Crash of an Antonov AN-24RV in Igarka: 12 killed

Date & Time: Aug 3, 2010 at 0119 LT
Type of aircraft:
Operator:
Registration:
RA-46524
Survivors:
Yes
Schedule:
Krasnoyarsk - Igarka
MSN:
4 73 100 03
YOM:
1974
Flight number:
KTK9357
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
17250
Captain / Total hours on type:
14205.00
Copilot / Total flying hours:
5838
Copilot / Total hours on type:
2670
Aircraft flight hours:
53760
Aircraft flight cycles:
38383
Circumstances:
The aircraft departed Krasnoyarsk on a night schedule flight to Igarka, carrying 11 passengers and 4 crew members. On approach to Igarka Airport, the crew encountered poor weather conditions with a visibility below minimums due to fog. On final, the pilot-in-command was unable to establish a visual contact with the ground but continued the approach. The aircraft descended below the glide, collided with trees and crashed 477 metres short of runway 12 and 234 metres to the right of its extended centerline, bursting into flames. All 11 passengers were killed while all four crew members survived. The following day, the stewardess died from her injuries.
Probable cause:
Controlled flight into terrain after the crew descended in IMC conditions below the glide without visual contact with the ground. The following contributing factors were identified:
- The failure of the crew to initiate a go-around procedure,
- Incorrect weather forecast with regards to cloud ceiling, visibility and severe weather (fog),
- Inaccurate information about the actual weather on the glide path at the Middle Marker with course 117°, radioed to the crew 40 minutes before the accident.
Final Report:

Crash of an ATR72-212A in Manila

Date & Time: Jul 28, 2010 at 1515 LT
Type of aircraft:
Operator:
Registration:
RP-C7254
Survivors:
Yes
Schedule:
Tuguegarao – Manila
MSN:
828
YOM:
2008
Flight number:
5J509
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Cebu Pacific Air flight 5J509, an ATR 72-500, took off from Tuguegarao Airport, Philippines, bound for Manila-Ninoy Aquino International Airport. The first officer was the Pilot Flying (PF) while the captain was the Pilot Not Flying (PNF). Approaching Manila, the flight was under radar vector for a VOR/DME approach to runway 24. At 7 miles on finals the approach was stabilized. A sudden tailwind was experienced by the crew at 500 feet radio altitude (RA) which resulted in an increase in airspeed and vertical speed. The captain took over the controls and continued the approach. Suddenly, the visibility went to zero and consequently the aircraft experienced a bounced landing three times, before a go-around was initiated. During climb out the crew noticed cockpit instruments were affected including both transponders and landing gears. They requested for a priority landing and were vectored and cleared to land on runway 13. After landing the aircraft was taxied to F4 where normal deplaning was carried out. No injuries were reported on the crew and passengers.
Probable cause:
Primary Cause Factor:
- Failure of the flight crew to discontinue the approach when deteriorating weather and their associated hazards to flight operations had moved into the airport (Human Factor)
Contributory Factor:
- The adverse weather condition affected the judgment and decision-making of the PIC even prior to the approach to land. With poor weather conditions being encountered, the PIC still continued the approach and landing. (Environmental Factor)
Underlying Factor:
- As a result of the bounced landing, several cockpit instruments were affected including both transponders on board. One of the nosewheels was detached and all the landing gears could not be retracted. Further, the integrity of the structure may have been affected and chance airframe failure was imminent. With all of these conditions, the Captain still opted to request for a priority landing when emergency landing was needed.

Crash of an Airbus A321-231 in Islamabad: 152 killed

Date & Time: Jul 28, 2010 at 0941 LT
Type of aircraft:
Operator:
Registration:
AP-BJB
Survivors:
No
Site:
Schedule:
Karachi - Islamabad
MSN:
1218
YOM:
2000
Flight number:
ABQ202
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
146
Pax fatalities:
Other fatalities:
Total fatalities:
152
Captain / Total flying hours:
25497
Captain / Total hours on type:
1060.00
Copilot / Total flying hours:
1837
Copilot / Total hours on type:
286
Aircraft flight hours:
34018
Aircraft flight cycles:
13566
Circumstances:
Flight ABQ202, operated by Airblue, was scheduled to fly a domestic flight sector Karachi - Islamabad. The aircraft had 152 persons on board, including six crew members. The Captain of aircraft was Captain Pervez Iqbal Chaudhary. Mishap aircraft took-off from Karachi at 0241 UTC (0741 PST) for Islamabad. At time 0441:08, while executing a circling approach for RWY-12 at Islamabad, it flew into Margalla Hills, and crashed at a distance of 9.6 NM, on a radial 334 from Islamabad VOR. The aircraft was completely destroyed and all souls on board the aircraft, sustained fatal injuries.
Probable cause:
- Weather conditions indicated rain, poor visibility and low clouds in and around the airport. The information regarding prevalent weather and the required type of approach on arrival was in the knowledge of aircrew.
- Though aircrew Captain was fit to undertake the flight on the mishap day, yet his portrayed behavior and efficiency was observed to have deteriorated with the inclement weather at BBIAP Islamabad.
- The chain of events leading to the accident in fact started with the commencement of flight, where Captain was heard to be confusing BBIAP Islamabad with JIAP Karachi while planning FMS, and Khanpur Lake (Wah) with Kahuta area during holding pattern. This state continued when Captain of the mishap flight violated the prescribed Circling Approach procedure for RWY-12; by descending below MDA (i.e 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield and instead resorting to fly the non-standard self created PBD based approach, thus transgressing out of protected airspace of maximum of 4.3 NM into Margallas and finally collided with the hills.
- Aircrew Captain not only clearly violated the prescribed procedures for circling approach but also did not at all adhere to FCOM procedures of displaying reaction / response to timely and continuous terrain and pull up warnings (21 times in 70 seconds) – despite these very loud, continuous and executive commands, the Captain failed to register the urgency of the situation and did not respond in kind (break off / pull off).
- F/O simply remained a passive bystander in the cockpit and did not participate as an effective team member failing to supplement / compliment or to correct the errors of his captain assertively in line with the teachings of CRM due to Captain’s behavior in the flight.
- At the crucial juncture both the ATC and the Radar controllers were preoccupied with bad weather and the traffic; the air traffic controller having lost visual contact with the aircraft got worried and sought Radar help on the land line (the ATC does not have a Radar scope); the radar controller having cleared aircraft to change frequency to ATC, got busy with the following traffic. Having been alerted by the ATC, the Radar controller shifted focus to the mishap aircraft – seeing the aircraft very close to NFZ he asked the ATCO (on land line) to ask the aircraft to immediately turn left, which was transmitted. Sensing the gravity of the situation and on seeing the aircraft still heading towards the hills, the Radar controller asked the ATCO on land line “Confirm he has visual contact with the ground. If not, then ask him to immediately climb, and make him execute missed approach”. The ATCO in quick succession asked the Captain if he had contact with the
airfield – on receiving no reply from aircrew the ATCO on Radars prompting asked if he had contact with the ground. Aircrew announced visual contact with the ground which put ATS at ease.
Ensuing discussion and mutual situational update (on land line) continued and, in fact, the ATC call “message from Radar immediately turn left” was though transmitted, but by the time the call got transmitted, the aircraft had crashed at the same time.
- The accident was primarily caused by the aircrew who violated all established procedures for a visual approach for RWY-12 and ignored several calls by ATS Controllers and EGPWS system warnings (21) related to approaching rising terrain and PULL UP.
Final Report:

Crash of a Boeing 737-7L9 in Conakry

Date & Time: Jul 28, 2010 at 0130 LT
Type of aircraft:
Operator:
Registration:
TS-IEA
Survivors:
Yes
Schedule:
Nouakchott - Dakar - Conakry
MSN:
28014/766
YOM:
2001
Flight number:
MTW620
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
91
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Nouakchott in he evening of July 27 on a regular schedule service to Conakry with an intermediate stop in Dakar, carrying 91 passengers and a crew of six. Following an uneventful flight from Dakar, the crew started a night approach to Conakry-Gbessia Airport. After touchdown on a wet runway (due to recent rain falls), the aircraft was unable to stop within the remaining distance. It overran, collided with the ILS antenna and some approach lights, lost its nose gear and came to rest 500 metres further. Ten passengers were injured while all 87 other occupants escaped unhurt. The aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew, causing the aircraft to land half way down the runway and reducing the landing distance available. The crew failed to follow SOP's and to initiate a go-around procedure as the landing was obviously missed.

Crash of a Fokker F27 Friendship 600 in Lubumbashi

Date & Time: Jul 20, 2010
Type of aircraft:
Operator:
Registration:
9Q-CJV
Survivors:
Yes
MSN:
10430
YOM:
1970
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing, one of the main landing gear collapsed. The aircraft slid for few dozen metres before coming to rest on the runway. All occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Failure of a landing gear upon landing for unknown reasons.

Crash of a McDonnell Douglas MD-82 in Kinshasa

Date & Time: Jun 21, 2010 at 1200 LT
Type of aircraft:
Operator:
Registration:
9Q-COQ
Survivors:
Yes
Schedule:
Kinshasa – Lubumbashi
MSN:
49178/1122
YOM:
1983
Flight number:
EO601
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Kinshasa-N'Djili Airport, a tyre burst on the left main gear. After liftoff, while in initial climb, the crew was forced to shut down the left engine while the hydraulic system failed. The crew declared an emergency and was cleared for an immediate return. On approach, he was unable to lower the nose gear due to the malfunction of the hydraulic system. After touchdown on runway 06, the aircraft rolled for a distance of 1,000 metres then veered off runway to the right, slid on a grassy area and came to rest 500 metres further. All 110 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
A tyre burst on the left main gear during the takeoff procedure. Debris damaged hydraulic lines and were ingested in the left engine that should be shut down.

Crash of a Boeing 737-800 in Mangalore: 158 killed

Date & Time: May 22, 2010 at 0605 LT
Type of aircraft:
Operator:
Registration:
VT-AXV
Survivors:
Yes
Schedule:
Dubai - Mangalore
MSN:
36333/2481
YOM:
2007
Flight number:
IX812
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
160
Pax fatalities:
Other fatalities:
Total fatalities:
158
Captain / Total flying hours:
10215
Captain / Total hours on type:
2844.00
Copilot / Total flying hours:
3620
Copilot / Total hours on type:
3319
Aircraft flight hours:
7199
Aircraft flight cycles:
2833
Circumstances:
Air India Express flight IX-811/812 is a daily round trip between Mangalore and Dubai. The outbound flight IX-811 was uneventful and landed at Dubai at 23:44 hours Local Time. The airplane was serviced and refuelled. The same flight crew operated the return leg, flight IX-812. The airplane taxied out for departure at 01:06 LT (02:36 IST). The takeoff, climb and cruise were uneventful. There was no conversation between the two pilots for about 1 hour and 40 minutes because the captain was asleep. The First Officer was making all the radio calls. The aircraft reported position at IGAMA at 05:33 hours IST and the First Officer was told to expect an ILS DME Arc approach to Mangalore. At about 130 miles from Mangalore, the First Officer requested descent clearance. This was, however, denied by the ATC Controller, who was using standard procedural control, to ensure safe separation with other air traffic. At 05:46 IST, the flight reported its position when it was at 80 DME as instructed by Mangalore Area Control. The aircraft was cleared to 7000 ft and commenced descent at 77 DME from Mangalore at 05:47 IST. The visibility reported was 6 km. Mangalore airport has a table top runway. As the AIP India states "Aerodrome located on hilltop. Valleys 200ft to 250ft immediately beyond paved surface of Runway." Owing to the surrounding terrain, Air India Express had made a special qualification requirement that only the PIC shall carry out the take off and landing. The captain on the accident flight had made a total of 16 landings in the past at this airport and the First Officer had operated as a Co-pilot on 66 flights at this airport. While the aircraft had commenced descent, there was no recorded conversation regarding the mandatory preparation for descent and landing briefing as stipulated in the SOP. After the aircraft was at about 50 miles and descending out of FL295, the conversation between the two pilots indicated that an incomplete approach briefing had been carried out. At about 25 nm from DME and descending through FL184, the Mangalore Area Controller cleared the aircraft to continue descent to 2900 ft. At this stage, the First Officer requested, if they could proceed directly to Radial 338 and join the 10 DME Arc. Throughout the descent profile and DME Arc Approach for ILS 24, the aircraft was much higher than normally expected altitudes. The aircraft was handed over by the Mangalore Area Controller to ATC Tower at 05:52 IST. The Tower controller, thereafter, asked the aircraft to report having established on 10 DME Arc for ILS Runway 24. Considering that this flight was operating in WOCL (Window Of Circadian Low), by this time the First Officer had also shown signs of tiredness. This was indicated by the sounds of yawning heard on the CVR. On having reported 10 DME Arc, the ATC Tower had asked aircraft to report when established on ILS. It appears that the captain had realized that the aircraft altitude was higher than normal and had selected Landing Gear 'DOWN' at an altitude of approximately 8,500 ft with speed brakes still deployed in Flight Detent position, so as to increase the rate of descent. As indicated by the DFDR, the aircraft continued to be high and did not follow the standard procedure of intercepting the ILS Glide Path at the correct intercept altitude. This incorrect procedure led to the aircraft being at almost twice the altitude as compared to a Standard ILS Approach. During approach, the CVR indicated that the captain had selected Flaps 40 degrees and completed the Landing Check List. At 06:03 hours IST at about 2.5 DME, the Radio Altimeter had alerted an altitude of 2500 ft. This was immediately followed by the First Officer saying "It is too high" and "Runway straight down". In reply, the captain had exclaimed "Oh my god". At this moment, the captain had disconnected the Auto Pilot and simultaneously increased the rate of descent considerably to establish on the desired approach path. At this stage, the First Officer had queried "Go around?" To this query from the First Officer, the captain had called out "Wrong loc .. ... localiser .. ... glide path". The First Officer had given a second call to the captain for "Go around" followed by "Unstabilized". However, the First Officer did not appear to take any action, to initiate a Go Around. Having acquired the runway visually and to execute a landing, it appears that the captain had increased the rate of descent to almost 4000 ft per minute. Due to this, there were numerous warnings from EGPWS for 'SINK RATE' and 'PULL UP'. On their own, the pilots did not report having established on ILS Approach. Instead, the ATC Tower had queried the same. To this call, the captain had forcefully prompted the First Officer to give a call of "Affirmative". The Tower controller gave landing clearance thereafter and also indicated "Winds calm". The aircraft was high on approach and touched down on the runway, much farther than normal. The aircraft had crossed the threshold at about 200 ft altitude with indicated speed in excess of 160 kt, as compared to 50 ft with target speed of 144 kt for the landing weight. Despite the EGPWS warnings and calls from the First Officer to go around, the captain had persisted with the approach in unstabilized conditions. Short of touchdown, there was yet another (Third) call from the First Officer, "Go around captain...We don't have runway left". However, the captain had continued with the landing and the final touchdown was about 5200 ft from the threshold of runway 24, leaving approximately 2800 ft of remaining paved surface. The captain had selected Thrust Reversers soon after touchdown. Within 6 seconds of applying brakes, the captain had initiated a 'Go Around', in contravention of Boeing SOP. The aircraft overshot the runway including the strip of 60 metres. After overshooting the runway and strip, the aircraft continued into the Runway End Safety Area (RESA) of 90 metres. Soon after which the right wing impacted the localiser antenna structure located further at 85 metres from the end of RESA. Thereafter, the aircraft hit the boundary fence and fell into a gorge.
Probable cause:
The Court of Inquiry determines that the cause of this accident was Captain's failure to discontinue the unstabilized approach and his persistence in continuing with the landing, despite three calls from the First Officer to go around and a number of warnings from the EGPWS.
Contributing Factors were:
1. In spite of availability of adequate rest period prior to the flight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia. As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgment. This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL).
2. In the absence of Mangalore Area Control Radar (MSSR), due to unserviceability, the aircraft was given descent at a shorter distance on DME as compared to the normal. However, the flight crew did not plan the descent profile properly, resulting in remaining high on approach.
3. Probably in view of ambiguity in various instructions empowering the 'copilot' to initiate a 'go around ', the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.
Final Report:

Crash of an Antonov AN-24B near Salang Pass: 44 killed

Date & Time: May 17, 2010 at 0937 LT
Type of aircraft:
Operator:
Registration:
YA-PIS
Flight Phase:
Survivors:
No
Site:
Schedule:
Kunduz – Kabul
MSN:
2 73 079 03
YOM:
1972
Flight number:
PM1102
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
44
Circumstances:
The twin engine aircraft departed Kunduz Airport at 0900LT on a flight to Kabul, carrying 38 passengers and six crew members, among them six foreigners. En route, while flying in marginal weather conditions with limited visibility due to fog, the aircraft struck the slope of a mountain located south of the Salang Pass. The crew of an ISAF helicopter localized the wreckage 3 days later in a snow covered area at an altitude of 4,270 metres. The aircraft disintegrated on impact and all 44 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew continued the descent despite he was instructed by ATC to maintain his actual altitude. Poor visibility due to heavy fog was a contributing factor, as well as a non reaction of the crew regarding the GPWS alarm, due to a misunderstanding by the crew, either due to language problems or because of previous false alerts.

Crash of a PZL-Mielec AN-28 in Poeketi: 8 killed

Date & Time: May 15, 2010 at 1510 LT
Type of aircraft:
Operator:
Registration:
PZ-TSV
Flight Phase:
Survivors:
No
Schedule:
Godo Olo – Paramaribo
MSN:
1AJ007-10
YOM:
1990
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
En route from Godo Olo to Paramaribo, the twin engine aircraft crashed in unknown circumstances in a wooded area located 5 km northeast from Poeketi. The wreckage was found few hours later and all 8 occupants were killed.

Crash of an Airbus A330-202 in Tripoli: 103 killed

Date & Time: May 12, 2010 at 0601 LT
Type of aircraft:
Operator:
Registration:
5A-ONG
Survivors:
Yes
Schedule:
Johannesburg - Tripoli - London
MSN:
1024
YOM:
2009
Flight number:
AAW771
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
93
Pax fatalities:
Other fatalities:
Total fatalities:
103
Captain / Total flying hours:
17016
Captain / Total hours on type:
516.00
Copilot / Total flying hours:
4216
Copilot / Total hours on type:
516
Aircraft flight hours:
2175
Aircraft flight cycles:
572
Circumstances:
The aircraft was on a schedule flight from O. R. Tambo International Airport - Johannesburg (South Africa) to London, with an intermediate stop at Tripoli international Airport, Libya. The Aircraft took off on May 11th 2010 at 19:25 UTC as flight number 8U771/AAW771. There were three cockpit crew, eight cabin crew, and 93 passengers on board, with fifty thousand kg of fuel during takeoff role and the Aircraft mass was 187,501 kg. During final approach towards runway 09 at Tripoli international Airport, the crew announced go-around and initiated the miss approach procedure with the knowledge and confirmation of Tripoli tower. During the missed approach phase, the Aircraft responded to the crew’s inputs, velocity and altitude increased above the MDA, then the aircraft descended dramatically until collided with the ground about 1,200 meters from the threshold of the runway 09 and 150 meters to the right of its centerline, impact and post impact fire caused complete destruction to the Aircraft. A boy aged 8 was injured while 103 other occupants were killed.
Probable cause:
A final approach carried out in common managed guidance mode should have relieved the crew of their tasks. The limited coordination and cooperation between the two crew members, especially the change into vertical selected guidance mode by the PF, probably led to a lack of a common action plan. The lack of feedback from the 28 April 2010 flight, flown by the same crew on the same aircraft, did not allow them to anticipate the potential risks associated with managing non-precision approaches. The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined. During the go-around, the crew was surprised not to acquire visual references. On one hand the crew feared exceeding the aircraft’s speed limits in relation to its configuration, and on the other hand they were feeling the effects of somatogravic illusion due to the aircraft acceleration. This probably explains the aircraft handling inputs, mainly nose-down inputs, applied during the go-around. These inputs were not consistent with what is expected in this flight phase. The degraded CRM did not make it possible for either crew member to identify and recover from the situation before the collision with the ground, even when the TAWS warnings were activated close to the ground.
Based on elements from the investigation, the accident resulted from:
- The lack of common action plan during the approach and a final approach continued below the MDA, without ground visual reference acquired.
- The inappropriate application of flight control inputs during a go- around and on the activation of TAWS warnings,
- The lack of monitoring and controlling of the flight path.
These events can be explained by the following factors:
- Limited CRM on approach that degraded during the missed approach. This degradation was probably amplified by numerous radio-communications during the final approach and the crew’s state of fatigue,
- Aircraft control inputs typical in the occurrence of somatogravic perceptual illusions,
- Inappropriate systematic analysis of flight data and feedback mechanism within the AFRIQIYAH Airways.
- Non adherence to the company operation manual, SOP and standard terminology.
In addition, the investigation committee found the following as contributing factors to the accident:
- Weather available to the crew did not reflect the actual weather situation in the final approach segment at Tripoli International Airport.
- In adequacy of training received by the crew.
- Occupancy of tower frequency by both air and ground movements control.
Final Report: