Scheduled Revenue Flight

Flight Type:

Survivors:

Site:

Schedule:

Krasnoyarsk – Osh

MSN:

24681/1929

YOM:

1990

Flight number:

AVJ768

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

148

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

10600

Captain / Total hours on type:

6362.00

Copilot / Total flying hours:

16400

Copilot / Total hours on type:

3731

Aircraft flight hours:

50668

Aircraft flight cycles:

43958

Circumstances:

The crew departed Krasnoyarsk-Yemilianovo Airport on a night flight to Osh, Kyrgyzstan. En route, he was informed that a landing in Osh was impossible to due low visibility caused by foggy conditions. The captain decided to divert to Bishkek-Manas Airport where the aircraft landed safely at 0520LT. As weather conditions seems to improve at destination, the crew left Bishkek bound for Osh some ninety minutes later. On approach to Osh, the vertical visibility was reduced to 130 feet when the aircraft hit violently the runway 12 surface. Upon impact, the left main gear was sheared off, the aircraft slid for several yards, overran, hit obstacles and came to rest in a field located 529 meters past the runway end with its left engine detached and its right engine destroyed. All 154 occupants were evacuated, ten passengers were injured, six of them seriously. The aircraft was damaged beyond repair.

Probable cause:

It was determined that the accident occurred in poor weather conditions with an horizontal visibility reduced to 50 meters and a vertical visibility limited to 130 feet. It was reported that the accident was caused by the combination of the following factors:
- the crew decided to leave Bishkek Airport for Osh without taking into consideration the weather forecast and the possibility of deteriorating weather,
- the competences of the captain for a missed approach procedure in poor weather conditions were limited to a simulator training despite the fact that he was certified for Cat IIIa approaches,
- failure of the crew to comply with the standard operating procedures for a missed approach,
- wrong actions on part of the pilot in command while crossing the runway threshold at a height of 125 feet and about five seconds after the initiation of the TOGA procedure, disrupting the go around trajectory and causing the aircraft to continue the descent,
- lack of reaction of the copilot who did not try to correct the wrong actions of the pilot in command,
- lack of concentration on part of the crew who failed to control the approach speed and failed to recognize the pitch angle that was increasing,
- it is possible that the crew suffered somatogravic illusions caused by fatigue due to a duty time period above 13 hours,
- a non proactive reaction of the crew when the GPWS alarm sounded.

Final Report:

Crash of a Boeing 737-4H6 in Lahore

Date & Time: Nov 3, 2015 at 0926 LT

Type of aircraft:

Boeing 737-400

Operator:

Registration:

AP-BJO

Flight Phase:

Flight Type:

Survivors:

Site:

Lahore-Allama Muhammad Iqbal

Schedule:

Karachi – Lahore

MSN:

27166/2410

YOM:

1992

Flight number:

NL142

Location:

Punjab (پنجاب)

Country:

Pakistan

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

114

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

19302

Captain / Total hours on type:

4859.00

Copilot / Total flying hours:

2076

Copilot / Total hours on type:

410

Aircraft flight hours:

51585

Aircraft flight cycles:

46547

Circumstances:

On 03rd November 2015, M/s Shaheen Air International Flight NL-142, Boeing 737-400 aircraft Reg # AP-BJO, was on a scheduled passenger flight from Karachi to Lahore. The flight landed on Runway 36L as Runway 36R was not available due to ILS CAT-III up-gradation. After touchdown, both main landing gears broke one after the other. Subsequently, the aircraft departed runway while resting on both engines and stopped 8302 ft from Runway Threshold (RWT), 197ft left of runway centreline. The nose landing gear, however, remained intact. All the passengers were safely evacuated through emergency procedure.

Probable cause:

The accident took place due to:
- Cockpit crew landing the aircraft through unstabilized approach (high ground speed and incorrect flight path).
- Low sink rate of left main landing gear (LMLG) as it touched down and probable presence of (more than the specified limits) play in the linkages of shimmy damper mechanism. This situation led to torsional vibrations / breakage of shimmy damper after touchdown. The resultant torsional excitation experienced by the LMLG due to free pivoting of wheels (along vertical axis) caused collapse of LMLG.
- The RMLG collapsed due to overload as the aircraft moved on unprepared surface.

Final Report:

Crash of a Grumman G-159 Gulfstream I in Kinshasa

Date & Time: Nov 1, 2015

Type of aircraft:

Grumman G-159 Gulfstream I

Operator:

Registration:

9Q-CNP

Flight Phase:

Flight Type:

Survivors:

Site:

Democratic Republic of Congo

MSN:

164

YOM:

1965

Location:

Kinshasa-N'Djili

Kinshasa City Province

Country:

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

After takeoff from Kinshasa-Ndolo Airport, the crew reported technical problems with the undercarriage and was cleared to divert to Kinshasa-N'Djili Airport. A belly landing was completed on runway 24 and the aircraft slid for few dozen metres then veered off runway to the right and came to rest in a grassy area. All 26 occupants evacuated safely and the aircraft was damaged beyond repair. It is believed that the left main gear was torn off upon takeoff from Kinshasa-Ndolo Airport for unknown reasons.

Ground fire of a Boeing 767-269ER in Fort Lauderdale

Date & Time: Oct 29, 2015 at 1233 LT

Type of aircraft:

Boeing 767-200

Operator:

Registration:

N251MY

Flight Phase:

Taxiing

Flight Type:

Survivors:

Site:

Fort Lauderdale-Hollywood

Schedule:

Fort Lauderdale - Caracas

MSN:

23280/131

YOM:

1986

Flight number:

DYA405

Location:

Florida

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

15700

Copilot / Total flying hours:

4140

Aircraft flight hours:

30108

Aircraft flight cycles:

9986

Circumstances:

On October 29, 2015, about 12:33 pm eastern daylight time (EDT), Dynamic International Airways flight 405, a Boeing 767-200ER, N251MY, experienced a fuel leak and subsequent fire while taxiing for departure at the Fort Lauderdale-Hollywood International Airport, Florida (FLL). Of the 101 passengers and crew onboard, one passenger received serious injuries. The airplane sustained substantial damage from the fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 supplemental as a scheduled charter from FLL to Maiquetía Simón Bolívar International Airport (CCS), Caracas, Venezuela. A significant fuel leak and subsequent fire occurred in the left engine strut and nacelle during taxi, resulting in substantial damage to the airplane. The fuel leak was the result of a fuel line flexible coupling (Wiggins fitting) loosening and becoming disengaged due to the lack of a safety lockwire on the coupling as required by the maintenance manual. The leaking fuel contacted hot engine case surfaces which ignited the fire. Records indicate that maintenance was conducted on this fitting in October of 2012 at the 4C check prior to the airplane being prepared for storage. The area would also have been subject to a visual inspection when the airplane was brought out of storage in 2015. The same maintenance facility conducted both of these activities. About 240 flight hours were logged between the aircraft returning to service and the accident. The leak occurred after the coupling loosened due to the missing safety wire which was the result of an error by the third-party maintenance provider. The flight crew promptly shut down the left engine using the fire handle, and requested fire equipment. As the airplane stopped on the taxiway, passengers saw the fire and insisted that the cabin crew initiate an evacuation. One passenger opened an overwing exit on his own, and the slide did not deploy. The cabin crew initiated the evacuation without coordination with the flight crew. After the evacuation had already begun, the flight crew advised over the PA to evacuate out the right side of the airplane. The flight crew did not immediately shut down the right engine and an evacuating passenger ran behind the engine and was blown to the pavement resulting in serious injuries. The lack of coordination between the flight crew and cabin crew resulted in the evacuation initiating while the right engine was still running.

Probable cause:

The separation of the flexible fuel line coupling and subsequent fuel leak due to the failure of maintenance personnel to install the required safety lockwire. Contributing to the severity of the accident was the initiation of the evacuation before the right engine was shut down which led to the passenger's injury.

Final Report:

Crash of a Boeing 737-4L7 in Johannesburg

Date & Time: Oct 26, 2015 at 1206 LT

Type of aircraft:

Boeing 737-400

Operator:

Registration:

ZS-OAA

Flight Phase:

Flight Type:

Survivors:

Site:

Johannesburg-Oliver Reginald Tambo (Jan Smuts)

Schedule:

Port Elizabeth - Johannesburg

MSN:

26960/2483

YOM:

1993

Flight number:

BA6234

Location:

Gauteng

Country:

South Africa

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

9186

Captain / Total hours on type:

2899.00

Copilot / Total flying hours:

5817

Copilot / Total hours on type:

480

Aircraft flight hours:

57543

Circumstances:

The aircraft Boeing 737-400, operated by Comair, flight number BA6234, was on a scheduled domestic flight operated under the provisions of Part 121 of the Civil Aviation Regulations (CARs). The aircraft was on the third leg for the day, after it had performed two uneventful legs. According to their recorded flight plan, the first leg departed from King Shaka International Airport (FALE) to O.R. Tambo International Airport (FAOR), the second leg was from FAOR to Port Elizabeth International Airport (FAPE) on the same day, during which the Captain was flying. During this third leg, the aircraft departed from FAPE at 0820Z on an instrument flight plan rule for FAOR. On board were six (6) crew members, ninety four (94) passengers and two (2) live animals. The departure from FAPE was uneventful, whereby the first officer (FO) was the flying pilot (FP) for this leg. During the approach to FAOR, the aircraft was cleared for landing on runway 03R. The accident occurred at approximately 1 km past the threshold. The crew stated that a few seconds after a successful touchdown, they felt the aircraft vibrating, during which they applied brakes and deployed the reverse thrust. The vibration was followed by the aircraft rolling slightly low to the left. It later came to a full stop slightly left of the runway centre line, resting on its right main landing gear and the number one engine, with the nose landing gear in the air. The crash alarm was activated by the FAOR Air Traffic Controller (ATC). The Airport Rescue and Fire Fighting (ARFF) personnel responded swiftly to the scene of the accident. The accident site was then secured with all relevant procedures put in place. The aircraft sustained substantial damage as the number one engine scraped along the runway surface when the landing gear detached from the fuselage. ARFF personnel had to prevent an engine fire in which they saw smoke as a result of runway contact. The occupants were allowed to disembark from the aircraft via the left aft door due to the attitude in which the aircraft came to rest. The accident occurred during daylight meteorological conditions on Runway 03R at O.R. Tambo International Airport (FAOR) located at GPS reading as: S 26°08’01.30” E 028°14’32.34” and the field elevation 5558 ft.

Probable cause:

Unstable approach whereby the aircraft was flared too high with high forward speed resulting with a low sink rate in which during touch down the left landing gear
experienced excessive vibration and failed due to shimmy events.
The following findings were identified:
- According to the FDR recordings, the aircraft flare was initiated earlier at 65ft than at 20ft as recommended by aircraft manufacture, which contributed to the low sink rate.
- The shimmy damper failed the post-accident lab-test and fluid was found in the thermal relief valve, which could have contributed to the shimmy damper failure.
- According to the lab results, significant wear was found on the upper torsion link bushing and flange, which could have contributed to undamped vibration
continuation.
- The aircraft had a tailwind component during landing, which could have prolonged the landing distance.

Final Report:

Crash of a Boeing 737-3K2 in Cuzco

Date & Time: Oct 23, 2015 at 1115 LT

Type of aircraft:

Boeing 737-300

Operator:

Registration:

OB-2040-P

Flight Phase:

Flight Type:

Survivors:

Site:

Cuzco-Alejandro Velasco Astete

Schedule:

Lima - Cuzco

MSN:

24329/1858

YOM:

1990

Flight number:

P9216

Location:

Cuzco

Country:

Peru

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

133

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6352

Captain / Total hours on type:

1971.00

Copilot / Total flying hours:

1455

Copilot / Total hours on type:

1219

Aircraft flight hours:

74018

Aircraft flight cycles:

42389

Circumstances:

Following an uneventful flight from Lima, the crew started the descent to Cuzco-Alejandro Velasco Astete Airport Runway 28. On approach, the aircraft was configured for landing and flaps were deployed to 15°. Following a smooth landing, the crew started the braking procedure when, eight seconds after touchdown, he noticed vibrations coming from the left main gear. At a speed of 100 knots, the right main gear collapsed. The aircraft rolled for few hundred metres then came to a halt on the runway. All 139 occupants evacuated safely and the aircraft was damaged beyond repair.

Probable cause:

Unstable approach and inadequate landing technique for high altitude fields, which resulted in increased landing speed, the start of the flare manoeuvre at higher altitude, and low descent speed, which made the OB-2040-P aircraft make soft contact with the runway, causing inefficiency in operation of the shimmy damper, which did not prevent uncontrolled oscillation of the shock absorbers.
Contributing factors:
- Lack of instruction and training in simulators that include techniques and maneuvers of landing at high altitude fields, with emphasis on speed control at landing.
- Lack of a performance analysis process, through the use of flight recorders or other installed data recording equipment and flight parameters, by the operating company, to enable supervision, control and corrective measures in the operational use of its aircraft.

Final Report:

Crash of a BAe 146-300 in Tamale

Date & Time: Oct 6, 2015 at 0831 LT

Type of aircraft:

BAe 146

Operator:

Registration:

9G-SBB

Flight Phase:

Flight Type:

Survivors:

Site:

De Havilland DHC-6 Twin Otter

Schedule:

Accra – Tamale

MSN:

E.3123

YOM:

1989

Flight number:

IKM110

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

After landing on runway 23 at Tamale Airport, the four engine aircraft failed to stop within the remaining distance. It went through a fence that was delimiting a work area as the runway was subject to an extension. Upon impact, the nose gear was torn off and the aircraft slid for few dozen metres before coming to rest. All 76 occupants escaped uninjured but the aircraft was damaged beyond repair. It was specified in a NOTAM that the runway 23 length was reduced to 1,860 meters and that works were in progress to extend runway 23, with the presence of men and equipment. So, caution was advised during landing and takeoff procedures.

Crash of a De Havilland DHC-6 Twin Otter 300 on Mt Bajaja: 10 killed

Date & Time: Oct 2, 2015 at 1451 LT

Type of aircraft:

Operator:

Registration:

PK-BRM

Flight Phase:

Flight

Flight Type:

De Havilland DHC-8-400 (Dash-8)

Survivors:

Site:

Mountains

Schedule:

Masamba – Makassar

MSN:

741

YOM:

1981

Flight number:

VIT7503

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2911

Captain / Total hours on type:

2911.00

Copilot / Total flying hours:

4035

Copilot / Total hours on type:

4035

Aircraft flight hours:

45242

Aircraft flight cycles:

75241

Circumstances:

On 2 October 2015, a DHC-6 Twin Otter, registered PK-BRM, was being operated by PT. Aviastar Mandiri as a scheduled passenger flight with flight number MV 7503. The aircraft departed from Andi Jemma Airport, Masamba (WAFM)1 with the intended destination of Sultan Hasanuddin International Airport, Makassar (WAAA) South Sulawesi, Indonesia. On board the flight were 10 persons consisting of two pilots and eight passengers, including one company engineer. The previous flights were from Makassar – Tana Toraja – Makassar – Masamba – Seko - Masamba and the accident flight was from Masamba to Makassar which was the 6th sector of the day. The aircraft departed from Masamba at 1425 LT (0625 UTC2 ) with an estimated time of arrival at Makassar of 0739 UTC. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight was conducted under the Visual Flight Rules (VFR) and cruised at an altitude of 8,000 feet. At 0630 UTC, the pilot reported to Ujung Pandang Information officer that the aircraft passed an altitude of 4,500 feet and was climbing to 8,000 feet. The Ujung Pandang Information officer requested the pilot of the estimate time of aircraft position at 60 Nm out from MKS VOR/DME. At 0632 UTC, the pilot discussed about the calculation of estimate time to reach 60 Nm out from MKS and afterward the pilot informed Ujung Pandang Information officer that the estimate at 60 Nm was at 0715 UTC. At 0633 UTC, the Ujung Pandang Information officer informed the pilot to call when reaching 8,000 feet and was acknowledged by the pilot. At 0636 UTC, the pilot informed the Ujung Pandang Information officer that the aircraft had reached 8,000 feet and requested the squawk number (ATC transponder code). The Ujung Pandang Information officer acknowledged and gave the squawk number of A5616, which was acknowledged by the pilot. At 0637 UTC, the pilots discussed to fly direct to BARRU. BARRU is a town located at about 45 Nm north of Makassar. Both pilots agreed to fly direct and the SIC explained the experience of flying direct on the flight before. At 0651 UTC, the PIC told the SIC that he wanted to climb and one second later the CVR recorded the sound of impact.

Probable cause:

The following findings were identified:
1. The aircraft had valid Certificate of Airworthiness prior to the accident and was operated within the weight and balance envelope.
2. Both pilots had valid licenses and medical certificates.
3. The accident flight from Masamba (WAFM) to Makassar (WAAA) was the 6th sector for the aircraft and the crew that day. The PIC acted as Pilot Flying and the
SIC acted as Pilot Monitoring.
4. The satellite image published by BMKG at 0700 UTC showed that there were cloud formations at the accident area. The local villagers stated that the weather
on the accident area was cloudy at the time of the accident.
5. The aircraft departed Masamba at 0625 UTC (1425 LT), conducted under VFR with cruising altitude of 8,000 feet and estimated time of arrival Makassar at 0739 UTC.
6. After reached cruising altitude, at about 22 Nm from Masamba, the flight deviated from the operator visual route and directed to BARRU on heading 200° toward the area with high terrain and cloud formation based on the BMKG satellite image
7. The pilots decision making process did not show any evidence that they were concerned to the environment conditions ahead which had more risks and required correct flight judgment.
8. The CVR did not record EGPWS aural caution and warning prior to the impact. The investigation could not determine the reason of the absence of the EGPWS.
9. The CVR data and cut on the trees indicated that the aircraft was on straight and level flight and there was no indication of avoid action by climb or turn.
10. The SAR Agency did not receive any crashed signal from the aircraft ELT most likely due to the ELT antenna detached during the impact.
11. Regarding to the operation of the EGPWS for the flight crew, a special briefing was performed however there was no special training.
12. The operational test of TAWS system was not included in the pilot checklist.
13. The investigation could not determine the installation and the last revision of TAWS terrain database.
14. The investigation could not find the functional test result document after the installation of the TAWS.
15. Some of the DHC-6 pilots have not been briefed for the operation of the TAWS and EGPWS.

Contributing Factors:
Deviation from the company visual route without properly considering the elevated risks of cruising altitude lower than the highest terrain and instrument meteorological condition in addition with the absence of the EGPWS warning resulted in the omission of avoidance actions.

Final Report:

Crash of a De Havilland DHC-8-Q402 in Saarbrücken

Date & Time: Sep 30, 2015 at 1016 LT

Type of aircraft:

Operator:

Registration:

LX-LGH

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

Piper PA-31-350 Navajo Chieftain

Schedule:

Hamburg - Saarbrücken - Luxembourg

MSN:

4420

YOM:

2012

Flight number:

LG9562

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

11927

Captain / Total hours on type:

3649.00

Copilot / Total flying hours:

3295

Copilot / Total hours on type:

1483

Aircraft flight hours:

7131

Circumstances:

On the day of the accident, the crew of four was deployed for flights from Luxembourg (LUX) via Saarbrucken (SCN) to Hamburg (HAM) and back again via Saarbrucken to Luxembourg with a Bombardier DHC-8-402. The crew stated that they had met at about 0530 hrs for pre-flight preparations. The flights up until the take-off in Saarbrucken had occurred without incident. All in all the working atmosphere had been good and relaxed and they had been ahead of schedule. Saarbrucken was the destination airport for 14 passengers. The remaining 16 passengers’ destination airport was Luxembourg. According to the Cockpit Voice Recorder (CVR), the Flight Data Recorder (FDR), and the radio communication recordings, the engine start-up clearance was issued at 1009:47 hrs approximately 25 minutes ahead of schedule. At 1015:03 hrs while taxiing on taxiway C take-off clearance was issued. The Into Position Check was conducted at 1015:33 hrs on runway 09. The Pilot in Command (PIC) was Pilot Flying (PF) and the co-pilot Pilot Non Flying (PNF). The plan was to conduct take-off with reduced engine thrust (81%). During take-off the following callouts were made:
1016:24 PF take off, my controls
1016:25 PNF your controls
1016:27 PNF spoiler is closed
1016:30 PNF autofeather armed
1016:33 PF looks like spring
1016:35 PNF yeah, power is checked
1016:36 PNF 80 knots
1016:37 PF checked
1016:40 PNF V1, rotate
1016:42 Background click sound, probably gear lever UP
1016:43 PNF upps, sorry
During the rotation phase with approximately 127 KIAS and a nose-up attitude of approximately 5°, the landing gear retracted. At 1016:44 hrs the airplane’s tail had the first ground contact (tail strike). The tail strike warning light illuminated. Approximately 875 m after the initial ground contact the airplane came to a stop after it had bounced three times and skidded on the fuselage. The cabin crew stated that due to smoke and fume development in the cabin the airplane was evacuated right away. All passengers and the crew were uninjured and left the severely damaged airplane without help.

Probable cause:

The air accident was the result of an early retraction of the retractable landing gear during take-off, which was not prevented by the landing gear selector lever and the retracting control logic.
Contributory factors:
- Reduced concentration level,
- A break in the callout process / task sequence on the part of the PNF,
- Actuation of the landing gear lever to the UP Position too early,
- Control logic design allows retraction of the landing gear with one wheel airborne.

Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Thompson

Date & Time: Sep 15, 2015 at 1821 LT

Type of aircraft:

Operator:

Registration:

C-FXLO

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site: