Charter/Taxi (Non Scheduled Revenue Flight)

The amphibious-float-equipped airplane departed from a paved runway for the 40-nautical mile flight to its destination, where a water landing on a lake was to be made. The pilot did not raise the landing gear after takeoff. During the flight, the air was bumpy and turbulent, and this resulted in the gear advisory system activating numerous times. The purpose of the system is to alert the pilot of the landing gear position--up for a water landing or down for a runway landing--when the airspeed decreased below a set threshold value. The pilot disabled the system by pulling its circuit breaker because the alerts were becoming a nuisance; he intended to reset the breaker during descent, but did not do so. Upon reaching the destination, the pilot set up a 150- to 200-feet-per-minute rate of descent for a glassy water landing on the lake. With the landing gear in the down position, the airplane contacted the water and abruptly nosed over. The airplane came to rest floating inverted, suspended by the floats. The pilot reported that the day of the accident was his nineteenth consecutive duty day, including office duty and flight duty. He stated that he feels the lack of days off during the previous 19 days was a contributing factor to this accident. When asked what would have prevented the accident, the pilot suggested consistency in using the checklist. On two flights earlier in the day he had used a written checklist; on the accident flight he did not.

Pilot B arrived at Biggin Hill Airport, Kent, at about 1100 hrs for the planned flight to Pau, France. At about 1130 hrs he helped tow the aircraft from its overnight parking position on the Southern Apron to a nearby handling agent whose services were being used for the flight. A member of staff employed by the handling agent saw Pilot B carry out what was believed to be an external pre-flight check of the aircraft. Pilot B also asked another member of staff to provide a print out of the weather information for the flight. Pilot A arrived at about 1145 hrs and joined Pilot B at the aircraft. Witnesses described nothing unusual in either pilots’ demeanour. Three passengers arrived at the handling agent at about 1300 hrs and waited in a lounge whilst their bags were taken to the aircraft and loaded into the baggage hold in the nose. A member of the handling agency, who later took the passengers to the aircraft, reported that Pilot B met them outside the aircraft. After they had all boarded, the agent heard Pilot B say that he would give them a safety brief. Pilot B then closed the aircraft door. Pilot A called for start at 1317 hrs. He called for taxi at 1320 hrs and the aircraft was cleared to taxi to the holding point A1. No one could be identified as a witness to the aircraft’s start or subsequent taxi to the holding point. At 1331 hrs ATC cleared the aircraft to line up on Runway 21 and at 1332 hrs cleared it to take off. Both clearances were acknowledged by Pilot A. The takeoff was observed by the tower controller who stated that everything appeared normal. No transmissions were made between the aircraft and ATC until one minute after takeoff when, at 1334 hrs, the following exchange was made. Numerous witnesses reported seeing the aircraft at around this time flying over a built-up area, about 2 nm north-north-east of Biggin Hill Airport, where it was observed flying low, passing over playing fields and nearby houses. Witnesses reported that the aircraft was maintaining a normal flying attitude with some reporting that the landing gear was up and others that it was down. Some described seeing it adopt a nose-high attitude and banking away from the houses just before it crashed. Some witnesses stated that there was no engine noise coming from the aircraft whilst others stated that they became aware of the aircraft as it flew low overhead due to the loud noise it was making, as if the engines were at high thrust. Two witnesses described hearing the aircraft make a pulsing, intermittent noise. The location of witnesses and the description of the aircraft noise they heard are also shown in Figure 1. Having flown over several houses at an extremely low height the aircraft’s left wing clipped a house which bordered a small area of woodland. The aircraft then impacted the ground between this and another house and caught fire. There were no injuries to anyone on the ground but all those on board the aircraft were fatally injured.

TF-ARS (B747-300) was on a scheduled flight from Medina (Saudi Arabia) to Dhaka (Bangladesh), flight number SVA810. The flight crew consisted of a commander, copilot and a flight engineer. The cabin crew consisted of 15 crew members including one senior cabin attendant. Additionally to the cabin crew, one “off duty” cabin crew member was in the cabin. According to the commander, the flight from Medina and the landing at Dhaka was uneventful. During the landing roll, approximately 50 seconds after touchdown, the flight crew received a call from the tower controller where the tower controller inquired whether the aircraft was under control. The flight crew responded to the call by stating that the aircraft was completely under control and asked what the problem seemed to be. The controller then informed the flight crew that fire was observed at the right wing area. At this point the Aerodrome Fire Operator had already activated the fire fighters as well as the rescue team. As soon as the controller had informed the flight crew about the fire, the flight crew received a No. 3 engine fire alarm. The co-pilot immediately discharged the first engine fire bottle and the flight crew requested firefighter assistance and shut down all engines. The co-pilot waited 20 seconds until the second fire bottle was discharged. At this time the commander called the senior cabin attendant to the flight deck using the public address system (PA). This command was followed by a command to the cabin crew to remain seated. The commander informed the senior cabin attendant of the situation and instructed him to evaluate the situation and to evacuate the passengers if necessary. The senior cabin attendant went back down to the main deck and saw the smoke and the fire through the windows. He then commanded the cabin crew as well as passengers, by using a megaphone, to evacuate the aircraft. The cabin attendant at location L2 (see figure 6-7, page 21) had already operated the emergency exit and started evacuating the passengers. Cabin attendants at locations L1 and R2 (see figure 6-7, page 21) also operated their respective emergency exits. After realizing that smoke and fire were at the right hand side, the emergency exit at R2 was blocked by one of the cabin attendants. All passengers managed to evacuate without serious injuries and the fire department at Zia International Airport managed to extinguish the fire successfully. The damage to the aircraft was later evaluated as beyond economical repair.

The twin engine aircraft was completing a touristic flight from Punta Cana to Santiago de los Caballeros and back. During the return flight to Punta Cana, the pilot elected to make a fuel stop at La Romana because he failed to refuel at Santiago de los Caballeros and was aware that the left tank fuel gage was inoperative. En route, the left engine failed. The pilot elected to restart it but without success. He decided to attempt an emergency landing in a sugarcane field located in El Prado. Upon landing, the aircraft lost its undercarriage and slid for few dozen metres before coming to rest. All nine occupants escaped uninjured while the aircraft was damaged beyond repair.

The airline transport pilot and nine passengers were departing in a twin-engine airplane on a 14 Code of Federal Regulations Part 135 air taxi flight from a runway adjacent to an ocean bay. According to the air traffic control tower specialist on duty, the airplane became airborne about midway down the runway. As it approached the end of the runway, the pilot said he needed to return to the airport, but gave no reason. The specialist cleared the airplane to land on any runway. As the airplane began a right turn, it rolled sharply to the right and began a rapid, nose- and right-wing-low descent. The airplane crashed about 200 yards offshore and the fragmented wreckage sank in the 10-foot-deep water. Survivors were rescued by a private float plane. A passenger reported that the airplane's nose baggage door partially opened just after takeoff, and fully opened into a locked position when the pilot initiated a right turn towards the airport. The nose baggage door is mounted on the left side of the nose, just forward of the pilot's windscreen. When the door is opened, it swings upward, and is held open by a latching device. To lock the baggage door, the handle is placed in the closed position and the handle is then locked by rotating a key lock, engaging a locking cam. With the locking cam in the locked position, removal of the key prevents the locking cam from moving. The original equipment key lock is designed so the key can only be removed when the locking cam is engaged. Investigation revealed that the original key lock on the airplane's forward baggage door had been replaced with an unapproved thumb-latch device. A Safety Board materials engineer's examination revealed evidence that a plastic guard inside the baggage compartment, which is designed to protect the door's locking mechanism from baggage/cargo, appeared not to be installed at the time of the accident. The airplane manufacturer's only required inspection of the latching system was a visual inspection every 100 hours of service. Additionally, the mechanical components of the forward baggage door latch mechanism were considered "on condition" items, with no predetermined life-limit. On May 29, 2008, the Federal Aviation Administration issued a safety alert for operators (SAFO 08013), recommending a visual inspection of the baggage door latches and locks, additional training of flight and ground crews, and the removal of unapproved lock devices. In July 2008, Piper Aircraft issued a mandatory service bulletin (SB 1194, later 1194A), requiring the installation of a key lock device, mandatory recurring inspection intervals, life-limits on safety-critical parts of forward baggage door components, and the installation of a placard on the forward baggage door with instructions for closing and locking the door to preclude an in-flight opening. Post accident inspection discovered no mechanical discrepancies with the airplane other than the baggage door latch. The airplane manufacturer's pilot operating handbook did not contain emergency procedures for an in-flight opening of the nose baggage door, nor did the operator's pilot training program include instruction on the proper operation of the nose baggage door or procedures to follow in case of an in-flight opening of the door. Absent findings of any other mechanical issues, it is likely the door locking mechanism was not fully engaged and/or the baggage shifted during takeoff, and contacted the exposed internal latching mechanism, allowing the cargo door to open. With the airplane operating at a low airspeed and altitude, the open baggage door would have incurred additional aerodynamic drag and further reduced the airspeed. The pilot's immediate turn towards the airport, with the now fully open baggage door, likely resulted in a sudden increase in drag, with a substantive decrease in airspeed, and an aerodynamic stall.

Around 1100LT, an airport maintenance team consisting of four people in two cars (Kia minivan) was cleared to enter runway 08R to perform maintenance work on the runway lighting system. Two of the men were working at about 600 meters from the threshold and the two other men were working at about 1500 meters from the threshold. Visibility at the time was poor due to thick fog. At 11:04 the runway was vacated by both vehicles due to landing traffic. At 11:06 they were recleared to enter the runway. At 11:25:13 flight ROT3107, a Boeing 737-300, was cleared to enter runway 08R for takeoff. The flight was cleared for takeoff at 11:26:07. Between 11:26:40 and 11:26:50 the control tower asked the maintenance workers if the runway was clear but got no reply. During the takeoff roll, at a speed of 90 knots, the aircraft collided with one of the van that was 'parked' about 600 metres from the threshold with its left engine and left main gear. The van was totally destroyed upon impact and the aircraft veered off runway to the left and came to rest 137 metres to the left of the centerline and 950 metres from the threshold. All 123 occupants evacuated safely and there were no injuries with ground maintenance personnel.

On December 25, 2007 a crew of JetConnection Businessflight AG airline including the PIC, the co-pilot and a flight attendant was conducting a charter flight JCX826 routed Hannover (Germany), Astana (Republic of Kazakhstan) – Macao (China) on a CL-604 aircraft (registration D-ARWE). Apart from the crew there was one passenger on board. At 12:10 (hereinafter UTC time is used) on December 25, 2007 the crew took off at Hannover Airport. During the flight the crew was informed that there was no fuel available for refueling the aircraft at Astana Airport. Due to this the crew decided to change the flight route and refuel the aircraft at Almaty International Airport (Republic of Kazakhstan). The flight from Hannover to Almaty in accordance with the PIC explanations was normal. No faults in the operation of the aircraft systems or equipment were detected. At 18:46 the crew landed at Almaty Airport. The ground handling service at Almaty Airport was provided by Bercut Air Services KZ based at the airport. The departure from Almaty to Macao according to the schedule was planned for 20:50 on December 25, 2007. The ground handling and servicing was provided by Bercut Air Services KZ Company. In accordance with the work order the Almaty ground services conducted refueling and anti-icing. The Pre-Flight Check was conducted by the PIC. He also monitored the refueling and stabilizer and wing anti-icing. According to the PIC interrogation there were no faults detected in the operation of aircraft systems and equipment. 8460 liters (6827 kg) of TC-1 condition fuel was refueled. According to the estimations, total fuel on board was 7605 kg. The refueled fuel was distributed in the fuel tanks in accordance with the AFM of the CL-604 aircraft. In accordance with the estimations the aircraft weight was 20659 kg, CG 33,1%, which was within the CL-604 AFM limitations. During the pre-flight preparation for the flight to Macao the crew of the CL-604 D-ARWE did not receive the meteorological consultation or documentation at the Almaty Meteorological Center. According to BFU information the crew of the JCX826 flight had received the integrated meteorological consultation for the flight to Macao before the takeoff from Hannover. In Almaty PIC has received updated data through the Internet from the website of the German Meteorological Service (DWD) and also from the PPS provider of the JetConnection Businessflight AG (Billund, Denmark). According to the ATC tape recorder data containing the communication of the СL-604 D-ARWE crew with the ATC offices of Almaty airport, at 20:17:55 the crew informed the Ground Control that they were ready to startup and taxi right after the completion of the anti-icing procedure. At 20:18:24 the Ground Control instructed the crew: “JCX826, expect start up in 5 minutes.” At 20:20:48 in reply to the Controller’s request if they were ready for start-up the crew reported: “We are expecting anti-icing which is about to start now”. While waiting for the anti-icing the crew received the ATC clearance for departure. In accordance with the DE-ICING\ANTI-ICING REQUEST from the 25.12.2007, signed by the PIC and the Bercut Air Servises KZ manager the processing with using Type 1 and Type 2 fluids was conducted in two steps. On the first stage Type 1 deicing fluid (Killfrost DF Plus) was applied to remove the icing with the estimated fluid to water ratio of 70/30%. According to the enquiry of the de-icing operator the temperature of the Type 1 fluid in the tank of the SIMON GLOBAL 2110 machine used for the fluid application was about + 80˚ С, and at the outlet of the sprayer it was not less than +60˚ С. Note: The check of the SIMON GLOBAL 2110 machine conducted by the investigation team after the accident revealed that the temperature of the Type 1 fluid at the outlet of the sprayer is +66˚ С, which complies with the СL-604 OM (Part 1, page 06-12-17). On the second stage of the anti-icing procedure the Type 2 anti-icing fluid was used (Killfrost ABC 2000) with the estimated fluid to water ratio of 100/0%. Note: In the fluid Type 1 and Type 2 delivery receipt No.4002014 by mistake was shown unreal concentration 70/00 for the Type 2 fluid instead of its real concentration 100/00. The OM of the CL-604 does not suggest preliminary heating and heating monitoring of Type 2 fluid. According to the record in the aircraft fuelling receipt the amount of the applied Type 2 fluid was 250 liters. According to the requirements of Annex A, page XXI of the AEA, Training Recommendation and background Information for de-icing/anti-icing of aircraft on the ground, Edition 2, September 2005 the recommended anti-icing fluid minimum for the wing and stabilizer of a CL-604 type aircraft was 100 liters. Thus enough Type 2 fluid was applied for the anti-icing of CL-604 D-ARWE. The inspection of the fluid samples used for the de-icing/anti-icing of the CL-604 D-ARWE aircraft conducted at Almaty airport laboratory revealed that the Type 1 fluid had an actual fluid to water ratio of 67/33% while the Type 2 fluid 99/1%. Provided the OAT at Almaty airport at the time of the fluid application was minus 13˚ С, the mentioned ratios were within the requirements of the CL-604 OM (Part 1, Section VI, Cold Weather Operations). The actual weather at Almaty airport according to the request of the Approach Control for 20:49 was as follows: surface wind 360˚ 2 m/sec, RVR 2900 m, light snow, mist, clouds 8 oktas, nimbostratus, fractonimbus, cloudbase 150 m, QFE 718 mm mercury, OAT minus 12,9˚ С, dewpoint minus 13,7˚, moisture content 93%, QFE 718 mm mercury. In accordance with the de-icing/anti-icing operator the de-/anti-icing procedure was conducted in compliance with the CL-604 OM recommendations in the following order: stabilizer, left wing, right wing. Every surface was applied first with Type 1 and then Type 2 fluid. The time between the completion of the Type 1 application and the beginning of the Type 2 application in accordance with the operator’s explanations did not exceed 1.5-2 minutes which is suggested in Section VI of the CL0604 OM. According to the estimations conducted by the investigation team the application of the Type 2 fluid was started at 20:37. Note: In accordance with the CL-604 OM (Part 1, page 06-12-13), the holdover time of the Type 2 fluid with the fluid to water ration of 100/0 in the OAT range of -3…-20˚ С, with precipitation in the form of snow and snow grain is 15…30 minutes. According to the information recorded by the FDR, during the de-/anti-icing the aircraft flaps were retracted while the stabilizer deflection was minus 4,7˚. By 20:43 the de-/anti-icing procedure was completed. On leaving the aircraft the PIC made a visual and tactile (by touching the wing surface) inspection of the anti-icing quality, admitted that it was satisfactory by signing in the de-/anti-icing receipt. After that the PIC returned to the aircraft and the crew began the engine start-up. In accordance with the FDR information, by 20:46 the crew had started up first the right engine and then the left engine. The N2 of the right and left engine in the idle mode was 61,5 % and 62,0 % respectively. In 10 seconds after the left engine start-up the Cowl Anti-Ice was engaged. In accordance with the CVR information, a check at a stage After Engine Start was performed by the flight crew in a volume which stipulated by the JetConnection Businessflight AG “ABBRIVIATED CHECKLIST”. However a comparison of this checklist with the CL-604 D-ARWE AFM checklist (Chapter 4 “Normal Procedures” Section “Consolidated Checklists” Item L “After Engine Start Check”) shows the absences of WAI and CAI systems checks. Note: For a number of other preflight preparation stages the JetConnection Businessflight AG “ABBRIVIATED CHECKLIST” also doesn’t cover all procedures stipulated by the CL-604 AFM. At 20:47:42 the crew reported the Ground Control that they were ready for taxiing. At 20:48:25 the Ground Control cleared the crew for the holding point following the leader van. Within 20:51:17 – 20:51:45, the crew checked the rudder, the ailerons and elevators and extended the flaps to the takeoff position (Flaps 20). The stabilizer position (-4,7˚) did not change. At 20:51:55 the crew was instructed by the Ground Control to expect further instructions at the holding point and contact the Tower Control. At 20:52:17 after contacting the Tower Control the crew was instructed to wait on the holding point as there was an MD-83 aircraft making Flight UKM 109 on final at a distance of 14 km. At 20:57:15, after the MD-83 landed the Tower Control cleared the CL-604 D-ARWE to line up at RWY 05 and at 21:01:30 they were cleared for takeoff. During the takeoff an increasing right bank started developing. As the aircraft was banking to the right it touched the right runway edge with its right wing tip. Then the aircraft, leaning on the right wing, moved to the graded airfield to the right of the runway and hit its surface with the right main landing gear and nose landing gear. During the further movement the aircraft hit the reinforced fence of the airdrome and shifting on the ground 190 m beyond the airdrome finally stopped. At the final stage of movement a fire occurred which was extinguished by the airport fire brigades. The actual weather at Almaty airport checked after the accident alert at 21:04 was as follows: wind 350° 4 m/sec, visibility 1200 m (RVR 2500 m), snow, mist, clouds 8 oktas, nimbostratus, fractonimbus, cloudbase 120 m, OAT minus 14° С, dewpoint minus 15° С, moisture content 92%, pressure 718 mm mercury. Runway 05 condition – dry snow up to 10 mm, friction factor 0.32. The accident occurred on December 25, 2007 at 21:02 UTC (26.12.2007 at 03:02 local time).

En route from Hurghada to Warsaw, while cruising over Turkey, the crew contacted ATC and reported electrical and hydraulic problems. The crew was cleared to divert to Istanbul-Atatürk Airport for an emergency landing. After touchdown, the aircraft was unable to stop within the remaining distance. It overran and came to rest near the ILS antenna after both main gears collapsed. All 163 occupants evacuated safely and the aircraft was damaged beyond repair.

On final approach to Malemba Nkulu, the twin engine aircraft stalled and crashed in a cemetery located 500 metres short of runway. The copilot was killed while four passengers and the captain were seriously injured. The stewardess escaped unhurt. The aircraft was destroyed.

Prior to departing, the pilot looked at the fuel quantity indicators, and believed that approximately 3 hours of fuel was available for the estimated 1 hour 20 minute flight. Upon reaching the cruise portion of the flight, the pilot realized that an insufficient quantity of fuel remained in order to complete the planned flight, and he elected to divert to a closer airport. While on final approach to the diversionary airport, both engines lost power, and the pilot made a forced landing to a parking lot. When asked about the performance and handling of the airplane during the flight, the pilot stated, "the airplane performed the way it was suppose to when it ran out of fuel."