Crash of a Let L-410UVP-E9 in Ngerende: 4 killed

Date & Time: Aug 22, 2012 at 1220 LT
Type of aircraft:
Operator:
Registration:
5Y-UVP
Flight Phase:
Survivors:
Yes
Schedule:
Amboseli – Ngerende – Mara North – Ukunda – Mombasa
MSN:
91 26 27
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7480
Captain / Total hours on type:
1150.00
Copilot / Total flying hours:
312
Circumstances:
This was a commercial non scheduled flight which was being operated for air transport for local flights. The operator is based in Mombasa and mostly executes passenger flights to the Masai Mara and other game parks and reserves within the Republic of Kenya. On 22nd Aug 2012, the aircraft was scheduled to carry out a flight to the Masai Mara, do several sectors to pick and drop passengers and return to Moi international Airport via Ukunda Airport. The call sign was 5Y-UVP. The last point of departure was Ngerende Airstrip in the Masai Mara at 0917 with intention of onward flight to Mara North airstrip in the Masai Mara. The flight had earlier left Amboseli Airstrip with two crew, and 17 passengers for Ngerende Airstrip. 6 passengers had disembarked at Ngerende and the remaining 11 passengers were continuing to other destinations. No additional passengers or cargo was picked up from Ngerende airstrip. No refueling was done at the airstrip. The airfield is an unmanned airfield, with crew executing unmanned airfield communication procedures to execute approach and landings and also during takeoff. There is however a ground time keeper and a fueling bay at the airfield. Due to terrain and prevailing winds at the time of the flight, Runway 28 was in use. The crew was using unmanned airfield procedures and after the drop-off of 6 passengers, the aircraft lined up runway 28 and proceeded with the take off run. Ground staff at the airstrip reported a normal takeoff run and rotation. During the initial climb, the ground staff still had the aircraft in sight and reported to have seen the aircraft veer sharply to the left and then disappear behind terrain. Shortly afterwards, a loud sound was heard followed by dust in the air. Emergency SAR was initiated with the airport and hotel staff rushing to the accident site. The location of the accident was about 310 meters from the threshold of Runway 10, offset 30° to the left of the extended center line Runway 28. GPS coordinates (figure 1.2) 01.084189° S, 35.1781127° E, Ngerende airstrip. The accident occurred at 0917 UTC on 22nd Aug 2012, during daytime.
Probable cause:
The following findings were identified:
- The left engine was most probably not developing power at the time of impact,
- The left engine propeller was most probably in feather at the time of impact,
- Both CVR and FDR were unserviceable at the time of the accident,
- AAID was unable to determine origin of contaminant found in the left engine Fuel Control Unit,
- Sufficient oversight was not exercised over the Operator,
- High turnover of the Operator’s staff.
Final Report:

Crash of an ATR42-320 in Jersey

Date & Time: Jun 16, 2012 at 0823 LT
Type of aircraft:
Operator:
Registration:
G-DRFC
Survivors:
Yes
Schedule:
Guernsey - Jersey
MSN:
007
YOM:
1986
Flight number:
BCI308
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6106
Captain / Total hours on type:
1255.00
Circumstances:
The crew, comprising a commander, co-pilot and cabin crewmember, reported for duty at 0620 hrs at Guernsey Airport. The commander was conducting line training of the co-pilot, a first officer who had recently joined the companyThe first sector was to be from Guernsey to Jersey. No problems were identified during the pre-flight preparation and the aircraft departed on time at 0705 hrs, with the commander acting as handling pilot. The short flight was without incident and the weather for landing was reported as good, with the wind from 210° at 16 kt, FEW cloud at 2,000 ft and visibility in excess of 10 km. The commander elected to carry out a visual approach to Runway 27 at Jersey, using a planned approach speed of 107 kt and flap 30 selected for landing. During the approach, the gear was selected down and the flight crew confirmed the three green ‘gear safe’ indication lights were illuminated, indicating that the gear was locked in the down position. The commander reported that both the approach and touchdown seemed normal, with the crosswind from the left resulting in the left main gear touching first. Just after touchdown both pilots heard a noise and the commander stated the aircraft appeared to settle slightly differently from usual. This made him believe that a tyre had burst. The cabin crew member also heard a noise after touchdown which she too thought was from a tyre bursting. The commander selected ground idle and partial reverse pitch and, as the aircraft decelerated through 70 kt, the co-pilot took over control of the ailerons, as per standard procedures, to allow the commander to take control of the steering tiller. The co-pilot reported that despite applying corrective inputs the aircraft continued rolling to the left. A member of ground operations staff, situated at Holding Point E, reported to the tower controller that the left landing gear leg of the aircraft did not appear to be down properly as it passed him. The aircraft continued to quickly roll to the left until the left wingtip and propeller contacted the runway. The aircraft remained on the runway, rapidly coming to a halt to the left of the centreline, approximately abeam Holding Point D. Both propellers continued to rotate and the commander selected the condition levers to the fuel shutoff position and pulled the fire handles to shut both engines down. The tower controller, seeing the incident, pressed the crash alarm and airfield emergency services were quickly in attendance.
Probable cause:
The recorded data indicates that the rate of descent during the final approach phase was not excessive and remained low through the period of the touchdown. Although the registered vertical acceleration at ground contact was high, this is not consistent with the recorded descent rate and is believed to have been the effect of the close physical proximity of the accelerometer to the location of the fractured side brace. It is reasonable to assume that the release of strain energy during the fracturing process produced an instant shock load recorded as a 3 g spike.The general nature of the failure mechanism precipitating the collapse of the landing gear is clear. A fatigue crack propagated through most of the cross-section of one side of an attachment lug of the left main landing gear side brace upper arm. This continued as a final region of ductile cracking until complete failure occurred. The increased loading, during normal operation, on other elements of the twin lugs, once the initial crack was large or had passed completely through the section, led to overloading in the other section of the forward lug and both sections of the aft lug. This caused rapid onset of three small areas of fatigue damage followed by ductile overload failure of both lugs. The failure rendered the side brace ineffective and the unrestrained main trunnion continued to translate outboard leading to the collapse of the gear. The aluminium was found to be within the specifications to which it was made. The initial fatigue crack emanated from a feature which was inter-granular and high in titanium content, which was probably a TiB2 particle introduced during grain refining. This was surrounded by an area consistent with static loading before propagating a crack in fatigue. Given that there was not a measurable effect on the fatigue life of the material with the feature, and that an area of static overload was evident immediately surrounding the TiB2 particle, it is therefore concluded that at some time during the life of the side brace component it probably suffered a single loading event sufficient to exploit the presence of the origin, initiating a crack that remained undetectable until failure.
Final Report:

Crash of a McDonnell Douglas MD-83 in Lagos: 159 killed

Date & Time: Jun 3, 2012 at 1545 LT
Type of aircraft:
Operator:
Registration:
5N-RAM
Survivors:
No
Site:
Schedule:
Abuja - Lagos
MSN:
53019/1783
YOM:
1990
Flight number:
DAV992
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
147
Pax fatalities:
Other fatalities:
Total fatalities:
159
Captain / Total flying hours:
18116
Captain / Total hours on type:
7466.00
Copilot / Total flying hours:
1143
Copilot / Total hours on type:
808
Aircraft flight hours:
60850
Aircraft flight cycles:
35220
Circumstances:
On 3rd June, 2012 at about 1545:00hrs, 5N-RAM, a Boeing MD-83, a domestic scheduled commercial flight, operated by Dana Airlines (Nig.) Limited as flight 0992 (DANACO 0992), crashed into a densely populated area of Iju-Ishaga, a suburb of Lagos, following engine number 1 loss of power seventeen minutes into the flight and engine number 2 loss of power while on final approach to Murtala Muhammed Airport Lagos, Nigeria. Visual Meteorological Conditions prevailed at the time and the airplane was on an instrument flight plan. All 153 persons onboard the airplane, including the six crew were fatally injured. There were also six confirmed ground fatalities. The airplane was destroyed. There was post impact fire. The flight originated at Abuja (ABV) and the destination was Lagos (LOS). The airplane was on the fourth flight segment of the day, consisting of two round-trips between Lagos and Abuja. The accident occurred during the return leg of the second trip. DANACO 0992 was on final approach to runway 18R at LOS when the crew declared a Mayday call “Dual Engine Failure – negative response from the throttles.” According to records, the flight arrived ABV as Dana Air flight 0993 at about 1350:00hrs and routine turn-around activities were carried out. DANACO 0992 initiated engine start up at 1436:00hrs. Abuja Control Tower cleared the aircraft to taxi to the holding point of runway 04. En-route ATC clearance was passed on to DANACO 0992 on approaching holding point of runway 04. According to the ATC ground recorder transcript, the aircraft was cleared to line-up on runway 04 and wait, but the crew requested for some time before lining-up. DANACO 0992 was airborne at 1458:00hrs after reporting a fuel endurance of 3 hours 30 minutes. The aircraft made contact with Lagos Area Control Centre at 1518:00hrs and reported 1545:00hrs as the estimated time of arrival at LOS at cruising altitude of 26,000 ft. The Cockpit Voice Recorder (CVR) retained about 30 minutes 53 seconds of the flight and started recording at 1513:44hrs by which time the Captain and First Officer (F/O) were in a discussion of a non-normal condition regarding the correlation between the engine throttle setting and an engine power indication. However, they did not voice concerns then that the condition would affect the continuation of the flight. The flight crew continued to monitor the condition and became increasingly concerned as the flight transitioned through the initial descent from cruise altitude at 1522:00hrs and the subsequent approach phase. DANACO 0992 reported passing 18,100ft and 7,700ft, at 1530:00hrs and 1540:00hrs respectively. After receiving radar vectors in heading and altitude from the Controller, the aircraft was issued the final heading to intercept the final approach course for runway 18R. According to CVR transcript, at 1527:30hrs the F/O advised the Captain to use runway 18R for landing and the request was made at 1531:49hrs and subsequently approved by the Radar Controller. The crew accordingly changed the decision height to correspond with runway 18R. At 1531:12hrs, the crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as Pilot Flying (PF) at 1531:27hrs. The flight was however continued towards Lagos with no declaration of any distress message. With the confirmation of throttle response on the right engine, the engine anti-ice, ignition and bleed-air were all switched off. At 1532:05hrs, the crew observed the loss of thrust in No.1 Engine of the aircraft. During the period between 1537:00hrs and 1541:00hrs, the flight crew engaged in prelanding tasks including deployment of the slats, and extension of the flaps and landing gears. At 1541:46hrs the First Officer inquired, "both engines coming up?" and the Captain replied “negative” at 1541:48hrs. The flight crew subsequently discussed and agreed to declare an emergency. At 1542:10hrs, DANACO 0992 radioed an emergency distress call indicating "dual engine failure . . . negative response from throttle." At 1542:35hrs, the flight crew lowered the flaps further and continued with the approach and discussed landing alternatively on runway 18L. At 1542:45hrs, the Captain reported the runway in sight and instructed the F/O to retract the flaps and four seconds later to retract the landing gears. At 1543:27hrs, the Captain informed the F/O, "we just lost everything, we lost an engine. I lost both engines". During the next 25 seconds until the end of the CVR recording, the flight crew attempted to recover engine power without reference to any Checklist. The airplane crashed into a densely populated residential area about 5.8 miles north of LOS. The airplane wreckage was approximately on the extended centreline of runway 18R, with the main wreckage concentrated at N 06o 40.310’ E 003o 18.837' coordinates, with elevation of 177ft. During the impact sequence, the airplane struck an uncompleted building, two trees and three other buildings. The wreckage was confined in a small area, with the separated tail section and engines located at the beginning of the debris trail. The airplane was mostly consumed by post crash fire. The tail section, both engines and portions of both wings representing only about 15% of the airplane, were recovered from the accident site for further examination.
Probable cause:
Probable Causal Factors:
1. Engine number 1 lost power seventeen minutes into the flight, and thereafter on final approach, Engine number 2 lost power and failed to respond to throttle movement on demand for increased power to sustain the aircraft in its flight configuration.
2. The inappropriate omission of the use of the Checklist, and the crew’s inability to appreciate the severity of the power-related problem, and their subsequent failure to land at the nearest suitable airfield.
3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Tear down of the engines showed that the no.1 engine was overhauled in the U.S in August 2011 and was not in compliance with Service Bulletin SB 6452. Both engines had primary and secondary fuel manifold assemblies fractured, cracked, bent, twisted or pinched which led to fuel leaks, fuel discharge to bypass duct, loss of engine thrust and obvious failure of engine responding to
throttle movement. This condition was similar to the no.1 engine of a different Dana Air MD-80, 5N-SAI, that was involved in an incident in October 2013 when the aircraft returned to the departure airport with the engine not responding th throttle movements. This engine also was not in compliance with Service Bulletin SB 6452. This bulletin was issued in 2003 and called for the installation of new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that was approximately 2 times greater than the previous tube material.
Final Report:

Crash of a Boeing 737-4Y0 in Pontianak

Date & Time: Jun 1, 2012 at 1235 LT
Type of aircraft:
Operator:
Registration:
PK-CJV
Survivors:
Yes
Schedule:
Jakarta - Pontianak
MSN:
24689/1883
YOM:
1990
Flight number:
SJY188
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
155
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Circumstances:
The approach to Pontianak was unstable and really difficult due to turbulence and poor weather conditions (heavy rain falls). The aircraft landed on wet runway 15 and skidded. It eventually veered off runway to the left and went through a muddy field. The nose gear was torn off while both main gears sank, leaving both engines on the ground. While all 163 occupants were evacuated safely, the aircraft was damaged beyond repair. At the time of the accident, weather conditions were as follow: wind from 230 at 22 knots, visibility 600 metres, few clouds at 900 feet, broken at 700 feet, CB's above the terrain and turbulences.

Crash of a Dornier DO228-212 in Jomsom: 15 killed

Date & Time: May 14, 2012 at 0945 LT
Type of aircraft:
Operator:
Registration:
9N-AIG
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
8216
YOM:
1997
Flight number:
AG-CHT
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
5776
Captain / Total hours on type:
596.00
Circumstances:
On final approach to Jomsom Airport runway 06, the crew lowered the landing gear when they noticed a technical issue. On short final, the captain decided to initiate a go-around procedure and to divert to Pokhara. He made a sharp U-turn to the left at a speed of 73 knots when the left wing impacted a rocky hill located 270 meters above the runway 24 threshold. The aircraft stalled and crashed on the slope of the hill and was destroyed by impact forces. The stewardess and five passengers were seriously injured while all 15 other occupants, among them both pilots, were killed.
Probable cause:
The captain took the decision to make a sharp turn to the left at 73 knots without considering the turn radial and the rising terrain, which resulted in a continuous stall warning during the remaining 12 seconds of flight. The left hand wing of the aircraft struck a rock and the aircraft crashed. The decision of the captain to initiate a turn to the left at this stage of the flight was against all published procedures. It was reported that the commander was a senior flight instructor employed by the Civil Aviation Authority of Nepal.

Crash of an Antonov AN-24RV in Galkayo

Date & Time: Apr 28, 2012 at 1433 LT
Type of aircraft:
Operator:
Registration:
3X-GEB
Survivors:
Yes
Schedule:
Hargeisa - Galkayo
MSN:
3 73 084 03
YOM:
1973
Flight number:
6J711
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Hargeisa, the crew started the descent to Galkayo-Abdullahi Yusuf Airport runway 05L. On short final, at a height of about 5-7 feet, the captain spotted an animal crossing the runway from left to right. He attempted to extend the flare in order to avoid a collision but the aircraft subsequently touched down hard and bounced several times. Out of control, it veered off runway and came to rest with both wings partially detached. All 36 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Boeing 737-236 in Islamabad: 127 killed

Date & Time: Apr 20, 2012 at 1840 LT
Type of aircraft:
Operator:
Registration:
AP-BKC
Survivors:
No
Schedule:
Karachi - Islamabad
MSN:
23167/1074
YOM:
1984
Flight number:
BHO213
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
121
Pax fatalities:
Other fatalities:
Total fatalities:
127
Captain / Total flying hours:
10158
Captain / Total hours on type:
2027.00
Copilot / Total flying hours:
2832
Copilot / Total hours on type:
750
Aircraft flight hours:
46933
Aircraft flight cycles:
37824
Circumstances:
On 20th April, 2012, M/s Bhoja Air Boeing 737-236A Reg # AP-BKC was scheduled to fly domestic Flight BHO-213 from Jinnah International Airport (JIAP) Karachi to Benazir Bhutto International Airport (BBIAP) Islamabad. The aircraft had 127 souls onboard including 06 flight crew members. The Mishap Aircraft (MA) took off for Islamabad at 1705 hrs Pakistan Standard Time (PST) from Karachi. The reported weather at Islamabad was thunderstorm with gusty winds. During approach for landing at BBIAP, Islamabad (OPRN), Flight BHO-213 was cleared by Islamabad Approach Radar for an Instrument Landing System (ILS) approach for Runway 30. The MA, while established on ILS (aligned with Runway 30 at prescribed altitude), at 6 miles to touchdown was asked by the Approach Radar to change over to Air Traffic Control (ATC) Tower frequency for final landing clearance. The cockpit crew came on ATC Tower frequency and flight was cleared to land at BBIAP, Islamabad, but the cockpit crew did not respond to the landing clearance call. The ATC Tower repeated the clearance but there was no response. After a few minutes, a call from a local resident was received in ATC Tower, stating that an aircraft had crashed close to Hussain Abad (A population around 4 nm short of runway 30 BBIAP, Islamabad). It was later confirmed that Flight BHO-213 had crashed and all 127 souls onboard (121 passengers + 6 flight crew) had sustained fatal injuries along with complete destruction of aircraft.
Probable cause:
Factors Leading to the Accident:
- The aircraft accident took place as a result of combination of various factors which directly and indirectly contributed towards the causation of accident. The primary causes of accident include, ineffective management of the basic flight parameters such as airspeed, altitude, descent rate attitude, as well as thrust management. The contributory factors include the crew’s decision to continue the flight through significant changing winds associated with the prevailing weather conditions and the lack of experience of the crew to the airplane’s automated flight deck.
- The reasons of ineffective management of the automated flight deck also include Bhoja Air’s incorrect induction of cockpit crew having experience of semi automated aircraft, inadequate cockpit crew simulator training and absence of organizational cockpit crew professional competence and monitoring system.
- The incorrect decision to continue for the destination and not diverting to the alternate aerodrome despite the presence of squall line and very small gaps observed by the Captain between the active weather cells is also considered a contributory factor in causation of the accident.
- The operator’s Ops Manual (CAA Pakistan approved) clearly states to avoid active weather cells by 5 to 10 nm which was violated by the cockpit crew is also considered a contributory factor in causation of the accident.
- FO possessed average professional competence level and was due for his six monthly recurrent simulator training for Boeing 737-200 aircraft (equipped with a semi-automated flight deck). Bhoja Air requested an extension for his recurrent simulator training on 07th March, 2012. As per the existing laid down procedures of CAA Pakistan, two months extension was granted for recurrent simulator training on 09th March, 2012. The extension was granted for Boeing 737-200 aircraft, whereas the newly inducted Boeing 737-236A aircraft was equipped with automated flight deck. It is important to note that Bhoja Air did not know this vital piece of information till their cockpit crew went for simulator training to South Africa. This critical information regarding automation of the newly inducted Boeing 737-236A was not available with Flight Standard Directorate CAA, Pakistan as the information was not provided by the Bhoja Air Management.
- Therefore it is observed that due to the ignorance of Bhoja Air Management and CAA Pakistan, the said extension in respect of FO for simulator training was initially requested by former and subsequently approved by the latter. This resulted in absence of variance type training conformance of FO because of which he did not contribute positively in recovering the aircraft out of unsafe set of conditions primarily due to lack of automation knowledge, proper training and relying on captain to take remedial actions. This is also considered as one of the contributory factors in causation of accident.
- The Captain’s airline flying experience on semi automated flight deck aircraft and his selection for automated aircraft without subsequent training and monitoring to enhance his professional competence and skill, is one of the factors in causation of the accident.
- None of the cockpit crew member challenged the decision of each other to continue for the destination despite violation of Ops Manual instructions which is against the essence of CRM training.
- After experiencing the extremely adverse weather conditions, the cockpit crew neither knew nor carried out the Boeing recommended QRH and FCOM / Ops Manual procedures to handle the abnormal set of conditions / situations due to non availability of customized Boeing documents for Boeing 737-236A (advanced version of Boeing 737-200 series).

Finalization:
- The ineffective automated flight deck management in extreme adverse weather conditions by cockpit crew caused the accident. The ineffective automated flight deck management was due to various factors including; incorrect selection of cockpit crew on account of their inadequate flying experience, training and competence level for Boeing 737-236A (advanced version of Boeing 737-200 series), absence of formal simulator training in respect of FO for handling an automated flight deck, non-existence of cockpit crew professional competence / skill level monitoring system at operator level (Bhoja Air).
- The cockpit crew incorrect decision to continue the flight for destination and non- adherence to Boeing recommended QRH and FCOM remedial actions / procedures due to non-availability of customized aircraft documents (at Bhoja Air) for Boeing 737-236A (advanced version of Boeing 737-200 series) contributed towards the causation of accident. The inability of CAA Pakistan to ensure automated flight deck variance type training and monitoring requirements primarily due to incorrect information provided by the Bhoja Air Management was also a contributory factor in causation of the accident.
Final Report:

Crash of a De Havilland DHC-8-Q311 in Kigoma

Date & Time: Apr 9, 2012 at 1014 LT
Operator:
Registration:
5H-MWG
Flight Phase:
Survivors:
Yes
Schedule:
Kigoma - Tabora - Dar es-Salaam
MSN:
462
YOM:
1997
Flight number:
ATC119
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 34, the right engine failed. The captain rejected takeoff and initiated an emergency braking procedure. Unable to stop within the remaining distance (runway 34 is 1,767 metres long), the aircraft overran when the right main gear hit a pot hole, causing the right wing to be torn off. The aircraft slid for few dozen metres before coming to rest in a pasture. Two passengers were injured while 37 other occupants escaped unhurt. The aircraft was destroyed.

Crash of an ATR72-201 in Tyumen: 33 killed

Date & Time: Apr 2, 2012 at 0735 LT
Type of aircraft:
Operator:
Registration:
VP-BYZ
Flight Phase:
Survivors:
Yes
Schedule:
Tyumen - Surgut
MSN:
332
YOM:
1992
Flight number:
UT120
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
33
Captain / Total flying hours:
2602
Captain / Total hours on type:
2522.00
Copilot / Total flying hours:
1825
Copilot / Total hours on type:
1765
Aircraft flight hours:
35523
Aircraft flight cycles:
49663
Circumstances:
On 01.04.2012 the the UTAir Air Division 1 crew (based at Surgut AP) was conducting a scheduled passenger flight UTA-119 on the АТR 72-201 VP-BYZ A/C from Surgut to Tyumen. The landing at Tyumen (Roschino) AP was performed at 17:41 (23:41 local time). Descending for landing at Roschino (Tyumen) AD was conducted in extended cloudiness with icing conditions. According to the FDR records, the flight crew used the aircraft ice protection system. At the time of flight UTA-119 landing at Roschino (Tyumen) AD the weather was as follows: surface wind 090°-7 m/s, visibility 1600 m, showers of moderate snow with rain, significant cumulonimbus (5-7 oct.) clouds, fractonimbus, cloud base at 140 m, temperature + 0.2°C, dew point + 0.2°C, QFE 735 mmhg (980 hPa), friction coefficient 0.6; moderate icing at cloud layer from 140 m to 4800 m. Forecast for landing: tempo visibility 500 m, showers of heavy snow with rain, vertical visibility 90 m. Weather at Roschino (Tyumen) AD at day time on 01.04.2012 and at night from 01.04.2012 to 02.04.2012 was formed by the cyclone trough forward part with the widespread precipitation area associated with warm front. A passage of the warm front through Roschino (Tyumen) AD was expected in the period from 20:00 to 21:00, with a temperature of 0°C and relative humidity 100% precipitations were fallen from the cumulonimbus and fractonimbus clouds in form of showers of snow with rain. Visibility in precipitations was 1200–1600 m with individual charges of heavy wet snow with visibility 600–700 m and vertical visibility 100 m. Precipitation was followed by east wind 9–10 m/s, direction 90–110°, with individual gusts up to 13–14 m/s. This direction of wind remained till 21:00. After the passage of front through the region of Roschino (Tyumen) AD, at 21:05 the surface wind changed its direction to the west 250° – 260° with gradual increase of wind speed from 2–4 m/s to 7–10 m/s. Precipitation in the form of showers of moderate snow with rain at Roschino (Tyumen) AD went on till 22:00, 01.04.2012. From 22:00, 01.04.2012 to 01:00, 02.04.2012 precipitation turned into showers of slight snow with rain with a temperature of 0°C and relative humidity 100%. According to the observations of weather stations situated at a distance of about 200– 250 km from Roschino (Tyumen) AD and affected by the cyclone on 01.04.2012 as well as on 02.04.2012 storm detecting information was sent to the Roschino (Tyumen) AD AMC about glaze-ice accretion of wet snow. After the landing the A/C was placed at stand 3 heading to the air terminal (MH 30°). According to the flight shift work schedule, the crew left for rest to the Liner Hotel at Roschino AP and had a rest till 23:30 (05:30 local time). After having their rest, the crew members arrived to the AP and started the preflight preparation for the UTA120 scheduled passenger flight from Tyumen to Surgut with visiting AMC where at 00:15 they got weather briefing and documentation. The Nizhnevartovsk AD had been appointed as the alternate AP. At the end of the weather briefing the PIC received Form АВ-11 No.1 and put his signature at the sheet of the "Log of flight crews’ weather briefings at Tyumen-Roschino AMC" indicating the flight number and the A/C number. The weather forecast and actual weather at the departure AD, destination AD and alternate AD as well as their technical conditions did not imply any hazard for the flight operation. At 00:20 the crew passed a medical examination at the AP pre-start medical station and was cleared for the flight. According to the intra-airport radio conversation, around the same time the PIC made his decision to fly. After the medical examination, the F/O visited the aeronautical information office and received a navigator’s briefcase and flight plan; which is recorded in pertinent logbooks. Further, the crew continued the preflight preparation in the briefing room. According to the load documents there were 39 passengers, 133 kg of cargo, 143 kg of passengers’ luggage, and 1 kg of mail registered for the UTA120 flight. The fuel on board was 2000 kg, the A/C TOW was 18730 kg, the A/C weight balance was 30.72% mean aerodynamic chord. The TOW and weight balance were inside the AFM (FCOM) limitations. According to an avionics technician's statements the crew arrived to the A/C around 00:30. By the external observation video camera records it can be seen that the PIC performed the preflight inspection very briefly. He lingered for a few minutes by the right engine then moved along the fuselage sides, then stopped by the left main gear, and finally went into the cockpit. The after-inspection FTLB entry made by the PIC was: "LC PERFORMED BY CDR", the PIC also put the time of inspection which was 00:40 and quantity of fuel 2000 kg. There were no remarks made against the A/C condition in the FTLB. By the records of the external observation video camera, it can be seen that at 01:13 the boarding had been completed and the entrance door was closed. So, the A/C had been remaining at the AD under the influence of precipitations in the form of rain and wet snow with ambient temperature around zero degrees Celsius and wind velocity more than 10 m/s for more than 7 hours. There was no de/anti-icing treatment performed for the A/C before the flight. At 01:20 the flight crew performed the engine start, and after that passed through the Before Taxi checklist. At 01:24:46 the flight crew obtained clearance for holding position. At 01:32:08 after clearance for lineup position the flight crew reported: “Lining up”. At 01:32:58 the A/C started taking off. The takeoff was performed with flaps extended at 15°. The A/C lift-off occurred at 01:33:28 with a speed of around ≈127 kt. At 01:33:56 at height 600 ft2 and speed of 135 kt the A/P was engaged. At 01:34:00 at height 640 ft and speed of 139 kt the flaps retraction was started. At 01:34:08 after the retraction had been completed, at 690 ft and at a speed of 150 kt uncommanded development of right bank started. At 01:34:10 the A/P was disengaged. The bank angle reached around 40° to the right within 3 s and after that was counteracted by ailerons and rudder deflection. Further, the A/C banked to the left, which the flight crew was not able to compensate with full deflection of ailerons to the right. The A/C collision into terrain occurred at 01:34:35 with a pitch down angle ≈11°, left bank angle ≈55° and vertical rate of descent over 20 m/s. The ASL elevation of the accident area is about ≈110 m. The accident resulted in the A/C full destruction and partial damage by the ground fire. From the 43 persons onboard 4 crew members and 29 passengers were killed. Others sustained serious injuries.
Probable cause:
The immediate cause of the АТR 72-201 VP-BYZ aircraft accident was the PIC’s decision to takeoff without de/anti-icing treatment despite the fact that snow and ice deposits were present on aircraft surface and were discovered by the crew members during taxi which resulted in degradation of aircraft aerodynamic performance and stall during climbing after takeoff as well as inability of the crew to recognize stall and, consequently, failure to undertake recovery procedure. The aircraft stall occurred at the operational angles of attack right after flaps retraction with engaged autopilot before stall warning system activation and was caused by the loss of the wing lift effectiveness due to takeoff with non-removed ground icing. The system cause of the accident were shortcomings in ground handling activities and staff training in UTAir-Technik that became possible because of absence of due monitoring by the Technical and Operation Supervising Directorates of UTAir airline for compliance with airline requirements regarding ground handling and aircraft ground icing protection which resulted in erroneous evaluation of aircraft conditions by the PIC and aircraft mechanic (the shift head kept himself aloof from monitoring mechanic’s activities) after the aircraft has been on ground in icing conditions for a long time and in release the aircraft to fly without de/anti-icing treatment.
The contributing factors were:
- The shortcomings in the UTAir safety management system, which contains, all in all, general issues only and is not adopted for the implementation of Airline activities in particular areas, which did not allow to reveal and correct existing safety risks in a timely manner.
- The shortcomings in the UTAir-Technic quality management system, resulted in neglecting of certain requirements of the UTAir ground handling management manual regarding staff training and monitoring for aircraft de/anti-icing treatment which led to the situation when not sufficiently-qualified staff performed the evaluation of the aircraft surface conditions and made the decision on need for the aircraft to be de-iced/anti-iced.
- The absence at the time of the accident of basic regulations in force that establish state requirements for ground handling (de/anti-icing treatment in particular) including staff training and organization licensing.
- The shortcomings in crew members initial and recurrent training as far as the danger of ground icing, its influence on the aircraft aerodynamic performance together with aircraft anti-icing system operation features and design are concerned that did not allow the crew to make the only appropriate decision to return for de-icing/anti-icing treatment after the observation of the snow and ice contamination on the wing after anti-icing system activation in de-icing mode while taxiing for takeoff.
- The methodological imperfection of the crew computer based and simulator training programs concerning the prevention of aircraft stall, identification of approach to stall and taking timely actions for recovery.
- The increasing need for number of flight crews to perform highly growing flights schedule which, with ineffective SMS, resulted in flight instructor work deficiencies during PIC training and absence of PIC skills to take correct decisions and to strictly comply with the regulations in force.
- The possible fatigue of the crew members due to the violation of the work and rest balance while performing split flight shifts together with a large number of unused days-off.
Final Report:

Crash of a Fokker 50 in Wau

Date & Time: Mar 29, 2012 at 0945 LT
Type of aircraft:
Operator:
Registration:
ST-NEX
Survivors:
Yes
Schedule:
Juba - Wau
MSN:
20248
YOM:
1992
Flight number:
FDD360
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was carrying 50 passengers and a crew of five from Juba to Wau. After landing, the left main gear collapsed. The aircraft skidded on the 2,175 metres long and unpaved runway, veered off and came to rest with its nose gear torn off. While all five crew members were injured, all 50 passengers escaped uninjured. The aircraft was damaged beyond repair. The airport reported that the first part of runway 09 was closed due to work in progress since three months. It appears from various sources that the airline reported there was no NOTAM indicating the work in progress to resurface the runway and tower did not advise about the work in progress, too. Due to the slope of the runway it was impossible to see the workers on the runway in time. After landing, the aircraft impacted obstacles and went out of control.