Scheduled Revenue Flight

The Swiftair MD-83 was performing flight AH5017 on behalf of Air Algérie (this regular schedule is performed four times a week). The aircraft left Ouagadougou at 0117Z and was attempting to land in Algiers at 0510LT but failed to arrive. 116 people (110 passengers and a crew of 6) were on board. The last position of the MD-83 was west of Gao, Mali. In the evening of July 24 (some 16 hours after the aircraft disappearance), the wreckage was eventually located and spotted some 50 km west of the city of Gossi, south Mali. The aircraft disintegrated on impact and no survivors was found among the 116 occupants. At the time of the accident, bad weather conditions with storm activity, winds, turbulence and icing was confirmed over the region of Gao, until an altitude of 40,000 feet. At the time of the accident, the aircraft was flying west of this marginal weather area and referring to the French BEA graphic, the aircraft did not properly get around this turbulent area. It was confirmed the aircraft started a left turn from the altitude of 31,000 feet and then spiraled to the ground in less than three minutes (140° bank left and 80° nose down until impact). The last position recorded by the FDR at 0147LT and 15 seconds was at the altitude of 1,600 feet (490 meters) and at a speed of 380 KIAS (740 km/h) with a very high rate of descent.

The aircraft was being operated on an instrument flight rules (IFR) regular public transport service from Kaohsiung to Magong in the Penghu archipelago. At 1906 Taipei Local Time, the aircraft impacted terrain approximately 850 meters northeast of the threshold of runway 20 at Magong Airport and then collided with a residential area on the outskirts of Xixi village approximately 200 meters to the southeast of the initial impact zone. At the time of the occurrence, the crew was conducting a very high frequency omni-directional radio range (VOR) non-precision approach to runway 20. The aircraft was destroyed by impact forces and a post-impact fire. Ten passengers survived the occurrence and five residents on the ground sustained minor injuries. The occurrence was the result of controlled flight into terrain, that is, an airworthy aircraft under the control of the flight crew was flown unintentionally into terrain with limited awareness by the crew of the aircraft’s proximity to terrain. The crew continued the approach below the minimum descent altitude (MDA) when they were not visual with the runway environment contrary to standard operating procedures. The investigation report identified a range of contributing and other safety factors relating to the flight crew of the aircraft, TransAsia’s flight operations and safety management processes, the communication of weather information to the flight crew, coordination issues at civil/military joint-use airport, and the regulatory oversight of TransAsia by the Civil Aeronautics Administration (CAA).

Following an uneventful flight from Dhaka, the crew initiated the approach to Cox's Bazar in poor weather conditions due to heavy rain falls. After touchdown, the nose gear collapsed. The airplane slid on its nose for few dozen metres before coming to rest in the middle of the runway that was blocked for almost 22 hours. All 48 occupants evacuated safely while the aircraft was damaged beyond repair.

Flight MH17 departed the gate at Amsterdam-Schiphol Airport, the Netherlands at 12:13 hours local time, bound for Kuala Lumpur, Malaysia. It was airborne at 12:31 (10:31 UTC) from runway 36C and reached a cruising altitude of FL310 at 12:53 (10:53 UTC). Ninety minutes into the flight, at 12:01 UTC and just prior to entering Ukrainian airspace, the flight climbed to FL330. According to the flight plan, flight MH17 would continue at the flight level until the waypoint PEKIT, which is on the Flight Information Region (FIR) boundary between Kiev FIR (UKBV) and Dnipropetrovs’k FIR (UKDV). From waypoint PEKIT the flight plan indicates a climb to FL350 on airway L980 for the remaining part over Ukraine. According to ATC data, at 12:53 UTC the aircraft was flying within the Dnipropetrovs’k FIR, Control Sector 2, at FL330, controlled by Dnipro Control. At that time, Dnipro Control asked whether MH17 was able to climb to FL350 in accordance with the flight plan and also to clear a potential separation conflict with other traffic in the area. This traffic was Singapore Airlines flight SQ351 from Copenhagen, a Boeing 777, flying at FL330 and approaching from behind. The crew replied they were unable to comply and requested to maintain at FL330. This was agreed by Dnipro Control. As an alternative to solve the separation conflict, the other traffic climbed to FL350. According to ATC data, at 13:00 UTC the crew of flight MH17 requested to divert the track 20 NM to the left, due to weather. This also was agreed by Dnipro Control, after which the crew requested whether FL340 was available. Dnipro control informed MH17 that FL340 was not available at that moment and instructed the flight to maintain FL330 for a while. At 13:07 UTC the flight was transferred to Dnipropetrovs’k CTA 4, also with call sign Dnipro Control. At 13:19:53 UTC, radar data showed that the aircraft was 3.6 NM north of centreline of airway L980 having deviated left of track, when Dnipro Control directed the crew to alter their route directly to waypoint RND due to other traffic. The crew acknowledged at 13:19:56 hrs. At 13.20:00 hrs, Dnipro Control transmitted an onward ATC clearance to "proceed direct to TIKNA after RND", no acknowledgement was received. Data from the Flight Data Recorder and the Digital Cockpit Voice Recorder both stopped at 13:20:03 hrs. No distress messages were received from the aircraft. The airplane apparently broke up in mid-air as debris was found in a large area. The centre section of the fuselage along with parts of the horizontal and vertical stabilizers was found near Hrabove. The cockpit and lower nose section came down in a sunflower field in Rozsypne, nearly four miles (6,5 km) west-southwest of Hrabove. The L2 and R2 doors along with various parts of the fuselage were found near Petropavlivka, about 5 miles (8 km) west of Hrabove. At the point of last contact it was flying 1000 feet above airspace that had been classified as restricted by Ukrainian authorities as a result of ongoing fighting in the area. In the preceding days before the accident two Ukraine Air Force aircraft that were shot down in the region: a Su-25 and an An-26 transport plane.

The Authority said the aircraft left the Ogle International Airport earlier in the day and made stops at Omai and Mahdia before heading at Monkey Mountain Airfield with several goods on board. On approach to Monkey Mountain, the plane circled the airstrip several times before landing. Shortly after setting down, it was claimed the aircraft veered off the runway, hit few obstacles and came to rest. While both occupants were uninjured, the aircraft was damaged beyond repair. It appears that weather was poor at the time of the accident with rain and winds and low clouds.

During the takeoff roll from Coari-Urucu Airport by night, the aircraft collided with a tapir that struck the right main gear. The crew continued the takeoff procedure and the flight to Manaus. After two hours and burning fuel, the aircraft landed at Manaus-Eduardo Gomes Airport. Upon touchdown, the right main gear collapsed and the aircraft veered to the right and came to rest. All 49 occupants evacuated safely while the aircraft was damaged beyond repair.

On approach to Zahedan Airport, the crew followed the checklist and configured the aircraft for landing when he realized that the left main gear remained stuck in its wheel well. The crew abandoned the landing manoeuvre and initiated a go-around procedure. During an hour, the crew followed a holding circuit to burn fuel and also to try to lower the left main landing gear but without success. Eventually, the crew was cleared to land on runway 35. After touchdown, the aircraft rolled for about 1,500 metres then veered off runway to the left before coming to rest in a sandy area. All 103 occupants evacuated safely and the aircraft was damaged beyond repair.

Following an uneventful flight from New Delhi-Indira Gandhi Airport, the crew was cleared for an ILS approach to Kabul Airport Runway 29. On short final, the aircraft entered an area of heavy rain falls. The crew continued the approach and the aircraft landed after the touchdown zone. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage, collided with the ILS antenna and slid for 285 metres before coming to rest. All 132 occupants evacuated safely and the aircraft was damaged beyond repair.

The aircraft took off from the Senador Nilo Coelho Aerodrome (SBPL), Petrolina - PE, to Presidente Juscelino Kubitschek International Airport (SBBR), Brasilia - DF, at 1752 (UTC), in order to complete the scheduled cargo and personnel flight O6 6393, with 5 crewmembers and 44 passengers on board. During the level flight, thirty minutes after takeoff, the aircraft presented low level in the hydraulic system 1. The crew performed the planned operational procedures and continued the flight to Brasilia, with the hydraulic system degraded. During the SBBR landing procedures, the crew used the alternative system for lowering the landing gears. The main landing gears lowered and locked, the nose landing gear unlocked, but did not lower. After coordination with the air traffic control, the aircraft was instructed to land on SBBR runway 11R. The landing took place at 2042 (UTC). After the touchdown, the aircraft covered a total distance of 900 meters until its full stop. The initial 750 meters were with the aircraft supported only by the main landing gears and the last 150 meters were with the aircraft supported by the main landing gears and by the lower part of the front fuselage. The aircraft stopped on the runway. Substantial damage to structural elements of the aircraft occurred near the nose section. The evacuation of the crewmembers and passengers was safe and orderly. The copilot suffered fractures in the thoracic spine. The other crewmembers and passengers left unharmed.

Before pushback from the gate, the first officer, who was the pilot monitoring, initialized the flight management computer (FMC) and mistakenly entered the incorrect departure runway (27R instead of the assigned 27L). As the captain taxied onto runway 27L for departure, he noticed that the wrong runway was entered in the FMC. The captain asked the first officer to correct the runway entry in the FMC, which she completed about 27 seconds before the beginning of the takeoff roll; however, she did not enter the FLEX temperature (a reduced takeoff thrust setting) for the newly entered runway or upload the related V-speeds. As a result, the FMC's ability to execute a FLEX power takeoff was invalidated, and V-speeds did not appear on the primary flight display (PFD) or the multipurpose control display unit during the takeoff roll. According to the captain, once the airplane was cleared for takeoff on runway 27L, he set FLEX thrust with the thrust levers, and he felt that the performance and acceleration of the airplane on the takeoff roll was normal. About 2 seconds later, as the airplane reached about 56 knots indicated airspeed (KIAS), cockpit voice recorder (CVR) data indicate that the flight crew received a single level two caution chime and an electronic centralized aircraft monitoring (ECAM) message indicating that the thrust was not set correctly. The first officer called "engine thrust levers not set." According to the operator's pilot handbook, in response to an "engine thrust levers not set" ECAM message, the thrust levers should be moved to the takeoff/go-around (TO/GA) detent. However, the captain responded by saying "they're set" and moving the thrust levers from the FLEX position to the CL (climb) detent then back to the FLEX position. As the airplane continued to accelerate, the first officer did not make a callout at 80 KIAS, as required by the operator's standard operating procedures (SOPs). As the airplane reached 86 KIAS, the automated RETARD aural alert sounded and continued until the end of the CVR recording. According to Airbus, the RETARD alert is designed to occur at 20 ft radio altitude on landing and advise the pilot to reduce the thrust levers to idle. The captain later reported that he had never heard an aural RETARD alert on takeoff, only knew of it on landing, and did not know what it was telling him. He further said that when the RETARD aural alert sounded, he did not plan to reject the takeoff because they were in a high-speed regime, they had no red warning lights, and there was nothing to suggest that the takeoff should be rejected. The first officer later reported that there were no V-speeds depicted on the PFD and, thus, she could not call V1 or VR during the takeoff. She was not aware of any guidance or procedure that recommended rejecting or continuing a takeoff when there were no V-speeds displayed. She further said she "assumed [the captain] wouldn't continue to takeoff if he did not know the V-speeds." The captain stated that he had recalled the V-speeds as previously briefed from the Taxi checklist, which happened to be the same V-speeds for runway 27L. The captain continued the takeoff roll despite the lack of displayed V-speeds, no callouts from the first officer, and the continued and repeated RETARD aural alert. FDR data show that the airplane rotated at 164 KIAS. However, in a postaccident interview, the captain stated that he "had the perception the aircraft was unsafe to fly" and that he decided "the safest action was not to continue," so he commenced a rejected takeoff. FDR data indicate that the captain reduced the engines to idle and made an airplane-nose-down input as the airplane reached 167 KIAS (well above the V1 speed of 157 KIAS) and achieved a 6.7 degree nose-high attitude. The airplane's pitch decreased until the nose gear contacted the runway. However, the airplane then bounced back into the air and achieved a radio altitude of about 15 ft. Video from airport security cameras show the airplane fully above the runway surface after the bounce. The tail of the airplane then struck the runway surface, followed by the main landing gear then the nose landing gear, resulting in its fracture. The airplane slid to its final resting position on the left side of runway 27L. The operator's SOPs address the conditions under which a rejected takeoff should be performed within both low-speed (below 80 KIAS) and high-speed (between 80 KIAS and V1) regimes but provide no guidance for rejecting a takeoff after V1 and rotation. Simulator testing performed after the accident demonstrated that increasing the thrust levers to the TO/GA detent, as required by SOPs upon the activation of the "thrust not set" ECAM message, would have silenced the RETARD aural alert. At the time of the accident, neither the operator's training program nor manuals provided to flight crews specifically addressed what to do in the event the RETARD alert occurred during takeoff; although, 9 months before the accident, US Airways published a safety article regarding the conditions under which the alert would activate during takeoff. The operator's postaccident actions include a policy change (published via bulletin) to its pilot handbook specifying that moving the thrust levers to the TO/GA detent will cancel the RETARD aural alert. Although simulator testing indicated that the airplane was capable of sustaining flight after liftoff, it is likely that the cascading alerts (the ECAM message and the RETARD alert) and the lack of V-speed callouts eventually led the captain to have a heightened concern for the airplane's state as rotation occurred. FDR data indicate that the captain made erratic pitch inputs after the initial rotation, leading to the nose impacting the runway and the airplane bouncing into the air after the throttle levers had been returned to idle. Airbus simulation of the accident airplane's acceleration, rotation, and pitch response to the cyclic longitudinal inputs demonstrated that the airplane was responding as expected to the control inputs. Collectively, the events before rotation (the incorrect runway programmed in the FMC, the "thrust not set" ECAM message during the takeoff roll, the RETARD alert, and the lack of required V-speeds callouts) should have prompted the flight crew not to proceed with the takeoff roll. The flight crewmembers exhibited a self-induced pressure to continue the takeoff rather than taking the time to ensure the airplane was properly configured. Further, the captain initiated a rejected takeoff after the airplane's speed was beyond V1 and the nosewheel was off the runway when he should have been committed to the takeoff. The flight crewmembers' performance was indicative of poor crew resource management in that they failed to assess their situation when an error was discovered, to request a delayed takeoff, to communicate effectively, and to follow SOPs. Specifically, the captain's decision to abort the takeoff after rotation, the flight crew's failure to verify the correct departure runway before gate departure, and the captain's failure to move the thrust levers to the TO/GA detent in response to the ECAM message were all contrary to the operator's SOPs. Member Weener filed a statement, concurring in part and dissenting in part, that can be found in the public docket for this accident. Chairman Hart, Vice Chairman Dinh-Zarr, and Member Sumwalt joined the statement.