Scheduled Revenue Flight

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.

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.

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.

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).

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.

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.

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.

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.

The airline transport pilot was conducting an air taxi commuter flight between two Hawaiian islands with eight passengers on board. Several passengers stated that the pilot did not provide a safety briefing before the flight. One passenger stated that the pilot asked how many of the passengers had flown over that morning and then said, “you know the procedures.” The pilot reported that, shortly after takeoff and passing through about 500 ft over the water, he heard a loud “bang,” followed by a total loss of engine power. The pilot attempted to return to the airport; however, he realized that the airplane would not be able to reach land, and he subsequently ditched the airplane in the ocean. All of the passengers and the pilot exited the airplane uneventfully. One passenger swam to shore, and rescue personnel recovered the pilot and the other seven passengers from the water about 80 minutes after the ditching. However, one of these passengers died before the rescue personnel arrived. Postaccident examination of the recovered engine revealed that multiple compressor turbine (CT) blades were fractured and exhibited thermal damage. In addition, the CT shroud exhibited evidence of high-energy impact marks consistent with the liberation of one or more of the CT blades. The thermal damage to the CT blades likely occurred secondary to the initial blade fractures and resulted from a rapid increase in fuel flow by the engine fuel control in response to the sudden loss of compressor speed due to the blade fractures. The extent of the secondary thermal damage to the CT blades precluded a determination of the cause of the initial fractures. Review of airframe and engine logbooks revealed that, about 1 1/2 years before the accident, the engine had reached its manufacturer-recommended time between overhaul (TBO) of 3,600 hours; however, the operator obtained a factory-authorized, 200-hour TBO increase. Subsequently, at an engine total time since new of 3,752.3 hours, the engine was placed under the Maintenance on Reliable Engines (MORE) Supplemental Type Certificate (STC) inspection program, which allowed an immediate increase in the manufacturer recommended TBO from 3,600 to 8,000 hours. The MORE STC inspection program documents stated that the MORE STC was meant to supplement, not replace, the engine manufacturer’s Instructions for Continued Airworthiness and its maintenance program. Although the MORE STC inspection program required more frequent borescope inspections of the hot section, periodic inspections of the compressor and exhaust duct areas, and periodic power plant adjustment/tests, it did not require a compressor blade metallurgical evaluation of two compressor turbine blades; however, this evaluation was contained in the engine maintenance manual and an engine manufacturer service bulletin (SB). The review of the airframe and engine maintenance logbooks revealed no evidence that a compressor turbine metallurgical evaluation of two blades had been conducted. The operator reported that the combined guidance documentation was confusing, and, as a result, the operator did not think that the compressor turbine blade evaluation was necessary. It is likely that, if the SB had been complied with or specifically required as part of the MORE STC inspection program, possible metal creep or abnormalities in the turbine compressor blades might have been discovered and the accident prevented. The passenger who died before the first responders arrived was found wearing a partially inflated infant life vest. The autopsy of the passenger did not reveal any significant traumatic injuries, and the autopsy report noted that her cause of death was “acute cardiac arrhythmia due to hyperventilation.” Another passenger reported that he also inadvertently used an infant life vest, which he said seemed “small or tight” but “worked fine.” If the pilot had provided a safety briefing, as required by Federal Aviation Administration regulations, to the passengers that included the ditching procedures and location and usage of floatation equipment, the passengers might have been able to find and use the correct size floatation device.

The scheduled commuter flight departed 40 minutes late for a two-stop flight. During the first leg of the night visual flight rules (VFR) flight, weather at the first destination airport deteriorated, so the pilot diverted to the second destination airport. The pilot requested and received a special VFR clearance from an air route traffic controller into the diversion airport area. Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that, after the clearance was issued, the airplane's track changed and proceeded in a direct line to the diversion airport. Postaccident examination of the pilot's radio showed that his audio panel was selected to the air route traffic control (ARTCC) frequency rather than the destination airport frequency; therefore, although the pilot attempted to activate the pilot-controlled lighting at the destination airport, as heard on the ARTCC frequency, it did not activate. Further, witnesses on the ground at St. Mary's reported that the airport lighting system was not activated when they saw the accident airplane fly over, and then proceed away from the airport. Witnesses in the area described the weather at the airport as deteriorating with fog and ice. About 1 mile from the runway, the airplane began to descend, followed by a descending right turn and controlled flight into terrain. The pilot appeared to be in control of the airplane up to the point of the right descending turn. Given the lack of runway lighting, the restricted visibility due to fog, and the witness statements, the pilot likely lost situational awareness of the airplane's geographic position, which led to his subsequent controlled flight into terrain. After the airplane proceeded away from the airport, the witnesses attempted to contact the pilot by radio. When the pilot did not respond, they accessed the company's flight tracking software and noted that the airplane's last reported position was in the area of the airplane's observed flightpath. They proceeded to search the area where they believed the airplane was located and found the airplane about 1 hour later. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. About 3/4 inch of ice was noted on the nonprotected surfaces of the empennage. However, ice formation on the airplane's inflatable leading edge de-ice boots was consistent with normal operation of the de-ice system, and structural icing likely was not a factor in the accident. According to the company's General Operations Manual (GOM), operational control was held by the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and release of the flight, which included the risk assessment process. The flight coordinator assigned the flight a risk level of 2 (on a scale of 1 to 4) due to instrument meteorological and night conditions and contaminated runways at both of the destination airports. The first flight coordinator assigned another flight coordinator to create the manifest, which listed eight passengers and a risk assessment level of 2. According to company risk assessment and operational control procedures, a risk level of 2 required a discussion between the PIC and flight coordinator about the risks involved. However, the flight coordinators did not discuss with the pilot the risks and weather conditions associated with the flight. Neither of the flight coordinators working the flight had received company training on the risk assessment program. At the time of the accident, no signoff was required for flight coordinators or pilots on the risk assessment form, and the form was not integrated into the company manuals. A review of Federal Aviation Administration (FAA) surveillance activities revealed that aviation safety inspectors had performed numerous operational control inspections and repeatedly noted deficiencies within the company's training, risk management, and operational control procedures. Enforcement Information System records indicated that FAA inspectors observed multiple incidences of the operator's noncompliance related to flight operations and that they opened investigations; however, the investigations were closed after only administrative action had been taken. Therefore, although FAA inspectors were providing surveillance and noting discrepancies within the company's procedures and processes, the FAA did not hold the operator sufficiently accountable for correcting the types of operational deficiencies evident in this accident, such as the operator's failure to comply with its operations specifications, operations training manual, and GOM and applicable federal regulations.