Crash of a Let L-410UVP-E20 in Lukla: 2 killed

Date & Time: May 27, 2017 at 1404 LT
Type of aircraft:
Operator:
Registration:
9N-AKY
Flight Type:
Survivors:
Yes
Schedule:
Kathmandu – Lukla
MSN:
14 29 17
YOM:
2014
Flight number:
GO409
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9687
Captain / Total hours on type:
1897.00
Copilot / Total flying hours:
1311
Copilot / Total hours on type:
1028
Aircraft flight hours:
2550
Aircraft flight cycles:
5467
Circumstances:
On May 27, 2017 9N-AKY, LET 410 UVP-E20 of Goma Air (now Summit Air), a domestic carrier of Nepal had a published program to operate 5 flights to Lukla from Kathmandu. The first flight departed Kathmandu at 0026 UTC. By the time 0647 UTC they had completed 4 flights. The fifth and the last flight departed Kathmandu at 0744 UTC for Lukla as call sign Goma Air 409. Goma Air 409 was the cargo flight carrying 1680 kg cargo for Lukla. There were two cockpit crews, one cabin crew and no passengers on board the flight. It was pre-monsoon period. Lukla weather on that particular day was cloudy since morning. But ceiling and visibility were reported OK. However, CCTV footage shows rapidly deteriorating weather condition before and after the crash. Automatic VHF recorder of Lukla Tower and CVR recording showed Tower was regularly updating pilots of deteriorating weather. All the pre-and post-departure procedure of the flight was completed in normal manner. Before departure from Kathmandu Pilots were found to have obtained latest weather of Lukla, Phaplu and Rumjatar. PIC decided to remain south of track to avoid the terrain and cloud. When Goma 409 was about 11 miles East from Kathmandu they were informed that Lukla was having heavy rain and airport closed. By that time air traffic congestion in TIA was slowly developing. Traffics were holding in the air and in the ground as well. So Goma 409 continued for Lukla. However, after crossing 26 miles from Kathmandu, they were again informed that the rain had ceased and airport was open. An AS350 helicopter, 9N AGU which departed Lukla at 0803 UTC for Kathmandu had reported unstable wind on final Runway 06. Enroute weather reported by 9N AGU upon request of Lukla Tower was good beyond the Lukla valley. However, it was apprehended that for fixed wing, weather might be difficult to enter valley. Lukla Tower relayed all available information when Goma Air 409 had first established contact at time 0810 UTC. Later, Goma Air and 9N AGY, two reciprocal traffics were also in contact each other. 9N AGY relayed the actual weather status to GOMA AIR. Lukla valley's ceiling and visibility was OK for VFR until 0812UTC ( 6 minutes before crash). Weather started to deteriorate very fast. Mountain Ridges were visible through thin layer of foggy cloud until 0814 UTC. After one minute (approx.) Right Base for Runway 06, was covered up and cloud from left base was moving towards final. Duty ATS Officer of Lukla Tower was regularly up dating pilots about deteriorating weather condition. However, Tower was found to be failed to close the runway as per SOP in spite of rapidly deterioratingweather. Pilots ventured to continue though the weather was marginal. Aircraft reported entering valley at 0816. CVR record showed that First Officer sighted the runway at 0817 (64 seconds before the impact). Instantly PIC acknowledged he had also the runway in sight. Aircraft was at 9100 ft (approx.) when the cockpit crews sighted the runway. It maintained 9000 feet (approx.) for further 21 seconds. At time 0817:12i.e. 48 seconds before the impact Tower gave the latest wind as Westerly 04 knots and runway was clear. PIC was still in doubt and asked whether there was rain. Upon confirmation of having no rain from the Tower the aircraft started to descend further. The PIC, who was also the PF, found to have lost situational awareness deviated to the right with continued descend. At 0817:35 (25 seconds before impact) when the flight was descending through 8650 ft First Officer warned PIC that they were too low. PIC did not respond the F/O's call-out and continued descend. On reaching 8500 ft. F/O again warned PIC in panic. Then PIC asked in panic where the runway was. F/O directed towards the runway. But it was already too low and too late. There was initially two short stall warning sound. Then a continuous stall warning sounded till the impact, which lasted for 13 seconds. The last words in CVR records was "w]/ gtfg " (Do not pull too much). Abrupt change in aircraft attitude in an attempt to climb and reach threshold height at 8900 ft. (on Kathmandu QNH) in a landing configuration, with landing gears down and on full flaps, created excessive drag resulting the aircraft to stall. Subsequently, its left wing first hit a small tree branch 180 ft. short of the threshold. Then impacted the sloppy terrain 100ft. short of the runway. After the crash aircraft engine was reported to be running for about a minute. But there was no postcrash fire. Aircraft was totally damaged by the impact.
Crew:
Paras Kumar Rai, pilot, †
Srijan Manandhar, copilot, †
Pragya Maharjan, cabin crew.
Probable cause:
The Commission concludes that the probable cause of this accident was aircraft stall as a result of excessive drag created by sudden increase in angle of attack of the aircraft supplemented by low speed (below Vref) in an attempt to initiate immediate climb on a landing configuration (full flap and landing gear down) warranted by the critical situation of the final phase of flight.
Contributing factors:
- Critical terrain and rapidly deteriorating weather condition.
- Pilot's loss of situational awareness.
- Improper pilot response to stall warning including failure to advance power lever to maximum at appropriate time.
- Violation of SOP by the ATS and Pilot as well.
Final Report:

Crash of a Short 330-200 in Charleston: 2 killed

Date & Time: May 5, 2017 at 0651 LT
Type of aircraft:
Operator:
Registration:
N334AC
Flight Type:
Survivors:
No
Schedule:
Louisville – Charleston
MSN:
SH3029
YOM:
1979
Flight number:
2Q1260
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4368
Captain / Total hours on type:
578.00
Copilot / Total flying hours:
652
Copilot / Total hours on type:
333
Aircraft flight hours:
28023
Aircraft flight cycles:
36738
Circumstances:
The flight crew was conducting a cargo flight in instrument meteorological conditions. Takeoff from the departure airport and the en route portion of the flight were normal, with no reported weather or operational issues. As the flight neared Charleston Yeager International Airport (CRW) at an altitude of 9,000 ft, the captain and first officer received the most recent automatic terminal information service (ATIS) report for the airport indicating wind from 080º at 11 knots, 10 miles visibility, scattered clouds at 700 ft above ground level (agl), and a broken ceiling at 1,300 ft agl. However, a special weather observation recorded about 7 minutes before the flight crew's initial contact with the CRW approach controller indicated that the wind conditions had changed to 170º at 4 knots and that cloud ceilings had dropped to 500 ft agl. The CRW approach controller did not provide the updated weather information to the flight crew and did not update the ATIS, as required by Federal Aviation Administration Order 7110.65X, paragraph 2-9-2. The CRW approach controller advised the flight crew to expect the localizer 5 approach, which would have provided a straight-in final approach course aligned with runway 5. The first officer acknowledged the instruction but requested the VOR-A circling instrument approach, presumably because the approach procedure happened to line up with the flight crew's inbound flightpath and flying the localizer 5 approach would result in a slightly longer flight to the airport. However, because the localizer 5 approach was available, the flight crew's decision to fly the VOR-A circling approach was contrary to the operator's standard operating procedures (SOP). The minimum descent altitude (MDA) for the localizer approach was 373 ft agl, and the MDA for the VOR-A approach was about 773 ft agl. With the special weather observation indicating cloud cover at 500 ft agl, it would be difficult for the pilots to see the airport while at the MDA for the VOR-A approach; yet, the flight crew did not have that information. The approach controller was required to provide the flight crew with the special weather report indicating that the ceiling at the arrival airport had dropped below the MDA, which could have prompted the pilots to use the localizer approach; however, the pilots would not have been required to because the minimum visibility for the VOR-A approach was within acceptable limits. The approach controller approved the first officer's request then cleared the flight direct to the first waypoint of the VOR-A approach and to descend to 4,000 ft. Radar data indicated that as the flight progressed along the VOR-A approach course, the airplane descended 120 feet below the prescribed minimum stepdown altitude of 1,720 ft two miles prior to FOGAG waypoint. The airplane remained level at or about 1,600 ft until about 0.5 mile from the displaced threshold of the landing runway. At this point, the airplane entered a 2,500 ft-per-minute, turning descent toward the runway in a steep left bank up to 42º in an apparent attempt to line up with the runway. Performance analysis indicates that, just before the airplane impacted the runway, the descent rate decreased to about 600 fpm and pitch began to move in a nose-up direction, suggesting that the captain was pulling up as the airplane neared the pavement; however, it was too late to save the approach. Postaccident examination of the airplane did not identify any airplane or engine malfunctions or failures that would have precluded normal operation. Video and witness information were not conclusive as to whether the captain descended below the MDA before exiting the cloud cover; however, the descent from the MDA was not in accordance with federal regulations, which required, in part, that pilots not leave the MDA until the "aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal descent rate using normal maneuvers." The accident airplane's descent rate was not in accordance with company guidance, which stated that "a constant rate of descent of about 500 ft./min. should be maintained." Rather than continue the VOR-A approach with an excessive descent rate and airplane maneuvering, the captain should have conducted a missed approach and executed the localizer 5 approach procedure. No evidence was found to indicate why the captain chose to continue the approach; however, the captain's recent performance history, including an unsatisfactory checkride due to poor instrument flying, indicated that his instrument flight skills were marginal. It is possible that the captain felt more confident in his ability to perform an unstable approach to the runway compared to conducting the circling approach to land. The first officer also could have called for a missed approach but, based on text messages she sent to friends and their interview statements, the first officer was not in the habit of speaking up. The difference in experience between the captain and first officer likely created a barrier to communication due to authority gradient. ATC data of three VOR-A approaches to CRW flown by the captain over a period of 3 months before the accident and airport security footage of previous landings by the flight crew 1 month before the accident suggest that the captain's early descent below specified altitudes and excessive maneuvering during landing were not isolated to the accident flight. The evidence suggests that the flight crew consistently turned to final later and at a lower altitude than recommended by the operator's SOPs. The flight crew's performance on the accident flight was consistent with procedural intentional noncompliance, which—as a longstanding concern of the NTSB—was highlighted on the NTSB's 2015 Most Wanted List. The operator stands as the first line of defense against procedural intentional noncompliance by setting a positive safety attitude for personnel to follow and establishing organizational protections. However, the operator had no formal safety and oversight program to assess compliance with SOPs or monitor pilots, such as the captain, with previous performance issues.
Probable cause:
The flight crew's improper decision to conduct a circling approach contrary to the operator's standard operating procedures (SOP) and the captain's excessive descent rate and maneuvering during the approach, which led to inadvertent, uncontrolled contact with the ground. Contributing to the accident was the operator's lack of a formal safety and oversight program to assess hazards and compliance with SOPs and to monitor pilots with previous performance issues.
Final Report:

Crash of a Piper PA-31-310 Navajo C near Colton: 1 killed

Date & Time: May 3, 2017 at 2030 LT
Type of aircraft:
Operator:
Registration:
C-GQAM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Quebec - Montreal
MSN:
31-7912093
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5250
Captain / Total hours on type:
1187.00
Circumstances:
The commercial pilot departed on a planned 1-hour cargo cross-country flight in the autopilot-equipped airplane. About 3 minutes after departure, the controller instructed the pilot to fly direct to the destination airport at 2,000 ft mean sea level (msl). The pilot acknowledged the clearance, and there were no further radio transmissions from the airplane. The airplane continued flying past the destination airport in straight-and-level flight at 2,100 ft msl, consistent with the airplane operating under autopilot control, until it was about 100 miles beyond the destination airport. A witness near the accident site watched the airplane fly over at a low altitude, heard three "pops" come from the airplane, and then saw it bank to the left and begin to descend. The airplane continued in the descending left turn until he lost sight of it as it dropped below the horizon. The airplane impacted trees in about a 45° left bank and a level pitch attitude and came to rest in a heavily wooded area. The airplane sustained extensive thermal damage from a postcrash fire; however, examination of the remaining portions of the airframe, flight controls, engines, and engine accessories revealed no evidence of preimpact failure or malfunction. The fuel selector valves were found on the outboard tanks, which was in accordance with the normal cruise procedures in the pilot's operating handbook. Calculations based on the airplane's flight records and the fuel consumption information in the engine manual indicated that, at departure, the outboard tanks of the airplane contained sufficient fuel for about 1 hour 10 minutes of flight. The airplane had been flying for about 1 hour 15 minutes when the accident occurred. Therefore, it is likely that the fuel in the outboard tanks was exhausted; without pilot action to switch fuel tanks, the engines lost power as a result of fuel starvation, and the airplane descended and impacted trees and terrain. The overflight of the intended destination and the subsequent loss of engine power due to fuel starvation are indicative of pilot incapacitation. The pilot's autopsy identified no significant natural disease:however, the examination was limited by the severity of damage to the body. Further, there are a number of conditions, including cardiac arrhythmias, seizures, or other causes of loss of consciousness, that could incapacitate a pilot and leave no evidence at autopsy. The pilot's toxicology results indicated that the pilot had used marijuana/tetrahydrocannabinol (THC) at some point before the accident. THC can impair judgment, but it does not cause incapacitation; therefore, the circumstances of this accident are not consistent with impairment from THC, and, the pilot's THC use likely did not contribute to this accident. The reason for the pilot's incapacitation could not be determined.
Probable cause:
The pilot's incapacitation for unknown reasons, which resulted in an overflight of his destination, a subsequent loss of engine power due to fuel starvation, and collision with terrain.
Final Report:

Crash of a Cessna 208B Grand Caravan near Chignik: 1 killed

Date & Time: May 1, 2017 at 1350 LT
Type of aircraft:
Operator:
Registration:
N803TH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Port Heiden - Perryville
MSN:
208B-0321
YOM:
1992
Flight number:
GV341
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4989
Captain / Total hours on type:
904.00
Aircraft flight hours:
17990
Circumstances:
The airline transport pilot was conducting a commercial visual flight rules (VFR) flight. A passenger who was on the first segment stated that the pilot flew the airplane lower than usual for that route, and that the airplane flew through clouds during the flight. The passenger disembarked and the pilot departed on the second segment of the flight with a load of mail. The route included flight across a peninsula of mountainous terrain to a remote coastal airport that lacked official weather reporting or instrument approach procedures. About 28 minutes after departure, an emergency locator transmitter (ELT) signal from the airplane was received and a search and rescue operation was initiated. The wreckage was located about 24 miles from the destination in deep snow on the side of a steep, featureless mountain at an elevation about 3,000 ft mean sea level. The accident site displayed signatures consistent with impact during a left turn. Examination of the airplane revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The airplane was not equipped with any recording or flight tracking devices, nor was it required to be; therefore, the airplane's flight track before the accident could not be determined. The airplane was certified for instrument flight and flight in icing conditions and was equipped with a terrain avoidance warning system (TAWS) which was not inhibited during the accident. Although the TAWS should have provided the pilot with alerts as the airplane neared the terrain, it could not be determined if this occurred or if the pilot heeded the alerts. A review of nearby weather camera images revealed complete mountain obscuration conditions with likely rain shower activity in the vicinity of the accident site. Visible and infrared satellite imagery indicated overcast cloud cover over the accident site at the time of the accident. The graphical forecast products that were available to the pilot before the flight indicated marginal VFR conditions for the entire route. There was no evidence that the pilot obtained an official weather briefing, and what weather information he may have accessed before the flight could not be determined. Additionally, the cloud conditions and snow-covered terrain present in the area likely resulted in flat light conditions, which would have hindered the pilot's ability to perceive terrain features and closure rates. Based on the weather camera, surface, and upper air observations, it is likely that the pilot encountered instrument meteorological conditions inflight, after which he performed a left turn to return to visual meteorological conditions and did not recognize his proximity to the mountain due to the flat light conditions. The pilot and the dispatch agent signed a company flight risk assessment form before the flight, which showed that the weather conditions for the flight were within the company's acceptable risk parameters. Although the village agents at the departure and destination airports stated that the weather at those coastal locations was good, the weather assessment for the accident flight was based on hours-old observations provided by a village agent who was not trained in weather observation and did not include en route weather information, the area forecast, or the AIRMET for mountain obscuration effective during the dispatch time and at the time of the accident. Since acquiring the accident route from another operator years earlier, the company had not performed a risk assessment of the route and its associated hazards. Multiple company pilots described the accident route of flight as hazardous and considered it an undesirable route due to the terrain, rapidly changing weather, and lack of weather reporting infrastructure; however, the company did not address or attempt to mitigate these known hazards through its risk assessment processes. The company's controlled-flight-into-terrain (CFIT)-avoidance program stated that each pilot shall have one classroom training session and one CFIT-avoidance training session in an aviation training device (ATD) each year; however, the pilot's training records indicated that his most recent ATD session was 15 months prior. More recent CFIT avoidance training may have resulted in the pilot recognizing and responding to the reduced visibility and flat light conditions sooner.
Probable cause:
The pilot's continued visual flight rules flight into an area of mountainous terrain and instrument meteorological conditions, which resulted in controlled flight into terrain (CFIT). Contributing to the accident was the company's failure to provide the pilot with CFIT-avoidance recurrent simulator training as required by their CFIT avoidance program and the company's inadequate flight risk assessment processes, which did not account for the known weather hazards relevant to the accident route of flight.
Final Report:

Crash of a Cessna 208 Caravan I near Oksibil: 1 killed

Date & Time: Apr 12, 2017 at 1240 LT
Type of aircraft:
Operator:
Registration:
PK-FSO
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Tanah Merah – Oksibil
MSN:
208-0313
YOM:
1999
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4236
Captain / Total hours on type:
2552.00
Aircraft flight hours:
6226
Aircraft flight cycles:
9371
Circumstances:
On 12 April 2017, a Cessna C208 aircraft registered PK-FSO was being operated by PT. Spirit Avia Sentosa (FlyingSAS) for unscheduled cargo flight. The flights of the day scheduled for the aircraft were Mopah Airport (WAKK) – Tanah Merah Airport (WAKT) – Oksibil Airport (WAJO) – Tanah Merah – Oksibil – Tanah Merah. The estimated time departure of first flight from Mopah Airport to Tanah Merah was 0800 LT and the flight departed at 0848 LT, on board the aircraft were two pilots and seven passengers. The aircraft arrived in Tanah Merah at about 0943 LT. At 1012 LT, the flight departed from Tanah Merah to Oksibil. About 10 Nm from Oksibil the pilot contacted the Oksibil tower controller to get air traffic services and landed at 1044 LT. The flight then departed from Oksibil to Tanah Merah at 1058 LT and arrived about 1126 LT. These flights were single pilot operation. At 1144 LT on daylight condition, the aircraft departed Tanah Merah with intended cruising altitude of 7,000 feet. Prior to departure, there was no report or record of aircraft system malfunction. On board the aircraft was one pilot, 1,225 kg of general cargo and 800 pounds of fuel which was sufficient for about 3 hours of flight time. After departure, the pilot advised Tanah Merah tower controller of the estimate time arrival at Oksibil would be 1224 LT. At 1149 LT, the pilot advised Tanah Merah tower controller that the aircraft position was about 10 Nm from Tanah Merah and passing altitude of 3,500 feet. The Tanah Merah tower controller acknowledged the message and advised the pilot to monitor radio communication on frequency 122.7 MHz for traffic monitoring. At about 29 Nm from Oksibil, the PK-FSO aircraft passed a Cessna 208B aircraft which was flying on opposite direction from Oksibil to Tanah Merah at altitude 6,000 feet. At this time, the aircraft ground speed recorded on the flight following system was about 164 knots. The Cessna 208B pilot advised to the pilot on radio frequency 122.7 MHz that the PK-FSO aircraft was in sight. The pilot responded that the aircraft was maintaining 7,000 feet on direct route to Oksibil. At 1230 LT, the Oksibil tower controller received phone call from the FlyingSAS officer at Jakarta which confirming whether the PK-FSO aircraft has landed on Oksibil. The Oksibil tower controller responded that there was no communication with the PK-FSO pilot. The Oksibil tower controller did not receive the flight plan for the second flight of the PK-FSO flight. Afterwards, the Oksibil tower controller called Tanah Merah tower controller confirming the PK-FSO flight and was informed that PK-FSO departed Tanah Merah to Oksibil at 1144 LT and the reported estimate time of arrival Oksibil was 1224 LT. At 1240 LT, the Oksibil tower controller received another phone call from the FlyingSAS officer at Jakarta which informed that the FlyingSAS flight following system received SOS signal (emergency signal) from PK-FSO aircraft and the last position recorded was on coordinate 04°48’47.7” S; 140°39’31.7” E which located approximately 6 Nm north of Oksibil. Afterwards, the Oksibil air traffic controller advised the occurrence to the Search and Rescue Agency. On 13 April 2017, at 0711 LT, the PK-FSO aircraft was found on ridge of Anem Mountain which located about 7 Nm north of Oksibil. The following figure showed the illustration of the aircraft track plotted on the Google earth refer to the known coordinates of Tanah Merah, Oksibil and the crash site.
Probable cause:
The possibility of the pilot being fatigue, physical and environment condition increased pilot sleepiness which might have made the pilot inadvertently falling asleep indicated by no pilot activity. The absence of GA-EGPWS aural alert and warning was unable to wake up the pilot.
Final Report:

Crash of a Boeing 747-412F in Bishkek: 39 killed

Date & Time: Jan 16, 2017 at 0719 LT
Type of aircraft:
Operator:
Registration:
TC-MCL
Flight Type:
Survivors:
No
Site:
Schedule:
Hong Kong - Bishkek - Istanbul
MSN:
32897/1322
YOM:
2003
Flight number:
TK6491
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
39
Captain / Total flying hours:
10808
Captain / Total hours on type:
820.00
Copilot / Total flying hours:
5894
Copilot / Total hours on type:
1758
Aircraft flight hours:
46820
Aircraft flight cycles:
8308
Circumstances:
On 16.01.2017, the crew of the Boeing 747-412F TC-MCL aircraft was performing a THY6491 flight from Hong Kong via Bishkek (Manas Airport) to Istanbul (Ataturk Airport) in order to transport the commercial cargo (public consumer goods) of 85 618 kg. The cargo was planned to be offloaded in Istanbul (Ataturk Airport). Manas Airport was planned as a transit airport for crew change and refueling. From 12.01.2017 to 15.01.2017, the crew had a rest period of 69 h in a hotel in Hong Kong. The aircraft takeoff from the Hong Kong Airport was performed at 19:12 on 5.01.2017, with the delay of 2 h 02 min in respect to the planned takeoff time. During the takeoff, the climb and the on-route cruise flight, the aircraft systems operated normally. At 00:41, on 16.01.2017, the aircraft entered the Bishkek ATC Area Control Center over the reference point of KAMUD at flight level of 10 400 m (according to the separation system, established in the People's Republic of China). At 00:51, the crew requested a descent and reached the FL 220 (according to the separation system, established in the Kyrgyz Republic). At 00:59, the crew received the weather information for Manas Airport: "the RVR at the RWY threshold 400 m, the RWY midpoint and RWY end 300 m, the vertical visibility 130 ft". At 01:01, the crew received the specified data: " in the center of the runway RVR three zero zero meters, vertical visibility one five zero feet." At 01:03, the crew requested a descent, the controller cleared for the descent not below FL 180. At 01:05, the crew was handed over to the Approach Control. At 01:06, the crew was cleared for the descent to FL 60, TOKPA 1 ILS approach chart, RWY 26. At 01:10, the controller reported the weather: wind calm, visibility 50 m, RVR 300 m, freezing fog, vertical visibility 160 ft, and requested the crew if they would continue the approach. The crew reported that they would continue the approach. The crew conducted the approach to RWY 26 in accordance with the standard approach chart. At 01:11, the controller informed the crew: "… transition level six zero" and cleared them for the ILS approach to RWY 26. At 01:15, the crew contacted the Tower controller. The Tower controller cleared them for landing on RWY 26 and reported the weather: "…wind calm… RVR in the beginning of the runway four hundred meters, in the middle point three hundred two five meters and at the end of the runway four hundred meters and vertical visibility one six zero... feet". The aircraft approached the RWY 26 threshold at the height significantly higher than the planned height. Continuing to descend, the aircraft flew over the entire length of the RWY and touched the ground at the distance of 900 m away from the farthest end of the runway (in relation to the direction of the approach) (the RWY 08 threshold). After the touchdown and landing roll, the aircraft impacted the concrete aerodrome barrier and the buildings of the suburban settlement and started to disintegrate, the fuel spillage occurred. As a result of the impact with the ground surface and the obstacles, the aircraft was completely disintegrated, a significant part of the aircraft structure was destroyed by the post-crash ground fire. At 01.17 UTC, the Tower controller requested the aircraft position, but the crew did not respond.
Probable cause:
The cause of the Boeing 747-412F TC-MCL aircraft accident was the missing control of the crew over the aircraft position in relation to the glideslope during the automatic approach, conducted at night in the weather conditions, suitable for ICAO CAT II landing, and as a result, the measures to perform a go-around, not taken in due time with the aircraft, having a significant deviation from the established approach chart, which led to the controlled flight impact with terrain (CFIT) at the distance of ≈930 m beyond the end of the active RWY.
The contributing factors were, most probably, the following:
- the insufficient pre-flight briefing of the flight crew members for the flight to Manas aerodrome (Bishkek), regarding the approach charts, as well as the non-optimal decisions taken by the crew when choosing the aircraft descent parameters, which led to the arrival at the established approach chart reference point at a considerably higher flight altitude;
- the lack of the crew's effective measures to decrease the aircraft vertical position and its arrival at the established approach chart reference point while the crew members were aware of the actual aircraft position being higher than required by the established chart;
- the lack of the requirements in the Tower controllers' job instructions to monitor for considerable aircraft position deviations from the established charts while the pertinent technical equipment for such monitoring was available;
- the excessive psycho-emotional stress of the crew members caused by the complicated approach conditions (night time, CAT II landing, long-lasting working hours) and their failure to eliminate the flight altitude deviations during a long time period. Additionally, the stress level could have been increased due to the crew's (especially the PIC's) highly emotional discussion of the ATC controllers' instructions and actions. Moreover, the ATC controllers' instructions and actions were in compliance with the established operational procedures and charts;
- the lack of the crew members' monitoring for crossing the established navigational reference points (the glideslope capture point, the LOM and LIM reporting points);
- the crew's failure to conduct the standard operational procedure which calls for altitude verification at the FAF/FAP, which is stated in the FCOM and the airline's OM. On the other hand, the Jeppesen Route Manual, used by the crew, contains no FAF/FAP in the RWY 26 approach chart;
- the onboard systems' "capture" of the false glideslope beam with the angle of ≈9°;
- the design features of the Boeing 747-400 aircraft type regarding the continuation of the aircraft approach descent in the automatic mode with the constant descent angle of 3° (the inertial path) with the maintained green indication of the armed automatic landing mode (regardless of the actual aircraft position in relation to the RWY) while the aircraft systems detected that the glideslope signal was missing (after the glideslope signal "capture"). With that, the crew received the designed annunciation, including the aural and visual caution alerts;
- the absence of the red warning alert for the flight crew in case of a "false" glideslope capture and the transition to the inertial mode trajectory, which would require immediate control actions from the part of the crew;
- the lack of monitoring from the part of the crew over the aircraft position in regard to the approach chart, including the monitoring by means of the Navigation Display (ND), engaged in the MAP mode;
- the crew's failure to conduct the Airline's Standard Operational Procedures (SOPs), regarding the performance of the go-around procedure in case the "AUTOPILOT" (the AP switching to the inertial mode) and "GLIDESLOPE" (the EGPWS annunciation of the significant glideslope deviation) alerts during the automatic CAT II landing at true heights below 1000 ft (with no visual reference established with either the runway environment or with the lighting system);
- the delayed actions for initiating the go-around procedure with no visual reference established with the runway environment at the decision height (DH). In fact, the actions were initiated at the true height of 58 ft with the established minimum of 99 ft.
Final Report:

Crash of a Let L-410UVP in Shabunda

Date & Time: Jan 2, 2017 at 1220 LT
Type of aircraft:
Operator:
Registration:
9Q-CZR
Flight Type:
Survivors:
Yes
Schedule:
Bukavu – Shabunda
MSN:
85 13 36
YOM:
1985
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew, one Russian and one Congolese, was performing a cargo flight from Bukavu to Shabunda, carrying various goods for a total weight of 1,300 kilos. After touchdown, after a course of about 300 metres, it is believed that the tire on the right main gear burst. The aircraft veered off runway and eventually collided with banana trees. Both pilots were uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 727-2J0F in Puerto Carreño: 5 killed

Date & Time: Dec 20, 2016 at 1722 LT
Type of aircraft:
Operator:
Registration:
HK-4544
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Puerto Carreño - Bogotá
MSN:
21105/1158
YOM:
1975
Flight number:
KRE157
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8708
Captain / Total hours on type:
6822.00
Copilot / Total flying hours:
3285
Copilot / Total hours on type:
3285
Aircraft flight hours:
60199
Circumstances:
The crew started the takeoff procedure at 1718LT from Puerto Carreño-Germán Olano Airport Runway 07 which is 1,800 metres long. Following a long takeoff roll, the pilot-in-command initiated the rotation when the aircraft overran then rolled for about 95 metres. It collided with two perimeter fences, passed through a road then lifted off. During initial climb, the right main gear was torn off after it collided with a tree and the engine n°3 failed. The airplane continued to climb to an altitude of 790 feet then entered a right turn and eventually crashed in an open field located 7,5 km from the airport, bursting into flames. The flight engineer was seriously injured while five other occupants were killed.
Probable cause:
The following findings were identified:
- Inadequate flight planning by the operator of the aircraft, and by the crew, by failure to properly perform dispatch procedures, takeoff performance calculations and verification of limitations imposed by operational conditions of the aerodrome according to the configuration of the aircraft.
- Wrong crew decision making by not considering a key aspect affecting aircraft performance, such as the prevailing tailwind at takeoff.
- Erroneous selection of takeoff speeds V1/VR and V2, by the crew, corresponding to an aircraft without modification in its flap system, which led to rotate the aircraft with five more knots of speed, increasing the takeoff run.
- Erroneous rotation technique applied by the Pilot, delayed maneuver that extended the long takeoff run even more.
- Loss of components (landing gear, trailing inboard flap right) and damage to functional systems (loss of engine power n°3 and hydraulic system) necessary to control the aircraft in flight.
- Loss of control in flight generated by asymmetries of lift, power and emptying of the main hydraulic systems that exceeded the capacity of the crew and made it impossible to maintain adequate directional control and stability of the aircraft.
Contributing Factors:
- Non-compliance with the Aeronautical Regulations by the operating company of the aircraft, operating to an aerodrome unsuitable for the operation of B727-200 equipment, which, in addition, was not authorized for that type of aircraft in the company's Operating Specifications, approved by the Aeronautical Authority.
- Lack of standardization and supervision of the operating company of the aircraft, allowing the operation of the B727-200 equipment, to which a modification had been applied to the flap system, with the reference tables of speeds corresponding to the aircraft without modification.
- Execution of take-off with a weight that exceeded the maximum value established in the aircraft performance charts for the conditions prevailing at the Germán Olano airport.
- Omission of the crew by not activating the Standby hydraulic system, which might have allowed emergency hydraulic pressure, to regain control of the aircraft.
- Lack of supervision by the Aeronautical Authority, which allowed for several years the operation of equipment B727-200 of the company operating the aircraft at the Germán Olano aerodrome in Puerto Carreño, when the characteristics of the aerodrome did not allow it and without the operator being authorized to operate equipment B727-200 in that aerodrome.
Final Report:

Crash of a Swearingen SA227AC Metro III in Camilla: 1 killed

Date & Time: Dec 5, 2016 at 2222 LT
Type of aircraft:
Operator:
Registration:
N765FA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Panama City – Albany
MSN:
AC-765
YOM:
1990
Flight number:
LYM308
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8451
Captain / Total hours on type:
4670.00
Aircraft flight hours:
24233
Circumstances:
The airline transport pilot delayed his scheduled departure for the night cargo flight due to thunderstorms along the route. Before departing, the pilot explained to the flight follower assigned to the flight that if he could not get though the thunderstorms along the planned route, he would divert to the alternate airport. While en route, the pilot was advised by the air traffic controller in contact with the flight of a "ragged line of moderate, heavy, and extreme" precipitation along his planned route. The controller also stated that he did not see any breaks in the weather. The controller cleared the pilot to descend at his discretion from 7,000 ft mean sea level (msl) to 3,000 ft msl, and subsequently, the controller suggested a diversion to the northeast for about 70 nautical miles that would avoid the most severe weather. The pilot responded that he had enough fuel for such a diversion but concluded that he would "see what the radar is painting" after descending to 3,000 ft msl. About 1 minute 30 seconds later, as the airplane was descending through 7,000 ft msl, the controller stated, "I just lost you on radar, I don't show a transponder, it might have to do with the weather." About 40 seconds later, the pilot advised the controller that he intended to deviate to the right of course, and the controller told the pilot that he could turn left and right as needed. Shortly thereafter, the pilot stated that he was going to turn around and proceed to his alternate airport. The controller cleared the pilot direct to his alternate and instructed him to maintain 3,000 ft msl. The pilot acknowledged the instruction, and the controller then stated, "do you want to climb back up? I can offer you any altitude." The pilot responded that he would try to climb back to 3,000 ft msl. The controller then recommended a heading of 180° to "get you clear of the weather quicker," and the pilot responded, "alright 180." There were no further communications from the pilot. Shortly thereafter, radar data showed the airplane enter a right turn that continued through about 540°. During the turn its airspeed varied between 198 and 130 knots, while its estimated bank angles were between 40 and 50°. Examination of the wreckage indicated that airplane experienced an in-flight breakup at relatively low altitude, consistent with radar data that showed the airplane's last recorded altitudes to be around 3,500 ft msl. The symmetrical nature of the breakup, damage to the outboard wings, and damage to the upper fuselage were all signatures indicative that the left and right wings failed in positive overload almost simultaneously. All of the fracture surfaces examined had a dull, grainy appearance consistent with overstress separation. There was no evidence of pre-existing cracking noted at any of the separation points, nor was there evidence of any mechanical anomalies that would have prevented normal operation. Review of base reflectivity weather radar data showed that, while the pilot was maneuvering to divert to the alternate airport, the airplane was operating in an area of light precipitation that rapidly intensified to heavy precipitation, as shown by radar scans completed shortly after the accident. During this time, the flight was likely operating in clouds along the leading edge of the convective line, where the pilot most likely would have encountered updrafts and severe or greater turbulence. The low visibility conditions that existed during the flight, which was conducted at night and in instrument meteorological conditions, coupled with the turbulence the flight likely encountered, were conducive to the development of spatial disorientation. Additionally, the airplane's maneuvering during the final moments of the flight was consistent with a loss of control due to spatial disorientation. The pilot's continued flight into known convective weather conditions and his delayed decision to divert the flight directly contributed to the accident. Although the operator had a system safety-based program, the responsibility for the safe outcome of the flight was left solely to the pilot. Written company policy required completion of a flight risk assessment tool (FRAT) before each flight by the assigned flight follower; however, a FRAT was not completed for the accident flight. The flight followers responsible for completing the FRATs were not trained to complete them for night cargo flights, and the operator's management was not aware that the FRATs were not being completed for night cargo flights. Further, if a FRAT had been completed for the accident flight, the resultant score would have allowed the flight to commence into known hazardous weather conditions without any further review. If greater oversight had been provided by the operator, it is possible that the flight may have been cancelled or re-routed due to the severity of the convective weather conditions present along the planned route of flight.
Probable cause:
The pilot's decision to initiate and continue the flight into known adverse weather conditions, which resulted spatial disorientation, a loss of airplane control, and a subsequent in-flight breakup.
Final Report:

Crash of a De Havilland DHC-4T Caribou near Ilaga: 4 killed

Date & Time: Oct 31, 2016 at 0830 LT
Type of aircraft:
Registration:
PK-SWW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Timika - Ilaga
MSN:
303
YOM:
1972
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
9336
Captain / Total hours on type:
38.00
Copilot / Total flying hours:
3636
Copilot / Total hours on type:
17
Aircraft flight hours:
2748
Aircraft flight cycles:
5953
Circumstances:
A DHC-4 Caribou aircraft, registered PK-SWW was being operated by Perkumpulan Penerbangan Alfa Indonesia, on 31 October 2016 on an unscheduled cargo flight from Moses Kilangin Airport Timika, with intended destination to Kaminggaru Aerodrome, Ilaga Papua. On board on this flight was 4 persons consisted of two pilots, one company engineer and one flight operation officer. At 2257 UTC, the aircraft departed Timika with intended cruising altitude of 12,500 feet and estimated time of arrival Ilaga at 2327 UTC. At 2323 UTC, the pilot made initial contact with Ilaga Aerodrome Flight Information Services (AFIS) officer and reported that the aircraft position was at Ilaga Pass and informed the estimate time of arrival Ilaga would be on 2327 UTC. Ilaga Aerodrome Flight Information Services (AFIS) officer advised to continue descend to circuit altitude and to report when position on downwind. At 2330 UTC, the AFIS officer called the pilot and was not replied. The AFIS officer asked pilot of another aircraft in the vicinity to contact the pilot of the DHC-4 Caribou aircraft and did not reply. At 0020 UTC, Sentani Aeronautical Information Service (AIS) officer declared the aircraft status as ALERFA. At 0022 UTC, Timika Tower controller received information from a pilot of an aircraft that Emergency Locator Transmitter (ELT) signal was detected approximately at 40 – 45 Nm with radial 060° from TMK VOR (Very High Frequency Omni Range) or approximately at coordinate 4°7’46” S; 137°38’11” E. This position was between Ilaga Pass and Jila Pass. At 0053 UTC, the aircraft declared as DETRESFA. On 1 November 2016, the aircraft wreckage was found on a ridge of mountain between Ilaga Pass and Jila Pass at coordinate 4°5’55.10” S; 137°38’47.60” E with altitude approximately of 13,000 feet. All occupants were fatally injured and the aircraft destroyed by impact force.
Probable cause:
Controlled flight into terrain.
Final Report: