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:

Crash of an Embraer ERJ-145LR in Mitú

Date & Time: May 5, 2010 at 1049 LT
Type of aircraft:
Operator:
Registration:
FAC-1173
Survivors:
Yes
Schedule:
Villavicencio - Mitú
MSN:
145-879
YOM:
2005
Flight number:
NSE9634
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10254
Captain / Total hours on type:
1060.00
Copilot / Total flying hours:
1061
Copilot / Total hours on type:
806
Aircraft flight hours:
9095
Circumstances:
After landing on runway 20 (1,760 meters long) at Mitú-Fabio Alberto León Bentley Airport, the aircraft encountered difficulties and was unable to stop within the remaining distance. It overran at a speed of 52 knots, went through a fence, lost its undercarriage and came to rest in a prairie some 163 metres further. All 41 occupants were uninjured while the aircraft was damaged beyond repair. It was registered FAC-1173 (military) and HK-4536 (civil).
Probable cause:
Wrong approach configuration on part of the crew. Execution of the landing procedure on runway 20 despite the fact that aircraft was unstable on approach. At runway threshold, the aircraft altitude was too high and its speed upon touchdown was excessive (132 knots). The airplane touched down 562 metres past the runway threshold, well beyond the touchdown zone. All brakes systems were activated but the upper right thrust reverser deployed and retracted shortly later due to technical reasons, which was considered as a contributory factor. The following factors also contributed to the mishap:
- Poor techniques used by the pilot-in-command on approach and after touchdown,
- Deviation from standard operating procedures (SOP),
- Non-adherence to published procedures,
- No reaction or corrective action to the EGPWS alarm.
Final Report:

Crash of a Boeing 737-322 in Manokwari

Date & Time: Apr 13, 2010 at 1055 LT
Type of aircraft:
Operator:
Registration:
PK-MDE
Survivors:
Yes
Schedule:
Ujung Pandang - Sorong - Manokwari
MSN:
24660/1838
YOM:
1990
Flight number:
MZ836
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16450
Copilot / Total flying hours:
22139
Aircraft flight hours:
54759
Aircraft flight cycles:
38485
Circumstances:
On 13 April 2010, a Boeing B737-300 aircraft registered PK-MDE was being operated by PT. Merpati Nusantara Airline as a scheduled passenger flight MZ 836, from Hasanuddin Airport, Makassar, Sulawesi to Rendani Airport, Manokwari, Papua. It made a transit stop at Domine Eduard Osok Airport, Sorong, Papua. The aircraft departed from Makassar at 2010 UTC and landed at Sorong at 2214 UTC. The scheduled departure time from Sorong was 2235, but due to heavy rain over Manokwari, the departure was delayed for about two hours. The pilot in command was the pilot flying, and the copilot, who also held a command rating on the aircraft, was the support/monitoring pilot. The aircraft subsequently departed Sorong 2 hours and 43 minutes later, at 0118. The observed weather report issued by Badan Meteorologi dan Geofisika (BMG) Manokwari for takeoff and landing at 0100 indicated that the weather was “continuous slight rain, horizontal visibility of 3 to 4 kilometers, cloud overcast cumulus-stratocumulus, westerly wind at 5 knots”. The aircraft’s dispatch release from Sorong indicated that the flight was planned under the Instrument Flight Rules (IFR). The destination, Manokwari, had no published instrument approach procedure. Terminal area operations, including approach and landing, were required to be conducted under the Visual Flight Rules (VFR). At 0146 the crew made the first direct contact with Rendani Radio and reported their position as 14 Nm from Manokwari, and maintaining altitude 10,500 feet. Following this radio contact, Rendani Radio informed the crew that the weather was continuous slight rain, visibility 3 kilometers, cloud overcast with cumulus stratocumulus at 1,400 feet, temperature 24 degrees Celsius, QNH 1012 hectopascals. The transcript of the Rendani Radio communications with the aircraft indicated that controller then instructed the crew to descend and joint right downwind for runway 35, and to report when overhead the airport. Shortly after, the crew reported overhead the airport at 5,000 feet. The controller then instructed the crew to report when they were on final approach for runway 35. The crew acknowledged this instruction. At 0154 the crew reported that they were on final for runway 35. The controller informed them that the wind was calm, runway condition was wet and clear. The crew read back the wind condition and that the runway was clear, but did not mention the wet runway condition. According to the Rendani Airport Administrator’s report to the investigation, the aircraft was observed to make a normal touchdown on the runway at about 0155, about 120 meters from the approach end of runway 35. The report stated that the aircraft’s engine reverser sound was not heard during landing roll. Witnesses on board the aircraft also stated that the aircraft made a smooth landing, and the engine reversers were not heard during the landing roll. During the landing roll, the aircraft veered to the left about 140 meters from the end of runway 35, then overran the departure end of runway 35. At about 0156 it came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River. The Observed Weather Report issued by BMG Manokwari for takeoff and landing at 0200 (4 minutes after the accident) indicated that the weather was continuous moderate rain, with a horizontal visibility of 4 kilometers, cloud overcast cumulus stratocumulus, south-westerly wind at 5 knots. The airport rescue and fire fighting unit was immediately deployed to assist the post crash evacuation. Due to the steep terrain 155 meters from the end of runway 35, the rescuers had to turn back and use the airport’s main road to reach the aircraft. The accident site was in an area of shallow muddy water surrounded by mangrove vegetation. The aircraft was substantially damaged. Nearby residents, police and armed forces personnel assisted the evacuation from the aircraft. The Rendani Airport Administrator reported that the passengers and crew members were evacuated and moved from the site by 0230. They were taken to the Manokwari General Hospital, and Manokwari Naval Hospital for further medical treatment.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Kodiak

Date & Time: Mar 15, 2010 at 1243 LT
Type of aircraft:
Operator:
Registration:
N663SA
Flight Phase:
Survivors:
Yes
Schedule:
Kodiak - Old Harbor
MSN:
4
YOM:
1967
Flight number:
8D501
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7370
Captain / Total hours on type:
106.00
Aircraft flight hours:
11348
Circumstances:
The airline transport pilot was taking off on a passenger flight under Title 14, CFR Part 135, when the accident occurred. He reported that during takeoff the wind was reported from 290-300 degrees, at 15 knots, gusting to 27 knots. He chose to make an intersection takeoff on runway 25 at its intersection with runway 29, rather than use the full length of runway 29. He said his airspeed did not develop as quickly as he had anticipated, and that with his airspeed lagging and poor climb performance, he realized the airplane was not going to clear the ridge at the end of the runway. He said he initiated a right descending turn to maintain his airspeed, but impacted trees alongside the runway. He reported that the airplane sustained substantial damage to the wings and fuselage when it impacted trees. He said there were no mechanical problems with the airplane prior to the accident.
Probable cause:
The pilot's failure to maintain clearance from rising terrain during takeoff resulting in collision with trees.
Final Report: