Scheduled Revenue Flight | Bureau of Aircraft Accidents Archives

This was the first day on duty in the southern region operation for both pilots. In addition, they had never flown together. During the flight, the flight crew lost awareness of their airplane's position, erroneously believed that the flight was receiving radar services from ATC, and commenced the approach from an excessive altitude and at a cruise airspeed without accomplishing the published procedure specified on the approach chart. The crew believed that the airplane was south of the airport, and turned toward the north to execute the ILS runway 05 approach. In actuality, the airplane had intercepted the back course localizer signal, and the airplane continued a controlled descent until it impacted terrain. The captain and two passengers were killed while the copilot and two other passengers were seriously injured.

Probable cause:

The failure of senior management of GP Express to provide adequate training and operational support for the startup of the southern operation, which resulted in the assignment of an inadequately prepared captain with a relatively inexperienced first officer in revenue passenger service, and the failure of the flightcrew to use approved instrument flight procedures, which resulted in a loss of situational awareness and terrain clearance. Contributing to the causes of the accident was GP Express' failure to provide approach charts to each pilot and to establish stabilized approach criteria. Also contributing were the inadequate crew coordination and a role reversal on the part of the captain and first officer.

Final Report:

Crash of a Casa 212 Aviocar 200 in Mayaguez: 5 killed

Date & Time: Jun 7, 1992 at 1434 LT

Type of aircraft:

Casa 212 Aviocar

Operator:

Registration:

N355CA

Flight Phase:

Landing (descent or approach)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Airport (less than 10 km from airport)

Schedule:

San Juan - Mayaguez

MSN:

234

YOM:

1982

Flight number:

AA5456

Location:

Mayaguez-Eugenio Maria de Hostos

All Puerto Rico

Country:

Puerto Rico

Region:

Central America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6634

Captain / Total hours on type:

2634.00

Aircraft flight hours:

14135

Circumstances:

The airplane crashed on approach 3/4 mile southwest of the airport. A witness heard sound he associated with props going into reverse, then observed airplane emerge from clouds in a nose-low attitude. CVR tape revealed sound of an abrupt change in frequency and amplitude 10 seconds prior to impact. Exam of the left engine beta indicator lamp revealed heavy oxide deposit and stretched coils indicative of the lamp being illuminated at impact; right engine beta lamp was destroyed. Power levers and (beta mode) trigger locks operated normally; trigger return springs intact. Flight idle stops showed no evidence of excessive wear or deformation. The power lever (beta) blocking device lockout solenoid was tested electrically and functioned normally. The rigging of the beta lockout device could not be checked due to impact damage. The operator conducted a funct test of the electrical or backup beta blocking devices on the remaining 8 Casa 212 airplanes; 3 were found to be inoperative. Neither the manufacturing nor operator had an inspection or funct test requirement for the blocking devices. All five occupants were killed.

Probable cause:

The failure of the beta blocking device for undetermined reason(s), and the second-pilot's inadvertent activation of the power lever, or levers, aft of the flight idle position and into the beta range, resulting in a loss of airplane control.

Final Report:

Crash of a Boeing 737-204 near Tucutí: 47 killed

Date & Time: Jun 6, 1992 at 2100 LT

Type of aircraft:

Boeing 737-200

Operator:

Registration:

HP-1205CMP

Flight Phase:

Flight

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Plain, Valley

Schedule:

Miami – Panama City – Cali

MSN:

22059

YOM:

1979

Flight number:

CM201

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

45946

Aircraft flight cycles:

17845

Circumstances:

The airplane departed Panama City-Tocumen Airport runway 21L at 2036LT bound for Cali, Colombia. While cruising at FL250, the crew was informed about poor weather conditions 30-50 miles ahead. Shortly later, there was an intermittent failure of the main attitude indicator due to a short circuit. This was not noticed by the flight crew, who attempted to adjust the aircraft attitude based on the false information from the attitude indicator. They lost control of the aircraft which entered a steep descent and started to disintegrate at FL100, and impacting the ground 80° nose down. The wreckage was found in the jungle about 13 km southwest of Tucití. All 47 occupants were killed.

Probable cause:

The following findings were reported:
- Loss of control of the aircraft because the flight crew followed false information from an attitude indicator that operated intermittently.
- Lack of visible horizon during cruise flight due to night and approaching bad weather.
- Insufficient cross-checking between the primary and emergency (standby) attitude indicators to identify intermittent attitude errors and to select a reliable source of (correct) attitude information.
- Non-standard cabin configurations between aircraft in the fleet of the company, which required the crew to determine how to set the switches based on the aircraft was being operated at the time.
- Incomplete ground crew training simulator, as it did not present 'differences between aircraft' and 'crew resource management' in sufficient detail to give the crew knowledge to overcome intermittent attitude indicator errors and to maintain control of the aircraft.

Crash of a Yakovlev Yak-40 in Türkmenabat

Date & Time: May 13, 1992

Type of aircraft:

Yakovlev Yak-40

Operator:

Registration:

CCCP-88235

Flight Phase:

Landing (descent or approach)

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Airport (less than 10 km from airport)

Schedule:

Ashgabat - Türkmenabat

MSN:

9 64 04 51

YOM:

1976

Flight number:

TUA308

Location:

Türkmenabat

Lebap Province (Lebap welaýaty)

Country:

Turkmenistan

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

On final approach to Türkmenabat Airport following an uneventful flight from Ashgabat, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and limited visibility. On short final, the crew lost visual contact with the runway for few seconds, causing the aircraft to deviate from the approach path to the right. The crew decided to continue when, at a height of 12 metres, the right wing struck a mast. The aircraft caught fire, turned to the right and crashed at a speed of 220 km/h, bursting into flames. The wreckage was found one km from the runway end. All 38 occupants evacuated safely, among them five passengers were injured. The aircraft was destroyed by fire.

Probable cause:

The approach was completed in very bad weather conditions and a first approach was abandoned few minutes prior to the accident. During the second attempt to land, the crew lost visual contact with the runway for few seconds, causing the aircraft to deviate to the right of the approach path. The crew decided to continue the approach in such conditions rather than initiating a new go-around procedure.

Crash of a PZL-Mielec AN-2V in Taymyr Lake

Date & Time: May 6, 1992

Type of aircraft:

PZL-Mielec AN-2

Operator:

Registration:

CCCP-50585

Flight Phase:

Flight

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Lake, Sea, Ocean, River

MSN:

1G131-27

YOM:

1971

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Crashed in unknown circumstances in the Taymyr Lake. There were no casualties.

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

Date & Time: Apr 14, 1992

Type of aircraft:

PZL-Mielec AN-2

Operator:

Registration:

CCCP-35546

Flight Phase:

Flight

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Plain, Valley

MSN:

1G114-58

YOM:

1970

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Crashed in unknown circumstances. There were no casualties.

Crash of an Embraer EMB-110P1 Bandeirante near Goroka: 11 killed

Date & Time: Apr 14, 1992

Type of aircraft:

Embraer EMB-110 Bandeirante

Operator:

Registration:

P2-RDS

Flight Phase:

Landing (descent or approach)

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Mountains

Schedule:

Madang - Goroka

MSN:

110-355

YOM:

1981

Flight number:

GV709

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

While descending to Goroka Airport in marginal weather conditions, the twin engine aircraft struck the slope of a mountain located 16 km from the airport, near Daulo Pass. Four passengers were seriously injured while 11 other occupants were killed.

Probable cause:

For unknown reasons, the crew initiated the descent prematurely, causing the aircraft to descent below the MDA. Lack of visibility was a contributing factor.

Crash of a Britten-Norman BN-2A-26 off Lanyu: 7 killed

Date & Time: Apr 10, 1992

Type of aircraft:

Britten-Norman Islander

Operator:

Registration:

B-11116

Flight Phase:

Takeoff (climb)

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Lake, Sea, Ocean, River

Schedule:

Lanyu - Taitung

MSN:

2007

YOM:

1977

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

After takeoff from Lanyu, while climbing to an altitude of 1,500 feet, the left engine failed. The crew elected to maintain control of the aircraft that banked left, entered a dive and crashed in the sea few km offshore. A pilot and two passengers were rescued while seven other occupants were killed. It is believed that the second engine also failed during the dive according to the survivors.

Probable cause:

Engine failure for unknown reasons.

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