Crash of an Embraer ER-145LI in Shanghai

Date & Time: Jun 7, 2013 at 1725 LT
Type of aircraft:
Operator:
Registration:
B-3052
Survivors:
Yes
Schedule:
Huai’an – Shanghai
MSN:
145-905
YOM:
2006
Flight number:
MU2947
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Huai'an-Lianshui Airport, the crew initiated the approach to Shanghai-Hongqiao Airport in marginal weather conditions with light rain showers. After touchdown ont runway 18L, the crew started the braking procedure when the aircraft deviated to the left and veered off runway. While contacting soft ground, the nose gear collapsed and the aircraft slid for few dozen metres before coming to rest. All 49 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The cause of the runway excursion was foreign object debris inside the electrohydraulic servo valve (EHSV) that blocked a hydraulic port and caused an uncommanded nose wheel deflection to the left. Prior to the disassembly of the EHSV and discovery of the debris the unit had passed an acceptance test as performed on any newly manufactured unit. The NTSB reported that a number of pilots use binder brackets instead of the chart holders installed by Embraer to hold their binders (containing charts) etc., these binder brackets not having been approved by Embraer. The binder is directly above the nosewheel steering tiller, the NTSB wrote: "The NTSB is concerned that a binder being held by an unapproved bracket may become dislodged, fall, and strike the tiller, engaging the nosewheel steering system and possibly providing a nosewheel steering input. If this happens during the landing roll, the nosewheel steering input could cause a runway excursion." The NTSB therefore recommended to study and revise the acceptance tests and to issue an operational bulletin to inform flight crew that the use of binder brackets is not approved and could create a hazardous situation if the binder becomes dislodged.

Crash of a Xian MA60 in Mong Hsat

Date & Time: May 16, 2013 at 1148 LT
Type of aircraft:
Operator:
Registration:
XY-AIQ
Survivors:
Yes
Schedule:
Yangon - Heho - Mong Hsat
MSN:
08 08
YOM:
2010
Flight number:
UB646
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
51
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9066
Captain / Total hours on type:
2377.00
Copilot / Total flying hours:
3414
Copilot / Total hours on type:
1871
Aircraft flight hours:
3457
Aircraft flight cycles:
2973
Circumstances:
On 16 May 2013 at 08:00 local Time, Myanma Airways MA-60 aircraft registered XY- AIQ (MSN-0808) departed Yangon International Airport (VYYY) to Monghsat Airport. For this flight captain assigned FO to line training (Command) pilot and aircraft landed to Monghsat at about 09:25 local time. After passengers disembarked and boarded, aircraft departed to Heho at 09:55 local time and landed at about 10:40 local time. Aircraft refueled at Heho and departed to Monghsat at 11:10 local time with 4 crews and 51 passengers. First officer was designated as the Pilot flying for this flight. Captain contacted to Monghsat ATC weather information, and aircraft climbed to 15000-ft with indicated airspeed 200 knots. Where reaching 40 Miles to Monghsat airfield, Captain request descent clearance and descent to 8000 ft. After passing transition level 125 Monghsat airfield, QNH setting and performed approach check. During approach to Monghsat airfield, weather was fine and visibility was 4-5 Miles (8- km). When reaching 3 Miles distance to runway 12, approach speed was 120 knots IAS. At about 11:47:59 local time, aircraft first touchdown to runway 12 with IAS 114 knots, vertical speed -288, flap 30 degree. During landing roll, aircraft over run to runway 30. At about (11:48:33) local time, aircraft struck to tree stump with IAS 40 knots and passing across to water drainage (gutter) located 110 meters from runway 30. After striking, aircraft turned to left 80 degree and came to rest. Cabin crews performed emergency evacuation, one passenger suffered serious injury, other one suffered minor injury and 53 of the occupants were survived. One passenger was serious injury ( back pain) and one passenger was minor injury (shoulder joint injury) due to accident. The left main leading gear and nose landing gear strut broken, left engine propeller blades broken, left wing tip broken and lower fuselage frame dents. The aircraft was substantially damaged.
Probable cause:
Primary Cause:
- During landing roll FO retracted PIA to GI position, its remain above Ground Idle position (36.8/ 36.6) degree. After (18) seconds flap position changed to retract and both engines torque start to increase.
- Aircraft IAS unable to rapid decelerate during crews applied braking.
Secondary Cause:
- Both crews are not initiated power lever reversing position.
- Crews need multi-crew operation.
Final Report:

Crash of a De Havilland DHC-6 Twin 300 Otter in Jomsom

Date & Time: May 16, 2013 at 0833 LT
Operator:
Registration:
9N-ABO
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
638
YOM:
1979
Flight number:
RNA555
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8451
Captain / Total hours on type:
8131.00
Copilot / Total flying hours:
1396
Copilot / Total hours on type:
1202
Aircraft flight hours:
32291
Aircraft flight cycles:
54267
Circumstances:
The Twin Otter (DHC6/300) aircraft with registration number 9N-ABO, owned and operated by Nepal Airlines Corporation (NAC), departed Kathmandu to Pokhara for night stop on 15 May 2013 in order to accomplish up to 5 (five) Pokhara-Jomsom-Pokhara charter flights planned for the subsequent day on 16 May 2013. As per the programme, the aircraft completed first charter flight from Pokhara to Jomsom sector on 16 May 2013 morning after one and half hour waiting on ground due weather. For this second flight, the aircraft departed at 0225 UTC (08:10LT) from Pokhara to Jomsom in the command of Capt. Dipendra Pradhan and Mr. Suresh K.C. as co-pilot. There were 19 passengers including one infant and 3 crew members on board. The aircraft was operating under Visual Flight Rules (VFR). As per the CVR readout there was no reported difficulties and all the pre and post departure procedure and en-route portion of the flight were completed in normal manner. There was no indication of lacking of information and advice from Jomsom Tower. At first contact the co-pilot called Jomsom Tower and reported its position at PLATO (a compulsory reporting point) at 9 miles from Jomsom airport at 12500ft. AMSL. The Jomsom Tower advised runway 24 wind south westerly 08-12 KTS, QNH 1020, Temp 13 degree and advised to report downwind for runway 24.The co-pilot accepted by replying to join downwind for runway 24. There was no briefing and discussion between the two pilots regarding the tail wind at the airport. The PIC, then, took over the communication function from co-pilot and called Jomsom Tower, requesting to use runway 06 instead of runway 24, despite the advice of tower to use runway 24 to avoid tail wind effect in runway 06. Jomsom Tower repeated the wind speed to be 08-12 KTS for the runway 06, to which the PIC read back the wind and answered to have ”no problem”. As per the PIC request the Jomsom Tower designated runway 06 for landing and advised to report on final runway 06. The PIC did read back the same. The pre landing checklist was used, flaps with full fine in propeller rpm were taken and full flaps was also taken before touchdown. In the briefing of “missed approach” the PIC had answered to be “standard”. The aircraft touched down runway of Jomsom airport at 0245 UTC (08:30LT) at a distance of approximately 776 ft, far from the threshold of runway 06. After rolling 194 ft. in the runway, the aircraft left runway and entered grass area in the right side. The aircraft rolled around 705 ft in the grass area and entered the runway again. The maximum deviation from the runway edge was 19 ft. The Commission has observed that when aircraft touched down the runway, it was not heading in parallel to the runway centreline. After touchdown the aircraft rolled around 194ft on the runway, left the paved area and started rolling in the grass area in the right side. During the landing roll, when the aircraft was decelerating, the co-pilot had raised the flaps as per the existing practice of carrying out “after the landing “checks". As per the observation of passenger seated just behind the cockpit, after touchdown of the aircraft there was no communication between pilot and co-pilot. It seemed that pilot was busy in cockpit and facing problem. It was obvious that PIC was in dilemma in controlling aircraft. He added power to bring aircraft into the runway with an intention to lift up the aircraft. He did not brief anything to copilot about his intention and action. He started adding power with the intention of lifting up, but the aircraft was already losing its speed, due to extension of flaps by co-pilot without briefing to PIC and use of brakes (light or heavy, knowingly and unknowingly) simultaneously by the PIC. The accelerating aircraft with insufficient speed and lift to take off ran out of the runway 24 end, continued towards the river, hit the barbed fence and gabion wall with an initial impact and finally fell down into the edge of river. The left wing was rested in the mid of the river preventing the aircraft submerged into the river.
Probable cause:
The Accident Investigation Commission has determined the most probable cause of the accident as the inappropriate conduct of STOL procedure and landing technique carried out by the PIC, during landing phase and an endeavor to carry out take off again with no sufficient airspeed, no required lifting force and non availability of required runway length to roll. Contributory factors to the occurrence is the absence of proper CRM in terms of communication, coordination and briefing in between crew members on intention and action being taken by PIC, during pre and post landing phase.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Sam Neua

Date & Time: Apr 17, 2013 at 1435 LT
Operator:
Registration:
RDPL-34180
Flight Phase:
Survivors:
Yes
Schedule:
Sam Neua – Vientiane
MSN:
231
YOM:
1969
Flight number:
LOA201
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Sam Neua-Nathong Airport, while in initial climb, the twin engine aircraft collided with trees, lots height and crashed in a small river located 200 metres past the runway end. All 18 occupants were injured, five seriously. The aircraft was damaged beyond repair.

Crash of a Boeing 737-8GP off Denpasar

Date & Time: Apr 13, 2013 at 1510 LT
Type of aircraft:
Operator:
Registration:
PK-LKS
Survivors:
Yes
Schedule:
Bandung - Denpasar
MSN:
38728/4350
YOM:
2013
Flight number:
LNI904
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
101
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
6173.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
923
Aircraft flight hours:
142
Aircraft flight cycles:
104
Circumstances:
On 13 April 2013, a Boeing 737-800 aircraft, registered PK-LKS, was being operated by PT. Lion Mentari Airlines (Lion Air) on a scheduled passenger flight as LNI 904. The aircraft departed from Husein Sastranegara International Airport (WICC) Bandung at 0545 UTC to Ngurah Rai International Airport (WADD), Bali, Indonesia. The flight was the last sector of four legs scheduled for the crew on that day which were Palu (WAML) - Balikpapan (WALL) - Banjarmasin (WAOO) - Bandung (WICC) - Bali (WADD). The aircraft flew at FL 390, while the Second in Command (SIC) was the Pilot Flying (PF) and the Pilot in Command (PIC) was the Pilot Monitoring (PM). There were 2 pilots, 5 flight attendants and 101 passengers comprising 95 adults, 5 children and 1 infant making a total of 108 persons on board. The flight from the departure until start of the approach into Bali was uneventful. At 0648 UTC, the pilot made first communications with the Bali Approach controller (Bali Director) when the aircraft was located 80 Nm from BLI VOR. The pilot received clearance to proceed direct to the TALOT IFR waypoint and descend to 17,000 feet. At 0652 UTC, the Bali Director issued a further clearance for the pilot direct to KUTA point and descent to 8,000 feet. At 0659 UTC, the aircraft was vectored for a VOR DME approach for runway 09 and descent to 3,000 feet. At 0703 UTC, while the aircraft was over KUTA point, the Bali Director transferred communications with the aircraft to Bali Control Tower (Ngurah Tower). At 0704 UTC, the pilot contacted Ngurah Tower controller and advised that the aircraft was leaving KUTA point. The Ngurah Tower controller instructed the pilot to continue the approach and to reduce the aircraft speed to provide sufficient separation distance with another aircraft. At 0707 UTC, the Ngurah Tower issued take-off clearance for a departing aircraft on runway 09. At 0708 UTC, with LKS at approximately 1,600 feet AGL, the Ngurah Tower controller saw the aircraft on final approach and gave a landing clearance with additional information that the wind was from 120° at 05 knots. At 0708:47 UTC, the aircraft Enhance Ground Proximity Warning System (EGPWS) aural alert called “ONE THOUSAND”, the SIC said one thousand, stabilized, continue, prepare for go-around missed approach three thousand. The FDR showed that the pilot flown using LNAV (Lateral Navigation) and VNAV (Vertical Navigation) during the approach until disengagement of the Auto Pilot. The sequence of events during the final approach is based on the recorded CVR and FDR data, and information from crew interviews as follows: At 0708:56 UTC, while the aircraft altitude was approximately 900 feet AGL, the SIC commented that the runway was not in sight, whereas the PIC commented “OK. Approach light in sight, continue”. At 0709:33 UTC, after the EGPWS aural alert “MINIMUM” sounded at an aircraft altitude of approximately 550 feet AGL, the SIC disengaged the autopilot and the auto-throttle and then continued the approach. At 0709:43 UTC, the EGPWS called “THREE HUNDRED”. At 0709:47 UTC, the CVR recorded a sound similar to rain hitting the windshield. At 0709:49 UTC, the EGPWS called “TWO HUNDRED”. At 0709:53 UTC, while the aircraft altitude was approximately 150 feet AGL, the PIC took over control of the aircraft. The SIC handed control to the PIC and stated that he could not see the runway. At 0710:01 UTC, after the EGPWS called “TWENTY”, the PIC commanded for go-around. At 0710:02 UTC, the aircraft impacted the water, short of the runway. The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south-west of the beginning of runway 09. Between 0724 UTC to 0745 UTC, three other aircraft took-off and six aircraft landed using runway 09. At 0750 UTC, the airport was closed until 0850 UTC. At 0755 UTC, all occupants were completely evacuated, the injured passengers were taken to the nearest hospitals and uninjured occupants to the airport crisis centre.
Probable cause:
The National Transportation Safety Committee initial findings on the accident flight are as follows:
- The aircraft was airworthy prior to impact and has an item on the DMI (deferred maintenance item) category C (right engine oil filter).
- All crew has valid licenses and medical certificates.
- The Second in Command (SIC) acted as Pilot Flying (PF).
- The flight performed a VOR DME approach runway 09, and the published Minimum Descent Altitude (MDA) was 465 ft AGL.
- The approach configuration used was flap 40.
- At 900 ft AGL the PF did not have the runway in sight.
- Upon reaching the MDA the flight profile indicated a constant path.
- The PIC took over control of the aircraft at about 150 ft radio altitude.
- The SIC handed over control to the PIC at about 150 ft and stated that he could not see the runway.
- The final approach phase of the flight profile was outside the envelope of the EGPWS warning, therefore no EGPWS warning was recorded on the CVR.
The NTSC concluded in its final report that the accident was caused by the following factors:
- The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots.
- The flight crew loss of situational awareness in regards of visual references once the aircraft entered a rain cloud during the final approach below minimum descends altitude (MDA).
- The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully.
- The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.
Final Report:

Crash of a Boeing 737-33A in Muscat

Date & Time: Feb 11, 2013 at 1325 LT
Type of aircraft:
Operator:
Registration:
AP-BEH
Survivors:
Yes
Schedule:
Sialkot - Muscat
MSN:
25504/2341
YOM:
1992
Flight number:
PK259
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
107
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Sialkot, the crew completed the approach to Muscat-Seeb Runway 26L. After touchdown, while decelerating, the left main gear collapsed, causing the left engine to struck the ground. The aircraft slid for few dozen metres before coming to rest on the left edge of the runway. All 114 occupants evacuated uninjured while the aircraft was damaged beyond repair.

Crash of an Airbus A320-211 in Tunis

Date & Time: Feb 6, 2013 at 1423 LT
Type of aircraft:
Operator:
Registration:
TS-IMB
Survivors:
Yes
Schedule:
Casablanca - Tunis
MSN:
119
YOM:
1990
Flight number:
TU712
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
75
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Casablanca-Mohamed V Airport, the crew started the approach to Tunis-Carthage International Airport Runway 19 and encountered marginal weather conditions. After touchdown, the aircraft rolled for a distance of 1,600 metres then deviated to the right. The aircraft veered off runway, rolled in a grassy area for 114 metres when the nose gear impacted the concrete perpendicularly runway 11/29. On impact, the nose gear was torn off and the aircraft rolled for another 130 metres before coming to rest. All 83 occupants evacuated safely while the aircraft was damaged beyond repair. At the time of the accident, strong crosswinds and heavy rain falls passed over the airport.

Crash of an ATR72-500 in Rome

Date & Time: Feb 2, 2013 at 2032 LT
Type of aircraft:
Operator:
Registration:
YR-ATS
Survivors:
Yes
Schedule:
Pisa - Rome
MSN:
533
YOM:
1997
Flight number:
AZ1670
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18552
Captain / Total hours on type:
3351.00
Copilot / Total flying hours:
624
Copilot / Total hours on type:
14
Aircraft flight hours:
24088
Circumstances:
The Rome-Fiumicino Airport Runway 25 was closed to trafic due to work in progress so the crew was vectored and cleared for a landing on runway 16L. The approach was completed in good visibility with strong crosswinds from 250° at 28 knots gusting to 41 knots and windshear. On the last segment, the aircraft lost height and impacted ground 567 metres short of runway 16L threshold. The aircraft bounced three times, lost its right main gear, slid for few dozen metres and came to rest in a grassy area some 1,780 metres past the runway threshold. All 50 occupants were rescued, among them seven were slightly injured. The aircraft was damaged beyond repair.
Probable cause:
The accident is due to the human factor. In particular, it was caused by an improper conduct of the aircraft by the PF (commander) during landing, not consistent with the provisions of the operator's manuals, in an environmental context characterized by the presence of significant criticality (presence of crosswind with values at the limit/excess those allowed for the ATR 72) and in the absence of an effective CRM.
The following factors may have contributed to the event:
- The failure to carry out the landing briefing, which, in addition to being required by company regulations, would have been an important moment of pooling and acceptance of information fundamental to the safety of operations.
- The maintenance of a V APP significantly higher than expected.
- The conviction of the commander (PF), deriving from his considerable general and specific experience on the aircraft in question, to be able to conduct a safe landing in spite of the presence of critical wind conditions for the type of aircraft.
- The considerable difference in experience between the commander and the first officer, which has reasonably prevented the latter from showing his critical capacity, thus rendering CRM techniques ineffective.
Final Report:

Crash of a Canadair RegionalJet CRJ-200ER in Almaty: 21 killed

Date & Time: Jan 29, 2013 at 1310 LT
Operator:
Registration:
UP-CJ006
Survivors:
No
Schedule:
Kokshetau - Almaty
MSN:
7413
YOM:
2000
Flight number:
VSV760
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
18194
Captain / Total hours on type:
1010.00
Copilot / Total flying hours:
3507
Copilot / Total hours on type:
132
Aircraft flight hours:
25707
Aircraft flight cycles:
22975
Circumstances:
Following an uneventful flight from Kokshetau, the crew started the descent to Almaty Airport and was cleared for an ILS approach (Cat IIIb approach) to runway 23R. At this time, the horizontal visibility was 200 metres, the vertical visibility 40 metres and the RVR for runway 23R was 275-250-225 metres respectively. Due to this poor weather conditions at destination, the captain got stressed, creating a strong emotional reaction. On short final, at an altitude of 180 metres, the captain decided to abandon the landing procedure and initiated a go-around manoeuvre. The automatic pilot system was deactivated and the TO/GA mode was activated. Four seconds later, the captain pushed the control column forward, causing the aircraft to descend. The EGPWS alarm sounded in the cockpit but there was no response from the flying crew. In a pitch angle of -16° and with a descent rate of about 20-30 metres per second, the aircraft impacted ground and disintegrated in a snow covered field. The wreckage was found some 1,400 metres short of runway. All 21 occupants were killed. Due to the actual weather conditions, the crew should perform a Cat IIIc approach.
Probable cause:
The accident with aircraft CRJ-200 UP-CJ006 occurred during the execution of a go-around, in instrument meteorological conditions, without the possibility of visual contact with ground reference points (vertical visibility in the fog did not exceed 40 m), the necessity of which was caused by the mismatch between the actual weather conditions and the minimum conditions for which the crew was certified to land. As a result, the deflection of the elevator towards a dive of the aircraft caused a descent and collision with the ground. It was not possible to uniquely identify the causes of the aircraft's transfer to a dive from the available data. The Commission did not find evidence of failures of aviation equipment, as well as external to the aircraft (icing, wind shear, wake turbulence) when trying to perform a go-around.
The most likely factors that led to the accident, were:
- Partial loss performance of the pilot in command, which at the time of aircraft impact with the ground was not in a working position;
- The lack of CRM levels in the crew, and violation of the Fly-Navigate-Communicate principle, which manifested itself in diverting attention by the co-pilot to conduct external radio communication and lack of control of the flight instrument parameters;
- The lack of response to the EGPWS and the actions required;
- The impact somatogravic illusions of perception of the pitch angle (a nose-up illusion);
- Increased emotional stress by the crew members associated with the unjustified expectations of improved weather conditions at the time of landing;
- Failure to comply with the requirements for health examination of flight personnel, which led to the pilot in command flying without the rehabilitation period and without assessment of his health status after undergoing surgery.
Final Report:

Crash of a Britten Norman BN-2B-26 Islander at Okiwi Station

Date & Time: Jan 25, 2013 at 0827 LT
Type of aircraft:
Operator:
Registration:
ZK-DLA
Survivors:
Yes
Schedule:
Auckland – Okiwi Station
MSN:
2131
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3170
Captain / Total hours on type:
296.00
Circumstances:
On approach to runway 18 at Okiwi, New Zealand, the aircraft encountered windshear on short final as the pilot reduced power to land. The pilot was unable to arrest the descent rate and the aircraft landed heavily. Damage was caused to both landing gear oleos and one brake unit, with rippling found on the upper and lower skin of each wing. One passenger sustained a back injury, which was later identified as a fractured vertebra. The pilot was aware of fluctuating wind conditions at Okiwi and had increased the approach speed to 70 knots as per company standard operating procedures. The pilot reported that despite this, the airspeed reduced rapidly and significantly at 10 to 15 feet agl, leaving little time to react to the situation.
Probable cause:
Loss of height and hard landing due to windshear on short final.