Crash of a Cessna 340 in Riyadh

Date & Time: Dec 3, 2014 at 1757 LT
Type of aircraft:
Registration:
N340JC
Flight Type:
Survivors:
Yes
Schedule:
Heraklion – Hurghada – Riyadh
MSN:
340-0162
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a ferry flight from Heraklion to Riyadh with an intermediate stop in Hurghada, Egypt. On final approach to Riyadh-King Khaled Airport, at an altitude of about 600 feet, the left engine lost power and failed, followed 10 seconds later by the right engine. The crew reported his situation to ATC when the aircraft lost height, impacted ground and slid for few dozen metres before coming to rest against a pile of rocks. One of the pilot suffered a broken wrist while the second pilot escaped uninjured. The aircraft was damaged beyond repair.
Probable cause:
Double engine failure on approach due to fuel exhaustion. It was determined that the crew miscalculated the fuel consumption for the flight from Hurghada to Riyadh.

Crash of a Beechcraft B200 Super King Air in Wichita: 4 killed

Date & Time: Oct 30, 2014 at 0948 LT
Registration:
N52SZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wichita – Mena
MSN:
BB-1686
YOM:
1999
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3139
Aircraft flight hours:
6314
Aircraft flight cycles:
7257
Circumstances:
The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane. Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred. A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller. Although the pilot had a history of anxiety and depression, which he was treating with medication that he had not reported to the Federal Aviation Administration, analysis of the pilot's autopsy and medical records found no evidence suggesting that either his medical conditions or the drugs he was taking to treat them contributed to his inability to safely control the airplane in an emergency situation.
Probable cause:
The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.
Final Report:

Crash of a Fokker 100 in Ganla

Date & Time: May 10, 2014 at 2000 LT
Type of aircraft:
Operator:
Registration:
5N-SIK
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Bratislava – Ghardaïa – Kano
MSN:
11286
YOM:
1989
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a C-Check at Bratislava Airport, the aircraft was returning to its base in Kano, Nigeria, with an intermediate stop in Ghardaïa. While flying over the Niger airspace, the crew was in contact with Niamey ATC when he apparently encountered poor weather conditions (sand storm) and lost all communications. The exact circumstances of the accident are unclear, but it is believed that the crew was forced to attempt an emergency landing due to fuel shortage. The aircraft landed in a desert area located in the region of the Ganla beacon, south of Niger. Upon landing, the aircraft lost its undercarriage and slid for few dozen metres before coming to rest. Both pilots evacuated safely and the aircraft was damaged beyond repair. The wreckage was found about 190 km north of Kano.

Crash of a PZL-Mielec AN-28 near Addis Ababa

Date & Time: Jan 20, 2014 at 0935 LT
Type of aircraft:
Operator:
Registration:
UP-A2805
Flight Type:
Survivors:
Yes
Schedule:
Entebbe - Sana'a
MSN:
1AJ008-22
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
When flying in the Ethiopian Airspace, the crew informed ATC about engine problems and was cleared to divert to Addis Ababa-Bole Airport for an emergency landing. On approach, the twin engine aircraft crashed in an open field located in Legedadi, about 20 km northeast of the airport. Both pilots were seriously injured and the aircraft was destroyed.

Crash of a Piper PA-31-350 Navajo Chieftain in Langgur: 4 killed

Date & Time: Jan 19, 2014 at 1225 LT
Operator:
Registration:
PK-IWT
Flight Type:
Survivors:
No
Schedule:
Jayapura – Langgur – Kendari – Surabaya
MSN:
31-7752090
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2860
Captain / Total hours on type:
1045.00
Aircraft flight hours:
5859
Circumstances:
On 19 January 2014, a PA-31-350 Piper Chieftain, registered PK-IWT, was being operated by PT. Intan Angkasa Air Service, on positioning flight from Sentani Airport, Jayapura with intended destination of Juanda Airport, Surabaya for aircraft maintenance. The positioning flight was planned to transit at Dumatubun Airport Langgur of Tual, Maluku and Haluoleo Airport, Kendari at South East Sulawesi for refuelling. On the first sector, the aircraft departed Sentani Airport at 2351 UTC (0851 WIT) and estimated arrival at Langgur was 0320 UTC. On board on this flight was one pilot, two company engineers and one ground staff. At 0240 UTC the pilot contacted to the Langgur FISO, reported that the aircraft position was 85 Nm to Langgur Airport at altitude 10,000 feet and requested weather information. Langgur FISO acknowledged and informed that the weather was rain and thunderstorm and the runway in used was 09. When the aircraft passing 5,000 feet, the pilot contacted the Langgur FISO and reported that the aircraft position was 50 Nm from langgur and informed the estimated time of arrival was 0320 UTC. The Langgur FISO acknowledged and advised the pilot to contact when the aircraft was at long final runway 09. At 0318 UTC, the pilot contacted Langgur FISO, reported the position was 25 Nm to Langgur at altitude of 2,500 feet and requested to use runway 27. The Langgur FISO advised the pilot to contact on final runway 27. At 0325 UTC, Langgur FISO contacted the pilot with no reply. At 0340 UTC, Langgur FISO received information from local people that the aircraft had crashed. The aircraft was found at approximately 1.6 Nm north east of Langgur Airport at coordinate 5° 38’ 30.40” S; 132° 45’ 21.57” E. All occupants fatally injured and the aircraft destroyed by impact force and post impact fire. The aircraft was destroyed by impact forces and post impact fire, several parts of the remaining wreckage such as cockpit could not be examined due to the level of damage. The aircraft was not equipped with flight recorders and the communication between ATC and the pilot was not recorded. No eye witness saw the aircraft prior to impact. Information available for the investigation was limited. The analysis utilizes available information mainly on the wreckage information including the information of the wings, engines and propellers.
Probable cause:
The investigation concluded that the left engine most likely failed during approach and the propeller did not set to feather resulted in significant asymmetric forces. The asymmetric forces created yaw and roll tendency and the aircraft became uncontrolled, subsequently led the aircraft to impact to the terrain.
Final Report:

Crash of a Beechcraft B200 Super King Air in Akureyri: 2 killed

Date & Time: Aug 5, 2013 at 1329 LT
Operator:
Registration:
TF-MYX
Flight Type:
Survivors:
Yes
Schedule:
Reykjavik - Akureyri
MSN:
BB-1136
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2600
Captain / Total hours on type:
1700.00
Copilot / Total flying hours:
2200
Copilot / Total hours on type:
1100
Aircraft flight hours:
15247
Aircraft flight cycles:
18574
Circumstances:
On 4th of August 2013 the air ambulance operator Mýflug, received a request for an ambulance flight from Höfn (BIHN) to Reykjavík Airport (BIRK). This was a F4 priority request and the operator, in co-operation with the emergency services, planned the flight the next morning. The plan was for the flight crew and the paramedic to meet at the airport at 09:30 AM on the 5th of August. A flight plan was filed from Akureyri (BIAR) to BIHN (positioning flight), then from BIHN to BIRK (ambulance flight) and from BIRK back to BIAR (positioning flight). The planned departure from BIAR was at 10:20. The flight crew consisted of a commander and a co-pilot. In addition to the flight crew was a paramedic, who was listed as a passenger. Around 09:50 on the 5th of August, the flight crew and the paramedic met at the operator’s home base at BIAR. The flight crew prepared the flight and performed a standard pre-flight inspection. There were no findings to the aircraft during the pre-flight inspection. The pre-flight inspection was finished at approximately 10:10. The departure from BIAR was at 10:21 and the flight to BIHN was uneventful. The aircraft landed at BIHN at 11:01. The commander was the pilot flying from BIAR to BIHN. The operator’s common procedure is that the commander and the co-pilot switch every other flight, as the pilot flying. The co-pilot was the pilot flying from BIHN to BIRK and the commander was the pilot flying from BIRK to BIAR, i.e. during the accident flight. The aircraft departed BIHN at 11:18, for the ambulance flight and landed at BIRK at 12:12. At BIRK the aircraft was refueled and departed at 12:44. According to flight radar, the flight from BIRK to BIAR was flown at FL 170. Figure 4 shows the radar track of the aircraft as recorded by Reykjavík Control. There is no radar coverage by Reykjavík Control below 5000 feet, in the area around BIAR. During cruise, the flight crew discussed the commander’s wish to deviate from the planned route to BIAR, in order to fly over a racetrack area near the airport. At the racetrack, a race was about to start at that time. The commander had planned to visit the racetrack area after landing. The aircraft approached BIAR from the south and at 10.5 DME the flight crew cancelled IFR. When passing KN locator (KRISTNES), see Figure 6, the flight crew made a request to BIAR tower to overfly the town of Akureyri, before landing. The request was approved by the tower and the flight crew was informed that a Fokker 50 was ready for departure on RWY 01. The flight crew of TF-MYX responded and informed that they would keep west of the airfield. After passing KN, the altitude was approximately 800’ (MSL), according to the co-pilot’s statement. The co-pilot mentioned to the commander that they were a bit low and recommended a higher altitude. The altitude was then momentarily increased to 1000’. When approaching the racetrack area, the aircraft entered a steep left turn. During the turn, the altitude dropped until the aircraft hit the racetrack.
Probable cause:
The commander was familiar with the racetrack where a race event was going on and he wanted to perform a flyby over the area. The flyby was made at a low altitude. When approaching the racetrack area, the aircraft’s calculated track indicated that the commander’s intention of the flyby was to line up with the racetrack. In order to do that, the commander turned the aircraft to such a bank angle that it was not possible for the aircraft to maintain altitude. The ITSB believes that during the turn, the commander most probably pulled back on the controls instead of levelling the wings. This caused the aircraft to enter a spiral down and increased the loss of altitude. The investigation revealed that the manoeuvre was insufficiently planned and outside the scope of the operator manuals and handbooks. The low-pass was made at such a low altitude and steep bank that a correction was not possible in due time and the aircraft collided with the racetrack. The ITSB believes that human factor played a major role in this accident. Inadequate collaboration and planning of the flyover amongst the flight crew indicates a failure of CRM. This made the flight crew less able to make timely corrections. The commander’s focus was most likely on lining up with the racetrack, resulting in misjudging the approach for the low pass and performing an overly steep turn. The overly steep turn caused the aircraft to lose altitude and collide with the ground. The co-pilot was unable to effectively monitor the flyover/low-pass and react because of failure in CRM i.e. insufficient planning and communication. A contributing factor is considered to be that the flight path of the aircraft was made further west of the airfield, due to traffic, resulting in a steeper turn. The investigation revealed that flight crews were known to deviate occasionally from flight plans.
Causal factors:
- A breakdown in CRM occurred.
- A steep bank angle was needed to line up with the racetrack.
- The discussed flyby was executed as a low pass.
- The maximum calculated bank angle during last phase of flight was 72.9°, which is outside the aircraft manoeuvring limit.
- ITSB believes that the commander’s focus on a flyby that he had not planned thoroughly resulted in a low-pass with a steep bank, causing the aircraft to lose altitude and collide with the ground.
Contributory factors:
- The commander’s attention to the activity at the race club area, and his association with the club was most probably a source of distraction for him and most likely motivated him to execute an unsafe maneuver.
- Deviations from normal procedures were seen to be acceptable by some flight crews.
- A flyby was discussed between the pilots but not planned in details.
- The flight crew reacted to the departing traffic from BIAR by bringing their flight path further west of the airport.
- The approach to the low pass was misjudged.
- The steep turn was most probably made due to the commander’s intention to line up with the race track.
Final Report:

Crash of a Partenavia P.68 Observer in the Dzalanyama Forest Reserve

Date & Time: Jul 16, 2013 at 0900 LT
Type of aircraft:
Operator:
Registration:
ZS-LSX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tete – Lilongwe – Dar es-Salaam
MSN:
323-16-OB
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed South Africa on a flight to Tanzania with intermediate stops in Tete and Lilongwe, carrying one passenger and one pilot. The aircraft was en route to Dar es-Salaam to perform a Lidar (Laser Imaging Detection And Ranging) mission. En route, the pilot encountered engine problems and elected to make an emergency landing. Upon landing in an open field, the aircraft lost its tail and crashed landed about 45 km southwest of Lilongwe. Both occupants were rescued and the aircraft was destroyed.

Crash of a Beechcraft 1900C-1 off São Tomé: 1 killed

Date & Time: Apr 7, 2013 at 1613 LT
Type of aircraft:
Operator:
Registration:
ZS-PHL
Flight Type:
Survivors:
No
Schedule:
Johannesburg – Ondangwa – São Tomé – Accra – Bamako
MSN:
UC-74
YOM:
1989
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10756
Aircraft flight hours:
23388
Aircraft flight cycles:
29117
Circumstances:
The aircraft was planned to fly from Lanseria airport (FALA) in Republic of South Africa to Bamako airport (GABS) in Mali with a stopover in Ondangwa airport (FYOA) in Namibia, São Tomé International airport (FPST) in São Tomé and Príncipe and Accra airport (DGAA) in Ghana, with a rough estimating time of approximately 15hrs flying, not including the ground time at airports of stopover. The aircraft had been in Lanseria airport (FALA) in Republic of South Africa (RSA) for maintenance check (including but not limited to engine work and interior refurbishing). Prior to the planned flight, the aircraft underwent flight check for 45 minutes after completed planned maintenance on Saturday, April 6th, flown by the Captain and another SAS company pilot. The aircraft departed FALA to FYOA for its first stop over whose flight time was 03:35h. The planned departure from FYOA was delayed due to trouble in starting the right engine. The aircraft took off at 1021hrs contrary to planned 0830hrs. For the second leg of the flight, the aircraft departed FYOA to FPST with filed flight plan of 05 hours and 20 minutes (flight time) having FYOA as alternate. Leaving the Namibian airspace the pilot only contacted Luanda ATC and São Tomé Tower as destination, and at no time did he contact Brazzaville or Libreville for any further clearance within Brazzaville FIR: It is important to emphasize that on that day, the west coast of Africa in the vicinity of Gulf of Guinea had widespread moderate to severe thunderstorm activity with lighting and heavy rain. When initiating descent to São Tomé from FL 200 to 4000 feet as instructed by São Tomé ATC, the pilot was advised that weather was gradually deteriorating at airport vicinity. At 1610hrs the pilot had last transmission with Control Tower informing them about his position which was 9 nm inbound to São Tomé VOR at 4000 feet and also informed the ATC that he was encountering heavy rain. Having lost contact with aircraft at 1613hrs, the São Tomé ATC tried several times to contact the airplane by VHF118.9, 127.5, 121.5 and HF 8903 without success. Facing this situation the ATC sent messages to FIRs of Brazzaville and Accra and Libreville Control as well, some airlines flying within São Tomean an adjacent airspace were contacted for any information but all responses were negative. A Search and Rescue operation started on 7 April 2013 the same day the accident occurred and was conducted on the sea and on the island; no trace of aircraft or its debris, pilot or any cargo were found. The search was terminated on 20 April at 1730hrs.
Probable cause:
By the fact that there is no evidence of the crash, the cause of the accident cannot be conclusively decided, however the investigation discovered series of discrepancies and noncompliance which includes:
Pilot:
- Planned long flight as solo pilot from Lanseria to Bamako is excessive for pilot fatigue perspective (over 15 hours flying).
- The First Class FAA (USA) medical Certificate issued on April 23rd 2012 had expired on October 31st 2012.
Meteorological Conditions:
- Adverse weather conditions enroute and on arrival on that day, the west coast of Africa in the vicinity of Gulf of Guinea had widespread moderate to severe thunderstorm activity with lighting and heavy rain. When initiating descent to Sao Tome, the pilot was advised that weather was gradually deteriorating at airport vicinity.
Final Report:

Crash of a Grumman G-159 Gulfstream I in Djolu

Date & Time: Mar 22, 2013 at 1330 LT
Type of aircraft:
Operator:
Registration:
9Q-CTC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Djolu – Kinshasa
MSN:
001
YOM:
1958
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20412
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
795
Copilot / Total hours on type:
311
Aircraft flight hours:
17247
Aircraft flight cycles:
14728
Circumstances:
Last March 12, the aircraft sustained damages upon landing at Djolu Airport. Repairs were carried on and the aircraft was ready for its back trip to Kinshasa on March 22, carrying three crew members, two pilots and one mechanic. After the brakes were released, while accelerating on a dirt runway, the aircraft veered off runway, contacted trees and crashed in a wooded area, bursting into flames. All three crew members evacuated the burned wreckage and only the mechanic was injured. The aircraft was totally destroyed.
Probable cause:
Loss of control during the takeoff roll due to the poor condition of the runway.
Final Report:

Crash of a Tupolev TU-204-100V in Moscow: 5 killed

Date & Time: Dec 29, 2012 at 1633 LT
Type of aircraft:
Operator:
Registration:
RA-64047
Flight Type:
Survivors:
Yes
Schedule:
Pardubice - Moscow
MSN:
1450744864047
YOM:
2008
Flight number:
RWZ9268
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
14975
Captain / Total hours on type:
3080.00
Copilot / Total flying hours:
10222
Copilot / Total hours on type:
579
Aircraft flight hours:
8676
Aircraft flight cycles:
2484
Circumstances:
Approach was carried out on the runway 19 at Vnukovo Airport with length of 3060m. Pilot was performed by pilot in command (PIC). Before entering the glide path the aircraft was in landing configuration: with flaps deployed at 37°, slats - at 23 °, and the landing gear down. Decision height was calculated to be 60 m. Landing weight of the aircraft was approximately 67.5 tons, alignment ~26.5%, which did not exceed the limits specified by the flight operation manual (FOM). During flight preparation PIC determined the landing glide path speed as 210 km/h, and specified that the speed at least 230 km/h has to be maintained. Glideslope descent was made in director mode with automatic throttle disabled with an average instrument speed about 255 km/h vertical speed -3…-5 m/s. Descent was performed without significant deviations from the glide path. Flyby of the of the neighboring (to the runway) homing radio beacon was performed at the altitude 65…70 m. Runway threshold was passed at the altitude about 15 m and airspeed of 260 km/h. 5 seconds after the throttle control lever had been switched to the idle mode the aircraft landed at the speed about 230 km/h, distance from the runway threshold of 900-1000 m and left bank of 1... 1.5°, provided that the signal of the signal of left gear strut compression was produced. During aircraft landing the right side wind gust reached up to ~11.5 m/s. The maximum value of the vertical acceleration during touch down was recorded as 1.12g according to flight recorders (hereinafter - magnetic tape recorder). About 10 seconds had passed from the moment of passing 4 m height above ground and touchdown. 3 seconds after landing nose gear strut was compressed. At this stage the right gear strut compression signal had not yet been formed. Almost simultaneously with nose landing gear touchdown the crew moved thrust reverser lever in one motion to the "maximum reverse" position and applied mechanical brakes. Actuation of the reverse valves didn't occur. Air brakes and spoilers were not also activated automatically and the crew didn't make attempt to activate them manually. After thrust levers were moved to the "maximum reverse" position an increase of forward thrust (up to ~90% Nvd) was recorded with both engines. The pressure in the hydraulic system of wheel brakes of the left (compressed) landing gear was up to 50 kgf/сm², whereas there were no pressure in the wheel brakes of the right (not compressed) landing gear. The minimum airspeed to to which the aircraft slowed 7-8 seconds after landing was 200-205 km/h at ~0° pitch and roll of 1° to the left, after that the speed began to increase. 2 seconds after thrust levers were moved to the "maximum reverse" position the flight engineer reported that reversers had not been deployed. Thrust lever had been maintained in the "maximum reverse" position for about 8 seconds and was switched off after that. During this time the airspeed increased to 240 km/h. The increase in airspeed led to further unloading of the main landing gear. With fluctuations in roll (from 4.5° to the left to 2.6° to the right) compression was produced alternately on the left and right landing gear struts. Almost simultaneously sith the reversers being switched off the brake pedal was pushed by left-hand-seat pilot to 60°. As before the breaking was inefficient - hydraulic pressure in the wheel brake in only applied after sufficient compression of the gear strut. 5 seconds after reversers were deactivated, after words of the flight engineer "Turn on reverse! Reverse!" the control was moved to the "maximum reverse" position again. As in the first attempt the deployment of reversers didn't occur, both engines started to produce direct thrust (at Nvd ~ 84%). Aircraft braking didn't occur, airspeed was 230…240 km/h. In 4 seconds the reverse was switched off. At the moment of reverser reactivation the aircraft was at the distance of about 900...1000 m from the exit threshold. 6 seconds after reversers switch off the crew attempted to supply automatic braking as evidenced by the crew conversation and transient appearance of commands: "Automatic braking on" for the primary and backup subsystems. When the aircraft passed the exit threshold thrust levers were in the "small-reverse" position. The aircraft overrun occurred 32 seconds after landing, being almost on the axis of the runway, with an airspeed of about 215 km/h. In the process of overrun flight engineer by PIC command turned off the engines by means of emergency brakes. The aircraft continued to roll outside the runway slowly due to road bumps and snow cover. The compression on both landing gear struts occurred which led to activation of air brakes and spoilers. The aircraft collided with the slope of a ravine at the ground speed of about 190 km/h. Four stewardess were seriously injured while four other crew members were killed. The following day, one of the survivor died from her injuries.
Probable cause:
The accident with Тu-204-100В RA-64047 aircraft was caused by actuator maladjustment and reverse locking of both engines and incorrect crew actions (not complying with FOM provisions) performing landing run during spoilers and thrust reverse control that resulted in lack of efficient aircraft breaking action, RWY overrun, collision with obstacles at a high speed (~190 km/h), aircraft destruction and fatalities. (In accordance with the ICAO Accident and Incident Investigation Manual (DOC 9756 AN/965), causes and factors are in logical order, without the priority assessment).
Contributing factors to the fatal accident were:
- Actual structure stiffness of reverse control and locking mechanism unaccounted in operational documentation determining the engine control system inspection and adjustment procedure during its service replacement. This factor can emerge only in case of the crew thrust reverse control with violation of FOM provisions;
- Incoordination and conflicts in aircraft and engine operational and technical documentation and long-term formalism towards inspections of the engine control system adjustment (including reverse control and locking mechanism) by organisations performing engines replacement that didn't allow to ensure feedback with aircraft and engine designers and timely eliminate identified deficiencies;
- Unstabilized approach and significant (up to 45 km/h) rated overspeed during glide slope phase by the crew that resulted in long holding before landing, significant landing distance extension and aircraft overshoot landing (~950 m);
- Non-extension of spoilers and speed breaks in automatic mode due to the lack of the signal of simultaneous left and right struts compression caused by aircraft anticipatory "soft" landing (plunge acceleration 1.12g) at left main gear at right cross wind saturation (~11.5 м/с);
- Lack of crew monitoring for automatic extension of spoilers and speed brakes after landing and manual non-extension of spoilers;
- Violation of thrust reverse landing procedure be crew specified by FOM resulted in application of maximum thrust reverse by "one motion" without throttle intermediate stop setting (low reverse) and without reverse buckets position (stowage) monitoring that under deficiencies of the reverse control and locking mechanism resulted in immediate thrust increase;
- Lack of simultaneous main landing gear compression during the RWY motion due to design features of limit switches (no failures of limit switches were identified) of main landing gears compressed position (~5.5 tonnes leg load is required for switch actuation) and non compliance with the FOM on spoilers extension in manual mode that resulted in reverser buckets non-stowage into reversal thrust mode;
- Inadequate cockpit resource management by the PIC during flight that resulted in lack of monitoring for stabilized approach at the approach phase and in "fixation" at reverser deployment operation at the lack of monitoring for other systems operation;
- Untimely preventive measures during the investigation of the serious incident with Tu-204-100V RA-64049 aircraft operated by "Red Wings" Airlines occurred in Tolmachevo airport on December 20, 2012;
- Inadequate level of flight operation management and nonoperation of flight safety control system in the airline and formal attitude of the pilot-instructor towards proficiency check of the PIC and the lack of the appropriate supervision over proficiency checks and flight operations using flight recorders that didn't allow to timely identify and eliminate regular deficiencies in PIC's piloting technique regarding increased speed holding during glide-slope flight and the procedure of using reverse thrust application at landing run operation as well. Supervision over proficiency checks specified by FAR-128 (clause 5.7) wasn't held;
- Lack of actions training in situations connected with failure of main landing gears limit switches in line proficiency check programs of crew members followed by non-extension of spoilers and speed breaks in manual mode. Technical abilities of the available simulators don't allow to train this situation.
Final Report: