Crash of an Antonov AN-24RV at Rogachevo AFB

Date & Time: Dec 14, 2010
Type of aircraft:
Operator:
Registration:
RA-47305
Survivors:
Yes
Schedule:
Arkhangelsk - Rogachevo
MSN:
5 73 103 05
YOM:
1975
Flight number:
AUL137
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 16 at Rogachevo AFB (Anderma-2), the aircraft encountered difficulties to stop within the remaining distance. It overran, lost its left main gear and came to rest 8 metres further. All 39 occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Tupolev TU-154M in Moscow: 2 killed

Date & Time: Dec 4, 2010 at 1436 LT
Type of aircraft:
Operator:
Registration:
RA-85744
Survivors:
Yes
Schedule:
Moscow - Makhatchkala
MSN:
92A-927
YOM:
1992
Flight number:
DAG372
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
160
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17384
Captain / Total hours on type:
10000.00
Copilot / Total flying hours:
3111
Copilot / Total hours on type:
1150
Aircraft flight hours:
9285
Aircraft flight cycles:
2983
Circumstances:
Daghestan Airlines (Avialinii Dagestana) flight DAG372 departed Moscow-Vnukovo Airport at 1408LT bound for Makhatchkala, Daghestan. Fourteen minutes after takeoff, while cruising at an altitude of 9,000 metres some 80 kilometers south of Moscow, the crew informed ATC about the failure of the engines n°1 and 3 and was cleared to return to Moscow-Domodedovo Airport. On final, the aircraft descended below the clouds at a height of 500 feet but was not properly aligned with the runway centerline. It landed hard to the right of runway 32R, went out of control, impacted an earth mound and bushed before coming to rest, broken in two. Two passengers were killed while 78 other occupants were injured.
Probable cause:
Erroneous actions on part of the crew who, while landing in instrument meteorological conditions with one engine running, permitted the aircraft to touch down significantly to the right of the runway.
These actions were the result of following factors:
- The flight engineer inadvertently turned off the fuel booster pumps of the service tank while working the procedures for manual fuel transfer during the climb, which led to fuel starvation, all engines spooling down with the outer engines (#1 and #3) shutting down as well as loss of electrical power for 2:23 minutes due to loss of all three generators
- Failure by the crew to take use of all available possibilities to restore on-board systems after generator #2 was recovered and the APU spooled up and was successfully connected
- Failure to comply with recommendations "flying with two engines inoperative" and "approach and landing with two engines inoperative"
- Lack of leadership and lack of management and distribution of responsibilities by the captain leading to independent but not always accurate actions by the other crew members as result of insufficient training in crew resource management
- A complex wind environment varying with heights which contributed to the deviation from the proper approach trajectory while the crew was flying on stand by instruments rather than regular instruments
- Insufficient training of the crew as a whole as well as each individual to act in emergency and complex scenarios
- The non-implementation of safety recommendations developed in earlier investigations to prevent the flight engineer inadvertently turn off the fuel booster pumps.
Final Report:

Crash of a Beechcraft 1900C-1 in Maputo

Date & Time: Dec 3, 2010 at 2340 LT
Type of aircraft:
Operator:
Registration:
C9-AUO
Survivors:
Yes
Schedule:
Nampula - Maputo
MSN:
UC-148
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The flight from Nampula was uneventful until the approach to Maputo. Due to bad weather conditions at destination, the crew was vectored to a holding pattern. After two circuits, the captain decided to start the descent despite ATC informed him about very poor conditions. At this time, the visibility was reduced due to the night, heavy rain falls, thunderstorm activity with turbulences and lightnings. On final approach to runway 23, the aircraft was too low and impacted ground short of runway in a slight nose-up attitude. Upon impact, the aircraft broke in two and came to rest in a field. All 17 occupants escaped with minor injuries and the aircraft was destroyed.

Crash of a Swearingen SA227AC Metro III in Andahuaylas

Date & Time: Nov 13, 2010 at 1602 LT
Type of aircraft:
Operator:
Registration:
N781C
Survivors:
Yes
Schedule:
Huaraz - Andahuaylas
MSN:
AC-535
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6301
Captain / Total hours on type:
2615.00
Copilot / Total flying hours:
3253
Copilot / Total hours on type:
737
Aircraft flight hours:
27889
Aircraft flight cycles:
37163
Circumstances:
Following an uneventful flight, the twine engine aircraft approached Andahuaylas Airport and landed normally on runway 03. After touchdown, while decelerating to a speed of about 40 knots, the aircraft started to deviate to the left. The crew counteracted but the aircraft continued to the left, veered off runway, rolled through a grassy and eventually came down a four meters high embankment before coming to rest. While all 19 occupants escaped uninjured, the aircraft was damaged beyond repair.
Probable cause:
It appears that the loss of directional control after touchdown was caused by the failure of the brake systems. The aircraft had already several technical problems with its brake systems previous to the flight, and maintenance was performed by technicians the day before the accident. For unknown reasons, the problem was resolved but no feedback or troubleshooting was performed on part of the technicians or the crew. The Captain was aware of the problem and took the decision to complete the flight despite the risk the problem may persist or happen again.
Final Report:

Crash of an Antonov AN-24B in Zalingei: 2 killed

Date & Time: Nov 11, 2010 at 1618 LT
Type of aircraft:
Operator:
Registration:
ST-ARQ
Survivors:
Yes
Schedule:
Khartoum - Nyala - Zalingei
MSN:
0 73 059 10
YOM:
1970
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4400
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
900
Copilot / Total hours on type:
700
Circumstances:
The crew started the approach to Zaligei Airport runway 03 in good weather conditions. The aircraft landed hard 200 metres past the runway threshold, causing both propeller blades to struck the ground on a distance of 33 metres. The aircraft bounced and landed a second time 263 metres further then a third time after 15 metres. Upon impact, both engines were torn off and the aircraft rolled for about 400 metres before coming to rest, bursting into flames. Two passengers were killed while five others were injured. All 37 other occupants escaped unhurt. The aircraft was totally destroyed by a post crash fire.
Probable cause:
Sudan's Central Directorate of Air Accident Investigation concluded the probable causes as follow:
The accident cause is a complex set of reasons. The aircraft impacted the ground on three wheels at high forward speed shearing off both engines and propellers and damaging the left main landing gear which put the aircraft in an uncontrollable condition.
Contributory factors were:
- Absence of crew coordination,
- Absence of cabin procedure and check-lists for different phases of flight,
- Unsatisfactory Periodic and Annual job check being reflected on the inoperative Cockpit Voice and Flight Data Recorders,
- Bad planning of the flight and long period taken to clear the recorded defects before departure is considered to be a contributory factor to this accident.

Crash of a Swearingen SA227AC Metro III in Huánuco

Date & Time: Nov 5, 2010 at 1423 LT
Type of aircraft:
Operator:
Registration:
N115GS
Survivors:
Yes
Schedule:
Lima - Huánuco
MSN:
AC-715
YOM:
1988
Flight number:
LCB1331
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7590
Captain / Total hours on type:
553.00
Copilot / Total flying hours:
5348
Copilot / Total hours on type:
2050
Aircraft flight hours:
24342
Aircraft flight cycles:
32730
Circumstances:
Following an uneventful flight from Lima, the crew continued the approached while the aircraft was unstabilized. Upon touchdown on runway 07, the aircraft landed relatively hard then bounced three times when the crew retracted the landing gear. The aircraft slid on its belly for about 600 metres before coming to rest. All nine occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Erroneous retraction of the landing gear following three bounces on the runway due to an unstabilized final approach and poor crew resource management.
Contributing factors were:
- Although the descent and landing checklists were followed, the crew did not review stabilized approach criteria or procedures for a possible controlled flight into terrain and did not take into consideration the possibility of any go around procedure
- Several call-outs were non-standard while others were missing
- Descent was continued under visual flight rules, approach was unstabilized and not detected by crew
- Speed was too high on touch down while the power levers were not into idle position
- Lack of corrective action on part of the crew when the aircraft was bouncing
- Loss of situational awareness led to the retraction of the landing gear.
Final Report:

Crash of an ATR72-212 in Guasimal: 68 killed

Date & Time: Nov 4, 2010 at 1751 LT
Type of aircraft:
Operator:
Registration:
CU-T1549
Flight Phase:
Survivors:
No
Site:
Schedule:
Port-au-Prince - Santiago de Cuba - Havana
MSN:
459
YOM:
1995
Flight number:
CRN883
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
61
Pax fatalities:
Other fatalities:
Total fatalities:
68
Aircraft flight hours:
25000
Aircraft flight cycles:
34500
Circumstances:
The twin engine aircraft departed Port-au-Prince on a schedule service to Havana with an intermediate stop in Santiago de Cuba, carrying 61 passengers and 7 crew members. The airplane departed Santiago de Cuba-Antonio Maceo Airport at 1644LT and the crew was cleared to climb to his assigned altitude of 18,000 feet. At 1736LT, the crew was cleared to climb to 20,000 feet. During the climb, the Total Air Temperature (TAT) dropped from +3°C to -1°C and the aircraft' speed dropped from 196 knots to 176 knots. At 17:44, at FL200, the ICING caution light illuminated on the instrument panel with an associated chime. This was followed by the illumination of the AOA light several seconds later. At 17:46 the crew toggled the anti-icing switches on the overhead panel and contacted Havana Control to request permission to descent to FL160 due to icing. However, the controller reported conflicting traffic 30 miles ahead. The crew then requested vectors to enable them to descend. Clearance was given to change course from 295° to 330°. At 17:49, with an airspeed of 156 kts, the airplane commenced a right bank. Then suddenly the airplane banked left and right before banking 90° to the left again with a steep nose down attitude. The crew struggled to control the plane, which was banking turning and losing altitude. Out of control, the aircraft crashed in a wooded an hilly terrain. All 68 occupants were killed.
Probable cause:
Flight was proceeding normally until it found itself in extreme meteorological conditions that caused the airplane to ice up severely at an altitude of 20,000ft (6,100m). This, in conjunction with errors by the crew in managing the situation, caused the accident.

Crash of a Boeing 737-4Y0 in Pontianak

Date & Time: Nov 2, 2010 at 1118 LT
Type of aircraft:
Operator:
Registration:
PK-LIQ
Survivors:
Yes
Schedule:
Jakarta – Pontianak
MSN:
24911/2033
YOM:
1991
Flight number:
JT712
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
169
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8190
Copilot / Total flying hours:
656
Aircraft flight hours:
49107
Aircraft flight cycles:
28889
Circumstances:
On 2 November 2010, a Boeing Company B737-400 aircraft, registered PK-LIQ, was being operated by Lion Mentari Airlines on a passenger schedule flight with flight number JT 712. This flight was the first flight for the crew and was scheduled for departure at 09.30 LT (02.30 UTC). On board the flight was 175 person included 2 pilots and 4 flight attendants and 169 passengers consisted 2 infants and one engineer. The pilots stated that the aircraft had history problem on the difficulty of selection the thrust reversers and automatic of the speed brake deployment. This problem was repetitive since the past three months. The aircraft pushed back at 0950 LT (0250 UTC). During taxi out, the yaw damper light illuminated for two times. The pilot referred to the Quick Reference Handbook (QRH) which guided the pilot to turn off the yaw dumper switch then back to turn on. Considered to these problems, the pilot asked the engineer to come to cockpit and asked to witness the problem. The aircraft departed Soekarno Hatta International Airport, Jakarta at 1012 LT (0312 UTC) with destination of Supadio Airport, Pontianak. The Pilot in Command acted as pilot flying (PF) and the Second in Command acted as pilot monitoring (PM). The flight to Pontianak until commenced for descent was uneventful. Prior to descend, the PF performed approach crew briefing with additional briefing included review of the past experiences on the repetitive problems of thrust reversers which sometimes hard to operate and the speed brake failed to auto deploy. Considering these problems, the PF asked to the PM to check and to remind him to the auto deployment of the speed brake after the aircraft touch down. During descend, the pilot was instructed by Pontianak Approach controller to conduct Instrument Landing System (ILS) approach for runway 15 and was informed that the weather was slight rain. On the initial approach, the auto pilot engaged, flaps 5° and aircraft speed 180 knots. After the aircraft captured the localizer at 1300 feet, the PF asked to the PM to select the landing gear down, flaps 15° and the speed decreased to 160 knots. The PF aimed to set the flaps landing configuration when the glide slope captured. When the glide slope captured, the auto pilot did not automatically follow the glide path and the aircraft altitude maintained at 1300 feet, resulted in the aircraft slightly above the normal glide path. The PF realized the condition then disengaged the auto pilot and the auto throttle simultaneously, and fly manually to correct the glide path by pushing the aircraft pitch down. While trying to regain the correct the glide path, the PF commanded for flaps 40° and to complete the landing checklist. The flap lever has been selected to 40°, but the indicator indicated at 30°. Realized to the flaps indication, the PF asked the landing speed for flaps 30° configuration in case the flaps could not move further to 40°. When aircraft altitude was 600 feet and the pilots completing the landing checklist, the PM reselected the flap from 30° to 40° and was successful. The pilots realized that the aircraft touched down was beyond the touchdown zone and during the landing roll the PF tried to select the thrust reverser but the levers were hard to select and followed by the speed brake failed to automatic-deploy. The pilots did not feel the deceleration, and then the PF applied maximum manual braking and selected the speed brake handle manually. Afterward, the thrust reversers successfully operated and a loud sound was heard prior to the aircraft stop. The Supadio tower controller on duty noticed that the aircraft was about to overrun the runway and immediately pressed the crash bell. The aircraft stopped at approximately 70 meters from the runway or 10 meters from the end of stop-way. The PIC then commanded to the flight attendants to evacuate the passengers through the exits. No one injured in this accident.
Probable cause:
The following factors were identified:
- Inconsistency to the Aircraft Maintenance Manual (AMM) for the rectifications performed during the period of the reversers and auto speed brake deployment problem was might probably result of the unsolved symptom problems.
- The decision to land during the un-stabilized approach which occurred from 1000 feet to 50 feet above threshold influenced by lack of crew ability in assessing to accurately perceive what was going on in the flight deck and outside the airplane.
- The effect of delayed of the speed brake and thrust reverser deployment effected to the aircraft deceleration which required landing distance greater than the available landing distance.
Final Report:

Crash of a Cessna 208B Grand Caravan near Kirensk

Date & Time: Oct 2, 2010 at 1024 LT
Type of aircraft:
Operator:
Registration:
RA-67701
Flight Phase:
Survivors:
Yes
Schedule:
Lensk – Bratsk
MSN:
208B-0932
YOM:
2002
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13358
Captain / Total hours on type:
4083.00
Copilot / Total flying hours:
4824
Copilot / Total hours on type:
757
Aircraft flight hours:
3203
Aircraft flight cycles:
1423
Circumstances:
The single engine aircraft departed Lensk at 0813LT on a flight to Bratsk. While cruising at 4,200 metres over the cloud layer, the engine failed. The crew elected to divert to Kirensk Airport but was unable to maintain a safe altitude. Eventually, the captain attempted an emergency landing when the aircraft impacted trees and crashed in a wooded area located 37 km west of Kirensk. All nine occupants were injured and the aircraft was damaged beyond repair.
Probable cause:
Engine failure due to the damage of the bearings of the planetary gear from the first stage of the compressor, leading to vibration and destruction of the turbine. It is possible the damage to the bearings was caused by the presence of aluminium or silicon oxide. However, it was not possible to determinate the source of this contamination.

Crash of an Airbus A319-132 in Palermo

Date & Time: Sep 24, 2010 at 2007 LT
Type of aircraft:
Operator:
Registration:
EI-EDM
Survivors:
Yes
Schedule:
Rome - Palermo
MSN:
2424
YOM:
2005
Flight number:
JET243
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13860
Captain / Total hours on type:
2918.00
Copilot / Total flying hours:
1182
Copilot / Total hours on type:
937
Aircraft flight hours:
15763
Aircraft flight cycles:
8936
Circumstances:
Following an uneventful flight from Rome-Fiumicino Airport, the crew started a night approach to Palermo-Punta Raisi Airport in poor weather conditions with heavy rain falls, thunderstorm activity and reduced visibility. During the descent, weather information was transmitted to the crew, indicating a visibility of 4 km with few CB's at 1,800 feet and a windshear warning for runway 20. On final approach, at an altitude of 810 feet (100 feet above MDA), following the 'minimum' call, the captain instructed the copilot to continue the approach despite the copilot did not establish a visual contact with the runway. At an altitude of 240 feet, the copilot reported the runway in sight but informed the captain that all four PAPI's lights were red. The captain took over control and continued the approach after the airplane deviated from the descent profile. With an excessive rate of descent of 1,360 feet per minute, the aircraft impacted ground 367 metres short of runway 07 threshold and collided with the runway 25 localizer antenna. Upon impact, both main landing gear were partially torn off. The aircraft slid for about 850 metres before coming to rest on the left of the runway. All 129 occupants were rescued, among them 35 were injured. The aircraft was damaged beyond repair.
Probable cause:
The event is classified as short landing accident and the cause is mainly due to human factors. The fact that the aircraft contacted the ground took place about 367 meters short of the runway threshold was due to the crew's decision to continue the instrument approach without a declared shared acquisition of the necessary visual references for the completion of the non-precision procedure and of the landing maneuver. The investigation revealed no elements to consider that the incident occurred due to technical factors inherent in the aircraft.
The following contributing factors were identified:
- The poor attitude of those present in the cockpit to use of basics of CRM, particularly with regard to interpersonal and cognitive abilities of each and, overwhelmingly, the commander.
- Deliberate failure to comply with SOP in place which provided, reaching the MDA, to apply the missed approach procedure where adequate visual reference of the runway in use had not been in sight of both pilots.
- Failure to apply, by those present in the cockpit, the operators rules, concerning in particular: the concept of "sterile cockpit"; to do the descent briefing; to make callouts on final approach.
- The routine with the crew, carrying out approaches to Palermo-Punta Raisi Airport, from which the complacency to favor the personalization of the standards set by operator, and by law. The complacency is one of the most insidious aspects in the context of the human factor, as it creeps in individual self-satisfaction of a condition, which generates a lowering of situational awareness, however bringing them to believe they had found the best formula to operate.
- The existence of adverse weather conditions, characterized by the presence of an extreme rainfall, which significantly reduced the overall visibility.
- The "black hole approach" phenomenon, due to adverse weather conditions together with an approach carried out at night, the sea, to a coast characterized by few dimly lit urban settlements.
This created the illusion in the PF of "feeling high" compared to what he saw and believed to be the threshold, with the result to get him to abandon the ideal descent profile, hitherto maintained, to make a correction and the subsequent short landing.
- The decrease of performance of the light beam produced by SLTH in extreme rain conditions; The only bright horizontal reference for the crew consisted of the crossbar of the SALS, probably mistaken for the threshold lights.
Final Report: