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.

Crash of an ATR72-500 in Sandoway

Date & Time: Feb 17, 2012 at 1030 LT
Type of aircraft:
Operator:
Registration:
XY-AIT
Survivors:
Yes
Schedule:
Heho - Sandoway
MSN:
543
YOM:
1998
Flight number:
KBZ243
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Heho, the aircraft bounced six times upon landing on runway 20. The final touchdown was reported some 1,500 feet past its threshold. The last bounce was very rough so the nose gear collapsed. The aircraft the skidded on runway and overran. On soft ground, both main landing gears collapsed and the aircraft hit a sand pile before coming to rest. while all 54 occupants escaped uninjured, the aircraft was damaged beyond repair as some blade of the right engine penetrated the fuselage after they hit the sand pile. It appears that the copilot was the PIC at the time of the accident.

Crash of a Saab 2000 in Craiova

Date & Time: Feb 13, 2012 at 1108 LT
Type of aircraft:
Operator:
Registration:
YR-SBK
Flight Phase:
Survivors:
Yes
Schedule:
Craiova – Timişoara
MSN:
33
YOM:
1996
Flight number:
KRP2385
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
51
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6623
Copilot / Total flying hours:
700
Circumstances:
The crew started the takeoff procedure from runway 09 at Craiova Airport in a visibility of 500 metres due to freezing fog. During the course, the aircraft deviated to the right, causing the right engine to struck a snow berm (one meter high). The right propeller was torn off then aircraft rolled for few metres before coming to rest in snow. All 55 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the runway has not been properly cleared of snow prior to takeoff. This caused the lights ont both edges to be not visible to the crew. The crew failed to assess the takeoff conditions, the runway conditions and weather conditions.
The following contributing factors were identified:
- The takeoff conditions exceeded the training level of the crew,
- Change of takeoff procedure without prior training.
Final Report:

Crash of a Let L-410UVP-E9 in Kichwa Tembo

Date & Time: Jan 12, 2012 at 1955 LT
Type of aircraft:
Operator:
Registration:
5Y-BSA
Flight Phase:
Survivors:
Yes
Schedule:
Kichwa Tembo – Musiara
MSN:
89 23 23
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was returning to Mombasa with a scheduled stop in Musiara to pickup 15 additional passengers. On departure from Kichwa Tembo, there were four passengers and two pilots on board. During the takeoff roll from runway 08, the aircraft hit a bump half way down the runway and bounced. The aircraft hit a second bump shortly later and as the crew heard the stall alarm, he decided to reject takeoff. Unable to stop within the remaining distance, the aircraft overran, lost its nose gear and came to rest 300 metres further. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Antonov AN-24RV in Chita

Date & Time: Dec 31, 2011
Type of aircraft:
Operator:
Registration:
RA-46683
Survivors:
Yes
MSN:
4 73 097 06
YOM:
1974
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was damaged beyond repair following a hard landing at Chita Airport. The mishap occurred between 30 March 2011 and 29 December 2011 when it was cancelled from the Russian registry. There were no injuries.

Crash of a Tupolev TU-134A-3 in Osh

Date & Time: Dec 28, 2011 at 1246 LT
Type of aircraft:
Operator:
Registration:
EX-020
Survivors:
Yes
Schedule:
Bichkek - Osh
MSN:
61042
YOM:
1979
Flight number:
QH003
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
41313
Aircraft flight cycles:
25326
Circumstances:
Following an uneventful flight from Bishkek, the crew started the descent to Osh Airport. The approach was completed in reduced visibility due to foggy conditions. Not properly aligned with runway 12, the aircraft landed hard. It did not bounce but lost its right main gear due to excessive aerodynamic forces (2,5 g). Out of control, the aircraft veered off runway and came to rest upside down, bursting into flames. The aircraft was partially destroyed by fire. All 88 occupants were evacuated, among them 31 were injured, some seriously. At the time of the accident, the visibility was reduced to 300 metres horizontal and 200 metres vertical. RVR for runway 12 was 550 metres.
Probable cause:
On Apr 22nd 2013 a letter of Kyrgyzstan's Transport Prosecutor to Kyrgyzstan's Parliament of April 2012 became known indicating that the airport had been approved to operate in Category I weather minima without being properly equipped and should never have been approved to operate in these conditions, as a result of the investigation the aerodrome has been limited to operate according to visual flight rules only. The aircraft was not properly equipped to conduct the flight lacking a GPWS as well as passenger oxygen, the crew was not qualified to conduct the flight and the oversight by the airline's dispatch and chief pilot was insufficient, the Transport Prosecutor mentioned that the responsibles to oversee flight operation could not answer even the most basic questions. Kyrgyzstan's Civil Aviation Authority failed to oversee the operation of the airline as well. While on approach to Osh the crew was informed about weather conditions permitting an approach, the data transmitted however were incorrect and the actual weather did not even permit an approach. Instead of being established on the approach 10.5km/5.6nm before touchdown the aircraft was established on the extended centerline only about 4.02km/2.17nm before touchdown, however was above the glidepath. A steep dive to reach the runway resulted in a touch down at a high rate of descent and vertical forces beyond the design limit of the aircraft (more than 2.5G), as result of the high impact forces the aircraft did not even bounce but just started to disintegrate, reaching 58 degrees of right roll 270 meters past the runway threshold, between 270 and 550 meters past the threshold the tail fin separated, the aircraft was completely upside down 600 meters past the threshold and came to a stop about 1000 meters past the threshold of the runway. The main door was jammed, the occupants escaped through other doors and the overwing exits. No serious injury occurred, 6 people needed hospital treatment with minor injuries.

Crash of a Boeing 737-36M in Yogyakarta

Date & Time: Dec 20, 2011 at 1713 LT
Type of aircraft:
Operator:
Registration:
PK-CKM
Survivors:
Yes
Schedule:
Jakarta - Yogyakarta
MSN:
28333/2810
YOM:
1996
Flight number:
SJY230
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
29801
Copilot / Total flying hours:
562
Aircraft flight hours:
31281
Aircraft flight cycles:
21591
Circumstances:
On 20 December 2011, a Boeing 737-300 aircraft, registered PK-CKM, was being operated by PT. Sriwijaya Air on a schedule passenger flight SJ230 from Soekarno Hatta International Airport (WIII) Jakarta to Adisutjipto International Airport (WARJ), Yogyakarta. There were 141 persons on board; two pilots, four cabin crews and 135 passengers consisted124 adult, 7 children and 4 infant. The aircraft departed from Jakarta at 14.00 LT (07.00 UTC), the pilot in command was the pilot flying and the co-pilot was the pilot monitoring. At 08.10 UTC the aircraft made holding at 8 NM from JOG VOR due to bad weather. After the second holding and the weather was deteriorated, the airport authority closed the airport for takeoff and landing. The pilot requested divert to Juanda Airport (WARR), Surabaya and landed at 08.40 UTC. After refuelling and received the information about weather improvement in Yogyakarta then the aircraft departed, at 09.20 UTC, in this sequence of flight the PIC acted as PF, with 137 persons on board consisted of two pilots, four cabin crews and 131 passengers consisted 120 adult, 7 children and 4 infant. The aircraft was on the fifth sequence from seven aircraft approaching Adisucipto airport Yogyakarta. Passing JOG VOR it was seen on radar screen that the aircraft speed was read 203 Kts at 2700 ft. Approach Controller instructed to reduce the speed. At about 1200 ft, the pilot had the runway insight and disengaged the autopilot and auto throttle. The pilot made correction to the approach profile by roll up to 25 degrees and rate of descend up to 2040 ft per minute. The GPWS warning of ‘pull up’ and sink ‘rate were’ activated. Aircraft touched down at speed 156 Kts of 138 Kts target landing speed. During landing roll, the auto-brake and spoiler activated automatically. The thrust reverse were deployed and the N1 were recorded on the FDR increase and decrease to idle before increased to 80% prior to aircraft stop. The PIC noticed that the aircraft would not be able to stop in the runway and decided to turn the aircraft to the left. The aircraft stopped at 75 meter from the end of runway 09 and 54 meter on the left side of the centre line. Most of the passenger evacuated through left and right forward escape slides. All passengers were evacuated safely. The passenger on the stretcher case was evacuated by the airport rescue. 6 passengers reported minor injured while all crew and the remaining passengers were not injured. The aircraft suffered major damage on the right main and nose wheel.
Probable cause:
Findings:
1. The aircraft was airworthy prior the accident. There was no evidence that the aircraft had malfunction during the flight.
2. The crew had valid license and medical certificate. There was no evidence of crew incapacitation.
3. In this flight Pilot in Command acted as Pilot Flying and Second In command acted as Pilot Monitoring.
4. The flight crew did not conduct approach crew briefing.
5. There was no checklist reading.
6. The PIC as Pilot Flying did not have the instrument approach procedure immediately available to review during approach.
7. During the approach, the PIC course indicator was set at 091 and the SIC was at 084.
8. The rate of descend recorded vary and up to 1920 ft per minute and below 500 ft AGL the rate of descend recorded up to 2040 ft per minute.
9. The approach did not meet the stabilize approach criteria as stated in the FCOM.
10. There were several GPWS warning of ‘sink rate’ and ‘pull up’ activated during approach.
11. The aircraft touched down at speed 156 Kt before bounced, instead of 138 Kt target landing speed.
12. The flap extended to 40 after the aircraft touch down.
13. The FDR recorded reduction in N1 during thrust reverser activation after landing.
14. The CRM was not well implemented.
Factors:
Unsuccessful to recognize the two critical elements, namely fixation and complacency affected pilot decision to land the aircraft while the approach was not meet the criteria of stabilized approach.
Final Report:

Crash of a Casa 212 Aviocar 200 in Larat

Date & Time: Dec 3, 2011 at 1308 LT
Type of aircraft:
Operator:
Registration:
PK-NCZ
Survivors:
Yes
Schedule:
Langur - Larat
MSN:
274/79N
YOM:
1986
Flight number:
MNA9933
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
5500.00
Copilot / Total flying hours:
343
Copilot / Total hours on type:
72
Aircraft flight hours:
26935
Aircraft flight cycles:
30064
Circumstances:
The Casa 212-200 aircraft registered PK-NCZ operated by PT. Merpati Nusantara Airlines on a scheduled flight from Langur to Larat, touched down at 224 meters from runway 09, was bouncing twice to the left of runway centre line, out of the runway and stopped at 607 meters from runway 09 touch down area as final position, and 15 meters to the left of runway edge. The Pilot Flying was First Officer, and after second bouncing, PIC took over, and he tried to bring the aircraft to the centre line of the runway without success. The aircraft continued rolled to the shoulder away from the runway and stopped at the final position. This is the second landing at Larat runway on the same day. There were 15 passengers, 3 children, one baby, Pilot In Command, two First Officers, one First Officer was Pilot Flying from Langur to Larat, one engineer on board. One passenger was serious injured, another one passenger minor injured.
Final Report: