Crash of a Boeing 767-3Z9ER near Phu Toey: 223 killed

Date & Time: May 26, 1991 at 2317 LT
Type of aircraft:
Operator:
Registration:
OE-LAV
Flight Phase:
Survivors:
No
Schedule:
Hong Kong - Bangkok - Vienna
MSN:
24628
YOM:
1989
Flight number:
NG004
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
213
Pax fatalities:
Other fatalities:
Total fatalities:
223
Captain / Total flying hours:
11750
Copilot / Total flying hours:
6500
Aircraft flight hours:
7444
Aircraft flight cycles:
1135
Circumstances:
Lauda Air Flight 004 (NG004) was a scheduled passenger flight from Hong Kong to Vienna, Austria with an en route stop in Bangkok, Thailand. The flight departed Bangkok at 1602 hours on May 26, 1991 for the final flight sector to Vienna Austria. All pre-flight, ground, and flight operations appear routine until five minutes and forty five seconds after the cockpit voice recorder (CVR) recorded the sounds of engine power being advanced for takeoff. At this point a discussion ensued between the crew members regarding an event later identified as a crew alert associated with a thrust reverser isolation valve. The crew discussed this alert for some four and one half minutes. The Quick Reference Handbook (QRH) was consulted to determine appropriate crew actions in response to the alert. No actions were required, and none were identified as being taken. Ten minutes and twenty seconds into the flight the co-pilot advised the pilot-in-command of the need for rudder trim to the left. The pilot-in-command acknowledged the co-pilot's statement. Fifteen minutes and one second into the flight, the co-pilot stated "ah reverser's deployed." Sounds similar to airframe shuddering were then heard on the CVR. Twenty nine seconds later the CVR recording ended with multiple sounds thought to be structural breakup. Flight conditions were recovered from non-volatile memory in the left engine electronic engine control (EEC). At the suspected point of reverser deployment, the EEC readout indicated that the airplane was at an approximate altitude of 24,700 feet, a speed of Mach 0.78, and developing climb power. The airplane crashed in mountainous jungle terrain at 14 degrees 44 minutes North latitude and 99 degrees 27 minutes East longitude at approximately 1617 hours. Night time visual meteorological conditions prevailed. All 223 occupants were killed.
Probable cause:
The Accident Investigation Committee of the Government of Thailand determines the probable cause of this accident to be uncommanded in-flight deployment of the left engine thrust reverser, which resulted in loss of flight path control. The specific cause of the thrust reverser deployment has not been positively identified.
Final Report:

Crash of a Tupolev TU-154B-1 in Leningrad: 13 killed

Date & Time: May 23, 1991 at 1306 LT
Type of aircraft:
Operator:
Registration:
CCCP-85097
Survivors:
Yes
Schedule:
Sukhumi - Leningrad
MSN:
75A097
YOM:
1975
Flight number:
SU8556
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
174
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
Following an uneventful flight from Sukhumi, the crew initiate the approach to Leningrad-Pulkovo Airport in heavy rain falls. At a distance of 7 km on approach, at an altitude of 400 meters and at a speed of 287 km/h, flaps were deployed to an angle of 45°. Fifteen seconds laters, at a distance of 5,700 meters, the crew was cleared to land and continued the approach when the aircraft passed below the glide. With a rate of descent of 7 meters per second and at a speed of 250 km/h, the aircraft struck the ground 13 meters short of runway threshold in a 1° nose down attitude and with a positive acceleration of 4,5 g. The aircraft broke in three parts and came to rest 80 meters to the left of the runway. 13 passengers were killed, 38 other occupants were injured and 130 escaped uninjured.
Probable cause:
Wrong approach configuration on part of the flying crew. The following contributing factors were reported:
- Deviations in the actions of the crew during the approach procedure,
- Lack of crew coordination,
- Inconsistencies in crew actions during an instrument approach that resulted in a significant vertical deviation from the calculated descent trajectory and delayed actions to eliminate them,
- Lack of assistance from the approach controller,
- Decision of the crew to continue the approach maneuver instead of initiating a go-around procedure.

Crash of a Fokker F27 Friendship 600 near Manado: 13 killed

Date & Time: May 9, 1991 at 0237 LT
Type of aircraft:
Operator:
Registration:
PK-MFD
Survivors:
No
Site:
Schedule:
Ambon - Ternate - Manado
MSN:
10399
YOM:
1969
Flight number:
MZ7533
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
The aircraft departed Ternate Airport at 0153LT on the second leg of a flight from Ambon to Manado. While descending by night to Manado-Sam Ratulangi Airport, the crew encountered limited visibility due to poor weather conditions when the aircraft struck the slope of Mt Klabat located 15 km southeast of runway 36 threshold. The aircraft was destroyed upon impact and all 13 occupants were killed. It was raining at the time of the accident and the mountain was shrouded in clouds.
Probable cause:
Controlled flight into terrain.

Crash of a De Havilland DHC-3 Otter in Cameron Lake

Date & Time: May 8, 1991 at 1010 LT
Type of aircraft:
Operator:
Registration:
C-FQRI
Flight Phase:
Survivors:
Yes
Schedule:
Vancouver – Tofino
MSN:
326
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was supposed to proceed under VFR mode to the west but as weather conditions deteriorated with low clouds, he decided to continue to the south. While flying between two mountains, the single engine aircraft encountered atmospheric turbulences and the pilot elected to return when the aircraft lost height and struck trees. Upon impact, both wings were torn off and the aircraft crashed in a wooded area. All 11 occupants were injured, four of them seriously.

Crash of a Cessna 404 Titan II near Aweil: 8 killed

Date & Time: May 5, 1991
Type of aircraft:
Registration:
ST-AHX
Survivors:
No
MSN:
404-0657
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
While descending to Aweil Airport, the twin engine aircraft went shot down by a surface-to-air missile and crashed in an open field located about 25 km from Aweil. All eight occupants were killed.
Probable cause:
Shot down by a surface-to-air missile from Sudan People's Liberation Army.

Crash of a Dornier DO228-212 off Nuka Hiva: 10 killed

Date & Time: Apr 18, 1991 at 1156 LT
Type of aircraft:
Operator:
Registration:
F-OHAB
Survivors:
Yes
Schedule:
Hiva Oa - Nuku Hiva
MSN:
8196
YOM:
1990
Flight number:
VT805
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
8115
Captain / Total hours on type:
112.00
Copilot / Total flying hours:
4766
Copilot / Total hours on type:
95
Aircraft flight hours:
634
Circumstances:
On final approach to Nuku Hiva Airport runway 06, at an altitude of about 2,000 feet, the left engine failed. The crew decided to perform an approach to runway 24 when on final, the captain ditched the aircraft few dozen meters offshore. The impact was relatively violent and 10 occupants were killed, among them the captain. All 12 other occupants were injured, some seriously.
Probable cause:
The accident resulted from a series of inappropriate actions by the crew, facing a mechanical failure of an engine which alone should never have led to this outcome. Among the factors explaining this below-average performance of the crew, the inquiry committee noted:
- The influence of a possible levels of alcohol of the crew members;
- A lack of rigor in the type rating qualifying of the crew;
- Omissions in the Operations Manual (no division of tasks in some occasional or emergency situations);
- Deficiencies in the company's technical control of the state of the aircraft.
Final Report:

Crash of an Embraer EMB-120RT Brasilía in Brunswick: 23 killed

Date & Time: Apr 5, 1991 at 1451 LT
Type of aircraft:
Operator:
Registration:
N270AS
Survivors:
No
Schedule:
Atlanta - Brunswick
MSN:
120-218
YOM:
1990
Flight number:
EV2311
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
11724
Captain / Total hours on type:
5720.00
Copilot / Total flying hours:
3925
Copilot / Total hours on type:
2795
Aircraft flight hours:
816
Aircraft flight cycles:
845
Circumstances:
Witnesses reported that the airplane suddenly turned or rolled left until the wings were perpendicular to the ground. The airplane then fell in a nose-down attitude. Examination of the left propeller components indicated a blade angle of about 3°, while the left propeller control unit (pcu) ballscrew position was consistent with a commanded blade angle of 79.2°. Extreme wear on the pcu quill spline teeth, which normally engaged the titanium-nitrided splines of the propeller transfer tube, was found. The titanium-nitrided surface was much harder and rougher than the nitrided surface of the quill. Therefore, the transfer tube splines acted like a file and caused abnormal wear of the gear teeth on the quill. Wear of the quill was not considered during the certification of the propeller system. The aircraft was totally destroyed upon impact and all 23 occupants were killed, among them John Goodwin Tower, Senator of Texas and the astronaut Manley Sonny Carter.
Probable cause:
The loss of control in flight as a result of a malfunction of the left engine propeller control unit which allowed the propeller blade angles to go below the flight idle position. Contributing to the accident was the deficient design of the propeller control unit by hamilton standard and the approval of the design by the federal aviation administration. The design did not correctly evaluate the failure mode that occurred during this flight, which resulted in an uncommanded and uncorrectable movement of the blades of the airplane's left propeller below the flight idle position.
Final Report:

Crash of a Cessna 402B off San Pedro: 8 killed

Date & Time: Apr 1, 1991 at 1510 LT
Type of aircraft:
Operator:
Registration:
N402BL
Survivors:
No
Schedule:
Belize City - San Pedro
MSN:
402B-0827
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Aircraft flight hours:
4202
Circumstances:
On approach to San Pedro Airport runway 06, the aircraft was number 2 for landing. A Cessna 207, V3-HER was ahead and had broadcast its intention to land. A Tropic Air Twin Otter, call sign Tango Alfa, on the ground, requested that N402BL go around to allow Tango Alfa to takeoff because the ramp was full. N402BL acknowledged and was seen making a left turn with wheels down. No further communication was heard from N402BL. The aircraft was seen flying very low with wheels down and flaps down in a southerly direction and as it crossed the shoreline south of the airstrip the aircraft made a sharp left turn and crashed into the sea about 200 yards from the beach at approximately 1500 hours. The aircraft struck nose first then righted itself and sank in water about five feet deep. There was no fire. Boats in the vicinity reached the accident site within a few minutes and reported that all eight occupants were dead inside the aircraft.
Probable cause:
There is no evidence which permits the investigation to determine with certainty the actual cause of the accident. It is considered a reasonable deduction that:
- The pilot was unfit for flight due to fatigue,
- He stalled the aircraft while flying very low down wind with landing gear down,
- The aircraft was much too low to recover from the stall.
Final Report:

Crash of a Fokker F27 Friendship 200 in Khartoum

Date & Time: Mar 25, 1991
Type of aircraft:
Operator:
Registration:
ST-AAA
Flight Phase:
Survivors:
Yes
Schedule:
Khartoum - Dongola
MSN:
10192
YOM:
1962
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After liftoff from Khartoum-Haj Yussuf Airport, while in initial climb, the crew raised the landing gear when the captain realized that the aircraft did not get a positive rate of climb. He decided to land back on the runway when the aircraft landed on its belly and slid for few dozen meters before coming to rest. All 27 occupants escaped uninjured. The aircraft was written off.

Crash of an Antonov AN-24RV in Navoi: 34 killed

Date & Time: Mar 23, 1991 at 1137 LT
Type of aircraft:
Operator:
Registration:
CCCP-46472
Survivors:
No
Schedule:
Tashkent - Navoi
MSN:
27307910
YOM:
1972
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
59
Pax fatalities:
Other fatalities:
Total fatalities:
34
Circumstances:
Following a wrong approach configuration, the crew passed over the runway threshold at a height of 30 meters and an excessive speed of 350 km/h. Rather than initiating a go-around procedure, the pilot-in-command continued and the aircraft landed 710 meters past the runway threshold. Unable to stop within the remaining distance, the aircraft overran at a speed of 225 km/h, lost its undercarriage then slid for about 317 meters and eventually collided with concrete blocks (2 meters high), bursting into flames. 29 passengers were injured while 34 other occupants were killed, among them all four crew members.
Probable cause:
Wrong approach configuration on part of the flying crew (too high on the glide and excessive speed) who failed to initiate a go-around while the landing procedure was obviously missed. The concrete blocks struck by the airplane were part of construction work for the new runway. The following contributing factors were reported:
- The crew violated/neglected various procedures,
- Lack of crew discipline,
- Poor crew coordination,
- The crew failed to use all available braking systems.