Crash of an Antonov AN-24B in Wrocław

Date & Time: Jan 24, 1969 at 1730 LT
Type of aircraft:
Operator:
Registration:
SP-LTE
Survivors:
Yes
Schedule:
Warsaw - Wrocław
MSN:
67302405
YOM:
1966
Flight number:
LO149
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9500
Captain / Total hours on type:
2000.00
Copilot / Total hours on type:
3000
Aircraft flight hours:
3018
Circumstances:
Flight LO149 was a scheduled domestic flight from Warsaw to Wrocław. It took off from Warsaw at 1635 hours local time carrying a crew of 4 and 44 passengers. The flight was uneventful and about 10 minutes before reaching the Wrocław non-directional radio beacon, it was cleared by the Area Control Centre to descend from its cruising altitude of 4 500 m to 1 500 m and instructed to contact the Wrocław Control Zone. The Control Zone cleared the flight to 1 500 m, requested it to report when passing over the NDB - ETA 1722 hours - and gave it the latest weather information for Wrocław as being: cloud base 150 m, visibility 1600 m in light fog, wind 3000 to 310013 to 4 mfsec, QFE 765.5 mm. Hg. The altimeters were set at the correct setting and after having reported over the NDB the flight, which was descending towards the outer locator, was warned by the Control Zone that the visibility had deteriorated to 800 m, i.e. 300 m below the minimum authorized for landing at Wrocław Airport. However, the pilot continued to descend in the direction of the outer locator. At an altitude of 90 m the pilot-in-command ordered a reduction of engine power and flew over the outer locator at an altitude of 50 to 60 m instead of the prescribed 225 m. He reported over the outer locator and shortly thereafter was advised that the visibility had further deteriorated to 400 m and that fog had appeared. In spite of this information the pilot continued his approach and informed the Control Zone that he would try to land. After passing the outer locator the rate of descent of the aircraft was probably established at approximately 3 to 5 m/sec and the last altitude reported by the flight engineer was 30 m. Seven hundred metres beyond the outer locator the aircraft was levelled qff at a height of 10 m and both wings cut the tops of some trees. As a result of the impact part of the right wing (3 m long) and of its aileron were torn off from the aircraft and the aircraft went into a 400 bank to the right. Approximately 145 m from the point of contact with the trees, the right wing came into contact with the ground and left a trace 41 m long. The aircraft was then momentarily straightened up but the right wing dropped again, contacted the ground again and was further damaged. At approximately 350 m from the point of initial contact with the trees, the aircraft, still banked to the right, struck two 30 000 volt power lines breaking all six electric cables with its fuselage and left wing. It then flew over 5 railway tracks and struck with its right wing the five overhead electric traction cables as well as 25 wires of the railway signalling equipment located 60 cm above the ground. All cables and wires were broken and the right wing of the aircraft became entangled in the wires. This reduced the speed of the aircraft and straightened it up, but the angle strut of the right landing gear was damaged and the right landing gear folded backwards. After having travelled a short distance nearly level, with the left landing gear rolling on the ground, the nose gear and right propeller became detached and the aircraft turned slightly to the right, 141 m farther on the left landing gear struck a road embankment 70 cm high and immediately thereafter the aircraft struck a steel electric light pole on the road and bent it to the ground. The aircraft then made a 180° turn and came to a stop on the road at a point located 3.5 km before the threshold of the runway and nearly on the extended centre line of the runway. The accident occurred at 1730 hours.
Probable cause:
The accident was attributed to the decision of the pilot-in-command to carry out an approach in weather conditions below the minimum limits prescribed for Wrocław Airport and his non-observance of the prescribed altitude over the outer radio beacon while performing the approach procedure. The accident was the pilot-in-command's fault as well as the co pilot's since the latter did not prevent the pilot-in-command from violating the flight rules. The following findings were reported:
- The pilot-in-command carried out an approach procedure in weather conditions below the authorized minima for Wroclaw Airport,
- The pilot-in-command did not observe the prescribed minimum height limits for an approach procedure using two radio beacons at Wroclaw Airport,
- The copilot did not report to the pilot-in-command that the aircraft went below the prescribed minimum height limits during the approach.
Final Report:

Crash of a Boeing 727-22C off Los Angeles: 38 killed

Date & Time: Jan 18, 1969 at 1821 LT
Type of aircraft:
Operator:
Registration:
N7434U
Flight Phase:
Survivors:
No
Schedule:
Los Angeles – Denver – Milwaukee
MSN:
19891/631
YOM:
1968
Flight number:
UA266
Crew on board:
6
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
38
Captain / Total flying hours:
13665
Captain / Total hours on type:
1908.00
Copilot / Total flying hours:
6642
Copilot / Total hours on type:
1842
Aircraft flight hours:
1036
Circumstances:
Boeing 727-22C N7434U operated Flight 266 from Los Angeles to Denver, CO and Milwaukee, WI. The aircraft had been operating since January 15, 1969, with the No. 3 generator inoperative. This was allowed because according to the Minimum Equipment List, the aircraft is airworthy with only two generators operable provided certain procedures are followed and electrical loads are monitored during flight. Flight 266 was scheduled to depart the gate at 17:55, but was delayed until 18:07 because of the inclement weather and loading problems. The flight commenced its takeoff roll on runway 24 at approximately 18:17. At 18:18:30 the sound of an engine fire warning bell was heard in the cockpit. The crew reported a no. 1 engine fire warning and stated that they wanted to return to the airport. Shortly after shutdown of the No. 1 engine, electrical power from the remaining generator (No. 2) was lost. Following loss of all generator power, the standby electrical system either was not activated or failed to function. Electrical power at a voltage level of approximately 50 volts was restored approximately a minute and a half after loss of the No. 2 generator. The duration of this power restoration was just 9 to 15 seconds. The Boeing descended and struck the sea 11.3 miles west of the airport. The ocean depth at this point is approximately 950 feet.
Probable cause:
The loss of attitude orientation during a night, instrument departure in which all attitude instruments were disabled by loss of electrical power. The Board has been unable to determine (a) why all generator power was lost or (b) why the standby electrical power system either was not activated or failed to function.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Arboletes: 2 killed

Date & Time: Jan 17, 1969 at 0800 LT
Type of aircraft:
Operator:
Registration:
HK-1259
Survivors:
No
Schedule:
Berastegui – Arboletes
MSN:
744
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On final approach to Arboletes, Antioquia, while completing a flight from Berastegui, Cordóba, the single engine airplane crashed in a field located two km short of runway. Both occupants were killed.

Crash of a Douglas C-47-DL in Kabul

Date & Time: Jan 15, 1969
Operator:
Registration:
YA-AAB
Flight Phase:
Survivors:
Yes
MSN:
4275
YOM:
1942
Location:
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two Ariana Afghan Airlines aircraft collided in unknown circumstances at Kabul Airport. A C-47 registered YA-AAB was damaged beyond repair while a DC-6 registered YA-DAN was repaired. There were no injuries.

Crash of a BAc 111-201AC in Milan

Date & Time: Jan 14, 1969 at 2032 LT
Type of aircraft:
Operator:
Registration:
G-ASJJ
Flight Phase:
Survivors:
Yes
Schedule:
Milan - London
MSN:
14
YOM:
1965
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13360
Captain / Total hours on type:
2153.00
Copilot / Total flying hours:
10973
Copilot / Total hours on type:
497
Aircraft flight hours:
8310
Circumstances:
On 14 January 1969 the crew flew from Gatwick to Rotterdam and return, following which they departed on a scheduled international flight Gatwick-Genoa-Gatwick. For this flight Captain A occupied the left-hand seat as pilot-in-charge, Captain B the right hand seat as co-pilot and Captain C the centre supernumerary seat as pilot-in-command, ultimately responsible for the correct operation of the aircraft. Before leaving Gatwick Captain A briefed Captain B concerning the co-pilot duties assigned to him. Although Captain C, as pilot-in-command, did not himself formally brief Captains A and B there was no doubt that they were aware of their respective tasks. On the flight from Gatwick to Genoa the aircraft was forced, due to unfavourable weather conditions at Genoa, to divert to Milan-Linate Airport where it landed at 1430 hours. Before commencing the return flight to Gatwick the crew had to await the arrival of the passengers from Genoa. This took place at 1930 hours. During the five-hour waiting period on the ground, the aircraft APU was kept in operation to ensure cabin heating and air conditioning. While Captain C tried unsuccessfully to sleep in the aircraft, Captains A and B inspected the aircraft and found ice on the wings and tail unit. The aircraft was subsequently de-iced. Before boarding the aircraft, Captains A and B made another external inspection of the aircraft and established that there was no ice on any part of it. The result of this inspection was duly reported to Captain C. Captains A and B carried out the pre-flight checks in accordance with the company checklist and verified that the take-off weight and aircraft loading were within the permitted limits. The crew occupied the same positions as during the previous flight, Captain A being in the left-hand seat, Captain B in the right-hand seat and Captain C in the jump- seat. In view of the weather, temperature and runway conditions, the crew decided to use the 18O flap setting, Spey 2 thrust (full thrust), engine anti-icing and the APU for cabin air conditioning. V1 and Vr were established at 117 kt and V2 at 127 kt. At 2018 hours, after clearance from Linate ATC, the engines were started and engine anti-icing selected "ON". There was a considerable layer of snow along the sides of the taxiways and runway, but they themselves were clear and usable. In view of the isolated patches of slush or water on the runway, Captain A considered it essential for the engine igniter switches to be selected "ON" during the entire take-off. At 2028 hours the aircraft was cleared to enter runway 18 and, after receiving the latest information concerning visibility and wind, it was cleared for take-off at 2031 hours. Before the brakes were released, a check was made of engine P7 pressures and of the other engine instruments which were found to be normal. At about 80 kt Captain A took over the aircraft's control column. The airspeed indicators showed regular acceleration and Captain A stated that just before 100 kt the engine instruments were also registering normally. V1 and Vr were called and the aircraft was rotated into the initial climbing attitude; immediately after or during this manoeuvre, a dull noise was distinctly heard by all the crew members. This noise was variously described by them as: "not like a rifle shot, not like the slamming of a door or something falling in the aircraft but more like someone kicking the fuselage with very heavy boots, an expansive noise covering a very definite time span with a dull non-metallic thud". The bang was immediately associated by the crew with the engines. After looking at the TGT gauges, and observing that No. 1 engine was indicating a temperature 20°c higher than that of No. 2 engine, Captain C said: "I think it's number one" or wards to that effect, and after a brief pause "throttle it". On receipt of Captain C's comment Captain A closed the power level of No. 1 engine. During or just after the explosion, he had completed the rotation manoeuvre and the aircraft was climbing at 12O of pitch with reference to the flight director. As a precaution, after closing No. 1 power lever he reduced the angle of climb to 6O. At the same time the co-pilot (Captain B) who had reached for the check list and was looking for the page relating to an engine emergency, became aware of a sharp reduction in the aircraft's acceleration; he noticed that the undercarriage was still down and he retracted it immediately. According to the crew the aircraft reached a maximum height of 250 ft, after which a progressive loss of momentum became evident. A maximum speed of 1401145 kt was achieved immediately after rotation, but it fell to 127 kt after No. 1 engine had been throttled back, These figures were consistent with those subsequently derived from the flight recorder. The crew said that the stick-shaker operated three times between 125 and 115 kt. The co-pilot had a vague recollection that the stick-push and the warning klaxon operated during the critical phase before impact. The pilot-in-charge remembered vaguely that someone said "raise the flaps", but no crew member remembers doing so or making the re traction. On looking out of the aircraft the crew saw the ground and the obstructions close at hand and realized that contact of the aircraft with the ground was inevitable and imminent. Captain A controlled the aircraft extremely well during the touchdown; the aircraft slid along the snow-covered surface, passing over small obstructions, and came to a halt 470 m from the point of first contact with the ground (see Fig. 1-11. The co-pilot operated both engine fire-extinguishers and Captain C ordered the pilots to leave the aircraft immediately via the side windows. During the ground slide an orange glow was seen to light up the glass panels of the windows for a short time. There was no fire. After closing No. 1 power lever, Captain A remembered having ordered the shutdown drill for this engine but he could not say for certain whether this wae dme. It was established, however, that Captain B closed both the HP cocks at the first sensation of ground contact.
Probable cause:
The accident must be attributed to a combination of factors following a compressor bang/surge in No. 2 engine immediately after take-off and the aircraft crashed because the crew, after fully closing No. 1 throttle in error, failed to recognize their mistake and, in addition, were not aware that the thrust of No. 2 engine had also been partially reduced after an inadvertent displacement of the relevant throttle lever. The following findings were reported:
- A segment of the HP turbine seal of No. 2 engine caused a compressor bang/ surge which led the crew to think that there was a serious engine malfunction. The loss of thrust attributable to this defect was negligible,
- Tests have shown that there were no defects or failures of the engine fuel system or fuel controls which could be associated with the loss of thrust over and above that resulting from the deliberate throttling of No. 1 engine,
- N° 1 engine was throttled back after an erroneous order or piece of advice and its throttle lever was pulled rearwards rapidly,
- The major loss of thrust in No. 2 engine was probably due to the displacement of the throttle lever by a crew member and to the fact that its partially open position remained unnoticed during the period of confusion preceding the emergency landing,
- The incorrect diagnosis of a malfunction of No. 1 engine after the bangleurge can be attributed to the hasty intervention of the pilot-in-command and this could be attributed to fatigue, aggravated by the long duty period,
- In rapidly throttling back No. 1 engine, the pilot-in-charge promptly executed without question what he thought to be an order instead of waiting until a greater height was reached and then taking any appropriate action,
- The judgement and actions of the pilot-in-charge were influenced by the presence of an experienced pilot designated as pilot-in-command, although the latter's specific task was the supervision of the co-pilot,
- If the aircraft pilot-in-command had been seated at the controls, he might have acted correctly; similarly, if he had been responsible solely for the supervision of the co-pilot and had not been designated as pilot-in-command, the pilot-in-charge would have had a wider and more responsible field of action and would very probably have complied with the company's prescribed drills.
Final Report:

Crash of a Douglas DC-8-62 off Los Angeles: 15 killed

Date & Time: Jan 13, 1969 at 1921 LT
Type of aircraft:
Operator:
Registration:
LN-MOO
Survivors:
Yes
Schedule:
Copenhagen – Seattle – Los Angeles
MSN:
45822/272
YOM:
1967
Flight number:
SK933
Crew on board:
9
Crew fatalities:
Pax on board:
36
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
11135
Captain / Total hours on type:
900.00
Copilot / Total flying hours:
5814
Copilot / Total hours on type:
973
Aircraft flight hours:
6948
Circumstances:
The aircraft crashed in Santa Monica Bay, approximately 6 nautical miles west at 1921LT. The aircraft was operating as flight SK933 from Seattle, Washington, to Los Angeles, following a flight from Copenhagen, Denmark. A scheduled crew change occurred at Seattle for the flight to Los Angeles. The accident occurred in the waters of Santa Monica Bay while the crew attempting an instrument approach to runway O7R at Los Angeles International Airport. Of the 45 persons aboard the aircraft, 3 passengers and one cabin attendant drowned, 9 passengers and 2 cabin attendants are missing and presumed dead; 11 passengers and 6 crew members including the captain, the second pilot, and the systems operator, were injured in varying degrees; and 13 passengers escaped without reported injury. The aircraft was destroyed by impact. The fuselage broke into three pieces, two of which sank approximately 350 feet of water. The third section including the wings, the forward cabin and the cockpit, floated for about 20 hours before being towed into shallow water where it sank. This section was later recovered and removed from the water. The weather at Los Angeles International Airport was generally: 1,700 feet broken, 3,500 feet overcast; visibility 4 miles in light rain and fog, wind 060° at 10 knots; and the altimeter setting was 29.87 inches of mercury. The weather in the accident area was reported to be similar.
Probable cause:
The lack of crew coordination and the inadequate monitoring of the aircraft position in space during a critical phase of an instrument approach which resulted in an unplanned descent into the water. Contributing to this unplanned descent was an apparent unsafe landing gear condition induced by the design of the landing gear indicator lights, and the omission of the minimum crossing altitude at an approach fix depicted on the approach chart.
Final Report:

Crash of a Douglas C-47A-90-DL in Loanda

Date & Time: Jan 11, 1969
Operator:
Registration:
PP-SPR
Survivors:
Yes
MSN:
20544
YOM:
1944
Location:
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crash landed at Loanda Airport in unclear circumstances. No casualties.

Crash of an Antonov AN-2 near Malka: 2 killed

Date & Time: Jan 10, 1969 at 1133 LT
Type of aircraft:
Operator:
Registration:
CCCP-70940
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Petropavlovsk-Kamchatsky – Kozyrevsk – Esso
MSN:
1116 473 16
YOM:
1959
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
6557
Circumstances:
On the leg from Khalaktyrka to Kozyrevsk of a flight from Khalaktyrka to Esso when the crew decided to take the route over the mountains instead of the route along the valleys although the weather conditions did not allow such deviation. The aircraft entered clouds and crashed under control at a height of 1,230 metres on the slope of a mountain (1,280 metres) located in the Ganalskiye gory range, some 16 km east of Malka (Yelizovo district of Kamchatka). The airplane then slid down on the slope for 700 metres before coming to rest in the valley of the Zubastaya River. Both pilots were killed while all 11 passengers were injured (8 of them seriously). The wreckage and the survivors were found a day later, on 11JAN69.
Probable cause:
Wrong decision on part of the flying crew who deviated from the published procedures and followed a non-compliant route. The accident was the consequence of a controlled flight into terrain.

Crash of a Convair CV-580 in Bradford: 11 killed

Date & Time: Jan 6, 1969 at 2035 LT
Type of aircraft:
Operator:
Registration:
N5825
Survivors:
Yes
Schedule:
Washington DC – Harrisburg – Bradford – Erie – Detroit
MSN:
386
YOM:
1956
Flight number:
AL737
Crew on board:
3
Crew fatalities:
Pax on board:
25
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
5761
Captain / Total hours on type:
499.00
Copilot / Total flying hours:
8220
Copilot / Total hours on type:
738
Aircraft flight hours:
27285
Circumstances:
Allegheny Airlines Flight 737 was a scheduled passenger flight from Washington, DC, to Detroit, MI, with en route stops at Harrisburg, Bradford, and Erie, PA. The flight was uneventful until it arrived in the Bradford area, about 20:22. About 20:23, Erie Approach Control asked flight 737 to report their distance to the airport: "Allegheny seven thirty seven, what are you showing DME from Bradford?". Upon which the crew replied, "Fifteen". Erie Approach Control then instructed, "... descend and cruise four thousand via Victor thirty three and cleared for the VOR thirty two (runway 32) approach to the Bradford Airport, report leaving six and Bradford's current weather sky partially obscured, measured ceiling eight hundred overcast, visibility one and one half and light snow showers, wind one seventy degrees at ten (knots) Bradford altimeter twenty nine point four nine." At ten miles from the airport Flight 737 asked for clearance to make its instrument approach to runway 14 instead of runway 32. The Bradford FSS Specialist obtained approval for this change from Erie Approach Control and so advised the flight. At 20:31 the flight reported completing the procedure turn inbound. The Convair clipped treetops 4,7nm short of the airport and cut a swath through trees bordering a fairway of the Pine Acres Golf Course. The aircraft came to rest inverted. Both pilots and 9 passengers were killed while 17 other occupants were injured. The aircraft was destroyed.
Probable cause:
Investigations were unable to determine precisely the probable cause of this accident. Of some 13 potential causes examined by the Board, three remain after final analysis. They are:
- Misreading of the altimeter by the captain,
- A malfunction of the captain's altimeter after completion of the instrument approach procedure turn, and
- A misreading of the instrument approach chart. Of these three, no single one can be accepted or rejected to the exclusion of another based on the available evidence.
Final Report:

Crash of a Boeing 727-113C in London: 50 killed

Date & Time: Jan 5, 1969 at 0134 LT
Type of aircraft:
Operator:
Registration:
YA-FAR
Survivors:
No
Schedule:
Kabul - Kandahar - Beirut - Istanbul - Frankfurt - London
MSN:
19690/540
YOM:
1968
Flight number:
FG701
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
54
Pax fatalities:
Other fatalities:
Total fatalities:
50
Captain / Total flying hours:
10400
Captain / Total hours on type:
512.00
Copilot / Total flying hours:
3259
Copilot / Total hours on type:
210
Aircraft flight hours:
1715
Circumstances:
The accident occurred on a scheduled passenger flight from Frankfurt when the aircraft was making an ILS approach for a night landing on Runway 27 at Gatwick Airport. The weather was clear except that freezing fog persisted in places including the Gatwick area. The runway visual range (RVR) at Gatwick was 100 metres. The approach was commenced with the autopilot coupled to the instrument landing system (ILS) but after the glide-slope had been captured the commander who was at the controls, disconnected the autopilot because the "stabiliser out of trim" warning light illuminated. At the outer marker the flap setting was changed from 1° to 30° and shortly afterwards the rate of descent increased and the aircraft descended below the glide-slope. Some 200 feet from the ground the pilot realised that the aircraft was too low and initiated a missed approach procedure. The aircraft began to respond but the descent was not arrested in time to avoid a collision with trees and a house that destroyed both the aircraft and the house and set the wreckage on fire. 48 occupants as well as two people in the house were killed. 14 others were injured. The aircraft was totally destroyed by impact forces and a post crash fire.
Probable cause:
The accident was the result of the commander inadvertently allowing the aircraft to descend below the glide slope during the final stage of an approach to land until it was too low for recovery to be effected. The following findings were reported:
- The deceptive nature of the weather conditions led the commander to an error of judgment in deciding to make an approach to Gatwick,
- The commander's decision to conduct an approach was not in itself a cause of the accident,
- Incorrect flap configuration at glide-slope interception led to a temporary out-of-trim condition during the automatic approach and the illumination of the stabilizer "out-of-trim" warning light,
- The commander interpreted the "out-of-trim" warning light as indicating a possible malfunction and disconnected the auto-pilot,
- Out-of-sequence and late selection of 30° flaps from 15° while the-aircraft was being flown manually resulted in an increase in the rate of descent, causing the aircraft to go rapidly below the glide-slope,
- The commander did not become aware of the deviation from the glide-slope until it was too late to effect a full recovery,
- The pilot's attention was probably directed outside the aircraft at the critical time in an attempt to discover sufficient visual reference to continue the approach rather than to the flight instruments,
- Monitoring by precision approach radar would have warned the pilots of the deviation in time, if corrective action was taken promptly, to avoid the accident.