Cargo

Transair flight 810, a Title 14 Code of Federal Regulations Part 121 cargo flight, experienced a partial loss of power involving the right engine shortly after takeoff and a water ditching in the
Pacific Ocean about 11.5 minutes later. This analysis summarizes the accident and evaluates (1) the right engine partial loss of power, (2) the captain's communications with air traffic control (ATC) and the first officer's left and right engine thrust reductions, (3) the first officer's misidentification of the affected engine and the captain's failure to verify the information, (4) checklist performance, and (5) survival factors. Maintenance was not a factor in this accident. The flight data recorder (FDR) showed that, when the initial thrust was set for takeoff, the engine pressure ratios (EPR) for the left and right engines were 2.00 and 1.97, respectively. Shortly after rotation, the cockpit voice recorder (CVR) recorded a “thud” and the sound of a low-frequency vibration. The captain (the pilot monitoring at the time) and the first officer (the pilot flying) reported that they heard a “whoosh” and a “pop,” respectively, at that time. As the airplane climbed through an altitude of about 390 ft while at an airspeed of 155 knots, the right EPR decreased to 1.43 during a 2-second period. The airplane then yawed to the right; the first officer countered the yaw with appropriate left rudder pedal inputs. The CVR showed that the captain and the first officer correctly determined that the No. 2 (right) engine had lost thrust within 5 seconds of hearing the thud sound. After moving the flaps to the UP position, the captain reduced thrust to maximum continuous thrust, causing the left EPR to decrease from 1.96 to 1.91 while the airplane was in a climb. (The right EPR remained at 1.43). The captain reported that he did not move the thrust levers again until after he became the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. FDR data showed that thrust was incrementally reduced to near flight idle (1.05 EPR on the left engine and then 1.09 EPR on the right engine) and that airspeed decreased from about 250 to 210 knots. (A decrease in airspeed to 210 knots was consistent with the operator’s simulator guide procedures for a single-engine failure after the takeoff decision speed [V1]. The simulator guide, which supplemented information in the company’s flight crew training manual, contained the most recent operator guidance for single-engine failure training at the time of the accident.) The captain was unaware of the first officer’s thrust changes because he was busy contacting the controller about the emergency. The captain told the controller, “we’ve lost an engine,” but he had declared the emergency to the controller twice before this point, as discussed later in this analysis. The captain instructed the first officer to maintain a target speed of 220 knots (which the captain thought would be “easy on the running engine”), a target altitude of 2,000 ft, and a target heading of 240°. (About 52 seconds earlier, the controller had issued the 240° heading instruction to another airplane on the same radio frequency.) About 3 minutes 14 seconds after the right engine loss of thrust occurred, the captain assumed control of the airplane; at that time, the airplane’s airspeed was 224 knots and heading was 242°, but the airplane’s altitude had decreased from about 2,100 ft (the maximum altitude that the airplane reached during the flight) to 1,690 ft. The captain increased the airplane’s pitch to 9°; the airplane’s altitude then increased to 1,878 ft, but the airspeed decreased to 196 knots. The captain subsequently stated, “let’s see what is the problem...which one...what's going on with the gauges,” and “who has the E-G-T [exhaust gas temperature]?” The first officer stated that the left engine was “gone” and “so we have number two” (the right engine), thus misidentifying the affected engine. The captain accepted the first officer’s assessment and did not take action to verify the information. Afterward, the EPR level on the right engine began to increase in response to the captain advancing the right thrust lever so that the airplane could maintain airspeed and altitude. Right EPR increased and decreased several times during the rest of the flight (coinciding with crew comments regarding the EGT on the right engine and low airspeed) while the left EPR remained near flight idle. The first officer asked the captain if they “should head back toward the airport” before the airplane traveled “too far away,” and the captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain stated that, because there was no fire and an engine “was running,” he intended to have the airplane climb to 2,000 ft and stay within 15 miles of the airport to avoid traffic and have time to address the engine issue. The captain also stated that he had been criticized by the company chief pilot for returning to the airport without completing the required abnormal checklist for a previous in-flight emergency. Although the captain’s decision resulted in the accident airplane flying farther away from the airport and farther over the ocean at night, the captain’s decision was reasonable for a single-engine failure event. The captain directed the first officer to begin the Engine Failure or Shutdown checklist and stated that he would continue handling the radios. The first officer began to read aloud the conditions for executing the Engine Failure or Shutdown checklist but then stopped to tell the captain that the right EGT was at the “red line” and that thrust should be reduced on the right engine. The captain then decided that the airplane should return to the airport and contacted the controller to request vectors. The flight crew continued to express concern about the right engine. The first officer stated, “just have to watch this though…the number two.” The captain asked the first officer to check the EGT for the right engine, and the first officer responded that it was “beyond max.” Afterward, the captain told the first officer to continue with the Engine Failure or Shutdown checklist and finish as much as possible. The first officer resumed reading aloud the conditions for performing the checklist but then stopped to state, “we have to fly the airplane though,” because the airplane was continuing to lose altitude and airspeed. The captain replied “okay.” As a result, the flight crew did not perform key steps of the checklist, including identifying, confirming, and shutting down the affected (right) engine. The first officer told the captain that the airplane was losing altitude; at that time, the airplane’s altitude was 592 ft, and its airspeed was 160 knots. The captain agreed to select flaps 1 (which the first officer had previously suggested likely because the airplane was slowing). The CVR then recorded the first enhanced ground proximity warning system (EGPWS) annunciation (500 ft above ground level); various EGPWS callouts and alerts continued to be annunciated through the remainder of the flight. The captain then told the controller that “we’ve lost number one [left] engine…there’s a chance we’re gonna lose the other engine too it’s running very hot….we’re pretty low on the speed it doesn't look good out here.” Also, the captain mentioned that the controller should notify the US Coast Guard (USCG) because he was anticipating a water ditching in the Pacific Ocean. Because of the high temperature readings on the right engine, the flight crew thought, at this point in the flight, that a dual-engine failure was imminent. During a postaccident interview, the captain stated that his priority at that time was figuring out how the airplane could stay in the air and return safely to the airport. The captain also stated that he attempted to resolve the airplane’s deteriorating energy state by advancing the right engine thrust lever. However, with the left engine remaining near flight idle, the right engine was not producing sufficient thrust to enable the airplane to maintain altitude or climb. The captain’s communication with the controller continued, and the first officer stated, “fly the airplane please.” The controller asked if the airport was in sight, and the captain then asked the first officer whether he could see the airport. The first officer responded “pull up we’re low” to the captain and “negative” to the controller; the captain was likely unable to respond to the controller because he was trying to control the airplane. The captain asked the first officer about the EGT for the right engine; the first officer replied “hot…way over.” The captain then asked about, and the controller responded by providing, the location of the closest airport. Afterward, the CVR recorded a sound similar to the stick shaker, which continued intermittently through the rest of the flight. The CVR then recorded sounds consistent with water impact. The airplane came down into the Pacific Ocean about two miles offshore and sank. Both crew members were rescued, one was slightly injured and a second was seriously injured. The wreckage was later recovered for investigation purposes.

The twin engine aircraft departed Bukavu-Kavumu Airport on a cargo flight to Shabunda, carrying one passenger, two pilots and a load consisting of 1,600 kg of metal sheet. Shortly after takeoff, while in initial climb, the aircraft went out of control and crashed in a prairie located near the airport. The aircraft was totally destroyed and all three occupants were killed.

A Cirrus SR22 and a Swearingen AS226TC were approaching to land on parallel runways and being controlled by different controllers on different control tower frequencies. The pilot of the Swearingen was established on an extended final approach for the left runway, while the pilot of the Cirrus was flying a right traffic pattern for the right runway. Data from an on-board recording device showed that the Cirrus’ airspeed on the base leg of the approach was more than 50 kts above the manufacturer’s recommended speed of 90 to 95 kts. As the Cirrus made the right turn from the base leg to the final approach, its flight path carried it through the extended centerline for the assigned runway (right), and into the extended centerline for the left runway where the collision occurred. At the time of the collision, the Cirrus had completed about ½ of the 90° turn from base to final and its trajectory would have taken it even further left of the final approach course for the left runway. The pilot of the Swearingen landed uneventfully; the pilot of the Cirrus deployed the airframe parachute system, and the airplane came to rest upright about 3 nautical miles from the airport. Both airplanes sustained substantial damage to their fuselage. During the approach sequence the controller working the Swearingen did not issue a traffic advisory to the pilot regarding the location of the Cirrus and the potential conflict. The issuance of traffic information during simultaneous parallel runway operations was required by Federal Aviation Administration Order JO 7110.65Y, which details air traffic control procedures and phraseology for use by persons providing air traffic control services. The controller working the Cirrus did issue a traffic advisory to the Cirrus pilot regarding the Swearingen on the parallel approach. Based on the available information, the pilot of the Cirrus utilized a much higher than recommended approach speed which increased the airplane’s radius of turn. The pilot then misjudged the airplane’s flight path, which resulted in the airplane flying through the assigned final approach course and into the path of the parallel runway. The controller did not issue a traffic advisory to the pilot of Swearingen regarding the location of the Cirrus. The two airplanes were on different tower frequencies and had the controller issued an advisory, the pilot of the Swearingen may have been able to identify the conflict and maneuver his airplane to avoid the collision.

On 20 March 2021, a Boeing 737-400F, registered PK-YSF, was being operated by Trigana Air Service on a non-schedule cargo flight from Halim Perdanakusuma International Airport (WIHH), Jakarta, Indonesia with intended destination of Sultan Hasanuddin International Airport (WAAA), South Sulawesi, Indonesia. On board in this flight was two pilots, one engineer and one Flight Operation Officer (FOO). According to the weight and balance sheet, the flight carried 16,672 kgs of general cargo, takeoff fuel of 11,100 kg and the takeoff weight was 60,695 kg (133,835 lbs). The Pilot in Command (PIC) acted as Pilot Flying (PF) and the Second in Command (SIC) acted as Pilot Monitoring (PM). At 0328 UTC (1028 LT), the PM requested clearance to Halim Tower controller (the controller) to pushback and start the engines. At 1031 LT, the PM requested to the controller for taxi clearance. There was no report of aircraft system abnormality prior to the aircraft departure. At 1047 LT, the controller issued clearance to the PK-YSF pilot to enter and to backtrack Runway 24. At 1051 LT, the PM reported ready for departure to the controller. The controller issued takeoff clearance with additional departure clearance that after takeoff, turn left to heading 180° and initially climb to altitude of 3,000 feet. The PM acknowledged the clearance. The takeoff was conducted with reduced takeoff thrust by assumed temperature of 40°C and the aircraft became airborne at 10:52:57 LT. At 1055 LT, the controller advised the pilot to report when established on heading 180°. The PM reported that they were experiencing right engine failure and requested to fly to AL NDB . The controller advised the PM to turn left heading 060° and to climb to 2,500 feet. Furthermore, the controller asked the pilot intention whether to hold over AL NDB or direct for landing approach. The PM replied that they would hold over AL NDB and added the information that no fire was detected. The controller issued clearance to fly to AL NDB at altitude of 2,500 feet. The controller assumed that PK-YSF would return to Halim and advised the Airport Rescue and Fire-Fighting (ARFF) personnel that PK-YSF experienced right engine failure and would return to Halim. At 1058 LT, the controller requested the information of time required for holding over AL NDB and was replied by the PM that holding would require about 15 minutes. Furthermore, the controller requested whether the pilot able to hold at a point about 15 to 20 Nm from AL NDB and was replied by the PM that they did not objection to the proposal. The controller instructed the pilot to maintain outbound heading up to 15 Nm, at altitude of 2,500 feet. This was intended by the controller to manage the departure and arrival aircraft to and from Halim. At 1116 LT, the PM reported that they were ready to turn left for approach. The controller advised the pilot to turn left and to intercept localizer of the Instrument Landing System (ILS) Runway 24. At 1125 LT, the PM reported to the controller that the Runway was in sight. The controller advised that the wind was from 060° at velocity of 6 knots, QNH 1,007 mbs and issued landing clearance. The aircraft touched down on the touchdown zone and shortly after, both wheels of the right main landing gear detached. The controller noticed spark appeared from the aircraft and pressed the crash bell. At 1127 LT, the controller informed pilots of the other aircraft that the runway blocked by the landing aircraft and identified fire on one of the engines. Few seconds later, the PM called the controller whether any fire and was replied by the controller that fire was visible on the left side of the aircraft.

The twin engine airplane departed Detroit-Willow Run (Ypsilanti) Airport at 2337LT on March 6 on a cargo service to Akron-Canton Airport, carrying two pilots and a load of various goods. After takeoff, the crew encountered technical problems and declared an emergency. He completed two low passes in front of the tower, apparently due to gear problems. Eventually, the aircraft belly landed at 0008LT and came to rest on runway 05R. Both pilots evacuated safely and the aircraft was damaged beyond repair.

The crew were scheduled to operate two cargo flights from Exeter Airport (EXT), Devon, to East Midlands Airport (EMA), Leicestershire, and return. The co-pilot was the PF for both sectors, and it was night. The sector from EXT to EMA was uneventful with the crew electing to landed with FLAP 40. The subsequent takeoff and climb from EMA to EXT proceeded without event. During the cruise the crew independently calculated the landing performance, using the aircraft manufacturer’s software, on their portable electronic devices. Runway 26 was forecast to be wet, so they planned to use FLAP 40 for the landing on Runway 26, with AUTOBRAKE 3. With both pilots being familiar with EXT the PF conducted a short brief of the pertinent points for the approach. However, while they did mention that the ILS had a 3.5° glideslope (GS), they did not mention that the stabilized approach criteria differed from that on a 3° GS. From the ATIS they noted that the weather seemed to be better than forecast and the surface wind was from 230° at 11 kt. The ATC provided the flight crew with radar vectors from ATC to the ILS on Runway 26 at EXT. The landing gear was lowered and FLAP 25 selected before the aircraft intercepted the GS. FLAP 40 (the landing flap) was selected on the GS just below 2,000 ft amsl. With a calculated VREF of 134 kt and a surface wind of 10 kt the PF planned to fly the approach with a VAPP of 140 kt. At about 10 nm finals, upon looking at the flight management computer, the PM noticed there was a 30 kt headwind, so a VAPP of 144 kt was selected on the Mode Control Panel (MCP). The crew became visual with the runway at about 1,000 ft aal. The PF then disconnected the Auto Pilot and Auto Throttle; the Flight Directors remained on. As the wind was now starting to decrease, the VAPP was then reduced from 142 to 140 kt at about 600 ft aal. As the wind reduced, towards the 10 kt surface wind, the PF made small adjustments to the power to maintain the IAS at or close to VAPP. At 500 ft radio altimeter (RA) the approach was declared stable by the crew, as per their standard operating procedures. At this point the aircraft had a pitch attitude of 2.5° nose down, the IAS was 143 kt, the rate of descent (ROD) was about 860 ft/min, the engines were operating at about 68% N1 and the aircraft was 0.4 dots above the GS. However, the ROD was increasing and soon thereafter was in excess of 1,150 ft/min. This was reduced to about 300 ft/min but soon increased again. At 320 ft RA, the aircraft went below the GS for about 8 seconds and, with a ROD of 1,700 ft/min, a “SINK RATE” GPWS alert was enunciated. The PF acknowledged this and corrected the flightpath to bring the aircraft back to the GS before stabilizing slightly above the GS; the PM called this deviation too. As the PF was correcting back to the GS the PM did not feel there was a need to take control. During this period the maximum recorded deviation was ¾ of a dot below the GS. At about 150 ft RA, with a ROD of 1,300 ft/min, there was a further “SINK RATE” GPWS alert, to which the PM said, “WATCH THAT SINK RATE”, followed by another “SINK RATE” alert, which the PF responded by saying “AND BACK…”. The commander recalled that as the aircraft crossed the threshold, at about 100 ft, the PF retarded the throttles, pitched the aircraft nose down, from about 5° nose up to 4° nose down, and then applied some power in the last few feet. During these final moments before the landing, there was another “SINK RATE” alert. The result was a hard landing. A “PULL UP” warning was also triggered by the GPWS, but it was not audible on the CVR. The last surface wind transmitted by ATC, just before the landing, was from 230° at 10 kt. During the rollout the commander took control, selected the thrust reversers and slowed down to taxi speed. After the aircraft had vacated the runway at Taxiway Bravo it became apparent the aircraft was listing to the left. During the After Landing checks the co-pilot tried to select FLAPS UP, but they would not move. There was then a HYDRAULIC LP caution. As there was still brake accumulator pressure the crew were content to taxi the aircraft slowly the short distance onto Stand 10. Once on stand the listing became more obvious. It was then that the crew realized there was something “seriously wrong” with the aircraft. After they had shut the aircraft down, the flight crew requested that the wheels were chocked, and the aircraft be connected to ground power before going outside to inspect the aircraft. Once outside a hydraulic leak was found and the airport RFFS, who were present to unload the aircraft, were informed.

The four engine airplane departed Seoul-Incheon Airport on a cargo flight to Vienna, with an intermediate stop in Novosibirsk, carrying 14 crew members and a load consisting of 84 tons of automobile parts. Shortly after takeoff from runway 25 at Novosibirsk-Tolmachevo Airport, while in initial climb, a catastrophic failure occurred on the engine n°2. Several debris punctured the fuselage, damaging slats on both left and right side. As a result, radio communications were cut, the power supply failed and the thrust control on all three remaining engines dropped. The crew entered a circuit for an immediate return despite the aircraft was in an overweight condition for an emergency landing. After touchdown on runway 25 that offered an LDA of 3,597 metres, the crew started the braking procedure but the aircraft was unable to stop within the remaining distance. It overran, lost its both nose gears and slid in a snow covered field before coming to rest 300 metres further. All 14 occupants evacuated safely and the aircraft seems to be damaged beyond repair.

The pilot, sole on board, was completing a cargo flight to Cobán. After takeoff from Guatemala City-La Aurora runway 02, while in initial climb, the pilot lost control of the airplane that crashed in trees located in a garden along the 4th Avenue, in the Zone 9 district, approximately 980 metres from the end of runway 02. The aircraft was destroyed by impact forces and a post crash fire and the pilot was killed.

After touchdown on runway 06 at Iquitos-Coronel Francisco Secada Vignetta Airport, the aircraft went out of control and veered off runway to the left. It contacted small trees and bushes, lost its right wing and came to rest 100 metres to the left of the runway, broken in two. A fire erupted but was quickly extinguished. All four crew members were slightly injured and the aircraft was destroyed.

The aircraft departed Mogadishu-Aden Abdulle Airport on a cargo flight to Beledweyne, carrying four crew members and various goods on behalf of the AMISOM, the African Union Mission in Somalia. After takeoff, the crew informed ATC about hydraulic problems and was cleared to return. After touchdown on runway 05, the aircraft went out of control, veered off runway to the right and collided with a concrete wall. Two crew members were slightly injured while both pilots were seriously injured after the cockpit was severely damaged on impact.