Crash of a Convair CV-580 in Buena Vista

Date & Time: Jan 20, 1989 at 0925 LT
Type of aircraft:
Operator:
Registration:
N73160
Flight Phase:
Survivors:
Yes
Schedule:
Denver - Durango
MSN:
336
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18644
Captain / Total hours on type:
6224.00
Aircraft flight hours:
54108
Circumstances:
During flight, crew shut down the right engine when warning light for gearbox oil pressure illuminated and pressure was noted below minimum limit of 130 psi. Shortly after securing right engine, left engine lost power (fuel tank shutoff valve switch and fuel crossfeed valve switch were located near each other). Attempts to restart left engine were unsuccessful. With lack of alternative current electrical power, captain could not unfeather right engine for restart. During emergency landing, aircraft was damaged on uneven terrain. Operational check of right engine (at ground level) revealed no malfunction that would have prevented normal operation. Examination of left engine revealed turbine section had overheated and turbine blades had severe heat damage. Captain said that when he tried to restart left engine, fuel valves were in normal position and power lever was 1' above idle. He recalled an engine rpm of 8000, but didn't recall if he had used feather button to reduce rpm to 3000 (as directed by checklist). He verified fuel switches were 'on' and he tried to crossfeed fuel (in event of blockage). Cross feeding of fuel was not part of restart procedure. Flight manual cautioned about importance of reducing power to flight idle, to decrease fuel flow to engine and minimize possible overheating.
Probable cause:
Inadvertent deactivation of fuel to the left engine as the pilot was making a precautionary shutdown of the right engine, and his failure to follow the emergency checklist procedure. Related factors were: low gearbox oil pressure (at flight altitude), and uneven terrain that was encountered during the emergency landing.
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: cruise - normal
Findings
1. 1 engine
2. (f) lubricating system - pressure too low
3. Propeller feathering - intentional
----------
Occurrence #2: loss of engine power (total) - nonmechanical
Phase of operation: cruise
Findings
4. All engines
5. (c) fuel supply - inadvertent deactivation - pilot in command
----------
Occurrence #3: forced landing
Phase of operation: descent - emergency
Findings
6. (c) emergency procedure - improper - pilot in command
7. (c) checklist - not followed - pilot in command
----------
Occurrence #4: on ground/water encounter with terrain/water
Phase of operation: landing - roll
Findings
8. (f) terrain condition - rough/uneven
Final Report:

Crash of a Boeing 737-4Y0 in East Midlands: 47 killed

Date & Time: Jan 8, 1989 at 2025 LT
Type of aircraft:
Operator:
Registration:
G-OBME
Survivors:
Yes
Schedule:
London - Belfast
MSN:
23867
YOM:
1988
Flight number:
BD092
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
118
Pax fatalities:
Other fatalities:
Total fatalities:
47
Captain / Total flying hours:
13176
Captain / Total hours on type:
763.00
Copilot / Total flying hours:
3290
Copilot / Total hours on type:
192
Aircraft flight hours:
521
Circumstances:
British Midland Airways Flight BD092 took off from London-Heathrow Airport at 1952LT on a flight to Belfast, Northern Ireland. Some 13 minutes later, while climbing through FL283, moderate to severe vibration was felt, accompanied by a smell of fire in the cockpit. The outer panel of one of the n°1 engine fan blades detached, causing compressor stalls and airframe shuddering. Believing the n°2 engine had been damaged the crew throttled it back. The shuddering stopped and the n°2 engine was shut down. The crew then decided to divert to East Midlands Airport. The flight was cleared for an approach to runway 27. At 900 feet, 2.4 nm from the runway threshold, the n°1 engine power suddenly suffered a decrease in power. As the speed fell below 125 knots, the stick shaker activated and the aircraft struck trees at a speed of 115 knots. The aircraft continued and impacted the western carriageway of the M1 motorway 10 meters lower and came to rest against a wooded embankment, 1'023 meters short of runway threshold. 47 passengers were killed while all other occupants were injured, some of them seriously.
Probable cause:
The operating crew shut down the n°2 engine after a fan blade had fractured in the n°1 engine. This engine subsequently suffered a major thrust loss due to secondary fan damage after power had been increased during the final approach to land.
The following factors contributed to the incorrect response of the flight crew:
1. The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were outside their training and experience;
2. They reacted to the initial engine problem prematurely and in a way that was contrary to their training;
3. They did not assimilate the indications on the engine instrument display before they throttled back the n°2 engine;
4. As the n°2 engine was throttled back, the noise and shuddering associated with the surging of the n°1 engine ceased, persuading them that they had correctly identified the defective engine;
5. They were not informed of the flames which had emanated from the n°1 engine and which had been observed by many on board, including 3 cabin attendants in the aft cabin.
Final Report:

Crash of an Avro 748-2A-234 in Banjarmasin

Date & Time: Jan 4, 1989
Type of aircraft:
Operator:
Registration:
PK-IHA
Survivors:
Yes
MSN:
1614
YOM:
1967
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the twin engine aircraft belly landed on runway 29 at Banjarmasin-Syamsudin Noor Airport. All 52 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Vickers 757 Viscount in Tshikapa

Date & Time: Dec 31, 1988
Type of aircraft:
Operator:
Registration:
9Q-CTS
Survivors:
Yes
MSN:
310
YOM:
1958
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing, the nose gear collapsed. The airplane slid for few dozen meters before coming to rest. There were no casualties. The exact date of the mishap remains unknown, somewhere in 1988.

Crash of a Boeing 747-121A in Lockerbie: 270 killed

Date & Time: Dec 21, 1988 at 1903 LT
Type of aircraft:
Operator:
Registration:
N739PA
Flight Phase:
Survivors:
No
Site:
Schedule:
London - New York
MSN:
19646
YOM:
1970
Flight number:
PA103
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
243
Pax fatalities:
Other fatalities:
Total fatalities:
270
Captain / Total flying hours:
10910
Captain / Total hours on type:
4107.00
Copilot / Total flying hours:
11855
Copilot / Total hours on type:
5517
Aircraft flight hours:
72464
Aircraft flight cycles:
16497
Circumstances:
Flight PA103 departed London-Heathrow runway 27R for New York at 18:25. The aircraft levelled off at FL310, 31 minutes later. At 19:03 Shanwick Oceanic Control transmitted an oceanic clearance. At that time an explosion occurred in the aircraft's forward cargo hold at position 4L. The explosive forces produced a large hole in the fuselage structure and disrupted the main cabin floor. Major cracks continued to propagate from the large hole while containers and items of cargo ejected through the hole, striking the empennage, left- and right tail plane. The forward fuselage and flight deck area separated when the aircraft was in a nose down and left roll attitude, peeling away to the right at Station 800. The nose section then knocked the no. 3 engine off its pylon. The remaining aircraft disintegrated while it was descending nearly vertically from 19000 feet to 9000 feet. A section of cabin floor and baggage hold (from approx. Station 1241-1920) fell onto housing at Rosebank Terrace, Lockerbie. The main wing structure struck the ground with a high yaw angle at Sherwood Crescent, Lockerbie causing a massive fire. The Semtex bomb which caused the explosion had probably been hidden in a radio cassette player and was transferred to PA103 from a Pan Am Boeing 727 flight, arriving from Frankfurt. After a three-year joint investigation by the Dumfries and Galloway Constabulary and the U.S. Federal Bureau of Investigation indictments for murder were issued on November 13, 1991, against Abdel Basset Ali al-Megrahi, a Libyan intelligence officer and the head of security for Libyan Arab Airlines (LAA), and Lamin Khalifah Fhimah, the LAA station manager in Luqa Airport, Malta. United Nations sanctions against Libya and protracted negotiations with the Libyan leader Colonel Muammar al-Gaddafi secured the handover of the accused on April 5, 1999. On January 31, 2001, Megrahi was convicted of murder by a panel of three Scottish judges, and sentenced to 27 years in prison. Fhimah was acquitted.
Probable cause:
The in-flight disintegration of the aircraft was caused by the detonation of an improvised explosive device located in a baggage container positioned on the left side of the forward cargo hold at aircraft station 700.
Final Report:

Crash of a PZL-Mielec AN-2R near Naryan-Mar

Date & Time: Dec 13, 1988
Type of aircraft:
Operator:
Registration:
CCCP-81535
Flight Phase:
Survivors:
Yes
MSN:
1G208-39
YOM:
1984
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft crashed near Naryan-Mar and was written off. There were no casualties. It was reported that the total weight of the aircraft was above the MTOW and the center of gravity was well outside the admissible limits. In such conditions, the crew encountered difficulties to control the aircraft.

Crash of an Antonov AN-26 near Parachinar: 25 killed

Date & Time: Dec 10, 1988 at 2000 LT
Type of aircraft:
Operator:
Flight Phase:
Survivors:
No
Site:
Schedule:
Kabul - Khost
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
25
Circumstances:
En route from Kabul to Khost, the crew apparently got lost and the aircraft entered the Pakistan airspace without prior permission. The aircraft was shot down by the pilot of a Pakistan Air Force fighter air-air missile, entered a dive and crashed on the slope of a mountain located in the region of Parachinar. All 25 occupants were killed.
Probable cause:
Shot down by the pilot of a Pakistan Air Force fighter.

Crash of a Let L-410UVP in Kodinsk: 6 killed

Date & Time: Dec 7, 1988 at 1933 LT
Type of aircraft:
Operator:
Registration:
CCCP-67127
Survivors:
Yes
Schedule:
Krasnoyarsk – Boguchany – Kodinsk
MSN:
79 03 23
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
After being cleared for the approach, the crew descended to 1,200 meters then 500 meters. On final, while completing a last turn, the aircraft struck trees and crashed in a wooded area located 4,750 meters short of runway. The wreckage was found 735 meters to the left of the extended centerline. Both pilots and four passengers were killed while eight other occupants were injured.
Probable cause:
The exact cause of the accident could not be determined with certainty. However, the following findings were reported:
- It is believed that the crew got distracted during the last portion of the final approach,
- Lack of visibility due to the night,
- The aircraft was not properly aligned on the approach path,
- The crew failed to follow the published approach procedures,
- The crew failed to pass over the outer marker, causing the aircraft to follow an erratic approach trajectory,
- The crew switched their seats as the captain was seating in the right front seat and the copilot in the left front seat, which is prohibited in such operations,
- The radio altimeter alarm failed to sound due to wrong settings,
- The aircraft banked left to an angle of 48° and nosed down to an angle of 24° just before final impact.

Crash of a Vickers 807 Viscount in Tangier

Date & Time: Nov 23, 1988
Type of aircraft:
Operator:
Registration:
G-BBVH
Survivors:
Yes
Schedule:
Gibraltar - Tangier
MSN:
281
YOM:
1957
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Tangier-Boukhalef Airport was completed in heavy rain falls with a wind from 060° gusting at 24 knots. After touchdown on a wet runway, the crew encountered difficulties to decelerate. Following a course of about 1,000 meters on runway 28, the four engine aircraft veered off runway to the left and came to rest in a ditch. All 78 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The assumption that the loss of control was the consequence of aquaplaning was not ruled out.

Crash of a Swearingen SA226TC Metro II in Montluçon: 4 killed

Date & Time: Nov 18, 1988 at 0631 LT
Type of aircraft:
Operator:
Registration:
F-GCPG
Flight Phase:
Survivors:
No
Schedule:
Montluçon - Paris
MSN:
TC-334E
YOM:
1980
Flight number:
FU440
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Aircraft flight hours:
10346
Circumstances:
Following a night takeoff at Montluçon-Guéret Airport, while in initial climb, the aircraft nosed down and struck the ground 600 meters past the runway end. It slid for few dozen meters, collided with bushes and eventually came to rest, bursting into flames. All four occupants were killed. It appears that the Stall Avoidance System (SAS) had activated, resulting in the stick pusher activation at a critical altitude. The Metro's SAS system, as well as the SAS system on this particular aircraft, had a history of problems. These problems resulted in several NTSB Safety Recommendations (A-84-66, A-88-154). The copilot was at controls at the time of the accident.
Crew:
Gérard Van Der Veecken, pilot,
Christian Rémondon, copilot.
Passengers:
Robert Aupetit,
Patrick Desdoit.
Probable cause:
The accident resulted from a reduction in the attitude of the airplane causing a downward trajectory in the moments that followed the takeoff. It is likely that this decrease in attitude is due to an untimely triggering of the stick pusher. The absence of a recorder and the complete destruction of the SAS (apart from angle of attack vane and its transmitter) did not prove this hypothesis. With or without inadvertent triggering of the stick pusher, the imprecision of the right horizon and the absence of external visual references played an important role in this accident.