Crash of a Boeing 737-112 in Panama City

Date & Time: Nov 19, 1993 at 1919 LT
Type of aircraft:
Operator:
Registration:
HP-873CMP
Survivors:
Yes
Schedule:
Miami - Panama City
MSN:
19768
YOM:
1969
Flight number:
q
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Miami-Intl Airport, the crew started the descent to Panama City-Tocumen Airport. Actual weather conditions were poor with low clouds, rain falls and turbulences. On final, the aircraft was not properly aligned on runway 03R but the crew continued the approach. Too high on the glide, the aircraft landed 750 metres past the runway threshold and after a course of about 2,500 feet, it veered to the left and departed the runway. While contacting taxiway Hotel, the nose gear collapsed and the aircraft came to rest 450 metres further. All 92 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew who failed to initiate a go-around procedure while the aircraft was not properly aligned on runway 03R during an ILS approach. Poor crew coordination was a contributing factor.

Crash of an Airbus A300B2-101 near Tirupati

Date & Time: Nov 15, 1993 at 0925 LT
Type of aircraft:
Operator:
Registration:
VT-EDV
Flight Phase:
Survivors:
Yes
Schedule:
Madras - Hyderabad
MSN:
034
YOM:
1976
Flight number:
IC440
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
250
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17344
Circumstances:
Indian Airlines Airbus A-300 aircraft VT-EDV was operating scheduled flight IC-440 (Madras - Hyderabad sector) on 15.11.1993. There were a total of 262 persons were on board the aircraft including 247+3 passengers and 12 crew members. The aircraft could not land at Hyderabad due to low visibility and carried out a missed approach. After the missed approach, the aircraft reported "Flap Problem" and was holding overhead at Hyderabad during which the flight crew enquired visibility at nearby Air Force airfields which was also low. The aircraft then diverted to Madras. Due to flaps problem, the crew had to maintain low speed and low altitude as a result of which it experienced fuel shortage and sought permission from Madras control for landing at Tirupati. However, the aircraft could not reach even Tirupati airport and executed forced landing in an open paddy field about 14 nautical miles from Tirupati airport. The aircraft dragged on the soft paddy field before coming to final stop. There was no fire. Passenger evacuation was carried out by means of escape slides. All the persons on board escaped unhurt except four who received minor injuries.
Probable cause:
The probable cause of accident has been attributed to:
- The ill-conceived decision of the aircraft's Commander to divert to Madras, without ensuring that adequate fuel was available for reaching there, when he was faced with a flap-jam and poor
visibility at Hyderabad.
- The failure of the aircraft's Commander and his Flight Crew to monitor fuel consumption correctly, and the failure of the Commander to revise his decision accordingly, until it became impossible to reach any airfield.
- A forced landing due to the eventual shortage of fuel.
Final Report:

Crash of a McDonnell Douglas MD-82 in Ürümqi: 12 killed

Date & Time: Nov 13, 1993 at 1456 LT
Type of aircraft:
Operator:
Registration:
B-2141
Survivors:
Yes
Schedule:
Shenyang – Beijing – Ürümqi
MSN:
49849
YOM:
1990
Flight number:
UJ6901
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
92
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The approach to Ürümqi-Diwopu was completed in limited visibility due to foggy conditions. On short final, the aircraft descended below the glide and struck a concrete wall located 3 km short of runway 25. It gain height and collided with power lines before crashing in a field, bursting into flames. Twelve occupants were killed, among them four crew members. The aircraft was destroyed by a post crash fire.
Probable cause:
The automatic pilot system disconnect on final approach for unknown reasons, causing the aircraft to adopt a rate of descent of 800 feet per minute until the aircraft struck a concrete wall and crashed.

Crash of a PZL-Mielec AN-2P in Bekdash

Date & Time: Nov 11, 1993
Type of aircraft:
Operator:
Registration:
EZ-07469
Flight Phase:
Survivors:
Yes
MSN:
1G151-44
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The engine failed in flight, forcing the crew to attempt an emergency landing. All four occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Crash of an Avro 748-234-2A in Sandy Lake: 7 killed

Date & Time: Nov 10, 1993 at 1805 LT
Type of aircraft:
Operator:
Registration:
C-GQTH
Flight Phase:
Survivors:
No
Schedule:
Winnipeg – Sandy Lake – Saint Theresa Point – Island Lake – Winnipeg
MSN:
1617
YOM:
1967
Flight number:
7N205
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
16000
Captain / Total hours on type:
4500.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
1100
Aircraft flight hours:
29284
Circumstances:
The aircraft, a Hawker Siddeley 748 Series 2A Model 234 (HS 748) owned and operated by Air Manitoba Ltd. (Air Manitoba), took off from Winnipeg at 1438 central standard time (CST) , 10 November 1993, on scheduled flight NAM 205/ 206 that included stops at Sandy Lake, Ontario; St. Theresa Point, Manitoba; Island Lake, Manitoba; and return to Winnipeg, Manitoba. The flight was conducted in accordance with an instrument flight rules (IFR) flight plan and flight notification. On arrival at Sandy Lake at approximately 1549, the crew attempted to land but were unable to because of the low ceiling and visibility. They then diverted to St. Theresa Point, landing at 1630. A normal turnaround was completed; the number of passengers on departure was 26, and 2,086 pounds of fuel was uploaded to an estimated total of 6,700 pounds on board. The flight departed St. Theresa Point for Sandy Lake at 1720. The aircraft landed at approximately 1745 at Sandy Lake, where 22 passengers deplaned while four remained on board; the aircraft was not refuelled or otherwise serviced at Sandy Lake. During the stop, both engines were shut down. On take-off from Sandy Lake, there were two pilots, a flight attendant, and four passengers on board. The aircraft took off from runway 29 at Sandy Lake at approximately 1805 and entered a right turn. Witnesses indicate that the aircraft appeared to fly at a lower than normal height throughout the turn. After turning through approximately 120 degrees(°), the aircraft descended into 100-foot trees and crashed. The aircraft struck the ground about one nautical mile (nm) northwest of the airport. All seven occupants of the aircraft were fatally injured in the crash. The accident occurred during the hours of darkness. The wreckage was located at position latitude 53°04'71"N, longitude 93°21'38"W, at an elevation of approximately 940 feet above sea level (asl).
Probable cause:
After take-off, the crew most likely lost situational awareness and, as a result, did not detect the increasing deviation from their intended flight path. Contributing to the loss of situational awareness was the lack of AC power to some of the flight instruments; the reason for the lack of AC power could not be determined.
Final Report:

Crash of a Harbin Yunsunji Y-12-II in Jomsom

Date & Time: Nov 8, 1993
Type of aircraft:
Operator:
Registration:
9N-ACS
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
0044
YOM:
1991
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 24, the aircraft was unable to stop within the remaining distance. It overran, went down an embankment and came to rest in the Gandaki River with its right wing torn off. All 19 occupants were rescued, among them both pilots and three passengers were injured.
Probable cause:
For unknown reasons, the crew landed 240 metres past the runway 24 threshold (runway 24 is 600 metres long).

Crash of a Boeing 747-409 in Hong Kong

Date & Time: Nov 4, 1993 at 1136 LT
Type of aircraft:
Operator:
Registration:
B-165
Survivors:
Yes
Schedule:
Taipei - Hong Kong
MSN:
24313
YOM:
1993
Flight number:
CI605
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
274
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12469
Captain / Total hours on type:
3559.00
Copilot / Total flying hours:
5705
Copilot / Total hours on type:
908
Aircraft flight hours:
1969
Aircraft flight cycles:
359
Circumstances:
China Airlines' scheduled passenger flight CAL605 departed Taipei (TPE), Taiwan at 02:20 for the 75-minute flight to Hong Kong-Kai Tak (HKG). The departure and cruise phases were uneventful. During the cruise the commander briefed the co-pilot on the approach to Hong Kong using the airline's own approach briefing proforma as a checklist for the topics to cover. The briefing included the runway-in-use, navigation aids, decision height, crosswind limit and missed approach procedure. He paid particular attention to the crosswind and stated that, should they encounter any problem during the approach, they would go-around and execute the standard missed approach procedure. The commander did not discuss with the co-pilot the autobrake setting, the reverse thrust power setting or their actions in the event of a windshear warning from the Ground Proximity Warning System (GPWS). Weather reports indicated strong gusty wind conditions, rain and windshear. On establishing radio contact with Hong Kong Approach Control at 03:17, the crew were given radar control service to intercept the IGS approach to runway 13 which is offset from the extended runway centreline by 47°. After intercepting the IGS localiser beam, the pilots changed frequency to Hong Kong Tower and were informed by the AMC that the visibility had decreased to 5 kilometres in rain and the mean wind speed had increased to 22 kt. Two minutes before clearing CAL605 to land, the air traffic controller advised the crew that the wind was 070/25 kt and to expect windshear turning short final. During the approach the pilots completed the landing checklist for a flaps 30 landing with the autobrakes controller selected to position '2' and the spoilers armed. The reference airspeed (Vref) at the landing weight was 141 kt; to that speed the commander added half the reported surface wind to give a target airspeed for the final approach of 153 kt. Rain and significant turbulence were encountered on the IGS approach and both pilots activated their windscreen wipers. At 1,500 feet altitude the commander noted that the wind speed computed by the Flight Management Computer (FMC) was about 50 kt. At 1,100 feet he disconnected the autopilots and commenced manual control of the flightpath. A few seconds later at 1,000 feet he disconnected the autothrottle system because he was dissatisfied with its speed holding performance. From that time onwards he controlled the thrust levers with his right hand and the control wheel with his left hand. Shortly afterwards the commander had difficulty in reading the reference airspeed on his electronic Primary Flying Display (PFD) because of an obscure anomaly, but this was rectified by the co-pilot who re-entered the reference airspeed of 141 kt into the FMC. Shortly before the aircraft started the visual right turn onto short final, the commander saw an amber 'WINDSHEAR' warning on his PFD. A few seconds later, just after the start of the finals turn, the ground proximity warning system (GPWS) gave an aural warning of "GLIDESLOPE" which would normally indicate that the aircraft was significantly below the IGS glidepath. One second later the aural warning changed to "WINDSHEAR" and the word was repeated twice. At the same time both pilots saw the word 'WINDSHEAR' displayed in red letters on their PFDs. Abeam the Checkerboard the commander was aware of uncommanded yawing and pitch oscillations. He continued the finals turn without speaking whilst the co-pilot called deviations from the target airspeed in terms of plus and minus figures related to 153 kt. At the conclusion of the turn both pilots were aware that the aircraft had descended below the optimum flight path indicated by the optical Precision Approach Path Indicator (PAPI) system. The air traffic controller watched the final approach and landing of the aircraft. It appeared to be on or close to the normal glidepath as it passed abeam the tower and then touched down gently on the runway just beyond the fixed distance marks (which were 300 metres beyond the threshold) but within the normal touchdown zone. The controller was unable to see the aircraft in detail after touchdown because of water spray thrown up by it but he watched its progress on the Surface Movement Radar and noted that it was fast as it passed the penultimate exit at A11. At that time he also observed a marked increase in the spray of water from the aircraft and it began to decelerate more effectively. The commander stated that the touchdown was gentle and in a near wings level attitude. Neither pilot checked that the speed brake lever, which was 'ARMED' during the approach, had moved to the 'UP' position on touchdown. A few seconds after touchdown, when the nose wheel had been lowered onto the runway, the co-pilot took hold of the control column with both hands in order to apply roll control to oppose the crosswind from the left. The aircraft then began an undesired roll to the left. Immediately the commander instructed the co-pilot to reduce the amount of applied into-wind roll control. At the same time he physically assisted the co-pilot to correct the aircraft's roll attitude. Shortly after successful corrective action the aircraft again rolled to the left and the commander intervened once more by reducing the amount of left roll control wheel rotation. During the period of unwanted rolling, which lasted about seven seconds, the aircraft remained on the runway with at least the left body and wing landing gears in contact with the surface. After satisfactory aerodynamic control was regained, the co-pilot noticed a message on the Engine Indicating and Crew Alerting System (EICAS) display showing that the autobrake system had disarmed. He informed the commander that they had lost autobrakes and then reminded him that reverse thrust was not selected. At almost the same moment the commander selected reverse thrust on all engines and applied firm wheel braking using his foot pedals. As the aircraft passed abeam the high speed exit taxiway (A11), the commander saw the end of the runway approaching. At that point both he and the co-pilot perceived that the distance remaining in which to stop the aircraft might be insufficient. At about the same time the co-pilot also began to press hard on his foot pedals. As the aircraft approached the end of the paved surface the commander turned the aircraft to the left using both rudder pedal and nose wheel steering tiller inputs. The aircraft ran off the end of the runway to the left of the centreline. The nose and right wing dropped over the sea wall and the aircraft entered the sea creating a very large plume of water which was observed from the control tower, some 3.5 km to the northwest. The controller immediately activated the crash alarm and the Airport Fire Contingent, which had been on standby because of the strong winds, responded very rapidly in their fire vehicles and fire boats. Other vessels in the vicinity also provided prompt assistance. After the aircraft had settled in the water, the commander operated the engine fuel cut-off switches and the co-pilot operated all the fire handles. The commander attempted to speak to the cabin crew using the interphone system but it was not working. The senior cabin crew member arrived on the flight deck as the commander was leaving his seat to proceed aft. The instruction to initiate evacuation through the main deck doors was then issued by the commander and supervised by the senior cabin crew member from the main deck. Ten passengers were injured, one seriously.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The commander deviated from the normal landing roll procedure in that he inadvertently advanced the thrust levers when he should have selected reverse thrust.
- The commander diminished the co-pilot's ability to monitor rollout progress and proper autobrake operation by instructing him to perform a non-standard duty and by keeping him ill-informed about his own intentions.
- The copilot lacked the necessary skill and experience to control the aircraft during the landing rollout in strong, gusty crosswind conditions.
- The absence of a clearly defined crosswind landing technique in China Airline's Operations Manual deprived the pilots of adequate guidance on operations in difficult weather conditions.
Final Report:

Crash of a Beriev BE-12NKh off Yuzhno-Kurilsk

Date & Time: Oct 31, 1993
Type of aircraft:
Registration:
82 yellow
Survivors:
Yes
Schedule:
Yuzhno-Sakhalinsk - Yuzhno-Kurilsk
MSN:
9 6 017 02
YOM:
1969
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Yuzhno-Kurilsk, the crew realized that the sea was relatively rough with waves of 1,5 meter. Despite the situation, the crew decided to land in the bay. After touchdown, the right float was torn off and the aircraft rolled to the right and came to rest 120 metres offshore, partially submerged. All 20 occupants were rescued while a rescuer died from hypothermia. The aircraft partially sank as the fuselage was cut in several places after suffering chocks with water.

Crash of a De Havilland DHC-6 Twin Otter 300 in Namsos: 6 killed

Date & Time: Oct 27, 1993 at 1916 LT
Operator:
Registration:
LN-BNM
Survivors:
Yes
Schedule:
Trondheim - Namsos
MSN:
408
YOM:
1974
Flight number:
WF744
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
4835
Captain / Total hours on type:
1998.00
Copilot / Total flying hours:
6354
Copilot / Total hours on type:
1365
Aircraft flight hours:
40453
Circumstances:
On approach to Namsos Airport by night, the crew encountered poor visibility due to rain falls. In below weather minima, the crew descended below the minimum safe altitude until the aircraft struck the ground and crashed in a swampy area located about 6 km short of runway. The aircraft was destroyed on impact and six occupants including both pilots were killed. All 13 other occupants were injured.
Probable cause:
The accident was the consequence of a controlled flight into terrain. The following findings were reported:
- The company had failed to implement a standardized concept of aircraft operation that the pilots fully respected and lived by;
- The approach briefing was not not fully implemented in accordance with the rules. There were deficiencies in:
- "Call outs" during the approach
- Descent rate (feet/min) during "FAF inbound"
- Timing "outbound" from the IAF and the time from FAF to MAPt;
- The crew did not execute the "base turn" at the scheduled time, with the consequence that the plane ended up about 14 NM from the airport;
- The Pilot Flying ended the approach with reference to aircraft instruments and continued on a visual approach in the dark without visual reference to the underlying terrain. During this part of the approach the aircraft's position was not positively checked using any available navigational aids;
- Both crew members had in all likelihood most of the attention out of the cockpit at the airport after the Pilot Not Flying announced that he had it in sight;
- The crew was never aware of how close they were the underlying terrain;
- The last part of the descent from about 500 feet indicated altitude to 392 feet can be caused by inattention to the fact that the plane may have been a little out of trim after the descent;
- Crew Cooperation during the approach was not in accordance with with the CRM concept and seems to have ceased completely after the Pilot Not Flying called "field in sight";
- Before the accident the company had not succeeded well enough with the introduction of standardization and internal control/quality assurance. This was essentially because the management had not placed enough emphasis on awareness and motivate employees;
- The self-control system described in the airline operations manual and the parts of the quality system, was not incorporated in the organization and served as poor safety governing elements;
- Neither the Norwegian CAA nor the company had defined what visual reference to terrain is, what sufficient visual references are and what the references must be in relation to a moving aircraft.
Final Report:

Crash of a McDonnell Douglas MD-82 in Fuzhou: 2 killed

Date & Time: Oct 26, 1993 at 1304 LT
Type of aircraft:
Operator:
Registration:
B-2103
Survivors:
Yes
Schedule:
Shenzhen - Fuzhou
MSN:
49355
YOM:
1985
Flight number:
MU5398
Location:
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
71
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The descent to Fuzhou Airport was completed in poor weather conditions with limited visibility due to heavy rain falls. On short final, the aircraft was too high and about 350 metres to the right of the extended centerline. The captain realized he could not land in such conditions so, at a height of 20 metres, he decided to initiate a go-around procedure, increased engine power and retracted the flaps. The aircraft continued to descend so the crew finally decided to land. The aircraft touched down 1,983 metres past the runway threshold. On a wet runway surface, it was unable to stop within the remaining distance, overran, lost its undercarriage and came to rest in a swamp located 385 metres past the runway end, broken in three. Two passengers were killed while 25 others were injured.
Probable cause:
Wrong approach configuration on part of the flying crew. The braking coefficient was reduced because the runway surface was wet. The crew failed to initiate a go-around procedure earlier.