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:

Crash of an ATR42-320 in Puerto Ordaz: 17 killed

Date & Time: Sep 13, 2010 at 1023 LT
Type of aircraft:
Operator:
Registration:
YV1010
Survivors:
Yes
Schedule:
Porlamar - Puerto Ordaz
MSN:
371
YOM:
1994
Flight number:
VCV2350
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total hours on type:
1574.00
Copilot / Total flying hours:
1083
Copilot / Total hours on type:
483
Aircraft flight hours:
27085
Aircraft flight cycles:
29603
Circumstances:
Following two uneventful flights to Santiago Mariño and Maturín, the aircraft departed Porlamar on a flight to Puerto Ordaz with 47 passengers and a crew of four on board. While descending to Puerto Ordaz, at an altitude of 13,500 feet and at a distance of 79 km from the destination, the crew reported control difficulties. After being prioritized, the crew was instructed for an approach and landing on runway 07. At 1021LT, the crew reported his position at 3,000 feet and 28 km from the destination Airport. Two minutes later, the message 'mayday mayday mayday' was heard on the frequency. The aircraft went out of control and crashed in an industrial area located about 9 km short of runway, bursting into flames. Three crew members and 14 passengers were killed while 34 other occupants were injured, 10 seriously.
Probable cause:
The most probable cause for the occurrence of the accident was the malfunction of the centralized crew warning system (CCAS/CAC) with erroneous activation of the flight loss of lift warning system.
The following contributing factors were identified:
- Poor crew resources management,
- Loss of situational awareness,
- Inadequate coordination during the decision-making process to deal with abnormal situations in flight,
- Ignorance of the loss of lift warning system.
- Inadequate handling of flight controls.
Final Report:

Crash of a Fokker 100 in Tabriz

Date & Time: Aug 26, 2010 at 2245 LT
Type of aircraft:
Operator:
Registration:
EP-ASL
Survivors:
Yes
Schedule:
Tehran - Tabriz
MSN:
11432
YOM:
1992
Flight number:
EP773
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Tehran, the crew started the descent to Tabriz and was informed by ATC that visibility was low due to heavy rain falls. After landing on runway 30R (3,556 metres long), the aircraft was unable to stop within the remaining distance. It overran and rolled for about 500 metres before coming to rest in a ditch. All 110 occupants were rescued, among them two passengers were slightly injured. The aircraft was damaged beyond repair as the nose was destroyed and the bulkhead severely damaged.

Crash of an Embraer ERJ-145LU in Vitoria da Conquista

Date & Time: Aug 25, 2010 at 1440 LT
Type of aircraft:
Operator:
Registration:
PR-PSJ
Survivors:
Yes
Schedule:
São Paulo – Vitoria da Conquista
MSN:
145-351
YOM:
2000
Flight number:
PTB2231
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4400
Captain / Total hours on type:
3100.00
Copilot / Total flying hours:
1373
Copilot / Total hours on type:
813
Circumstances:
While approaching Vitoria da Conquista Airport runway 15, the crew failed to realize his altitude was too low. On short final, the aircraft impacted a small mound located few metres short of runway threshold. On impact, both main landing gears were torn off. The aircraft slid on runway for about 300 metres then veered off runway to the left and came to rest in a grassy area some 35 metres left of the runway with the right engine on fire. All 38 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- During the approach, the flight crew's attention was focused on the characteristics of the geographical relief and presence of birds, reducing their awareness as to the maintenance of the approach slope.
- The group culture of maintaining a low angle of approach led the crew to choose the runway aspect instead of the VASIS as a reference for the approach, making them susceptible to various types of spatial illusion.
- Taking into account copilot's report that he was not succeeding in correcting the aircraft glide path relative to the runway, one may suppose that he was not applying the appropriate amplitude for such correction.
- The physical characteristics of the runway 15 (the active one) contributed to a wrong perception of the ideal glide path. The pronounced acclivity of the runway, its width (narrower than the runways on which the crew was accustomed to operate), and the low terrain near the threshold, caused in the pilots a perception that they were above the ideal approach slope, leading them to seek correction, which resulted in an angle of approach below the ideal one.
- For the flight in question, the company chose two pilots who had never operated in SBQV. A crewmember with previous experience in the locality would have a higher level of awareness in relation to the specific characteristics of the aerodrome.
- No company publications were found that could provide the pilots with guidance on the specifics of SBQV, capable of helping with the management of the risks associated with the operation in that aerodrome.
Final Report:

Crash of a Let L-410UVP-E20C in Bandundu: 20 killed

Date & Time: Aug 25, 2010 at 1400 LT
Type of aircraft:
Operator:
Registration:
9Q-CCN
Survivors:
Yes
Schedule:
Kinshasa - Kiri - Bokoro - Semendwa - Bandundu - Kinshasa
MSN:
91 26 08
YOM:
1991
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
20
Circumstances:
On final approach to Bandundu Airport, the twin engine aircraft nosed down and crashed onto an earth made house. The aircraft was destroyed by impact forces and all occupants, except one passenger, were killed. According to the survivor, a passenger embarked illegally a crocodile he would sell to local market at Bandundu as 'bush meat'. On final approach, the animal went out of his bag and walked in the cabin. Panicked, the stewardess and several passengers departed their seats and rushed to the front of the cabin near the cockpit. After the CofG moved too far forward, the crew lost control of the aircraft that nosed down and crashed. The crocodile was later found unhurt but eventually killed by locals.
Probable cause:
Loss of control on final approach due to the movement of several passengers in the cabin, panicked by the presence of a crocodile.

Crash of an Embraer ERJ-190-100LR in Yichun: 44 killed

Date & Time: Aug 24, 2010 at 2138 LT
Type of aircraft:
Operator:
Registration:
B-3130
Survivors:
Yes
Schedule:
Harbin - Yichun
MSN:
190-00223
YOM:
2008
Flight number:
VD8387
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
91
Pax fatalities:
Other fatalities:
Total fatalities:
44
Aircraft flight hours:
5109
Aircraft flight cycles:
4712
Circumstances:
The crew started the approach in poor weather conditions with a visibility reduced at 2,800 metres. On short final, the aircraft was too low and the crew did not establish visual contact with the runway. The aircraft impacted ground 1,110 metres short of runway 30, slid and came to rest in flames 690 meters short of runway. 44 passengers were killed while the aircraft was destroyed by a post crash fire. First fatal accident involving an Embraer 190 and first accident at Yuchin Airport since it was open to traffic in 2009.
Probable cause:
- In violation of the airline's flight operation manual the captain attempted the approach to Yichun below required visibility. The airport reported 2800 meters of visibility while the manual required 3600 meters of visibility to begin the approach
- In violation of regulations by the Civil Aviation Authority the crew descended below minimum descent altitude although the aircraft was operating in fog and visual contact with the runway had not been established
- Despite the aural height announcements and despite not seeing the runway the crew continued the landing in the blind without initiating a go-around resulting in impact with terrain
Contributing factors were:
- The airline's safety management is insufficient:
* part of the flight crew arbitrarily implement the company's operations manual as the company does not follow up outstanding problems. Records suggest frequent deviations from approach profiles, i.e. deviation above or below glide slopes, excessive rates of descents and unstable approaches
* crew rostering and crew cooperation: Each of the crew was flying into Yichun for the first time despite the known safety risks at the airport, the communication and cooperation within the crew was insufficient, the crew members did not monitor each other in order to reduce human errors
* the airline's emergency training did not meet requirements, in particular the cabin crew training did not provide for hands on training on E190 cabin doors and overwing exits. Alternate means by the airline did prove ineffective and did not provide the quality China's Civil Aviation Authority requires thus leaving cabin crew unprepared to meet required cabin crew emergency response capabilities
- Parent company's Shenzhen Airlines oversight insufficient
* Shenzhen Airlines, after having taken over Henan Airlines in 2006, did not provide sufficient funding and technical support affecting the stability and safety of staff and quality management
* Air China, holding stock into Shenzhen Airlines, installed a safety supervisor but failed to address the safety management issues with Shenzhen and Henan Airlines
- No supervision by China's Civil Aviation Authority
* the license to operate the flight from Harbin to Yichun was granted without route validation and without safety management in violation of regulations
* to solve the lack of cabin crew flight attendants were certified although not meeting the relevant requirements for air transport operations
* the regional office of the Civil Aviation Authority did not communicate to their superiors that they had approved the domestic operation of the route from Harbin to Yichun permitting non-standard procedures
- China's Civil Aviation Authority safety management loopholes.

Crash of a Dornier DO228-101 near Kathmandu: 14 killed

Date & Time: Aug 24, 2010 at 0725 LT
Type of aircraft:
Operator:
Registration:
9N-AHE
Survivors:
No
Schedule:
Kathmandu - Lukla
MSN:
7032
YOM:
1985
Flight number:
AG101
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
On approach to Lukla, the crew encountered poor weather conditions. Unable to locate the runway, he decided to divert to Simara Airport. Unfortunately, the visibility at Simara Airport was insufficient and the crew eventually decided to return to Kathmandu. While descending to runway 02, a generator failed. The crew did not declare an emergency, contacted his maintenance base and was unable to switch to the backup generator. Shortly after the crew elected to reset the battery system, the aircraft entered an uncontrolled descent and crashed in a rice paddy field. The aircraft disintegrated on impact and all 14 occupants were killed, among them 4 Americans, one British and one Japanese. The wreckage was found about 30 km southeast of Tribhuvan Airport.
Probable cause:
Loss of control on approach following the failure of a generator for undetermined reasons.

Crash of a Boeing 737-73V in San Andrés: 2 killed

Date & Time: Aug 16, 2010 at 0147 LT
Type of aircraft:
Operator:
Registration:
HK-4682
Survivors:
Yes
Schedule:
Bogotá – San Andrés
MSN:
32416/1270
YOM:
2002
Flight number:
ARE8250
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
125
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7643
Captain / Total hours on type:
343.00
Copilot / Total flying hours:
1900
Copilot / Total hours on type:
800
Aircraft flight hours:
23485
Circumstances:
The aircraft departed Bogotá-El Dorado Airport at 0007LT on a night schedule service to San Andres Island, carrying 125 passengers and a crew of six. While approaching San Andres-Gustavo Rojas Pinilla Airport, the crew encountered poor weather conditions. Due to heavy rain falls, the crew was informed by ATC that the visibility dropped to 4 km. On short final, flaps were selected down to 30° then the autopilot system was deactivated. After passing 500 feet on approach, the captain repeated the procedures in case of a go-around would be needed due to windshear conditions. Shortly later, the copilot shouted 'go-around' but half a second later, the airplane impacted ground 49 metres short of runway. On impact, the undercarriage and both engines were torn off. The aircraft slid for few dozen metres before coming to rest, broken in three. Two passengers were killed while 129 other occupants were injured, nine seriously.
Probable cause:
Execution of the flight below the angle of approach, due to a misjudgment of the crew, believing to be much higher, leading the aircraft to fly a typical trajectory of a 'black hole' illusion, which was experienced during the night-time approach to a runway with low contrast surrounded in bright focused lights, aggravated by bad weather of heavy rain.
Final Report: