Crash of a McDonnell Douglas MD-82 in Miami

Date & Time: Jun 21, 2022 at 1738 LT
Type of aircraft:
Operator:
Registration:
HI1064
Survivors:
Yes
Schedule:
Santo Domingo - Miami
MSN:
53027/1805
YOM:
1990
Flight number:
L5203
Crew on board:
10
Crew fatalities:
Pax on board:
130
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14388
Captain / Total hours on type:
1400.00
Copilot / Total flying hours:
822
Copilot / Total hours on type:
269
Aircraft flight hours:
69838
Aircraft flight cycles:
36990
Circumstances:
Following an uneventful flight from Santo Domingo-Las Américas Airport, the crew was cleared to land on runway 09 at Miami-Intl Airport. The first officer recalled that the airplane touched down smoothly on the right and then the left main landing gear and that the airplane was slightly to the right of the centerline, which he corrected after touching down. Shortly afterward, the flight crew felt a vibration on the left side of the airplane. The vibration increased, and the airplane veered to the left despite the crew’s efforts to maintain the airplane on the runway centerline. The airplane subsequently departed the paved runway surface and impacted the glideslope equipment building for runway 30, which was located to the left of runway 09, causing the nose landing gear and the right main landing gear to collapse. A post crash fire began on the right wing after the fuel tank on that wing was breached, after which the airplane came to a stop. Nevertheless, fire was quickly extinguished and all 140 occupants evacuated safely, among them four passengers were taken to Jackson Hospital.
Probable cause:
The collapse of the left main landing gear during the landing roll resulted in a runway excursion due to a loss of controllability on the runway, during which the aircraft impacted a small equipment building, breaching the right-wing fuel tank and causing a post-crash fire. The performance of the crew was thoroughly evaluated during this investigation and found to be appropriate for the circumstances of the accident.
The focus of this analysis is the cause of the left main landing gear collapse. Particularly
(1) the left shimmy damper’s failure to adequately dampen vibration during landing and
(2) the failure of the left main gear downlock mechanism due to excessive vibration.
The structural failure of the left main landing gear downlock following ineffective shimmy dampening during the landing roll which caused the collapse of the left main landing gear, resulting in a runway excursion and post-flight fire.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Sanosware: 22 killed

Date & Time: May 29, 2022 at 1010 LT
Operator:
Registration:
9N-AET
Flight Phase:
Survivors:
No
Site:
Schedule:
Pokhara – Jomsom
MSN:
619
YOM:
1979
Flight number:
TRA197
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
17500
Captain / Total hours on type:
13500.00
Copilot / Total flying hours:
520
Copilot / Total hours on type:
315
Aircraft flight hours:
41336
Aircraft flight cycles:
71338
Circumstances:
On 29 May 2022, Tara Air’s 9N-AET, Twin Otter (DHC-6/300) aircraft was scheduled for three flights on Pokhara-Jomsom-Pokhara sector. Tara Air had also filed flight plans for two additional Charter flights on the same sector. Among those five flights, four flights were to be conducted by a set of crews already positioned at Pokhara while the last flight was scheduled to be commanded by the PIC who had reached Pokhara from Kathmandu that very morning. Since Jomsom Airport was closed for operations due to bad weather, the PIC went to Tara Air crew camp and waited for the updates of weather improvement of Jomsom. After Jomsom Airport was open for operations at 0321 UTC, Tara Air operation decided to operate the first scheduled flight. However suspecting the next flight operation to Jomsom could not be operated, the original PIC assigned to the flight seated on board as a passenger to Jomsom for his scheduled business trip and the PIC assigned for the last flight took command. The Flight Plan was amended accordingly. At 0342 UTC, Summit Air’s 9N-AKZ, LET-410 took-off from Pokhara to Jomsom. At 0405 UTC, it reported an altitude of 12,500 ft and patches of cloud over Tatopani. At 0409 UTC, Summit Air’s second aircraft 9N-AMG, LET-410, took-off for Jomsom and subsequently, at 0410 UTC, 9N-AET of Tara Air (TRA197) took-off with 19 passengers and three crews on board. The Copilot had initially reported 3 crew and 18 passengers onboard to Pokhara Tower but later, revised the passenger figure was 19 prior to takeoff. 9N-AET was supposed to take-off before SMT 601 but the PIC seemed hesitant to commence the flight due to weather PIREP from 9N-AKZ that, the en-route weather was not favorable for VFR flights and critical around LETE and TATOPANI. All the crew members of TRA 197 and SMT 601 were in their respective cockpits and communicating with the preceding flight 9N-AKZ as well as with Pokhara tower for the updated information of en-route and destination weather. No flights had been conducted since morning and most of the passengers of Tara air and Summit Air were already at airport. In this situation it can be assumed that there was pressure to conduct flight from each angle. While listening to the CVR of TRA 197, it was observed that someone, either ground staff or some intimate passenger to the crew, advising strongly to the PIC to conduct the flight. Following the PIREP from 9NAKZ, both TRA197 and SMT 601 subsequently started their engines to commence the flights. The PIC of TRA 197 was still hesitant to conduct the flight for Jomsom even after the engine start and delayed the taxi as he was not yet convinced about the weather report received from preceding 9N-AKZ aircraft. In the meantime, SMT 601 lined up for departure to Jomsom. That was one of the most important pressure points to the PIC of TRA 197 to initiate departure. TRA 197 finally lined up and took off from Pokhara at 0410 UTC following the SMT 601 based on the en-route weather information (VMC) from 9N-AKZ, through Pokhara Tower. The en-route weather provided by Summit Air’s 9N-AKZ to Pokhara Tower and the crewmembers of TRA 197 and SMT 601 was not the same. Aircraft took off from Pokhara from runway 04 heading North. Tower instructed “report 5 DME northwest RW 04”. Then after departure at 90 climb power aircraft turned left to maintain a heading of 345 and planned to join heading 305 degree towards Ghodepani. After four minutes, TRA 197 reported, “Now on course…. 6000 climbing and ETA Jomsom 32” (0432 UTC). At 04:21 TRA 197 reported to Pokhara Tower as position approaching Ghodepani 12000 climbing for 12500. After 6 Seconds ATC Pokhara asked TRA 197, “confirm would like to change level and TRA 197 replied, “No Ma'am we have crossed Ghodepani and like to be on”. Pokhara Tower instructed, “Tara 197 contact Jomsom Tower 122.5” CVR recordings show that after TRA 197 crossed Ghodepani, the PIC was not comfortable with the en-route weather. However, the flight was continued following the advice of SMT 601. At 0426 UTC, TRA 197made the first contact with Jomsom AFS and reported its position to which Jomsom Tower conveyed the prevailing weather as “Wind South Westerly up to 30 kts, QNH 1019, Temp 18º”. The PIC of TRA 197 reconfirmed twice if the wind was maximum, up to 30 Kts and currently South Westerly-25kts. The crew was discussing about the bad weather being encountered and the PIC himself voiced his dissatisfaction about the behavior of other pilots who conduct VFR flights in such unfavorable weather. The CVR recordings reveal that the aircraft was encountering clouds and the PIC was trying his best to remain clear of the clouds. During the course of flight, TRA 197 hadn’t reported any abnormalities encountered and neither any technical defect on aircraft either to Jomsom tower or Pokhara Tower. As per CVR, PIC was searching for light and brighter areas and adamantly heading towards it. As per CVR and V2 tracker data, the aircraft was maintaining 12000 ft and was in a climbing attitude. During the continuous attempts of crew to avoid the clouds with Terrain Avoidance and Warning System [TAWS] inhibited, the aircraft met with an unfortunate CFIT accident into the rocky terrain at an altitude of 4050 meter AMSL at Sanusare Mountain, Thasang Rural Municipality, Mustang. As per V2 tracker, last position of 9N-AET was 7.7 nm SW of Jomsom Airport. The aircraft was completely destroyed by the impact and there were no survivors.
Probable cause:
The probable cause of this accident was the flight crew's failure to monitor and maintain the proper course while inadvertently flying in IMC conditions with the aircraft Terrain Avoidance and Warning System (TAWS) inhibited which resulted into a Controlled Flight Into Terrain (CFIT) accident.
The following contributing factors were identified:
1. The flight crew's failure to follow the SOP of company.
2. The aircraft flight operation with TAWS inhibited during deteriorating en-route weather condition.
3. Loss of situational awareness of crew.
4. Deteriorating en route weather.
5. Less experienced copilot for that sector and high crew gradient.
6. Poor CRM during the flight.
7. The whole cockpit duties [both PF and PM] were undertaken by the PlC, which likely impaired his performance.
8. Underutilization of the available Navigation instruments.
Final Report:

Crash of an Airbus A319-115 in Chongqing

Date & Time: May 12, 2022 at 0805 LT
Type of aircraft:
Operator:
Registration:
B-6425
Flight Phase:
Survivors:
Yes
Schedule:
Chongqing – Nyingchi
MSN:
5157
YOM:
2012
Flight number:
TV9833
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
113
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
28364
Aircraft flight cycles:
14495
Circumstances:
The airplane was departing Chongqing-Jiangbei Airport on a regular schedule service to Nyingchi, Tibet, carrying 113 passengers and a crew of nine. During the takeoff roll on runway 03, at a speed of 145 knots (just below V1 speed), the captain encountered an unexpected situation and decided to abandon the takeoff procedure. He initiated an emergency braking manoeuvre when the airplane started to deviate to the left. It veered off runway and went through a grassy area. While contacting the parallel concrete taxiway, the nose gear was sheared off. The airplane continued for 120 metres when it impacted a drainage ditch, causing both main landing gears and both engines to be sheared off as well. The airplane later came into a stop, bursting into flames. 36 occupants were injured while all others evacuated safely. The aircraft was destroyed.
Probable cause:
It was determined that, during the takeoff run, the captain was distracted by items falling, and momentarily lost the monitoring of the aircraft's flight sequence. During this short period of time, he unconsciously held the left rudder, which resulted in an unintended deviation of the aircraft to the left direction. After he noticed the deviation, the crew failed to execute the standard callouts, and the captain reduced the throttle in an attempt to abort the takeoff. Due to the combined effects of maximum braking force and inertia, the crew was unable to maintain a safe control, causing the airplane to veer off the runway to the left at a speed of approximately 127 knots. Poor decision makings on part of the crew was considered as the main cause of the accident.
Final Report:

Crash of a Boeing 737-89P near Wuzhou: 132 killed

Date & Time: Mar 21, 2022 at 1422 LT
Type of aircraft:
Operator:
Registration:
B-1791
Flight Phase:
Survivors:
No
Site:
Schedule:
Kunming - Guangzhou
MSN:
41474/5433
YOM:
2015
Flight number:
MU5735
Location:
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
123
Pax fatalities:
Other fatalities:
Total fatalities:
132
Captain / Total flying hours:
6709
Copilot / Total flying hours:
31769
Aircraft flight hours:
18239
Aircraft flight cycles:
8986
Circumstances:
The airplane departed Kunming-Wujiaba Airport at 1315LT on a schedule service (flight MU5735) to Guangzhou, carrying 123 passengers and a crew of nine. At 1420LT, while cruising at an altitude of 29,100 feet, the aircraft entered an uncontrolled descent until 7,400 feet then climbed to 8,600 feet. It finally entered a steep descent and crashed almost two minutes later in a vertical attitude on hilly and wooded terrain located some 20 km southwest of Wuzhou. The airplane disintegrated on impact and all 132 occupants were killed. Two days after the accident, the CVR was found while the DFDR was found on March 27.

Crash of a Cessna 208B Grand Caravan off Mohéli: 14 killed

Date & Time: Feb 26, 2022 at 1230 LT
Type of aircraft:
Operator:
Registration:
5H-MZA
Flight Phase:
Survivors:
No
Schedule:
Moroni - Mohéli
MSN:
208B-5278
YOM:
2016
Flight number:
Y61103
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
The single engine airplane departed Moroni Airport at 1155LT on a schedule flight to Mohéli, carrying 12 passengers and two pilots. While approaching Mohéli, the crew encountered marginal weather conditions when the aircraft crashed in the sea some 2,5 km northwest of Mohéli-Bander es Eslam Airport. After 24 hours of intense research, only few debris were found floating on water (such a wheel and wing fragments). No trace of the 14 occupants was found.

Crash of a Cessna 207 Stationair 8 in Bethel

Date & Time: Nov 20, 2021 at 1755 LT
Operator:
Registration:
N9794M
Survivors:
Yes
Schedule:
Bethel – Kwethluk
MSN:
207-0730
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1480
Captain / Total hours on type:
659.00
Aircraft flight hours:
15727
Circumstances:
The pilot was conducting a scheduled air taxi flight with five passengers onboard. Shortly after departure, the pilot began to smell an electrical burn odor, and he elected to return to the airport. About 1 minute later, the electrical burn smell intensified, which was followed by visible smoke in the cockpit, and the pilot declared an emergency to the tower. After landing and all the passengers had safely departed the airplane, heavy smoke filled the cockpit and passenger compartment, and the pilot saw a candle-like flame just behind the pilot and co-pilot seats, just beneath the floorboards of the airplane. Moments later, the airplane was engulfed in flames. Postaccident examination of the airframe revealed the origin of the fire to be centered behind the pilot’s row of seats, where a wire harness was found improperly installed on top of the aft fuel line from the left tank. Examination of the wire harness found a range of thermal and electrical damage consistent with chafing from the fuel line. It is likely that the installation of the wire harness permitted contact with the fuel line, which resulted in chafing, arcing, and the subsequent fire.
Probable cause:
The improper installation of an avionics wire harness over a fuel line, which resulted in chafing of the wire harness, arcing, and a subsequent fire.
Final Report:

Crash of a Britten Norman BN-2A-6 Islander in Beaver Island: 4 killed

Date & Time: Nov 13, 2021 at 1349 LT
Type of aircraft:
Operator:
Registration:
N866JA
Survivors:
Yes
Schedule:
Charlevoix – Beaver Island
MSN:
185
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2949
Captain / Total hours on type:
136.00
Aircraft flight hours:
20784
Circumstances:
A pilot-rated witness observed the airplane during the final approach to the destination airport and stated that the airplane was flying slowly, with a high pitch attitude, and was “wallowing” as if nobody was flying. The airplane stalled and impacted the ground about 300 ft from the runway. GPS and automatic dependent surveillance-broadcast (ADS-B) data captured the accident flight, but the ADS-B data ended about 0.24 miles before the accident. GPS data showed that the airplane’s speed was at or near the published stall speed for the airplane’s given loading condition. The airplane sustained substantial damage to the fuselage and both wings. Examination of the airplane verified flight and engine control continuity. No preimpact anomalies were found with respect to the airplane, engines, or systems. The pilot allowed the airspeed to decrease during the approach, increased pitch attitude, and exceeded critical angle of attack, which resulted in an aerodynamic stall and spin into terrain.
Probable cause:
The pilot's exceedance of the airplane's critical angle of attack during final approach, which resulted in an aerodynamic stall and loss of control at an altitude too low to recover.
Final Report:

Crash of a Britten Norman BN-2B-26 Islander in Montserrat

Date & Time: Sep 29, 2021 at 1733 LT
Type of aircraft:
Operator:
Registration:
J8-VBI
Survivors:
Yes
Schedule:
Saint John’s – Montserrat
MSN:
2025
YOM:
1981
Flight number:
SVD207
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2650
Captain / Total hours on type:
712.00
Circumstances:
After an uneventful return flight to Barbuda, the aircraft departed Antigua at 2114 hrs (1714 hrs local) for John A Osborne Airport, Montserrat, with the pilot and six passengers on board. The aircraft cruised at 2,000 ft enroute and the pilot recalled there were good visual meteorological conditions throughout the 19 minute flight. On arriving at Montserrat there were no other aircraft operating in the vicinity of the airport and the pilot positioned the aircraft visually on a downwind leg for Runway 10. The pilot reported he commenced the approach, flying an approach speed of 65 kt, reducing to 60 kt as the aircraft touched down. The runway surface was dry and the pilot described the landing as “smooth”. After the main landing gear touched down, but prior to the nosewheel contacting the runway, the pilot applied the brakes. He reported that the left brake felt “spongy” and did not seem to act, but that the right brake felt normal. The pilot was unable to maintain directional control of the aircraft which veered to the right two seconds after touchdown, departing the runway a further three seconds later. The aircraft continued across the adjacent grassed area before impacting an embankment close to the runway. After the aircraft had come to a stop, the pilot shut down the engines using the normal shut down procedure. The left main gear had collapsed and rendered the left cabin exit unusable. The pilot evacuated through the flight deck door which was on the left of the aircraft. The six passengers were able to evacuate through the right cabin exit. The airport fire service then arrived at the aircraft, less than one minute after the accident.
Probable cause:
On landing at John A. Osborne Airport, Montserrat, the pilot was unable to maintain directional control of the aircraft, later reporting the left brake felt “spongy”. The aircraft veered off the right side of the runway and came to rest in an adjacent drainage ditch. An inspection of the aircraft’s braking system revealed a slight brake fluid leak from one of the pistons in the left outboard brake calliper. This would have prevented full brake pressure being achieved on the left brakes, resulting in an asymmetric braking effect. Difficulty in maintaining directional control was compounded by the use of an incorrect braking technique on landing. The investigation identified shortcomings with the operator’s manuals, procedures and regulatory oversight.
Final Report:

Crash of a Let L-410UVP-E20 in Kazashinskoye: 4 killed

Date & Time: Sep 12, 2021 at 2251 LT
Type of aircraft:
Operator:
Registration:
RA-67042
Survivors:
Yes
Schedule:
Irkutsk – Kazashinskoye
MSN:
14 29 16
YOM:
2014
Flight number:
SL51
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5623
Captain / Total hours on type:
4625.00
Copilot / Total flying hours:
1385
Copilot / Total hours on type:
693
Aircraft flight hours:
5481
Aircraft flight cycles:
3632
Circumstances:
The twin engine airplane was supposed to depart Irkust at 1435LT but the flight had been delayed for several hours. On approach to Kazashinskoye Airport, the crew encountered poor visibility due to the night and fog. On final approach to runway 04, at an altitude of 130 metres, the crew initiated a go-around procedure as he was unable to establish a visual contact with the ground. Few minutes later, during a second attempt to land, the crew descended to the height of 10 metres when he initiated a second go-around procedure, again for the same reason. The airplane climbed to an altitude of 400 metres then the crew made a 180 turn in an attempt to land on runway 22. In below minima weather conditions, the airplane deviated 1,100 metres to the right of the runway 22 extended path, descended into trees and crashed in a wooded area located about 3 km from the airport. Three passengers and a pilot were killed while 12 others occupants were injured. The aircraft was totally destroyed by impact forces.
Probable cause:
The accident was the consequence of the crew's non-compliance with the rules for visual flights at night, which was expressed in making an approach to land with visibility below the established minimum values, leading to a collision with natural obstacles and resulting in a controlled flight into terrain (CFIT).
The following contributing factors were identified:
- The discrepancy between the coordinates of the runway thresholds at Kazachinskoe in the GPS receivers of the aircraft commander and the co-pilot and their actual values, which led to an incorrect calculation for landing ;
- The failure of the aircraft commander to make a timely decision to divert to an alternate airport despite having information about the meteorological conditions not meeting the established minimum values. The individual psychological characteristics of the aircraft commander allowed him to make leadership decisions, but in the case of their erroneousness, he did not possess the ability to correct them and was inclined to unjustifiably risky, dangerous decisions ;
- The crew's use of the autopilot in the final stage of flight, which did not comply with the Flight Operations Manual. The autopilot modes selected significantly reduced the crew's situational awareness. In fact, the descent was carried out significantly to the right of the extended runway centerline over an area that lacked light landmarks ;
- The lack of proper interaction within the crew and insufficient monitoring of flight parameters.
Final Report:

Crash of a Cessna 402C in Provincetown

Date & Time: Sep 9, 2021 at 1600 LT
Type of aircraft:
Operator:
Registration:
N88833
Survivors:
Yes
Schedule:
Boston – Provincetown
MSN:
402C-0265
YOM:
1979
Flight number:
9K2072
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17617
Captain / Total hours on type:
10000.00
Aircraft flight hours:
36722
Circumstances:
The pilot was transporting six passengers on a scheduled revenue flight in instrument meteorological conditions. The pilot familiarized himself with the weather conditions before departure and surmised that he would be executing the instrument landing system (ILS) instrument approach for the landing runway at the destination airport. The operator prohibited approaches to runways less than 4,000 ft long if the tailwind component was 5 knots or more. The landing runway was 498 ft shorter than the operator-specified length. The pilot said he obtained the automated weather observing system (AWOS) data at least twice during the flight since he was required to obtain it before starting the instrument approach and then once again before he crossed the approach’s final-approach-fix (FAF). Though the pilot could not recall when he checked the AWOS, he said the conditions were within the airplane and company performance limits and he continued with the approach. A review of the wind data at the time he accepted the approach revealed the tailwind component was within limitations. As the airplane approached the FAF, wind speed increased, and the tailwind component ranged between 1 and 7 knots. Since the exact time the pilot checked the AWOS is unknown, it is possible that he obtained an observation when the tailwind component was within operator limits; however, between the time that the airplane crossed over the FAF and the time it landed, the tailwind component increased above 5 knots. The pilot said the approach was normal until he encountered a strong downdraft when the airplane was about 50 to 100 ft above the ground. He said that the approach became unstabilized and that he immediately executed a go-around; the airplane touched down briefly before becoming airborne again. The pilot said he was unable to establish a positive rate of climb and the airplane impacted trees off the end of the runway. The accident was captured on three airport surveillance cameras. A study of the video data revealed the airplane made a normal landing and touched down about 500 ft from the beginning of the runway. It was raining heavily at the time. The airplane rolled down the runway for about 21 seconds, and then took off again. The airplane entered a shallow climb, collided with trees, and caught on fire. All seven occupants were seriously injured and the airplane was destroyed.
Probable cause:
The pilot’s delayed decision to perform an aborted landing late in the landing roll with insufficient runway remaining. Contributing to the accident was the pilot’s failure to execute a go-around once the approach became unstabilized, per the operator’s procedures.
Final Report: