Crash of a Boeing 737-7H4 in New York

Date & Time: Jul 22, 2013 at 1744 LT
Type of aircraft:
Operator:
Registration:
N753SW
Survivors:
Yes
Schedule:
Nashville – New York
MSN:
29848/400
YOM:
1999
Flight number:
WN345
Crew on board:
5
Crew fatalities:
Pax on board:
145
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12522
Captain / Total hours on type:
7909.00
Copilot / Total flying hours:
5200
Copilot / Total hours on type:
1100
Aircraft flight hours:
49536
Circumstances:
As the airplane was on final approach, the captain, who was the pilot monitoring (PM), realized that the flaps were not configured as had been briefed, with a setting of 40 degrees for the landing. Data from the flight data recorder (FDR) indicate that the captain set the flaps to 40 degrees as the airplane was descending through about 500 ft altitude, which was about 51 seconds from touchdown. When the airplane was between 100 to 200 ft altitude, it was above the glideslope. Concerned that the airplane was too high, the captain exclaimed repeatedly "get down" to the first officer about 9 seconds from touchdown. About 3 seconds from touchdown when the airplane was about 27 ft altitude, the captain announced "I got it," indicating that she was taking control of the airplane, and the first officer replied, "ok, you got it." According to FDR data, after the captain took control, the control column was relaxed to a neutral position and the throttles were not advanced until about 1 second before touchdown. The airplane touched down at a descent rate of 960 ft per minute and a nose-down pitch attitude of -3.1 degrees, resulting in the nose gear contacting the runway first and a hard landing. The airplane came to a stop on the right side of the runway centerline about 2,500 ft from its initial touchdown. The operator's stabilized approach criteria require an immediate go-around if the airplane flaps or landing gear were not in the final landing configuration by 1,000 ft above the touchdown zone; in this case, the flaps were not correctly configured until the airplane was passing through 500 ft. Further, the airplane's deviation about the glideslope at 100 to 200 ft would have been another opportunity for the captain, as the PM at this point during the flight, to call for a go-around, as indicated in the Southwest Airlines Flight Operations Manual (FOM). Accident data suggest that pilots often fail to perform a go-around or missed approach when stabilized approach criteria are not met. A review of NTSB investigated accidents by human factors researchers found that about 75% of accidents were the result of plan continuation errors in which the crew continued an approach despite cues that suggested it should not be continued. Additionally, line operations safety audit data presented at the International Air Safety Summit in 2011 suggested that 97% of unstabilized approaches were continued to landing even though doing so was in violation of companies' standard operating procedures (SOPs). The Southwest FOM also states that the captain can take control of the airplane for safety reasons; however, the captain's decision to take control of the airplane at 27 ft above the ground did not allow her adequate time to correct the airplane's deteriorating energy state and prevent the nose landing gear from striking the runway. The late transfer of control resulted in neither pilot being able to effectively monitor the airplane's altitude and attitude. The first officer reported that, after the captain took control of the airplane, he scanned the altimeter and airspeed to gain situational awareness but that he became distracted by the runway "rushing" up to them and "there was no time to say anything." The captain should have called for a go-around when it was apparent that the approach was unstabilized well before the point that she attempted to salvage the landing by taking control of the airplane at a very low altitude. In addition, the captain did not follow SOPs at several points during the flight. As PM, she should have made the standard callout per the Southwest FOM when the airplane was above glideslope, stating "glideslope" and adding a descriptive word or words to the callout (for example, "one dot high"). Rather than make this callout, however, the captain repeatedly said "get down" to the first officer before stating "I got it." The way she handled the transfer of airplane control was also contrary to the FOM, which indicates that the PM should say "I have the aircraft." The flight crew's performance was indicative of poor crew resource management.
Probable cause:
The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. Contributing to the accident was the captain's failure to comply with standard operating procedures.
Final Report:

Crash of a Boeing 777-28E in San Francisco: 3 killed

Date & Time: Jul 6, 2013 at 1128 LT
Type of aircraft:
Operator:
Registration:
HL7742
Survivors:
Yes
Schedule:
Seoul - San Francisco
MSN:
29171/553
YOM:
2005
Flight number:
OZ214
Crew on board:
16
Crew fatalities:
Pax on board:
291
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9684
Captain / Total hours on type:
33.00
Copilot / Total flying hours:
12307
Copilot / Total hours on type:
3208
Aircraft flight hours:
37120
Aircraft flight cycles:
5388
Circumstances:
On July 6, 2013, about 1128 Pacific daylight time, a Boeing 777-200ER, Korean registration HL7742, operating as Asiana Airlines flight 214, was on approach to runway 28L when it struck a seawall at San Francisco International Airport (SFO), San Francisco, California. Three of the 291 passengers were fatally injured; 40 passengers, 8 of the 12 flight attendants, and 1 of the 4 flight crewmembers received serious injuries. The other 248 passengers, 4 flight attendants, and 3 flight crewmembers received minor injuries or were not injured. The airplane was destroyed by impact forces and a postcrash fire. Flight 214 was a regularly scheduled international passenger flight from Incheon International Airport, Seoul, Korea, operating under the provisions of 14 Code of Federal Regulations Part 129. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight was vectored for a visual approach to runway 28L and intercepted the final approach course about 14 nautical miles (nm) from the threshold at an altitude slightly above the desired 3° glidepath. This set the flight crew up for a straight-in visual approach; however, after the flight crew accepted an air traffic control instruction to maintain 180 knots to 5 nm from the runway, the flight crew mismanaged the airplane’s descent, which resulted in the airplane being well above the desired 3° glidepath when it reached the 5 nm point. The flight crew’s difficulty in managing the airplane’s descent continued as the approach continued. In an attempt to increase the airplane’s descent rate and capture the desired glidepath, the pilot flying (PF) selected an autopilot (A/P) mode (flight level change speed [FLCH SPD]) that instead resulted in the autoflight system initiating a climb because the airplane was below the selected altitude. The PF disconnected the A/P and moved the thrust levers to idle, which caused the autothrottle (A/T) to change to the HOLD mode, a mode in which the A/T does not control airspeed. The PF then pitched the airplane down and increased the descent rate. Neither the PF, the pilot monitoring (PM), nor the observer noted the change in A/T mode to HOLD. As the airplane reached 500 ft above airport elevation, the point at which Asiana’s procedures dictated that the approach must be stabilized, the precision approach path indicator (PAPI) would have shown the flight crew that the airplane was slightly above the desired glidepath. Also, the airspeed, which had been decreasing rapidly, had just reached the proper approach speed of 137 knots. However, the thrust levers were still at idle, and the descent rate was about 1,200 ft per minute, well above the descent rate of about 700 fpm needed to maintain the desired glidepath; these were two indications that the approach was not stabilized. Based on these two indications, the flight crew should have determined that the approach was unstabilized and initiated a go-around, but they did not do so. As the approach continued, it became increasingly unstabilized as the airplane descended below the desired glidepath; the PAPI displayed three and then four red lights, indicating the continuing descent below the glidepath. The decreasing trend in airspeed continued, and about 200 ft, the flight crew became aware of the low airspeed and low path conditions but did not initiate a go-around until the airplane was below 100 ft, at which point the airplane did not have the performance capability to accomplish a go-around. The flight crew’s insufficient monitoring of airspeed indications during the approach resulted from expectancy, increased workload, fatigue, and automation reliance. When the main landing gear and the aft fuselage struck the seawall, the tail of the airplane broke off at the aft pressure bulkhead. The airplane slid along the runway, lifted partially into the air, spun about 330°, and impacted the ground a final time. The impact forces, which exceeded certification limits, resulted in the inflation of two slide/rafts within the cabin, injuring and temporarily trapping two flight attendants. Six occupants were ejected from the airplane during the impact sequence: two of the three fatally injured passengers and four of the seriously injured flight attendants. The four flight attendants were wearing their restraints but were ejected due to the destruction of the aft galley where they were seated. The two ejected passengers (one of whom was later rolled over by two firefighting vehicles) were not wearing their seatbelts and would likely have remained in the cabin and survived if they had been wearing their seatbelts. After the airplane came to a stop, a fire initiated within the separated right engine, which came to rest adjacent to the right side of the fuselage. When one of the flight attendants became aware of the fire, he initiated an evacuation, and 98% of the passengers successfully self-evacuated. As the fire spread into the fuselage, firefighters entered the airplane and extricated five passengers (one of whom later died) who were injured and unable to evacuate. Overall, 99% of the airplane’s occupants survived.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances.
Contributing to the accident were:
(1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error;
(2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems;
(3) the pilot flying’s inadequate training on the planning and executing of visual approaches;
(4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue, which likely degraded their performance.
Final Report:

Crash of a Saab 340 in Marsh Harbour

Date & Time: Jun 13, 2013 at 1345 LT
Type of aircraft:
Operator:
Registration:
C6-SBJ
Survivors:
Yes
Schedule:
Fort Lauderdale – Marsh Harbour
MSN:
316
YOM:
1992
Flight number:
SBM9561
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
4700.00
Aircraft flight hours:
45680
Aircraft flight cycles:
49060
Circumstances:
On Thursday June 13, 2013 at approximately 1750UTC (1:50pm local time), a fixed wing, twin turboprop regional airliner, was involved in an accident as a result of a runway excursion while landing during heavy rain showers at Marsh Harbor Int’l Airport, Marsh Harbor, Abaco, Bahamas. The aircraft, a SAAB 340B aircraft was operated by SkyBahamas Airlines and bore Bahamas registration C6-SBJ, serial number 316. C6-SBJ departed Fort Lauderdale Int’l Airport (KFLL), Fort Lauderdale, Florida in the USA as Tropical Sky 9561. The airline, SkyBahamas Airline is a Bahamas Air Operator Certificate Holder with approved scheduled operations to and from Fort Lauderdale International Airport, Florida USA (KFLL) and Marsh Harbor Int’l Airport, Marsh Harbor, Abaco in the Bahamas. The crew received weather information and IFR route clearance from KFLL Control Tower. This passenger carrying flight departed KFLL at 1706UTC (1:06pm local) on an instrument flight rules (IFR) flight plan. The point of intended landing was Marsh Harbor International Airport, Abaco, Bahamas (MYAM). The crew selected runway 09 at MYAM for landing. At 17:45:30, the aircraft leveled off at 1,500 feet ASL on a heading of 096 degrees magnetic, with airspeed of 236 knots indicated (KIAS). The flaps were extended to 15 degrees at 17:47:18 with the aircraft level at 1,300 feet ASL, approximately 4.2 nm on the approach. The autopilot was disconnected at 17:47:26 with the aircraft level at 1,300 feet ASL, approximately 3.8 nm on the approach. Heading was 097 degrees magnetic and airspeed was 166 KIAS. The Landing Gear was extended and in the down and locked position by 17:48:01 as the aircraft descended through 730 feet ASL. At 17:48:03, the flaps were extended to landing flap 20 degrees with the aircraft approximately 1.9 nm from the runway on the approach. At 17:48:47, as the aircraft approached the threshold, the power levers were retarded (from 52 degrees) and the engine torques decreased from approximately 20%. Approximately one second later, the aircraft crossed the threshold at a radio altitude of 50 feet AGL on a heading 098 degrees magnetic and airspeed of 171 KIAS. The crew encountered rain showers and a reduction in visibility. The aircraft initially touched down at 17:49:02 with a recorded vertical load factor of +2.16G, approximately 14 seconds after crossing the threshold. There were no indications on the runway to indicate where the initial touchdown had occurred. Upon initial landing however, the aircraft bounced and became airborne, reaching a calculated maximum height of approximately 15 feet AGL. The aircraft bounced a second time at 17:49:07 with a recorded vertical load factor of +3.19* G. During this second bounce, the pitch attitude was 1.8 degrees nose down, heading 102 degrees magnetic and airspeed 106 KIAS. The aircraft made consecutive contact with the runway approximately three times. The third and final bounce occurred at 17:49:14 with a recorded vertical load factor of +3.66G*. During the third bounce, the pitch attitude was 2.2 degrees nose down, heading 099 degrees magnetic and airspeed 98 KIAS. As a result of the hard touchdown, damage was sustained to the right wing and right hand engine/propeller. The right hand engine parameters recorded a rapid loss of power with decreasing engine speed and torque, and subsequent propeller stoppage. The aircraft veered off to the right at approximate time of 17:49:20 on a heading of 131 degrees magnetic at a point approximately 6,044 feet from the threshold of runway 09. The recorded airspeed was 44 KIAS with the left hand engine torque at 26 % and the right hand engine torque at 0%. The aircraft came to a full stop at approximate time 17:49:25 on a heading of 231 degrees magnetic. When the aircraft came to a stop, the flight and cabin crew and twenty-one (21) passengers evacuated the aircraft. The evacuation was uneventful using the main entrance door. Due to the damage sustained by the right wing and engine, evacuation on the right side was not considered. The evacuation occurred during heavy rainfall. No injuries were reported as a result of the accident or evacuation process. The airplane sustained substantial damage as a result of the impact sequence. The elevation of the accident site was reported as approximately 10 feet Mean Sea Level (MSL). Instrument Meteorological Conditions (IMC) prevailed at the time of the accident. The cockpit voice recorder (CVR) uncovered that this crew used no crew resource management or adherence to company standard operating procedures. During the final seconds of the flight, there was complete confusion on the flight deck as to who was in control of the aircraft. After failure of the windshield wiper on the left side of the aircraft, the captain continued to maneuver the aircraft despite having no visual contact of the field due to heavy rain. Sterile Cockpit procedures were not adhered to by this crew as they continued with non-essential conversation throughout the flight regime from engine start up in KFLL up until the “before landing checklist” was requested prior to landing.
Probable cause:
Contributing factors:
- Inexperienced and undisciplined crew,
- Lack of crew resource management training,
- Failure to follow company standard operating procedures,
- Condition known as “get-home-itis” where attempt is made to continue a flight at any cost, even if it means putting aircraft and persons at risk in order to do so,
- Failure to retrieve, observe and respect weather conditions,
- Thunderstorms at the airfield.
Final Report:

Crash of a Xian MA60 in Kawthaung

Date & Time: Jun 10, 2013 at 1255 LT
Type of aircraft:
Operator:
Registration:
XY-AIP
Survivors:
Yes
Schedule:
Yangon – Mawlamyine – Kawthaung
MSN:
08 07
YOM:
2010
Flight number:
UB609
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
60
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7815
Captain / Total hours on type:
2502.00
Copilot / Total flying hours:
3169
Copilot / Total hours on type:
361
Aircraft flight hours:
4395
Aircraft flight cycles:
3711
Circumstances:
On 10 June 2013, at 6:55 local time, Myanma Airways MA-60 (XY-AIP) departed from Yangon to Mawlamyine- Kawthaung and back with 4 crews and 27 passengers. During climbing, hydraulic pressure low warning (LEDPL), intermittently illuminated and aircraft returned back to Yangon. After snag rectification, aircraft departed to Mawlamyine at about 10:15 local time. During final approach, while landing gear down hydraulic pressure low warning illuminated and disappeared at aircraft parking. At about 11:10, aircraft departed from Mawlamyine with 4 crews and 60 passengers. During the route Mawlamyine to Kawthaung, no warning light illuminated. While approaching to Kawthaung RW, PIC check hydraulic quantity and flap down to 5°, landing gear down and final turn to runway 02. During final approach, LEDPL warning light was come again. PIC set flaps 15° to 30° respectively, but he noticed flaps position was not fully extended. As soon as aircraft touch down, PIC apply reverse power at about 2,500 ft from runway end. After recognition of aircraft swing, PIC changed power lever to GI position and applied brake and changed nose wheel to taxi mode and steering. Aircraft cannot able to steer and veer off left side of runway at about 3,200 ft. Firstly aircraft stroke two fence pillars with propellers and nose wheel, then aircraft turned 90° to left and stopped after striking to tree with left wing. There was no injury to crews and passengers due to accident. The aircraft was damaged beyond repair.
Probable cause:
Primary cause:
- During landing roll, due to hydraulic system pressure low, nose wheel steering mechanism and braking action are not effectively operated and aircraft veer off runway left side.
- PIC did not operated the emergency hydraulic pump while hydraulic low pressure warning come on.
Secondary cause:
- Hydraulic system pressure low due to hydraulic tank fluid level more than normal and tank pressurize compress air line filter blockage.
Final Report:

Crash of a Xian MA60 in Kupang

Date & Time: Jun 10, 2013 at 0954 LT
Type of aircraft:
Operator:
Registration:
PK-MZO
Survivors:
Yes
Schedule:
Bajawa - Kupang
MSN:
06 08
YOM:
2008
Flight number:
MZ6517
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12530
Captain / Total hours on type:
2050.00
Copilot / Total flying hours:
311
Copilot / Total hours on type:
141
Aircraft flight hours:
4486
Aircraft flight cycles:
4133
Circumstances:
On 10 June 2013, a Xi ‘An MA60 aircraft registered PK-MZO was being operated by PT. Merpati Nusantara Airlines on a scheduled passenger flight as MZ 6517. The aircraft departed from Bajawa Airport (WATB) Nusa Tenggara Timur, at 0102 UTC to El Tari (WATT) Kupang, Nusa Tenggara Timur. On board this aircraft were 2 pilots, 2 flight attendants with 46 passengers consisted of 45 adults and 1 infant. The flight was the second sectors for the aircraft and the crew on that day. The first flight was from Kupang to Bajawa Airport. During the flight the Second in Command (SIC) acted as the Pilot Flying (PF) and the Pilot in Command (PIC) as the Pilot Monitoring (PM). The flight from the departure until commencing for approach was un-eventful. At 0122 UTC, the pilot made first communication with El Tari Control Tower controller (El Tari Tower) and reported their position was on radial 298° 110 Nm from KPG VOR and maintaining 11,500 ft. The pilot received information that the runway in use was 07 and the weather information (wind 110° 11 kts, visibility 10 km, weather NIL, cloud few 2,000 ft, temperature 30° C, dew point 22° C, QNH 1010 mbs and QFE 998 mbs). At 0133 UTC, the aircraft was on radial 297° 68 Nm from KPG VOR and the pilot ready to descend and approved by El Tari Tower to descend to 5,000 ft. At 0138 UTC, the pilot reported the aircraft was passing 10,500 ft and stated that the flight was on Visual Meteorological Condition (VMC). At 0150 UTC, the aircraft position was on left base runway 07 at 5 Nm from KPG VOR. The El Tari Tower had visual contact with the aircraft and issued a landing clearance with additional information that the wind condition was 120° at 14 kts, QNH 1010 mbs. At 0151 UTC, the pilot reported that their position was on final and the El Tari Tower re-issued the landing clearance. The Flight Data Recorder (FDR) recorded that the left power lever was in the range of BETA MODE while the aircraft altitude was approximately 112 ft and followed by the right power lever at 90 ft until hit the ground. At 0154 UTC, the aircraft touched down at about 58 meters and halted on the runway at about 261 meters from the beginning of runway 07. The vertical deceleration recorded on FDR was 5.99 G and followed by - 2.78 G. After the aircraft stopped, the flight attendants assessed the situation and decided to evacuate the passengers through the rear main entrance door. One pilot and four passengers who seated on row number three, seven and eight suffered serious injury. On 11 June 2013, the aircraft was evacuated from the runway and moved to the Air Force hangar at 2100 UTC.
Probable cause:
The following contributing factors were identified:
- The procedure of selecting Power Lever Lock to “OPEN” during approach was made without comprehensive risk assessment.
- Both power levers entered BETA MODE at 90 feet due to the safety device namely Power Lever Lock has been opened during approach, which was in accordance to the operator procedure and lifting of Mechanical Power Lever Stop Slot which was not realized by the pilots.
- The movement of power levers to BETA MODE resulted the pitch angle changed to low pitch angle which produced significant drag and made the aircraft loss of significant lift.
Final Report:

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: