Crash of an Antonov AN-12BK in Brazzaville: 6 killed

Date & Time: Aug 26, 2009 at 0500 LT
Type of aircraft:
Registration:
TN-AIA
Flight Type:
Survivors:
No
Schedule:
Pointe-Noire – Brazzaville
MSN:
6 3 446 07
YOM:
1966
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft departed Pointe-Noire Airport at 0400LT on a cargo flight to Brazzaville, carrying one passenger, five crew members and a load consisting of food, one minibus and three cars. On final approach by night to Brazzaville-Maya Maya Airport, at an altitude of about 2,000 feet, the four engine aircraft went out of control and crashed near Nganga Lingolo, 11 km short of runway 05. The aircraft was totally destroyed and all six occupants were killed.

Crash of a Piper PA-31-350 Navajo Chieftain in Vancouver: 2 killed

Date & Time: Jul 9, 2009 at 2208 LT
Operator:
Registration:
C-GNAF
Flight Type:
Survivors:
No
Schedule:
Vancouver – Nanaimo – Victoria – Vancouver
MSN:
31-8052130
YOM:
1980
Flight number:
APEX511
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2300
Copilot / Total flying hours:
400
Circumstances:
The Canadian Air Charters Piper PA-31-350 Chieftain (registration C-GNAF, serial number 31-8052130) was operating under visual flight rules as APEX 511 on the final leg of a multi-leg cargo flight from Vancouver to Nanaimo and Victoria, British Columbia, with a return to Vancouver. The weather was visual meteorological conditions and the last 9 minutes of the flight took place during official darkness. The flight was third for landing and turned onto the final approach course 1.5 nautical miles behind and 700 feet below the flight path of a heavier Airbus A321, approaching Runway 26 Right at the Vancouver International Airport. At 2208, Pacific Daylight Time, the target for APEX 511 disappeared from tower radar. The aircraft impacted the ground in an industrial area of Richmond, British Columbia, 3 nautical miles short of the runway. There was a post-impact explosion and fire. The 2 crew members on board were fatally injured. There was property damage, but no injuries on the ground. The onboard emergency locator transmitter was destroyed in the accident and no signal was detected.
Probable cause:
Findings as to Causes and Contributing Factors:
1. APEX 511 turned onto the final approach course within the wake turbulence area behind and below the heavier aircraft and encountered its wake, resulting in an upset and loss of control at an altitude that precluded recovery.
2. The proximity of the faster trailing traffic limited the space available for APEX 511 to join the final approach course, requiring APEX 511 not to lag too far behind the preceding aircraft.
Findings as to Risk:
1. The current wake turbulence separation standards may be inadequate. As air traffic volume continues to grow, there is a risk that wake turbulence encounters will increase.
2. Visual separation may not be an adequate defence to ensure that appropriate spacing for wake turbulence can be established or maintained, particularly in darkness.
3. Neither the pilots nor Canadian Air Charters (CAC) were required by regulation to account for employee duty time acquired at other non-aviation related places of employment. As a result, there was increased risk that pilots were operating while fatigued.
4. Not maintaining engine accessories in accordance with manufacturers’ recommendations can lead to failure of systems critical to safety.
Other Finding:
1. APEX 511 was not equipped with any type of cockpit recording devices, nor was it required to be. As a result, the level of collaboration and decision making discussion between the 2 pilots remains unknown.
Final Report:

Crash of a PZL-Mielec AN-28 in Sarif-Umra

Date & Time: Jul 6, 2009 at 0950 LT
Type of aircraft:
Operator:
Registration:
ST-TYB
Flight Type:
Survivors:
Yes
Schedule:
Al Fashir - Sarif-Umra
MSN:
1AJ006-02
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10144
Captain / Total hours on type:
1269.00
Copilot / Total flying hours:
5500
Copilot / Total hours on type:
950
Aircraft flight hours:
2180
Aircraft flight cycles:
2113
Circumstances:
The flight progress strip at Al Fashir aerodrome control tower illustrate that on the 6th of July 2009 – ST-TYB, AN-28 departed Al Fashir at time 0601 UTC, estimated time to arrive destination Sarif-Umra was 0650 UTC, persons on board were two (crew only), intended flight level was 085 (VFR) re-cleared later FL105, fuel endurance was 3,5 hours, load on board as indicated on the cargo manifest was 1511 k.gm (food stuff) destined for the UNAMID forces. Aircraft center of gravity was organized. Calculated actual take off weight was 6335 k.gm and the actual landing weight was 6035 k.gm as reported by the pilot. The aircraft proceeded normally to destination at FL 105, when it reached the airfield, the pilot stated that, they started descend gradually at a speed of 250 km/h willing to check the strip serviceability and to specify the direction of landing from the located wind sock. They detected that, the strip was clear, dry and the wind was favorable to the direction of 23 (strip 23/05). As the crew established a speed of 210 km/h at an altitude of 60 meters on final approach, they saw a dust devil storm on their right crossing the air strip, to avoid this phenomena, they decided to go around for another approach. Eye witnesses confirmed the occurrence of the storm at the time the aircraft commenced the final approach. The crew reported that, they started a right turn and applied full power to gain height, but they felt that there was no response from the engines and the aircraft was influenced by a wind shear and began to sink. The crew managed to control the aircraft, but in few minutes its altitude decreased rapidly. At time 0650 UTC the aircraft impacted with the ground and rolled, there after struck a small rock and bounced, finally the aircraft impacted the ground by the left main gear and nose, and stopped at a distance of 1,850 meters from the beginning of strip 05 coordinates N 13 29.527 ـــــــ E 023 16.794. Crews (2) were safe and the aircraft sustained substantial damage.
Probable cause:
The unexpected weather phenomena at destination, and environmental conditions, wind shear and CB down drafts caused the accident.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Wamena: 3 killed

Date & Time: Jun 29, 2009 at 1601 LT
Operator:
Registration:
PK-BRO
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Dekai - Wamena
MSN:
756
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Dekai Airport at 1530LT on a cargo flight to Wamena, carrying three crew members and a load of 1,600 kilos of various goods. Between 1554LT and 1600LT, the crew was in contact with Wamena. At 1601LT, while cruising at an altitude of 9,600 feet in limited visibility, the aircraft collided with a mountain slope. The wreckage was found a day later about 19 km southeast from Wamena. The aircraft disintegrated on impact and all three occupants were killed.
Probable cause:
Controlled flight into terrain after the crew was flying under VFR mode in IMC conditions. IFR approach to Wamena are not possible, VFR only.

Crash of an Antonov AN-26 in Isiro: 3 killed

Date & Time: May 26, 2009 at 1616 LT
Type of aircraft:
Operator:
Registration:
9Q-CSA
Flight Type:
Survivors:
Yes
Schedule:
Goma – Isiro
MSN:
50 05
YOM:
1977
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft departed Goma on a cargo flight to Isiro, carrying one loadmaster, three crew members and a load of 7 tons of cigarettes. On approach to Isiro-Matari Airport, the aircraft crashed 3 km short of runway. The loadmaster was seriously injured while three others occupants were killed.

Crash of an Antonov AN-24T in Dire Dawa

Date & Time: May 18, 2009
Type of aircraft:
Registration:
EK-46839
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dire Dawa - Bosaso
MSN:
7910201
YOM:
1967
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Dire Dawa-Aba Tenna Dejazmach Yilma Airport in foggy conditions, control was lost. The aircraft veered off runway and came to rest. All four crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Ground fire of a Douglas DC-3C in San Juan

Date & Time: Apr 26, 2009 at 0428 LT
Type of aircraft:
Operator:
Registration:
N136FS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Juan - Charlotte Amalie
MSN:
10267
YOM:
1943
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
50233
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
957
Copilot / Total hours on type:
204
Aircraft flight hours:
19952
Circumstances:
During taxi to a runway, the instrument panel and cockpit floor erupted in flames. Examination of the wreckage revealed that the majority of the wires contained inside the main junction box had very little damage except for two wires that had insulation missing. The damage appeared to be associated with the routing of the two wires. Both wires were connected to the battery relay and ran through wires in and around the exposed terminal studs. Heat damage was noted on the insulation of wires and other components that were in contact with the exposed wires. The wires ran from the battery relay to the forward section of the cockpit, where the fire started. Due to the fire damage that consumed the cockpit, the examination was unable to determine what system the wires were associated with. Further examination revealed that the fuel pressure was a direct indicating system. Fuel traveled directly to the instruments in the cockpit via rigid aluminum lines routed on the right lower side of the fuselage, where more severe fire damage was noted. Review of maintenance records did not reveal any evidence of the fuel pressure indicating system lines and hoses having ever been replaced; however, they were only required to be replaced on an as-needed basis. The electrical system, instrument lines, and hoses through the nose compartment were required to be inspected on a Phase D inspection; the airplane's last Phase D inspection was completed about 9 months prior to the accident and the airplane had accrued 313.1 hours of operation since that inspection.
Probable cause:
Worn electrical wires and a fuel pressure indicating system hose, which resulted in a ground fire during taxi.
Final Report:

Crash of a BAe 146-300 in Wamena: 6 killed

Date & Time: Apr 9, 2009 at 0743 LT
Type of aircraft:
Operator:
Registration:
PK-BRD
Flight Type:
Survivors:
No
Schedule:
Jayapura - Wamena
MSN:
E3189
YOM:
1990
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
8305
Captain / Total hours on type:
958.00
Copilot / Total flying hours:
12389
Copilot / Total hours on type:
191
Aircraft flight hours:
22225
Circumstances:
On the morning of 9 April 2009, a British Aerospace BAe 146-300 aircraft, registered PK-BRD, was being operated by PT. Aviastar Mandiri Airlines as a scheduled passenger and cargo flight from Sentani Airport to Wamena Airport, Papua. The crew consisted of two pilots, two flight attendants, an engineer, and a load master. The aircraft performed a go-around from the initial landing approach on runway 15 at Wamena. The flight crew positioned the aircraft on a right downwind leg for another landing approach. As the aircraft was turned towards the final approach for the second landing approach at Wamena it impacted terrain and was destroyed. All of the occupants were fatally injured. The Enhanced Ground Proximity Warning System (EGPWS) manufacturer performed simulations using data from the flight recorders, and two separate terrain data sources. The manufacturer informed the investigation that “the GPWS/EGPWS alerts recorded in the CVR were issued as designed”. However the enhanced Look-Ahead function appeared to have been inhibited following the go around. There was no evidence from the CVR that the crew had deliberately inhibited the terrain function of the EGPWS. The investigation determined that the EGPWS issued appropriate warnings to the flight crew, in the GPWS mode. The pilot in command did not take appropriate remedial action in response to repeated EGPWS warnings. The investigation concluded that flight crew’s lack of awareness of the aircraft’s proximity with terrain, together with non conformance to the operator’s published operating procedures, resulted in the aircraft’s impact with terrain. As a consequence of this accident, the operator took safety action to address deficiencies in its documentation for missed approach procedures at Wamena. As a result of this accident, the National Transportation Safety Committee (NTSC) also issued safety recommendations to the operator and to the Directorate General Civil Aviation (DGCA) to ensure that relevant documented safety procedures are implemented. During the investigation, safety issues were identified concerning modification of aircraft and DGCA approval of those modifications. While those safety issues did not contribute to the accident, they nevertheless are safety deficiencies. Accordingly, the NTSC report includes recommendations to address those identified safety issues.
Probable cause:
The crew did not appear to have awareness of the aircraft’s proximity with terrain until impact with terrain was imminent. The flight crew did not act on the Enhanced Ground Proximity Warning System aural warnings, and did not conform to the operator’s published operating procedures. Together, those factors resulted in the aircraft’s impact with terrain.
Final Report:

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

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

Crash of an Ilyushin II-76T off Entebbe: 11 killed

Date & Time: Mar 9, 2009 at 0515 LT
Type of aircraft:
Operator:
Registration:
S9-SAB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Entebbe - Mogadishu
MSN:
0734 10301
YOM:
1977
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
Shortly after takeoff from Entebbe Airport runway 17, while climbing by night, the aircraft entered an uncontrolled descent and crashed in the Lake Victoria, some 10 km south from Entebbe airport. The aircraft disintegrated on impact and all 11 occupants were killed, among them 3 Army Officer from Burundi and one Army Officer from Uganda. They were flying to Mogadishu on behalf of the Amisom, the African Union Mission In Somalia. The aircraft was chartered by the US Company Dynacorp to carry tents and water purification equipments.