Scheduled Revenue Flight

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

Survivors:

Site:

Mountains

Schedule:

Barcelona – Düsseldorf

MSN:

147

YOM:

1990

Flight number:

4U9525

Location:

Prads-Haute-Bléone

Alpes-de-Haute-Provence

Country:

France

Region:

Europe

Crew on board:

Crew fatalities:

Pax on board:

144

Pax fatalities:

Other fatalities:

Total fatalities:

150

Captain / Total flying hours:

6763

Captain / Total hours on type:

3811.00

Copilot / Total flying hours:

919

Copilot / Total hours on type:

540

Aircraft flight hours:

58313

Aircraft flight cycles:

46748

Circumstances:

The aircraft left Barcelona at 1000LT on a scheduled flight to Düsseldorf (flight 4U9525/GWI18G). At 1032LT, one minute after reaching its assigned cruising altitude of 38,000 feet near Toulon (level off), the aircraft started to lose altitude and continued a straight in descent during nine minutes, until it reached the altitude of 6,800 feet. It was later confirmed that no distress call was sent by the crew. Radar contact was lost at a height of 6,800 feet at 1041LT when the aircraft hit a mountain slope located near Prads-Haute-Bléone, northeast of Digne-les-Bains. At the time of the accident, weather conditions were considered as good with no storm activity, reasonable wind component and no turbulence. The crash site was reached by first rescuers in the afternoon and the aircraft disintegrated on impact. None of the 150 occupants survived the crash. The second black box (DFDR) was found on April 2, nine days after the accident.

Probable cause:

The collision with the ground was due to the deliberate and planned action of the copilot who decided to commit suicide while alone in the cockpit. The process for medical certification of pilots, in particular self-reporting in case of decrease in medical fitness between two periodic medical evaluations, did not succeed in preventing the copilot, who was experiencing mental disorder with psychotic symptoms, from exercising the privilege of his licence. The following factors may have contributed to the failure of this principle:
-The copilot’s probable fear of losing his ability to fly as a professional pilot if he had reported his decrease in medical fitness to an AME,
-The potential financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly,
- The lack of clear guidelines in German regulations on when a threat to public safety outweighs the requirements of medical confidentiality.
Security requirements led to cockpit doors designed to resist forcible intrusion by unauthorized persons. This made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps.

Final Report:

Crash of a De Havilland DHC-8-402Q in Hubli

Date & Time: Mar 8, 2015 at 1915 LT

Type of aircraft:

Operator:

Registration:

VT-SUA

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Bangalore – Hubli

MSN:

4373

YOM:

2011

Flight number:

SG1085

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

7050

Captain / Total hours on type:

1850.00

Copilot / Total flying hours:

1343

Copilot / Total hours on type:

1083

Aircraft flight hours:

10224

Aircraft flight cycles:

9440

Circumstances:

On 08.03.2015 M/s Spice Jet Ltd. Bombardier Q-400 aircraft VT-SUA, was operating a scheduled flight from Bangalore to Hubli under the command of ATPL license holder endorsed on type with duly qualified First Officer on type. There were 78 passengers and 4 crew members on board the aircraft. Previous to the accident flight, the aircraft VT-SUA had operated a flight Chennai – Bangalore with the same PIC. The flight was uneventful and there was no snag reported by the PIC on the completion of the flight. Subsequently the aircraft was scheduled for SG-1085, Bangalore - Hubli on 08.03.2015 at around 13:00 UTC. The aircraft took off from Bangalore at around 1300 UTC and the visibility reported for Hubli was 10 km. When the aircraft came in contact with Mangalore ATC, Mangalore ATC cleared aircraft direct to Hubli and informed heavy rains and thunder showers over Hubli with visibility 3000 m. Since the weather at Hubli had deteriorated, the PIC reduced aircraft speed for reassuring the flight parameters. As there is no refueling facility available at Hubli, the sector is a tankering sector hence the aircraft had enough fuel for holding. While approaching into Hubli the pilot requested latest weather from ATC Hubli. At around 60 nm from Hubli, the weather reported by ATC Hubli was heavy rain and visibility 4000 meters. The ATC cleared aircraft for NDB approach runway 26, however the PIC preferred to carry out VOR DME trial procedure for runway 26. The runway condition was neither asked by the cockpit crew nor intimated by the ATC. The descent was commenced and about 25 nm short of Hubli, ATC again advised visibility has reduced to 3000 m due heavy rain and thunderstorm. Thereafter the crew decided to hold over Hubli until the weather improves. 20 minutes into holding, the ATC again informed that visibility has improved to 4000m in moderate rain. Subsequently descent was requested by the pilot for runway 26. The PIC stated that he had established visual reference with runway at about 6 nm on the final approach course. The crew also selected vipers on short finals to have a better visibility. The aircraft landed normally. The PIC had stated that after touch down and reducing power to DISC, as he was concentrating on the far end of the runway as the runway was wet, he did not realize that the aircraft was drifting to the left of the center line. He further mentioned that he selected full reverse on both the engines to maintain the aircraft on the center line however the aircraft veered toward the left side of the runway and in the process overrun the runway edge light followed by LH landing gear collapsed. After the left landing gear collapsed the left propeller blades hit the runway surface and sheared off from the root attachment. The PIC maneuvered the aircraft however the nose wheel tyre failed under over load conditions and the nose landing gear collapsed and the aircraft belly came in contact with the runway surface. Subsequently, the aircraft exited the runway on the left side on Kutcha and came to the final stop at round 52 meters away from the runway center line. The cockpit crew switched off the engines and the electrical power supply and cockpit door and announced evacuation. The cabin crew opened and the cabin doors on the right for evacuation. The ATC had alerted the fire services and the fire vehicles reached the aircraft after it came to final halt position. The fire personnel also assisted in the safe evacuation of all the passengers from the RH side. There was no injury to any of the occupants on board the aircraft. There was no postaccident fire.

Probable cause:

Loss of visual cues after touch down in inclemental weather conditions resulted in veering of the aircraft towards left of the centerline leading to runway excursion and accident.
Following are the contributory factors:
1. Inappropriate handling technique of the aircraft controls by the PIC to maintain the directional control of the aircraft after landing.
2. Non-standards callouts by the first officer to correct situation after landing.
3. Impact of the landing gear with the non-frangible erected runway edge light resulted in retraction of the same.
4. At the time of the accident DGCA O.M. No. AV.15026/006/92- AS dated 3rd February 1992 was in force, which dictated examiners and instructors of the operators only to carry out trial procedures in VMC and during Daytime only. M/s Spice jet instructions to the flight crew did not reflect the same and allowed flight crew with less experience & below VMC flight conditions to carry out trial procedures. This may have contributed to the accident.

Final Report:

Crash of a McDonnell Douglas MD-88 in LaGuardia

Date & Time: Mar 5, 2015 at 1102 LT

Type of aircraft:

McDonnell Douglas MD-88

Operator:

Registration:

N909DL

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Atlanta – New York

MSN:

49540/1395

YOM:

1987

Flight number:

DL1086

Location:

New York-LaGuardia

New York

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

125

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

15200

Captain / Total hours on type:

11000.00

Copilot / Total flying hours:

11000

Copilot / Total hours on type:

3000

Aircraft flight hours:

71196

Aircraft flight cycles:

54865

Circumstances:

The aircraft was landing on runway 13 at LaGuardia Airport (LGA), New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane’s nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident. The captain and the first officer were highly experienced MD-88 pilots. The captain had accumulated about 11,000 hours, and the first officer had accumulated about 3,000 hours, on the MD-88/-90. In addition, the captain was previously based at LGA and had made many landings there in winter weather conditions. The flight crew was concerned about the available landing distance on runway 13 and, while en route to LGA, spent considerable time analyzing the airplane’s stopping performance. The flight crew also requested braking action reports about 45 and 35 minutes before landing, but none were available at those times because of runway snow clearing operations. The unavailability of braking actions reports and the uncertainty about the runway’s condition created some situational stress for the captain, who was the pilot flying. After runway 13 became available for arriving airplanes, the flight crews of two preceding airplanes (which landed on the runway about 16 and 8 minutes before the accident landing) reported good braking action on the runway, so the flight crew expected to see at least some of the runway’s surface after the airplane broke out of the clouds. However, the flight crew saw that the runway was covered with snow, which was inconsistent with their expectations based on the braking action reports and the snow clearing operations that had concluded less than 30 minutes before the airplane landed. The snowier-than-expected runway, along with its relatively short length and the presence of Flushing Bay directly off the departure end of the runway, most likely increased the captain’s concerns about his ability to stop the airplane within the available runway distance, which exacerbated his situational stress. The captain made a relatively aggressive reverse thrust input almost immediately after touchdown. Reverse thrust is one of the methods that pilots use to decelerate the airplane during the landing roll. Reverse thrust settings are expressed as engine pressure ratio (EPR) values, which are measurements of engine power (the ratio of the pressure of the gases at the exhaust compared with the pressure of the air entering the inlet). Both pilots were aware that 1.3 EPR was the target setting for contaminated runways.As reverse thrust EPR was rapidly increasing, the captain’s attention was focused on other aspects of the landing, which included steering the airplane to counteract a slide to the left and ensuring that the spoilers had deployed (a necessary action for the autobrakes to engage). The maximum EPR values reached during the landing were 2.07 on the left engine and 1.91 on the right engine, which were much higher than the target setting of 1.3 EPR. These high EPR values likely resulted from a combination of the captain’s stress; his relatively aggressive reverse thrust input; and operational distractions, including the airplane’s continued slide to the left despite the captain’s efforts to steer it away from the snowbanks alongside the runway. All of these factors reduced the captain’s monitoring of EPR indications. The high EPR values caused rudder blanking (which occurs on MD-80 series airplanes when smooth airflow over the rudder is disrupted by high reverse thrust) and a subsequent loss of aerodynamic directional control. Although the captain stowed the thrust reversers and applied substantial right rudder, right nosewheel steering, and right manual braking, the airplane’s departure from the left side of the runway could not be avoided because directional control was regained too late to be effective.

Probable cause:

The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inability to maintain directional control of the airplane due to his application of excessive reverse thrust, which degraded the effectiveness of the rudder in controlling the airplane’s heading. Contributing to the accident were the captain’s:
- situational stress resulting from his concern about stopping performance and
- attentional limitations due to the high workload during the landing, which prevented him from immediately recognizing the use of excessive reverse thrust.

Final Report:

Crash of an Airbus A330-303 in Kathmandu

Date & Time: Mar 4, 2015 at 0744 LT

Type of aircraft:

Airbus A330

Operator:

Registration:

TC-JOC

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Istanbul – Kathmandu

MSN:

1522

YOM:

2014

Flight number:

TK726

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

224

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

14942

Captain / Total hours on type:

1456.00

Copilot / Total flying hours:

7659

Copilot / Total hours on type:

1269

Aircraft flight hours:

4139

Aircraft flight cycles:

732

Circumstances:

The aircraft departed Istanbul at 1818LT on March 3 on a scheduled flight to Tribhuvan International Airport (TIA), Kathmandu with 11 crew members and 224 passengers .The aircraft started contacting Kathmandu Control from 00:02 hrs to 00:11hrs while the aircraft was under control of Varanasi and descending to FL 250 but there was no response because Kathmandu Control was not yet in operation. The airport opened at its scheduled time of 00:15hrs. The aircraft established its first contact with Kathmandu Approach at 00:17 hrs and reported holding over Parsa at FL 270. Kathmandu Approach reported visibility 100 meters and airport status as closed. At 00:22 hrs the aircraft requested to proceed to Simara due to moderate turbulence. The Kathmandu Approach instructed the aircraft to descend to FL 210 and proceed to Simara and hold. At 01:05 hrs when Kathmandu Approach provided an updated visibility of 1000 meters and asked the flight crew of their intentions, the flight crew reported ready for RNAV (RNP) APCH for runway 02. The aircraft was given clearance to make an RNP AR APCH. At 01:23 hrs when the aircraft reported Dovan, Kathmandu Approach instructed the flight crew to contact Kathmandu Tower. Kathmandu Tower issued a landing clearance at 01:24 hrs and provided wind information of 100° at 03 knots. At 01:27 hrs the aircraft carried out a missed approach due to lack of visual reference. The aircraft was given clearance to proceed to RATAN hold via MANRI climbing to 10500 feet as per the missed approach procedure. During the missed approach the aircraft was instructed to contact Kathmandu Approach. At 01:43 hrs the aircraft requested the latest visibility to which Kathmandu Approach provided visibility 3000 m and Kathmandu Tower observation of 1000 meters towards the south east and few clouds at 1000 ft, SCT 2000 ft and BKN 10,000 feet. When the flight crew reported their intention to continue approach at 01:44 hrs, Kathmandu Approach cleared the aircraft for RNAV RNP APCH runway 02 and instructed to report RATAN. The aircraft reported crossing 6700 ft at 01:55 hrs to Kathmandu Tower. Kathmandu Tower cleared the aircraft to land and provided wind information of 160° at 04 kts. At 01:57 hrs Kathmandu Tower asked the aircraft if the runway was insight. The aircraft responded that they were not able to see the runway but were continuing the approach. The aircraft was at 880 ft AGL at that time. At 783 ft AGL the aircraft asked Kathmandu Tower if the approach lights were on. Kathmandu Tower informed the aircraft that the approach lights were on at full intensity. The auto-pilots remained coupled to the aircraft until 14 ft AGL, when it was disconnected, a flare was attempted. The maximum vertical acceleration recorded on the flight data recorder was approximately 2.7 G. The aircraft pitch at touchdown was 1.8 degree nose up up which is lower than a normal flare attitude for other landings. From physical evidence recorded on the runway and the GPS latitude and longitude coordinate data the aircraft touched down to the left of the runway centerline with the left hand main gear off the paved runway surface. The aircraft crossed taxiways E and D and came to a stop on the grass area between taxiway D and C with the heading of the aircraft on rest position being 345 degrees (North North West) and the position of the aircraft on rest position was at N 27° 41' 46", E 85° 21'29" At 02:00 hrs Kathmandu Tower asked if the aircraft had landed. The aircraft requested medical and fire assistance reporting its position at the end of the runway. At 02:03 hrs the aircraft requested for bridge and stairs to open the door and vacate passengers instead of evacuation. The fire and rescue team opened the left cabin door and requested the cabin attendant as well as to pilot through Kathmandu Tower to deploy the evacuation slides. At 02:10 hrs evacuation signal was given to disembark the passengers. All passengers were evacuated safely and later, the aircraft was declared as damaged beyond repair.

Probable cause:

The probable cause of this accident is the decision of the flight crew to continue approach and landing below the minima with inadequate visual reference and not to perform a missed approach in accordance to the published approach procedure. Other contributing factors of the accident are probable fixation of the flight crew to land at Kathmandu, and the deterioration of weather conditions that resulted in fog over the airport reducing the visibility below the required minima. The following findings were reported:
- On March 2, 2015 i.e. two days before the accident, the crews of the flight to Kathmandu reported through RNP AR MONITORING FORM that all the NAV. accuracy and deviation parameter were perfectly correct at MINIMUM but the real aircraft position was high (PAPI 4 whites) and left offset,
- The airlines as well as crews were unaware of the fact that wrong threshold coordinates were uploaded on FMGS NAV data base of the aircraft,
- The flight crew was unable to get ATIS information on the published frequency because ATIS was not operating. ATIS status was also not included in the Daily Facilities Status check list reporting form of TIA Kathmandu,
- Turkish Airlines Safety Department advised to change the scheduled arrival time at Kathmandu Airport,
- It was the first flight of the Captain to Kathmandu airport and third flight but first RNAV (RNP) approach of the Copilot,
- Both approaches were flown with the auto-pilots coupled,
- Crew comments on the CVR during approach could be an indication that they (crews) were tempted to continue to descend below the decision height despite lack of adequate visual reference condition contrary to State published Standard Instrument Arrival and company Standard Operating procedures with the expectation of getting visual contact with the ground,
- The flight crew were not visual with the runway or approach light at MDA,
- The MET Office did not disseminate SPECI representing deterioration in visibility according to Annex 3,
- The Approach Control and the Kathmandu Tower did not update the aircraft with its observation representing a sudden deterioration in visibility condition due to moving fog,
- The Air Traffic Control Officers are not provided with refresher training at regular interval,
- CAAN did not take into account for the AIRAC cycle 04-2015 from 05 Feb 2015 to 04 March 2015 while cancelling AIP supplement,
- The auto-pilots remained coupled to the aircraft until 14ft AGL when it was disconnected and a flare was attempted,
- The crews were not fully following the standard procedure of KTM RNAV (RNP) Approach and company Standard Operating procedures.

Final Report:

Crash of an ATR72-600 in Taipei: 43 killed

Date & Time: Feb 4, 2015 at 1054 LT

Type of aircraft:

ATR72-600

Operator:

Registration:

B-22816

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Taipei - Kinmen

MSN:

1141

YOM:

2014

Flight number:

GE235

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4914

Captain / Total hours on type:

3151.00

Copilot / Total flying hours:

6922

Copilot / Total hours on type:

5687

Aircraft flight hours:

1627

Aircraft flight cycles:

2356

Circumstances:

The twin turboprop took off from runway 10 at 1052LT. While climbing to a height of 1,200 feet, the crew sent a mayday message, stating that an engine flamed out. Shortly later, the aircraft stalled and banked left up to an angle of 90° and hit the concrete barrier of a bridge crossing over the Keelung River. Out of control, the aircraft crashed into the river and was destroyed. It has been confirmed that 40 occupants were killed while 15 others were rescued. Three occupants remains missing. A taxi was hit on the bridge and its both occupants were also injured. According to the images available, it appears that the left engine was windmilling when the aircraft hit the bridge. First investigations reveals that the master warning activated during the initial climb when the left engine was throttled back. Shortly later, the right engine auto-feathered and the stall alarm sounded.

Probable cause:

The accident was the result of many contributing factors which culminated in a stall-induced loss of control. During the initial climb after takeoff, an intermittent discontinuity in engine number 2’s auto feather unit (AFU) may have caused the automatic take off power control system (ATPCS) sequence which resulted in the uncommanded autofeather of engine number 2 propellers. Following the uncommanded autofeather of engine number 2 propellers, the flight crew did not perform the documented abnormal and emergency procedures to identify the failure and implement the required corrective actions. This led the pilot flying (PF) to retard power of the operative engine number 1 and shut down it ultimately. The loss of thrust during the initial climb and inappropriate flight control inputs by the PF generated a series of stall warnings, including activation of the stick shaker and pusher. After the engine number 1 was shut down, the loss of power from both engines was not detected and corrected by the crew in time to restart engine number 1. The crew did not respond to the stall warnings in a timely and effective manner. The aircraft stalled and continued descent during the attempted engine restart. The remaining altitude and time to impact were not enough to successfully restart the engine and recover the aircraft.
The following findings related to probable causes were noted:
An intermittent signal discontinuity between the auto feather unit (AFU) number 2 and the torque sensor may have caused the automatic take off power control system (ATPCS):
- Not being armed steadily during takeoff roll,
- Being activated during initial climb which resulted in a complete ATPCS sequence including the engine number 2 autofeathering.
The available evidence indicated the intermittent discontinuity between torque sensor and auto feather unit (AFU) number 2 was probably caused by the compromised soldering joints inside the AFU number 2.
The flight crew did not reject the take off when the automatic take off power control system ARM pushbutton did not light during the initial stages of the take off roll.
TransAsia did not have a clear documented company policy with associated instructions, procedures, and notices to crew for ATR72-600 operations communicating the requirement to reject the take off if the automatic take off power control system did not arm.
Following the uncommanded autofeather of engine number 2, the flight crew failed to perform the documented failure identification procedure before executing any actions. That resulted in pilot flying’s confusion regarding the identification and nature of the actual propulsion system malfunction and he reduced power on the operative engine number 1.
The flight crew’s non-compliance with TransAsia Airways ATR72-600 standard operating procedures - Abnormal and Emergency Procedures for an engine flame out at take off resulted in the pilot flying reducing power on and then shutting down the wrong engine.
The loss of engine power during the initial climb and inappropriate flight control inputs by the pilot flying generated a series of stall warnings, including activation of the stick pusher. The crew did not respond to the stall warnings in a timely and effective manner.
The loss of power from both engines was not detected and corrected by the crew in time to restart an engine. The aircraft stalled during the attempted restart at an altitude from which the aircraft could not recover from loss of control.
Flight crew coordination, communication, and threat and error management (TEM) were less than effective, and compromised the safety of the flight. Both operating crew members failed to obtain relevant data from each other regarding the status of both engines at different points in the occurrence sequence. The pilot flying did not appropriately respond to or integrate input from the pilot monitoring.
The engine manufacturer attempted to control intermittent continuity failures of the auto feather unit (AFU) by introducing a recommended inspection service bulletin at 12,000 flight hours to address aging issues. The two AFU failures at 1,624 flight hours and 1,206 flight hours show that causes of intermittent continuity failures of the AFU were not only related to aging but also to other previously undiscovered issues and that the inspection service bulletin implemented by the engine manufacturer to address this issue before the occurrence was not sufficiently effective. The engine manufacturer has issued a modification addressing the specific finding of this investigation. This new modification is currently implemented in all new production engines, and another service bulletin is available for retrofit.
Pilot flying’s decision to disconnect the autopilot shortly after the first master warning increased the pilot flying’s subsequent workload and reduced his capacity to assess and cope with the emergency situation.
The omission of the required pre-take off briefing meant that the crew were not as mentally prepared as they could have been for the propulsion system malfunction they encountered after takeoff.

Final Report:

Crash of a BAe 4100 Jetstream 41 in Rhodes

Date & Time: Feb 2, 2015 at 0736 LT

Type of aircraft:

Bae Jetstream 41

Operator:

Registration:

SX-DIA

Flight Phase:

Flight Type:

Survivors:

Site:

South Aegean / Νότιο Αιγαίο

Schedule:

Heraklion – Rhodes

MSN:

41075

YOM:

1995

Flight number:

SEH100

Location:

Rhodes-Diagoras

Country:

Greece

Region:

Europe

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

11117

Captain / Total hours on type:

3574.00

Copilot / Total flying hours:

3834

Copilot / Total hours on type:

1334

Aircraft flight hours:

28327

Circumstances:

The Jetstream 41 aircraft, with registration number SX-DIA, operated by “SKY EXPRESS”, took off on 2nd February 2015 at 07:00 hrs. local time from the Airport of Heraklion ‘N. Kazantzakis’, performing the scheduled flight No. ‘SEH100’, the first in the day, destined for the Airport of Rhodes ‘Diagoras’. Pre-flight checks were completed with no findings and in this flight the Captain was designated as the Pilot Flying. A 3-member crew and 16 passengers were onboard. The flight crew reported for duty one hour prior to the time of flight and proceeded with all actions as laid down in the Company manual. The flight crew was also briefed that in the area of the Airport of Rhodes the winds were S-SE at 17 kt with Wind Gust 36 kt. At 07:23:54 hrs., approximately 12 min prior to landing, in the first contact of the flight crew with the Control Tower of the Airport of Rhodes, the flight crew was briefed by the Air Traffic Controller (ATC) with respect to the weather conditions at the area of the airport, variable winds prevailing with a direction from 20° to 160°, average wind direction from 110°, wind velocity 20 kt gusting 38 kt. As laid down in the airport procedures, ATC, given the weather conditions, alerted the fire service vehicles to be stationed in readiness at their designated positions on the taxiways. At 07:24:43 hrs. Rhodes ATC contacted the flight crew wishing to remind that as a result of the strong wind shear and turbulence, landing at the airport is not recommended under the circumstances. At 07:29:34 hrs. Rhodes ATC contacted again the flight crew informing that the wind is shifting from 40° to 260°, average wind direction from 120°, mean wind velocity 20 kt and wind gust 32 kt. At 07:32:36 hrs., at about 8nm to the airport, the ATC contacting again the flight crew informed that wind in the last ten minutes is shifting in all directions, with mean wind velocity 16 kt and wind gust 37 kt; ATC also reminded that under these conditions landing is not recommended. At 07:34:04 hrs., at about 4 nm to the airport, Rhodes ATC contacted again the flight crew informing that wind is shifting from 60° to 200°, mean wind velocity 15 kt, wind gust 32 kt and that runway 07 is free for landing. At 07:35:08 hrs. ATC again reports wind direction from 110°, 17kt. Communication between ATC and the flight crew was smooth without any problem, with the flight crew each time acknowledging the information provided by ATC. Given the prevailing winds, landing with 9° flaps and an airspeed of about 129 kt was selected. With the flight crew having performed all pre-landing checks prescribed in the manual and with the indicator lights for the ‘Down and Lock’ landing system being illuminated green, at about 07:36 hrs. the aircraft landed, with the right main landing gear touching down first. During deceleration immediately after touchdown, with the flight crew having performed all checks specified in the a/c manual and after ATC directed the aircraft to vacate the runway via taxiway ‘C’, the aircraft veered to the left and came to rest at the left edge of the runway without exiting the runway, with an eastward direction. With the fire service vehicle approaching the aircraft, the flight crew contacted the Control Tower of the airport stating that everything is ok, and then reporting inability to taxi when asked whether the aircraft is able to taxi; when asked whether a tire was burst, the flight crew confirmed that this is the case. At 07:37:49 hrs. the Fire Service advises the Control Tower of the airport that the fire truck sprays foam due to fuel leakage. At 07:41:08 hrs. the Control Tower, when so asked by the ‘follow me’ vehicle, inquired of the flight crew whether passengers could be disembarked and the answer was that getting off from the passenger door (forward left) would not be feasible given the presence of the fire-fighting foam on the runway, and that the rear right door (Emergency Exit) would be used instead. As reported by the Air Traffic Controller passengers were disembarked 15 minutes after the incident, and the process lasted approximately 10 minutes. Upon a first visual inspection at the accident site and before the left wing of the aircraft was raised on jacks, it appeared that the left main landing gear folded back resulting in the aircraft’s left side dragging the runway (the left main landing gear and its housing into contact with the runway) and stopping at the left edge of the runway facing to the east.

Probable cause:

- The decision to perform a landing following a non-stabilized approach.
- Landing with a strong and variable wind, the speed and the crosswind component of which were in excess of the values specified by the standard operating procedures, the aircraft manufacturer and the recommendations for the said aerodrome in AIP GREECE.
- The failure to adhere to CRM principles.

Final Report:

Crash of a Britten Norman BN-2A-8 Islander in Los Roques

Date & Time: Jan 16, 2015

Type of aircraft:

Britten-Norman Islander

Operator:

Registration:

YV2238

Flight Phase:

Flight Type:

Survivors:

Site:

Los Roques Federal Dependencies

Schedule:

Higuerote - Los Roques

MSN:

296

YOM:

1971

Location:

Los Roques

Country:

Venezuela

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

For unknown reasons, the aircraft landed hard on runway 07 at Los Roques Airport. Upon impact, the right main gear collapsed and punctured the right wing. Out of control, the twin engine aircraft cartwheeled and came to rest near the runway shoulder. All 10 occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Saab 340B in Stornoway

Date & Time: Jan 2, 2015 at 0833 LT

Type of aircraft:

Saab 340

Operator:

Registration:

G-LGNL

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

Schedule:

Stornoway – Glasgow

MSN:

246

YOM:

Flight number:

BE6821

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3880

Captain / Total hours on type:

3599.00

Circumstances:

The aircraft had been prepared for a Commercial Air Transport flight from Stornoway Airport to Glasgow Airport with 26 passengers and three crew on board; the commander was the Pilot Flying (PF) and the co-pilot was the Pilot Monitoring (PM). At 0825 hrs the aircraft was taxied towards Holding Point A1 for a departure from Runway 18. At 0832 hrs G-LGNL was cleared to enter the runway from Holding Point A1 and take off, and the ATC controller transmitted that the surface wind was from 270° at 27 kt. The commander commented to the co-pilot that the wind was across the runway and that there was no tailwind. As the aircraft taxied onto the runway, the co-pilot applied almost full right aileron input consistent with a cross-wind from the right, and the commander said to the co-pilot “charlie1, one hundred, strong wind from the right”. The commander advanced the power levers, the co-pilot said “autocoarsen high” and the engine torques increased symmetrically. The commander instructed the co-pilot to “set takeoff power” to which the co-pilot replied “apr armed”. Approximately one second after this call, the engine torques began to increase symmetrically, reaching 100% as the aircraft accelerated through 70 kt. During the early stages of the takeoff, left rudder was applied and the aircraft maintained an approximately constant heading. As the aircraft continued accelerating, the rudder was centralised, after which there was a small heading change to the left, then to the right, then a rapid heading change to the left causing the aircraft to deviate to the left of the runway centreline. The pilot applied right rudder but although the aircraft changed heading to the right in response, it did not alter the aircraft’s track significantly and the aircraft skidded to the left, departing the runway surface onto the grass at an IAS of 80 kt. The power levers remained at full power as the aircraft crossed a disused runway and back onto grass. During this period the nose landing gear collapsed before the aircraft came to a halt approximately 38 m left of the edge of the runway and 250 m from where it first left the paved surface. After the aircraft came to a halt, the captain saw that the propellers were still turning and so called into the cabin for the passengers to remain seated. One of the passengers shouted for someone to open the emergency exit but the cabin crew member instructed the passengers not to do so because the propellers were still turning. The co-pilot observed that the right propeller was still turning so operated the engine fire extinguishers to shut down both engines. When the passenger seated in the emergency exit row on the right of the aircraft saw that the right propeller had stopped, he decided to open the exit. He climbed out onto the wing and helped the remaining passengers leave the aircraft through the same exit, instructing them to slide off the rear of the wing onto the ground. The left propeller was still turning at the time the right over-wing exit was opened and the passenger seated in the left-side emergency exit row decided not to open the left exit. The crash alarm was activated by ATC at 0833 hrs. An aircraft accident was declared and the aerodrome emergency plan was put into action. When the Rescue and Fire Fighting Services (RFFS) arrived at the scene, passengers were still exiting the aircraft and the left propeller was still turning. After leaving the aircraft, the cabin crew member confirmed to the RFFS that all passengers had exited the cabin and had been accounted for outside. The passengers were taken to the fire station and then on to the passenger terminal. There were no injuries.

Probable cause:

During the attempted takeoff, the rudder was central from 40 kt and remained so until approximately 65 kt. Between approximately 52 and 65 kt, the aircraft turned right slightly before it turned left sharply at approximately 65 kt. Given that the rudder was central, this change of direction might have been caused by one, or a combination of the following factors:
a. Differential braking
b. Asymmetric thrust
c. A change in wind speed and direction
d. A nose wheel steering input
Data from the FDR showed that thrust was applied symmetrically throughout the takeoff run, and the manufacturer did not consider that the data for longitudinal acceleration and indicated airspeed supported the use of differential braking.

Final Report:

Crash of a Boeing 737-4H6 in Lahore

Date & Time: Dec 30, 2014 at 1522 LT

Type of aircraft:

Boeing 737-400

Operator:

Registration:

AP-BJN

Flight Phase:

Flight Type:

Survivors:

Site:

Lahore-Allama Muhammad Iqbal

Schedule:

Karachi – Lahore

MSN:

26460/2533

YOM:

1993

Flight number:

NL148

Location:

Punjab (پنجاب)

Country:

Pakistan

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

166

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Following an uneventful flight from Karachi, the crew completed the approach and landing on runway 36L at Lahore-Allama Muhammad Iqbal Airport. After touchdown, the crew initiated the braking procedure when the left main gear partially collapsed. Control was lost and the aircraft veered to the right before coming to rest in a grassy area. All 172 occupants evacuated safely and the aircraft was damaged beyond repair.

Probable cause:

It was determined that the left main gear partially collapsed after it suffered a bird strike (rapacious) on approach.

Crash of an Airbus A320-216 into the Java Sea: 162 killed

Date & Time: Dec 28, 2014 at 0618 LT

Type of aircraft:

Airbus A320

Operator:

Registration:

PK-AXC

Flight Phase:

Flight

Flight Type: