Crash of a Beechcraft A100 King Air in Pointe-Noire

Date & Time: Dec 4, 2011 at 1422 LT
Type of aircraft:
Operator:
Registration:
9Q-CEM
Survivors:
Yes
Schedule:
Moanda - Pointe-Noire
MSN:
B-105
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Moanda, Gabon, the crew initiated the approach in poor weather conditions (rain falls, strong crosswinds and turbulences). After touchdown, the twin engine aircraft skidded then veered off runway to the left. While contacting soft ground, the landing gear collapsed and the left engine was partially torn off. All 10 occupants escaped uninjured while the aircraft was damaged beyond repair. Wind shear conditions are suspected.

Crash of a Cessna 208B Grand Caravan in Talcha

Date & Time: Nov 21, 2011 at 1600 LT
Type of aircraft:
Operator:
Registration:
9N-AJM
Survivors:
Yes
Schedule:
Nepalgunj – Talcha
MSN:
208B-0561
YOM:
1996
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 36 at Talcha Airport, the single engine aircraft veered off runway, went down an embankment and came to rest against a house down the runway. All 12 occupants escaped uninjured while the aircraft was damaged beyond repair. Downdrafts on final approach were reported, and the aircraft seemed to be unstable prior to landing.

Crash of a Piaggio P.180 Avanti II in Flint

Date & Time: Nov 16, 2011 at 0940 LT
Type of aircraft:
Operator:
Registration:
N168SL
Survivors:
Yes
Schedule:
Detroit - West Bend
MSN:
1139
YOM:
2007
Flight number:
VNR168
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3851
Captain / Total hours on type:
2023.00
Copilot / Total flying hours:
3957
Copilot / Total hours on type:
259
Aircraft flight hours:
4422
Circumstances:
During climb to cruise, the captain increased left engine power and the engine power lever became jammed in the full forward position. This condition resulted in an engine overtorque and overtemperture condition, and the captain shut down the left engine. After the engine shutdown, both primary flight display screens went blank. The captain reset the right generator and the flight displays regained power and display. Due to the engine shutdown, the captain diverted to a nearby airport and attempted a single-engine precautionary landing in visual flight rules conditions. Based on wind conditions at the airport (290 degrees at 18 knots), runway 27 was being used for operations. During the descent, the crew became confused as to their true heading and were only able to identify runway 27 about a minute before touching down due to a 50-degree difference in heading indications displayed to the crew as a result of the instrument gyros having been reset. Accurate heading information would have been available to the crew had they referenced the airplane’s compass. Having declared an emergency, the crew was cleared to land on any runway and chose to land on runway 18. After touchdown, the captain applied reverse thrust on the right engine and the airplane veered to the right. The airplane flight manual’s single-engine approach and landing checklist indicates that after landing braking and reverse thrust are to be used as required to maintain airplane control. The airplane continued to the right, departed the runway surface, impacted terrain, flipped over, and came to rest inverted. At the point of touchdown, there was about 5,000 feet of runway remaining for the landing roll. The loss of directional control was likely initiated when the captain applied reverse thrust shortly after touchdown, and was likely aggravated by the strong crosswind. Postaccident examination of the airplane showed a clevis pin incorrectly installed by unknown maintenance personnel that resulted in a jammed left engine power lever. No additional anomalies were noted with the airplane or engines that would have precluded normal operation.
Probable cause:
The captain's failure to maintain directional control during landing with one engine inoperative. Contributing to the accident was an improperly installed clevis pin in the left engine power lever, the crew’s delay in accurately identifying their heading, and their subsequent selection of a runway with a strong crosswind.
Final Report:

Crash of a PZL-Mielec AN-28 in Shabunda

Date & Time: Oct 31, 2011
Type of aircraft:
Operator:
Registration:
9Q-CSX
Survivors:
Yes
MSN:
1AJ003-12
YOM:
1987
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Shabunda Airport, the crew reported engine problems and elected to return. After touchdown, the twin engine airplane was unable to stop within the remaining distance, overran and came to rest against an embankment. All 16 passengers escaped unhurt while both pilots were injured. The aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere during October 2011.

Crash of a Cessna 401A near Nairobi: 2 killed

Date & Time: Oct 21, 2011 at 1523 LT
Type of aircraft:
Registration:
5Y-CAE
Survivors:
Yes
Schedule:
Nairobi - Marsabit - Lodwar - Nairobi
MSN:
401-0011
YOM:
1967
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Nairobi-Wilson Airport in the morning for a flight to Marsabit and Lodwar, carrying exam documents. While returning to Wilson Airport in the afternoon, the airplane went out of control and crashed in an open field located about 15 km west of Wilson Airport. The pilot and a passenger were killed while the second passenger was seriously injured. The aircraft was destroyed.

Crash of a Cessna 208B Grand Caravan in Xakanaka: 8 killed

Date & Time: Oct 14, 2011 at 1355 LT
Type of aircraft:
Operator:
Registration:
A2-AKD
Flight Phase:
Survivors:
Yes
Schedule:
Xakanaka - Pom Pom
MSN:
208B-0582
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
Shortly after takeoff from Xakanaka Airstrip on a taxi flight to the Pom Pom Camp located in the Okavango Delta, the single aircraft lost height and crashed, bursting into flames. The pilot and seven passengers were killed while four others were injured. The pilot was a British citizen as the seven passengers killed were respectively four Swedish, on British and two French. The aircraft was totally destroyed by a post crash fire. For unknown reasons, the aircraft caught fire shortly after takeoff.

Crash of a Mitsubishi MU-2B-25 Marquise in Cobb County

Date & Time: Sep 28, 2011 at 1715 LT
Type of aircraft:
Registration:
N344KL
Survivors:
Yes
Schedule:
Huntsville - Cobb County
MSN:
257
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11100
Captain / Total hours on type:
1500.00
Aircraft flight hours:
6196
Circumstances:
The pilot stated that after landing, the nose landing gear collapsed. Examination of the airplane nose strut down-lock installation revealed that the strut on the right side of the nose landing gear trunnion was installed incorrectly; the strut installed on the right was a left-sided strut. Incorrect installation of the strut could result in the bearing pulling loose from the pin on the right side of the trunnion, which could allow the nose landing gear to collapse. A review of maintenance records revealed recent maintenance activity on the nose gear involving the strut. The design of the strut is common for the left and right. Both struts have the same base part number, and a distinguishing numerical suffix is added for left side and right side strut determination. If correctly installed, the numbers should be oriented facing outboard. The original MU-2 Maintenance Manual did not address the installation or correct orientation of the strut. The manufacturer issued MU-2 Service Bulletin (SB) No. 200B, dated June 24, 1994, to address the orientation and adjustment. Service Bulletin 200B states on page 8 of 10 that the “Part Number may be visible in this (the) area from the out board sides (Inked P/N may be faded out).”
Probable cause:
The improper installation of the nose landing gear strut and subsequent collapse of the nose landing gear during landing.
Final Report:

Crash of a Beechcraft 1900D in Kathmandu: 19 killed

Date & Time: Sep 25, 2011 at 0731 LT
Type of aircraft:
Operator:
Registration:
9N-AEK
Survivors:
No
Schedule:
Kathmandu - Kathmandu
MSN:
UE-295
YOM:
1997
Flight number:
BHA103
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
19
Copilot / Total hours on type:
18
Circumstances:
The aircraft was performing a special flight with tourists above the Himalayan mountains and especially a tour of the Everest in the early morning. While returning to Kathmandu-Tribhuvan Airport, the copilot (PIC) was cleared to descend to 6,000 feet for a landing on runway 02. In marginal weather conditions, he passed below 6,000 feet until the aircraft contacted trees and crashed in hilly and wooded terrain located near the village of Bishanku Narayan, some 6,7 km southeast of the airport. The aircraft was destroyed by impact forces and a post crash fire. A passenger was seriously injured while 18 other occupants were killed. Few hours later, the only survivor died from his injuries. The 16 tourists were respectively 10 Indians, 2 Americans, 1 Japanese and 3 Nepalese.
Probable cause:
The Accident Investigation Commission assigned by Nepal's Ministry of Tourism and Civil Aviation have submitted their report to the Ministry. The investigators said in a media briefing, that human factors, mainly fatigue by the captain of the flight, led to the crash. The aircraft was flown by the first officer and was on approach to Kathmandu at 5,000 feet MSL instead of 6,000 feet MSL as required, when it entered a cloud. While inside the cloud in low visibility the aircraft descended, hit tree tops and broke up. The captain had flown another aircraft the previous day and had been assigned to the accident flight on short notice in the morning of the accident day, but did not have sufficient rest. The commission analyzed that due to the resulting fatigue the captain assigned pilot flying duties to the first officer although she wasn't yet ready to cope with the task in demanding conditions. The newly assigned first officer had only 18 hours experience on the aircraft type. The mountain view round trip had to turn back about midway due to weather conditions. While on a visual approach to Kathmandu at 5,000 instead of 6,000 feet MSL the aircraft entered a cloud and started to descend until impact with tree tops. The crew did not follow standard operating procedures, that amongst other details required the aircraft to fly at or above 6,000 feet MSL in the accident area, the interaction between the crew members did not follow standard operating procedures, for example the captain distracted the first officer with frequent advice instead of explaining the/adhering to procedures. The commission said as result of the investigation they released a safety recommendation requiring all operators to install Terrain Awareness and Warning Systems (TAWS) in addition to eight other safety recommendations regarding pilot training, installation of visual aids, safety audit and fleet policies.

Crash of a Pilatus PC-6/B2-H4 Turbo Porter near Yahatma: 3 killed

Date & Time: Sep 22, 2011 at 1313 LT
Operator:
Registration:
PK-UCE
Flight Phase:
Survivors:
No
Site:
Schedule:
Pagai - Wamena
MSN:
943
YOM:
2004
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11312
Captain / Total hours on type:
2647.00
Aircraft flight hours:
5774
Aircraft flight cycles:
6662
Circumstances:
On 22 September 2011, a PC 6 Pilatus Porter aircraft, registration PK-UCE was being operated by Yayasan Jasa Aviasi Indonesia (YAJASI) departed from Pagai to Wamena. The aircraft departed at 0403 UTC1 (1303 LT) and estimated to arrive at Wamena was at 0436 UTC. Aircraft cruise at altitude of 10,000 feet and conducted under Visual Flight Rules (VFR) and followed the visual route via North Gap corridor, which one of visual route to Wamena. Prior to enter the North Gap corridor at time 0413 UTC, the pilot sent a message via a system they called AFFIS to the company Flight Following Officer at Sentani Airport, which was the operation base. The pilot also sent a blind transmission message through Wamena Tower radio frequency. This was local procedure, to submit the message consists of position, altitude and destination to make the other aircraft pilots aware each other. As in the intern YAJASI flight following procedure, pilot should send message when the flying passes the North Gap corridor. In this flight, until the normal elapsed time, the pilot did not send any message to their Flight Following Officer at Sentani that the flight has passed the North Gap corridor. Since there was no message nor radio contact from the pilot until the ETA in Wamena, the Flight Following Officer at Sentani informed to the other personnel at the operation base, and alarmed to the other YAJASI aircraft which were flying in that area to start search the PK-UCE. Some other aircrafts which were flying in the vicinity also contacted to search the PKUCE. PK-UCE was found in mountain location adjacent to Pass Valley airstrip. The accident site was at coordinate S 030 54’ 54.4’’, E 1390 02’ 24.3”, the aircraft was hit the trees and the ground where the elevation was about 7500 feet , the propeller blades was not on feather and bent rearward, the left wing was broken and the aircraft stopped on heading about 85°.
Probable cause:
The pilot decided to descend from the cruise altitude 10000 feet to penetrate the area of marginal weather was most likely not as what his perceive. The pilot avoided the cloud to the left of the VFR route guidance and most likely that the space available was less than the requirement stated for the Weather Minimum class F.
Final Report:

Crash of a Yakovlev Yak-42D in Yaroslavl: 44 killed

Date & Time: Sep 7, 2011 at 1600 LT
Type of aircraft:
Operator:
Registration:
RA-42434
Flight Phase:
Survivors:
Yes
Schedule:
Yaroslavl - Minsk
MSN:
4520424305017
YOM:
1993
Flight number:
AEK9633
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
44
Captain / Total flying hours:
6954
Captain / Total hours on type:
1525.00
Copilot / Total flying hours:
13492
Copilot / Total hours on type:
613
Aircraft flight hours:
6490
Aircraft flight cycles:
3112
Circumstances:
The aircraft was chartered by the Lokomotiv Yaroslavl ice hockey team to carry his staff to Minsk to take part to the first game of the Russian 2011-2012 championship. During the takeoff roll from runway 23 at Yaroslavl-Tunoshna Airport, the crew selected flaps down at 20° and the stabilizer in a nose-up position of 8,7°. The aircraft slowly accelerated to 165 km/h due to a residual pressure on the brake pedal. At a speed of 185 km/h and at a distance of 1,350 metres from the runway end, the nose gear lifted off. But the aircraft continued, passed the runway end and rolled for about 400 metres before it took off. Then it collided with various approach lights and the localizer antenna, lost height and eventually crashed on the shore of the Volga River, bursting into flames, 2 minutes after the takeoff roll was initiated. A passenger and the flight engineer were seriously injured while 43 other occupants were killed. Almost a week later, the passenger died from his injuries. Among the passengers were 26 players from the Lokomotiv Yaroslavl ice hockey team, Russian citizens and also Canadian, Czech, Ukrainian, German and Slovak. The Canadian coach Brad McCrimmon, his both assistants, the cameraman, three masseurs, one admin and two doctors were among the victims.
Probable cause:
Erroneous actions on part of the crew, especially by applying brake pedal pressure just before rotation as result of a wrong foot position on the pedal during the takeoff run. This led to braking forces on the main gear requiring additional time for acceleration, a nose down moment preventing the crew to establish a proper rotation and preventing the aircraft to reach a proper pitch angle for becoming airborne, overrun of the runway at high speed with the elevator fully deflected for nose up rotation (producing more than double the elevator forces required to achieve normal takeoff rotation). The aircraft finally achieved a high rate of nose up rotation, became airborne 450 meters past the runway end and rotated up to a supercritical angle of attack still at a large rate of pitch up causing the aircraft to stall at low altitude, to impact obstacles and ground, break up and catch fire killing all but one occupants.
Contributing factors were:
- serious shortcomings in the re-training of the crew members with regards to the Yak-42, which did not take place in full, was spread out over a long period of time and took place while the crew remained in full operation on another aircraft type (Yak-40), which led to a negative transfer of skills, especially a wrong position of the foot on the brake pedal on the Yak-42,
- Lack of supervision of the re-training,
- errors and missed procedures by the crew in preparation and execution of the takeoff,
- inconsistent, uncoordinated actions by the crew in the final stages of the takeoff.
Final Report: