarded as a significant contributory factor to this accident,
- The pilot was observed to turn to the right shortly after takeoff, which increased the drag on the aircraft as well as the stall speed,
- Harsh anti-erosion rubber paint that was sprayed onto the leading edge of the wings resulted in an increased stall speed,
- Inadequate oversight by the regulatory authority should be regarded as a significant contributory factor to this accident.
Final Report:

Crash of a Beechcraft 1900D in Nairobi: 2 killed

Date & Time: Nov 9, 2009 at 0517 LT
Type of aircraft:
Operator:
Registration:
5Y-VVQ
Flight Type:
Survivors:
No
Schedule:
Nairobi – Guriceel
MSN:
UE-250
YOM:
1996
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
15866
Aircraft flight cycles:
15941
Circumstances:
The airplane departed Wilson Airport at 03:39 hours, transporting a cargo of miraa to Guriceel Airstrip, Somalia. Taxi, take off and climb were uneventful. However, at 04:23 and flying at FL230 the crew contacted Nairobi Area Control Centre (ACC) and requested for a turn back to Wilson Airport due to a 'slight problem'. At about the same time, the aircraft made a right turn from a heading of 50° to 240° magnetic and commenced descent. The crew reported descending to FL220 and expressed intention to descend further to FL180. However, ACC informed the crew to initially maintain FL200 due to traffic moving in the opposite direction. At 04:28 the crew informed ACC that they were unable to maintain FL200 and requested to descend to FL180 having crossed the opposite traffic. At 04:29, the crew confirmed to Air Traffic Control (ATC) that they were heading to Wilson Airport and indicated that they did not require any assistance. The aircraft continued descending until FL120. The Nairobi Approach Radar established contact with the aircraft at 04:41 and indicated to the crew that they were 98 nautical miles North East of November Victor. The crew was then told to turn left to a heading of 225° and report when they were top of descent, which they did. The crew reported again that they had a 'slight problem' and as a safety measure they had to shut down one engine. They also expressed desire to route direct to Silos. At 04:42 5Y-VVQ aligned with the North East access lane via Ndula Marker. At 04:45, the crew confirmed to Nairobi Approach Radar that the malfunction was on the left engine and again acknowledged that they did not require any assistance. At 04:51, the crew requested for radar vectors for an ILS approach to runway 06 at Jomo Kenyatta International Airport with a long final to runway 32 of Wilson Airport. At 05:09, the aircraft descended to 8000ft heading 260°. At 05:14, the crew was given vectors for runway 32 Wilson Airport. At the same time, the aircraft turned right to a heading 310° as it continued to descend to 7000ft. The crew confirmed the vectors and at 05:15 stated that they were passing Visual Meteorological Conditions (VMC). They were also informed that the Wilson Airport runway 32 was 6.5 nautical miles away in the two o'clock direction. The aircraft continued to descend to 6000ft and at 05:16, the crew confirmed sight of runway 32. The crew was then transferred from the radar to the Wilson Tower frequency for landing. 5Y-VVQ was cleared for a straight-in approach to runway 32. Wilson Tower then communicated to the crew airfield QNH was 1022hPa and that winds were calm. The Tower controller had 5Y-VVQ visual and it was cleared to land on runway 32. At about the same time, the aircraft made a 5° right bank and again leveled off before making a steep left bank rising to 30° within 4 seconds. According to Tower and eyewitness information, the aircraft appeared high on approach and on short-final, it was observed to turn a bit to the right. This was followed by a steep left bank. The aircraft left wing hit the ground first approximately 100 meters outside the airport perimeter fence. The aircraft then flipped over, hitting and breaking the airport fence and coming to rest on the left of runway 32 approximately 100 meters from its threshold. The aircraft immediately caught fire upon the impact. Upon further investigations and interview of company personnel, it was established that the crew had made the decision to shut down the left engine following a low oil pressure warning. The flight crew did not declare an emergency.
Probable cause:
The investigation determined the probable cause of the accident as loss of aircraft control at low altitude occasioned by operation of the aircraft below VMCA during one engine inoperative approach.
Other significant contributory factors to this accident include:
- Inadequate pilot training on single engine operation and VMCA;
- inappropriate handling technique during one engine inoperative flight;
- inability of the pilot to monitor the degrading airspeed.

Crash of a Boeing 707-330C in Sharjah: 6 killed

Date & Time: Oct 21, 2009 at 1531 LT
Type of aircraft:
Operator:
Registration:
ST-AKW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sharjah - Khartoum
MSN:
20123/788
YOM:
1969
Flight number:
AZZ2241
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
19943
Copilot / Total flying hours:
6649
Copilot / Total hours on type:
900
Aircraft flight hours:
77484
Aircraft flight cycles:
26888
Circumstances:
The Aircraft was operating a flight from Sharjah International Airport, UAE to Khartoum International Airport, Sudan, with a total of six persons on board: three flight crew members (captain, co-pilot, and flight engineer), a ground engineer, and two load masters. All of the crew members sustained fatal injuries due to the high impact forces. Sometime after of liftoff, the core cowls of No. 4 engine separated and collapsed onto the departure runway, consequently No. 4 Engine Pressure Ratio (“EPR”) manifold flex line ruptured leading to erroneous reading on the EPR indicator. The crew interpreted the EPR reading as a failure of No. 4 engine; accordingly they declared engine loss and requested the tower to return to the Airport. The Aircraft went into a right turn, banked and continuously rolled to the right at a high rate, sunk, and impacted the ground with an approximately 90° right wing down attitude.
Probable cause:
The Investigation identified the following Causes:
(a) the departure of the No. 4 engine core cowls;
(b) the consequent disconnection of No. 4 engine EPR Pt7 flex line;
(c) the probable inappropriate crew response to the perceived No. 4 engine power loss;
(d) the Aircraft entering into a stall after the published maximum bank angle was exceeded; and
(e) the Aircraft Loss of Control (“LOC”) that was not recoverable.

Contributing Factors to the Accident were:
(a) the Aircraft was not properly maintained in accordance with the Structure Repair
Manual where the cowls had gone through multiple skin repairs that were not up to
aviation standards;
(b) the Operator’s maintenance system failure to correctly address the issues relating to the No. 4 engine cowls failure to latch issues;
(c) the failure of the inspection and maintenance systems of the maintenance organization, which performed the last C-Check, to address, and appropriately report, the damage of the No. 4 engine cowls latches prior to issuing a Certificate of Release to Service;
(d) the Operator’s failure to provide a reporting system by which line maintenance personnel report maintenance deficiencies and receive timely and appropriate guidance and correction actions;
(e) the Operator’s quality system failure to adequately inspect and then allow repairs that were of poor quality or were incorrectly performed to continue to remain on the Aircraft; and
(f) the SCAA safety oversight system deficiency to adequately identify the Operator’s chronic maintenance, operations and quality management deficiencies.
Final Report:

Crash of a Douglas DC-3C in Manila: 4 killed

Date & Time: Oct 17, 2009 at 1214 LT
Type of aircraft:
Registration:
RP-C550
Flight Type:
Survivors:
No
Site:
Schedule:
Manila - Puerto Princesa
MSN:
14292/25737
YOM:
1944
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
On October 17, 2009at about 12:04 pm, RP-C550 a DC-3type of aircraft took off from Manila Domestic airport bound for Puerto Princesa, Palawan. Approximately 5 mins after airborne, the Pilot-in-Command (PIC) informed Manila Tower that they were turning back due to technical problem. The PIC was asked by the air controller whether he was declaring an “emergency” and the response was negative. The PIC was directed to proceed South Mall and wait for further instruction (a standard procedures for VFR arrivals for runway 13). At South Mall, RP-C550 was cleared to cross the end of runway 06, still without declaring an emergency. The tower controller sensed that something was wrong with the aircraft due to its very low altitude, immediately granted clearance to land runway 06. However, the aircraft was not able to make it to runway 06. At about 12:14, RP-C550 crashed at an abandoned warehouse in Villa Fidela Subd., Brgy. Elias Aldana Las Piñas City about 4 kms. from the threshold of runway 06. As a result, the aircraft was totally destroyed and all aboard suffered fatal injuries due to impact and post crash fire.
Probable cause:
The Aircraft Accident Investigation and Inquiry Board determine that the probable causes of this accident were the following:
- Non-procedural application of power during take-off and initial climb that led to left engine malfunction.
- The questionable qualifications of the flight crew.
- Low level of competence of the pilots.
- Not feathering the left engine.
- Turning towards the bad engine.
- Not declaring an emergency.
Final Report:

Crash of a Boeing 707-321C in Mombasa

Date & Time: Oct 13, 2009
Type of aircraft:
Registration:
J5-GGU
Flight Type:
Survivors:
Yes
MSN:
19372/655
YOM:
1967
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Mombasa-Moi Airport, the aircraft was too low and collided with approach lights. The crew continued the approach and the aircraft landed safely. Few seconds later, while evacuating the runway to the taxiway, the right main gear collapsed. All three crew members escaped uninjured while the aircraft was damaged beyond repair.