Crash of a Boeing 727-286 in Orūmīyeh: 78 killed

Date & Time: Jan 9, 2011 at 1945 LT
Type of aircraft:
Operator:
Registration:
EP-IRP
Survivors:
Yes
Schedule:
Tehran - Orumiyeh
MSN:
20945/1048
YOM:
1974
Flight number:
IR277
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
78
Aircraft flight hours:
9019
Circumstances:
The aircraft departed Tehran-Mehrabad Airport at 1815LT with a delay of more than two hours due to poor weather conditions at destination. While descending to Orūmīyeh Airport by night, the crew encountered poor weather conditions with snow falls, visibility 800 metres and three ceilings at 1,500, 2,000 and 6,000 feet. After the crew was unable to intercept the ILS, the decision to initiate a go-around procedure was taken. Approaching the stall speed, the stick shaker activated and the aircraft probably encountered icing conditions. In a left bank angle estimated between 26 and 40°, the engine n°3 and 1 failed. At an altitude of 600 feet and at a speed of 96 knots, the flaps were retracted, causing the aircraft to stall and to impact the ground. The aircraft broke in three but there was no fire. 70 passengers and 8 crew members were killed while 27 other occupants were injured, some seriously.
Probable cause:
Bad weather conditions for the aircraft and inappropriate actions by cockpit crew to confront the situation is the main cause of the accident. The following contributing factors were identified:
- The old technology of aircraft systems,
- Absence of a suitable simulator for adverse weather conditions,
- Failure to correctly follow the operating manual by the flight crew,
- Inadequate cockpit resources management (CRM).

Ground fire of a Tupolev TU-154B-2 in Surgut: 3 killed

Date & Time: Jan 1, 2011 at 1525 LT
Type of aircraft:
Operator:
Registration:
RA-85588
Flight Phase:
Survivors:
Yes
Schedule:
Surgut - Moscow
MSN:
83A588
YOM:
1983
Flight number:
KGL348
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
126
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12202
Captain / Total hours on type:
2780.00
Copilot / Total flying hours:
3775
Copilot / Total hours on type:
3279
Aircraft flight hours:
32354
Aircraft flight cycles:
13147
Circumstances:
Ready for taxi, the crew started the engines when a short circuit occurred and a fire erupted in the rear compartment. The evacuation of all 134 occupants was initiated but three passengers died while 32 others were seriously injured. The aircraft was totally destroyed by fire. The OAT was -29° C at the time of the incident.
Probable cause:
A short circuit emerged while the aircraft generators were connected to the aircraft's electrical system after start-up of the engines, via an APU. The short circuit caused a strong fire in the generators compartment in the tail which spread rapidly through the fuselage. The cause of the fire was an electrical arc produced by electrical currents exceeding ten to 20 times the nominal loads when two generators not synchronized with each other were brought online but got connected together instead of being connected to parallel busses. The following contributing factors were identified:
- Poor technical conditions of contacts TKS233DOD responsible for connecting the generators with the electrical busses, that were damaged by prolonged operation without maintenance. A contact normally open was welded and fractured insulation material moved between contacts that are normally closed. These abnormal contact positions led to the connection between #2 and #3 generators.
- Differences in the schematic diagrams of generator 2 and generators 1 and 3. When the switch is moved from "check" to "enable" with no delay in the "neutral" position generator 2 is brought online without time delay which leads to increased wear of normally closed contacts in the TKS233DOD unit.
- The specific design of the electrical systems to ensure power supply to each bus from either the APU or either engine integrated drive generator.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Okhaldhunga: 22 killed

Date & Time: Dec 15, 2010 at 1530 LT
Operator:
Registration:
9N-AFX
Flight Phase:
Survivors:
No
Site:
Schedule:
Lamidanda - Kathmandou
MSN:
806
YOM:
1984
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
6700
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
1100
Copilot / Total hours on type:
341
Circumstances:
The twin engine aircraft departed Lamidanda Airport at 1508LT on a flight to Kathmandu. Shortly after departure, the crew was cleared to climb to 10,500 feet but ATC ask them to maintain 8,500 feet due to traffic. The captain disagreed with this ATC instruction and continued to climb. The copilot asked the captain to accept the ATC proposal so finally, the captain cleared the copilot (who was the pilot in command) to descend to 8,500 feet despite the fact it was risky due to the mountainous terrain. Few minutes later, the aircraft entered clouds when the right wing impacted ground. The aircraft crashed in a rocky area located on the Palunge Hill, near Okhaldhunga. The wreckage was found the following morning. The aircraft was destroyed by impact forces and all 22 occupants were killed. IMC conditions prevailed at the time of the accident due to low visibility (cloudy conditions).
Probable cause:
The cause of the accident was the unwise decision taken by the crew to descend without taking the harsh mountain terrain into consideration. Controlled flight into terrain.

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.