Crash of an ATR42-300 in Churchill

Date & Time: Mar 9, 2014 at 1015 LT
Type of aircraft:
Operator:
Registration:
C-FJYV
Survivors:
Yes
Schedule:
Thompson – Churchill
MSN:
216
YOM:
1991
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Thompson, the crew completed the approach and landing at Churchill Airport. After touchdown, the crew started the braking procedure and was vacating the runway when the right main gear collapsed. This caused the right propeller and the right wing to struck the ground. The aircraft was stopped and all five occupants evacuated safely. The aircraft was damaged beyond repair.
Probable cause:
Failure of the right main gear for unknown reasons.

Crash of a Boeing 777-2H6ER in the Indian Ocean: 239 killed

Date & Time: Mar 8, 2014 at 0130 LT
Type of aircraft:
Operator:
Registration:
9M-MRO
Flight Phase:
Survivors:
No
Schedule:
Kuala Lumpur – Beijing
MSN:
28420/404
YOM:
2002
Flight number:
MH370
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
227
Pax fatalities:
Other fatalities:
Total fatalities:
239
Captain / Total flying hours:
18423
Captain / Total hours on type:
8559.00
Copilot / Total flying hours:
2813
Copilot / Total hours on type:
39
Aircraft flight hours:
53471
Aircraft flight cycles:
7526
Circumstances:
The Boeing 777-2H6ER took off from Kuala Lumpur Airport runway 32R at 0041LT bound for Beijing. Some 40 minutes later, while reaching FL350 over the Gulf of Thailand, radar contact was lost. At this time, the position of the aircraft was estimated 90 NM northeast of Kota Bharu, some 2 km from the IGARI waypoint. More than 4 days after the 'accident', no trace of the aircraft has been found. On the fifth day of operation, several countries were involved in the SAR operations, in the Gulf of Thailand, west of China Sea and on the Malacca Strait as well. All operations are performed in coordination with China, Thailand, Vietnam, Malaysia and Philippines. No distress call or any kind of message was sent by the crew. The last ACARS message was received at 0107LT and did not contain any error, failure or technical problems. At 0119LT was recorded the last radio transmission with the crew saying "All right, good night". At 0121LT, the transponder was switched off and the last radar contact was recorded at 0130LT. Several hypothesis are open and no trace of the aircraft nor the occupant have been found up to March 18, 2014. It is now understood the aircraft may flew several hours after it disappeared from radar screens, flying on an opposite direction from the prescribed flight plan, most probably to the south over the Indian Ocean. No such situation was ever noted by the B3A, so it is now capital to find both CVR & DFDR to explain the exact circumstances of this tragic event. Considering the actual situation, all scenarios are possible and all hypothesis are still open. On Mar 24, 2014, the Malaysian Prime Minister announced that according to new computations by the British AAIB based on new satellite data, there is no reasonable doubt that flight MH370 ended in the South Indian Ocean some 2,600 km west of Perth. Given the situation, the Malaysian Authorities believe that there is no chance to find any survivors among the 239 occupants.

***************************

According to the testimony of 6 Swiss Citizens making a cruise between Perth and Singapore via Jakarta, the following evidences were spotted on March 12 while approaching the Sunda Strait:
1430LT - latitude 6° S, longitude 105° E, speed 17,7 knots:
life jacket, food trays, papers, pieces of polystyrene, wallets,
1500LT:
a huge white piece of 6 meters long to 2,5 meters wide with other debris,
1530LT:
two masts one meter long with small flags on top, red and blue,
2030LT - latitude 5° S, longitude 107° E, speed 20,2 knots.

This testimony was submitted by these 6 Swiss Citizens to the Chinese and Australian Authorities.

On April 21, 2016, it was confirmed that this testimony was recorded by the Swiss Police and transmitted to the Swiss Transportation Safety Investigation Board (STSB), the State authority of the Swiss Confederation which has a mandate to investigate accidents and dangerous incidents involving trains, aircraft, inland navigation ships, and seagoing vessels. The link to the STSB is http://www.sust.admin.ch/en/index.html.

***************************

On July 29, 2015, a flaperon was found on a beach of the French Island of La Réunion, in the Indian Ocean. It was quickly confirmed by the French Authorities (BEA) that the debris was part of the Malaysian B777. Other debris have been found since, in Mozambique and South Africa.

On May 12, 2016, Australia's TSB reported that the part has been identified to be a "the decorative laminate as an interior panel from the main cabin. The location of a piano hinge on the part surface was consistent with a work-table support leg, utilised on the exterior of the MAB Door R1 (forward, right hand) closet panel". The ATSB reported that they were not able to identify any feature on the debris unique to MH-370, however, there is no record that such a laminate is being used by any other Boeing 777 customer.

***************************

On September 15, 2016, the experts from the Australian Transportation Safety Bureau (ATSB) have completed their examination of the large piece of debris discovered on the island of Pemba, off the coast of Tanzania, on June 20, 2016. Based on thorough examination and analysis, ATSB with the concurrence of the MH370 Safety Investigation Team have identified the following:
- Several part numbers, along with physical appearance, dimensions, and construction confirmed the piece to be an inboard section of a Boeing 777 outboard flap.
- A date stamp associated with one of the part numbers indicated manufacture on January 23, 2002, which was consistent with the May 31, 2002 delivery date for MH370,
- In addition to the Boeing part number, all identification stamps had a second 'OL' number that were unique identifiers relating to part construction,
- The Italian part manufacturer has confirmed that all numbers located on the said part relates to the same serial number outboard flap that was shipped to Boeing as line number 404,
- The manufacturer also confirmed that aircraft line number 404 was delivered to Malaysian Airlines and registered as 9M-MRO (MH370)

As such, the experts have concluded that the debris, an outboard flap originated from the aircraft 9M-MRO, also known as flight MH370. Further examination of the debris will continue, in hopes that further evidence may be uncovered which may provide new insight into the circumstances surrounding flight MH370.
Probable cause:
Due to lack of evidences the exact cause of the accident could not be determined.
Final Report:

Crash of an Embraer EMB-120RT Brasília in Lucapa

Date & Time: Feb 25, 2014 at 1000 LT
Type of aircraft:
Operator:
Registration:
D2-FFZ
Survivors:
Yes
Schedule:
Luanda – Lucapa
MSN:
120-212
YOM:
1990
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Lucapa, the crew encountered technical problems and was forced to shut an engine down for unknown reason. After touchdown, the aircraft went out of control and veered off runway to the left. While contacting rough terrain, the aircraft lost its undercarriage and came to rest on its belly with severe damages to both wings, engines and fuselage. Three passengers were slightly injured.

Crash of a De Havilland DHC-6 Twin Otter 300 near Dihidanda: 18 killed

Date & Time: Feb 16, 2014 at 1330 LT
Operator:
Registration:
9N-ABB
Flight Phase:
Survivors:
No
Site:
Schedule:
Pokhara – Jumla
MSN:
302
YOM:
1971
Flight number:
RNA183
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
8373
Captain / Total hours on type:
8131.00
Copilot / Total flying hours:
365
Aircraft flight hours:
43947
Aircraft flight cycles:
74217
Circumstances:
On 16 February 2014, the Twin Otter (DHC6/300) aircraft with registration number 9N-ABB, owned and operated by Nepal Airlines Corporation (NAC), departed Kathmandu at 0610 UTC (1155 LT) on its schedule flight to Jumla carrying 18 persons on board including 3 crews. Detailed sectors to be covered by the flight No. RA 183/718 was Kathmandu–Pokhara–Jumla-Nepālganj (Night stop). Flight from Kathmandu to Pokhara completed in normal condition. After 17 minutes on ground at Pokhara airport and refueling 9N-ABB departed Pokhara at 0658 for Jumla. After Jumla flight, the aircraft was scheduled to Night stop at Nepālganj. Next day it was to do a series of shuttle flights from Nepālganj. Prevailing westerly weather had a severe impact on most of the domestic flights since last two days. A.M.E. of Engineering Department of NAC who had performed D.I. of 9N ABB had mentioned in his written report to the Commission that he had reminded the diversion of Bhojpur flight of NAC due weather and asked the Captain whether he had weather briefing of the Western Nepal or not. In response to the AME's query the Captain had replied casually that- "weather is moving from west to east and now west is improving". Pilots behavior was reported normal by the ground staffs of Kathmandu and Pokhara airports prior to the commencement of flight on that day. All the pre and post departure procedure of the flight were completed in normal manner. Before departure to Jumla from Pokhara, Pilots obtained Jumla and Bhairahawa weather and seems to be encouraged with VFR Weather at both stations. However, they were unable to make proper assessment of en route weather. PIC decided to remain south of track to avoid the terrain and weather. CVR read out revealed that pilots were aware and concerned about the icing conditions due to low outside air temperature. After around 25 minutes, probably maneuvering to avoid weather, the PIC instructed the co-pilot to plan a route further south of their position, to fly through the Dang valley. The copilot selected Dang in the GPS, on a bearing of 283°, and determined the required altitude was 8500ft. He then raised concerns that the aircraft may not have enough fuel to reach the planned destination. Approximately two and a half minutes before the accident, the PIC initiated a descent, and the copilot advised against this. As per CVR read out, last heading recorded by copilot, approximately one minute before the crash, was 280. The last one minute was a very critical phase of the flight during which PIC said I am entering (perhaps inside the cloud). At that time copilot called Bhairahawa Tower on his own and got latest Bhairahawa weather. While copilot was transmitting its last position report to Bhairahawa Control Tower (approximately 25 miles from Bhairahawa), PIC interrupted and declared to divert Bhairahawa. Bhairahawa Control Tower wanted the pilots to confirm their present position. But crews were very much occupied and copilot said STANDBY. Just few seconds before crash copilot had told PIC not to descend. Copilot also suggested PIC in two occasions - sir don't turn. Very unfortunately aircraft was crashed. The aircraft disintegrated on impact and all 18 occupants were killed.
Probable cause:
Controlled flight into terrain after the pilot-in-command lost situation awareness while cruising in IMC.
The following factors were considered as contributory:
- Deteriorated weather associated with western disturbance, unstable in nature and embedded CB,
- Inappropriate and insufficient crew coordination while changing course of action.
Final Report:

Crash of an Airbus A320-231 in Kulob

Date & Time: Feb 2, 2014 at 0736 LT
Type of aircraft:
Operator:
Registration:
EY-623
Survivors:
Yes
Schedule:
Moscow – Kulob
MSN:
428
YOM:
1994
Flight number:
ETJ704
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
187
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18321
Captain / Total hours on type:
509.00
Copilot / Total flying hours:
2900
Copilot / Total hours on type:
1300
Aircraft flight hours:
54604
Aircraft flight cycles:
23974
Circumstances:
Following an uneventful flight from Moscow-Domodedovo Airport, the crew was cleared to land on runway 01 at Kulob Airport. In heavy snow falls, the aircraft landed 230 metres past the runway threshold at a speed of 255 km/h. After touchdown, the crew started the braking procedure when, after a course of 520 metres, the right main gear contacted a snow berm. Simultaneously, both engines impacted a snow berm (up to 95 cm high) and stopped due to the high quantity of snow ingested. The aircraft veered to the right, lost its nose gear and came to rest in snow, 20 metres to the right of the runway and 1,190 metres from its threshold. All 192 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The accident with A320-231 EY-623 aircraft was caused by the aircraft collision with snow parapet during landing on unprepared RWY that was cleared to 22 m in width (45 m RWY total width), and with 50-95 cm snow parapets along the cleared part that resulted in front gear leg destruction and engines flameout followed by aircraft runway overrun to the right. The accident was caused by the consequence of the following factors combination:
- flight operation officer decision for aircraft clearance on unprepared RWY,
- having unprepared RWY by the time of the aircraft arrival the aerodrome service didn't put temporary restrictions, didn't make the appropriate note in the "Aerodrome airworthiness log", didn't take any measures to prevent the aircraft landing on unprepared RWY.
Final Report:

Crash of a De Havilland DHC-8-202Q in Ilulissat

Date & Time: Jan 29, 2014 at 0842 LT
Operator:
Registration:
OY-GRI
Survivors:
Yes
Schedule:
Kangerlussuaq – Ilulissat
MSN:
477
YOM:
1997
Flight number:
GRL3205
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4201
Captain / Total hours on type:
739.00
Copilot / Total flying hours:
1592
Copilot / Total hours on type:
1022
Aircraft flight hours:
29947
Aircraft flight cycles:
41968
Circumstances:
Upon landing on runway 07 at Ilulissat (BGJN) in gusting crosswind conditions above the aircraft and the operator limited maximum crosswind components, the left main landing gear collapsed. The aircraft skidded off the left side of the runway in a nose right position and into the safety zone. The aircraft continued an increasingly sideways skid in a nose right position, skidded down a steep snow-covered slope and impacted a rocky area approximately 10 meters below the runway elevation. One passenger and one crew member suffered minor injuries. The aircraft was destroyed. The accident occurred in dark night and under visual meteorological conditions (VMC).
Probable cause:
The following factors were identified:
- A non-optimum CRM on final approach to runway 07 led to flight crew target fixation and a mental blocking of an appropriate decision on going around.
- A non-stabilized approach in crosswind conditions above the aircraft and the operator’s crosswind limitations combined with the actual crosswind landing technique and the power levers retarded below flight idle in flight resulted in an accelerated rate of descent leading to a hard landing, with side load on the left main landing gear at touchdown.
- The left main landing gear structural fuse pin sheared as a result of lateral and vertical overload stress.
- Cycling the power levers between ground and flight range prevented an appropriate deceleration of the aircraft and prolonged the landing roll.
- The combination of applying full left rudder and no decisive use of reverse thrust on the side with the unaffected main landing gear made it impossible for the flight crew to maintain directional control.
Final Report:

Crash of a Saab 2000 in Paris-Roissy-CDG

Date & Time: Jan 28, 2014 at 0731 LT
Type of aircraft:
Operator:
Registration:
HB-IZG
Survivors:
Yes
Schedule:
Leipzig – Paris
MSN:
010
YOM:
1994
Flight number:
DWT250
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6640
Captain / Total hours on type:
2260.00
Copilot / Total flying hours:
630
Copilot / Total hours on type:
80
Circumstances:
Following an uneventful flight from Leipzig, the crew started the descent to Paris-Roissy-CDG Airport runway 27R. At an altitude of 400 feet on approach, the automatic pilot system was deactivated. At an altitude of 200 feet, the decision height, the crew decided to continue the approach as the runway was in sight and the aircraft was stable. During the last segment, at a height of 50 feet, power levers were reduced to flight idle and the aircraft went into a nose up attitude (maximum value of 11°). Both main gears touched down at a speed of 120 knots but the aircraft bounced twice and went into a pitch down attitude, causing the nose gear to land first during the third touchdown. On impact, the nose gear collapsed and the aircraft slid for dozen yards before coming to rest. All 19 occupants were evacuated safely and the aircraft was later considered as damaged beyond repair.
Probable cause:
During the flare the captain detected that the landing would be hard and in an emergency action, he quickly pulled the nose up without announcing his intention to the first officer who was the pilot flying. This lack of coordination within the flight crew caused a double controls and successive and opposite actions on the flight controls during the bouncing management.
Final Report:

Crash of an Antonov AN-24RV in Moscow

Date & Time: Jan 22, 2014 at 0819 LT
Type of aircraft:
Operator:
Registration:
RA-46473
Survivors:
Yes
Schedule:
Pskov - Moscow
MSN:
2 73 081 01
YOM:
1972
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Moscow-Domodedovo Airport, the crew encountered poor visibility due to marginal weather conditions. Rather than initiating a go-around procedure, the crew continued the descent when the aircraft crash landed to the right of runway 14R, in an area between the runway and the boundary fence. All 28 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Airbus A320-231 in Jaipur

Date & Time: Jan 5, 2014 at 2110 LT
Type of aircraft:
Operator:
Registration:
VT-ESH
Survivors:
Yes
Schedule:
Imphal – Guwahati – New Delhi
MSN:
469
YOM:
1994
Flight number:
AI890
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
173
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8322
Captain / Total hours on type:
5502.00
Copilot / Total flying hours:
2798
Copilot / Total hours on type:
2610
Aircraft flight hours:
55705
Circumstances:
On 05.01.2014, Air India Ltd. Airbus A-320-231 aircraft was scheduled to operate flight AI-889 (Delhi – Guwahati – Imphal) and return flight, AI-890 (Imphal – Guwahati – Delhi). Air India dispatch section at Delhi, which has received the roster of flight crew for the flights, had prepared the operational and ATC flight plans by using FWz flight planning software and taking into account the weight & weather (forecast winds). Same set of flight crew and cabin crew was rostered to operate the four sectors mentioned above. The flight was under Command of an ATPL holder with another ATPL holder as First Officer (FO) and 04 Cabin Crew members. The Commander was CAT III qualified and the FO was CAT I qualified. The FWz plan was prepared for VT-ESL, but later on the aircraft was changed to VT-ESH. As per the pilot in command as both the aircraft have bogie gear type of landing gear and the performance factor is also same for these aircraft, he had accepted the FWz plan of VT-ESL. As per the manager flight dispatch on duty, only first leg i.e. Delhi Guwahati was dispatched. Required fuel figures were informed to the engineering & commercial departments. Pilots were briefed with folders which in addition to flight plans contained current NOTAMs and meteorological information. The relevant information in these documents was highlighted for briefing to the flight crew. For the remaining sectors which were self briefing sectors flight plan and NOTAMs were given to the flight crew. As per the pre flight briefing register, both the crew members have visited the flight dispatch section for briefing and at around 10:40 hrs. IST have signed the dispatch register. The sectors Delhi – Guwahati – Imphal – Guwahati were as per schedule and were uneventful. As per the flight sector report, the transit time at Guwahati prior to Guwahati-Delhi sector was 50 minutes. The aircraft landed at Guwahati from Imphal at 11:15 hrs. UTC and 12.7 tons of fuel was uplifted. The filed alternates for the sector were Lucknow and Jaipur in that order. METARs of Delhi, Lucknow and Jaipur were provided at Guwahati. There was no specific briefing. Flight crew has taken the weather updates of destination and alternates before departure from Guwahati. Lucknow visibility at that time was 2000 meters with temperature and dew point of 18°C & 13°C respectively. The weather at Delhi (11:05 UTC) was RVR as 500 meters for runway 29, general visibility of 150 meters, with both temperature and dew point of 12°C. A speci was issued at 1130 UTC for Jaipur with winds 04 kts. visibility 3000m and haze. There was no significant clouding (NSC), temperature (T) 18°C & dew point (Dp) 13°C, QNH 1013. Pre flight walk around inspection was carried out by the crew at Guwahati and the aircraft was released by an Aircraft Maintenance Engineer which was accepted by the Pilot-in-command. There was no snag or technical problem with the aircraft. There was no component or system released under Minimum Equipment List (MEL). For its last leg, the aircraft departed Guwahati for Delhi at 1205 UTC with 173 passengers on board. The fuel requirement from Guwahati to Delhi with 179 persons on board was 12.2 tonnes. As per the commander of flight, additional 500 kgs of fuel was taken (total on board was 12.7 tonnes) considering the time of arrival in Delhi was that of traffic congestion and because of weather in Delhi. As per the Operational Flight Plan (OFP), there was 10 minutes of arrival delay at the destination. The aircraft was flown on managed speeds. Initially the flight was cleared by ATC for a lower level and was later on cleared to fly at cruising level of 340. The fuel was checked visually on the Flight Management System (FMS) and Fuel Page which was further cross checked with the OFP planned figures by the crew on way points but was not recorded on the Operational Flight Plan. As per the crew, the fuel consumed was marginally higher than planned. The time taken to reach the way points was also noted, which was almost the same as planned figures were. Enroute, there was no briefing about traffic congestion over Delhi by any of the ground stations of AAI. The crew, on reaching overhead Lucknow, has taken Lucknow weather and when the aircraft was in range of ATIS Delhi, Delhi ATIS weather was also copied. The aircraft was not equipped with Aircraft Communications Addressing and Reporting System (ACARS) but was provided with HF/VHF system. As per the flight crew no flight following was provided either by flight dispatch or the IOCC of Air India. Weather updates were not seeked by the crew from the flight dispatch nor were any updates provided by Flight dispatch to the aircraft during the flight except when crew had asked Delhi dispatch about Jaipur visibility before finally making the decision to divert to Jaipur. Flight crew did not seek any update of Delhi or Jaipur weather till the time the aircraft came in contact with Delhi ATC. While in contact with Delhi ATC, the flight was advised to join hold as Delhi visibility Runway 28 RVR had dropped to the lower end of CAT I operations at this point runway 29 was below minima. AI 890 was number 12 in sequence and continued to remain in the holding pattern for the next 20-25 minutes. During this period there was no attempt on the part of flight crew to seek Lucknow weather. Air India Flight dispatch has also not given any advice to the flight about Jaipur or Lucknow weather. The weather (visibility / RVR) reported on Runway 29 was below CAT I conditions so runway was not available for this flight at that moment as the First Officer was only Cat I qualified. As per commander of the flight, they did 03 holds each of 1.5 minutes leg and flew headings 360° and 180° before intercepting the localizer Runway 28 at 35 miles. RVR runway 28 also dropped below Cat. I minimas, therefore the crew discontinued approach and climbed to 8000 feet on runway heading before going on heading 180. As per the Commander, though the 1st planned diversion alternate was Lucknow which had visibility of 2000 m i.e. above minima, but change of diversion to Jaipur was made as after missed approach they were closer to Jaipur and they had inquired about the visibility from Dispatch for Jaipur, which was provided as 2000 m. At this stage the crew did not check complete weather of Jaipur. Minimum diversion fuel to Jaipur was 2.9 tonnes as per FWz CFP. AI-890 commenced diversion to Jaipur with ―Fuel on Board‖ of 3.1 tonnes. As per the Station Manager of Air India at Jaipur Airport, he received a call from their Executive Director, Northern Region at around 2040 hrs. IST on 05.01.2014 that due to Delhi weather, AI 890 had diverted to Jaipur. He then conveyed the same to the airport office and the concerned engineer. The aircraft came in contact with Jaipur for the first time when it was at 68 DME from Jaipur. At that time the crew came to know of the complete weather of Jaipur from ATIS as visibility of 900 m, Dew Point as 13°C, temperature as 13°C, and RVR of 1000m. At 60 miles and passing flight level 138, the crew intimated Jaipur that the aircraft is descending for flight level 100 as cleared by Delhi control, which was acknowledged by Jaipur ATC. The aircraft again informed Jaipur ATC its position at 55 miles, 50 miles and 42 miles from Jaipur which were also acknowledged by Jaipur ATC. During these contacts, weather of Jaipur was neither asked by the crew nor provided by the ATC. When the aircraft was at flight level 83, the crew asked ATC Jaipur to confirm that they can carry out ILS approach for runway 27 via 10 DME arc. While confirming the requested approach, Jaipur ATC has informed all the stations about the weather at that moment as visibility 400 m and RVR 1000 m. When the aircraft was at 30 miles from Jaipur, Jaipur ATC passed weather as visibility 400 m, RVR 1000 m and trend visibility becoming 350 m. The crew was asked to come overhead by Jaipur ATC. At 28 DME from Jaipur, the aircraft was maintaining 6000 feet and on request was cleared by Jaipur ATC to descend to 5000 feet. When the aircraft was at 25 DME, from Jaipur, ATC advised that the weather was deteriorating rapidly and visibility was 400 meters. The crew however intimated the ATC that they were committed to land at Jaipur due fuel. As per the crew the fuel on board at that point of time was 2.6 tonnes (approx.) and approach was commenced for Jaipur with a visibility of 500 m with trend reducing. The aircraft was no. 2 in approach at Jaipur and was cleared for VORDME arc ILS approach runway 27 at 25 nm. Crew had, as per them, checked Ahmedabad distance as 291 nm, with a fuel calculation of 2.7 tonnes and as sufficient fuel was not available for Ahmedabad so did not consider diverting to Ahmedabad at that moment. Crew has also stated that Udaipur watch hours were not available with them, Jodhpur is an Air Force field with restrictions and Delhi was packed so they continued approach to Jaipur knowing that visibility / RVR was rapidly deteriorating. Due to reducing visibility, Jaipur ATC asked all the aircraft inbound for Jaipur to come over head and join JJP hold. The crew of the subject flight asked for the weather which was provided as visibility 400 m & RVR 1000 m though RVR deteriorating to 550 m. The flight from the ―Arrival Route‖ flew the VORDME arc for ILS runway 27. The ATC had transmitted the RVR as 200 m and visibility as 50 m with trend reducing. Another scheduled flight ahead of AI-890 carried out a missed approach and diverted to Ahmedabad. When the aircraft was above MDA (1480 feet AGL), ATC reported RVR 50 m and cleared the aircraft to land subject to minima. Both the flight crew maintained that they had seen the runway lights. ILS approach was performed with dual AP until 200ft RALT. After descending below MDA on auto pilot, the commander disconnected the auto pilot. Captain performed the final approach manually. The aircraft deviated to the left of the runway centre line and touched down on soft ground (in kutcha) on the LH side of the runway. During touchdown and landing roll, the visibility was zero and crew were unable to see any of the reference cues. The crew had heard rumbling sound during landing roll. As per the commander, he did the manual landing as he was not sure if he could do auto-land on a ground facility which is CAT I certified airfield in actual zero visibility. The aircraft continued to roll/ skid on the unpaved surface and during this period the left wing impacted trees causing damage to the left wing. Thereafter aircraft turned right and entered the runway finally coming to a halt on the LH side of runway. There was no fire. ATC Jaipur informed the Airport Manager of the Airline at Jaipur that their flight AI-890 had blocked the runway and also requested them to send equipments / manpower to attend the aircraft and get the aircraft removed. The Station AME of the airline alongwith the Asst Officer (Comm.), who was at the tarmac were instructed by the Station Manager to move to the aircraft. As per the AME, the visibility was almost nil and they could not move without the help of ‗Follow Me‘ Jeep. The ATC was informed to arrange the jeep to escort the personnel upto the aircraft. The AME after reaching the aircraft observed that the no. 1 main wheel of the aircraft had decapped/ damaged and the port side wing was damaged. The fuel remaining on board was 2400 kgs. The disembarkation of passengers was carried out on the runway itself and passengers were sent to the terminal building. Since the aircraft was not in a position to be either taxied or towed to the parking bay, the baggage of passengers was offloaded at the runway itself and sent to the terminal. One passenger suffered minor bruise on the knuckle of his right hand middle finger. He was attended to by the cabin crew in the aircraft and also by the doctor at the airport. Medical check-up of all the crew members including breathanalyser (BA) test was done by the medical officer, M.I. room Jaipur airport. The BA test was negative for all the crew members with a reading of 00.00. Since the aircraft was obstructing the runway, the airport was shut down for any further flight operations till the runway could be cleared. A NOTAM was issued to this effect. The aircraft was towed the next day to parking bay no.5 at terminal-1 by 1200 hrs and was later repositioned on a non-operational remote bay.
Probable cause:
The cause below has been given considering events as a combination of organizational factors and human error.
- The flight crew made an erroneous decision of diverting & continuing to an airfield with reducing visibility.
- The flight crew attempted a manual landing in below minima conditions.
- Lack of operational supervision and desired ground support to flight.
- Internal quality assurance not capturing the hazards which slipped through due complacency.
- Lack of oversight of the flight operations.
Final Report:

Ground accident of a Boeing 747-436 in Johannesburg

Date & Time: Dec 22, 2013 at 2243 LT
Type of aircraft:
Operator:
Registration:
G-BNLL
Flight Phase:
Survivors:
Yes
Schedule:
Johannesburg – London
MSN:
24054/794
YOM:
1990
Flight number:
BA034
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
185
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20050
Captain / Total hours on type:
12500.00
Copilot / Total flying hours:
5700
Copilot / Total hours on type:
1400
Aircraft flight hours:
110578
Aircraft flight cycles:
12832
Circumstances:
The British Airways aircraft B747-400, flight number BA034 with registration G-BNLL, was going to embark on a commercial international air transportation long haul flight from FAOR to EGLL. The ATC gave the crew instructions to push back, start and face south, then taxi using taxiway Bravo to the Category 2 holding point for Runway 03L. During the taxi, instead of turning to the left to follow Bravo, the crew continued straight ahead, crossing the intersection of taxiway Bravo and aircraft stand taxilane Mike. After crossing the intersection, still being on Mike, the aircraft collided with a building. An investigation was conducted and several causal factors were determined. Amongst others, it was determined that the crew erred in thinking they were still taxiing on Bravo while in fact they were taxiing on Mike. This mistake, coupled with other contributory factors such as the briefing information, taxi information, ground movement visual aids, confusion and loss of situational awareness led to the collision. All 202 occupants evacuated safely while four people in the building were injured. The aircraft was damaged beyond repair.
Probable cause:
The loss of situational awareness caused the crew to taxi straight ahead on the wrong path, crossing the intersection/junction of Bravo and Mike instead of following Bravo where it turns off to the right and leads to the Category 2 holding point. Following aircraft stand taxilane Mike; they collided with a building on the right-hand side of Mike.
Contributory Factors:
- Failure of the crew to carry out a briefing after they had received instruction from ATC that the taxi route would be taxiway Bravo.
- The lack of appropriate knowledge about the taxiway Bravo layout and relevant information (caution notes) on threats or risks to look out for while taxiing on taxiway Bravo en route to the Cat 2 holding point.
- The aerodrome infrastructure problems (i.e. ground movement navigation aids anomalies), which created a sense of confusion during the taxi.
- Loss of situation awareness inside the cockpit causing the crew not to detect critical cues of events as they were gradually unfolding in front of them.
- Failure of the other crew members to respond adequately when the Co-pilot was commenting on the cues (i.e. narrowness and proximity to the building).
- The intersection/junction of Bravo and Mike not being identified as a hotspot area on the charts.
Final Report: