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:

Crash of a Boeing 737-247 in Mwanza

Date & Time: Mar 1, 2010 at 0745 LT
Type of aircraft:
Operator:
Registration:
5H-MVZ
Survivors:
Yes
Schedule:
Dar es-Salaam - Mwanza
MSN:
23602/1347
YOM:
1987
Flight number:
ACT100
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
76
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Mwanza Airport, the crew encountered control problems. The aircraft deviated to the left then veered off runway. While contacting soft ground, the nose gear collapsed and the aircraft came to rest near a taxiway. All 80 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an ATR42-300 near Balikpapan

Date & Time: Feb 11, 2010 at 1150 LT
Type of aircraft:
Operator:
Registration:
PK-YRP
Flight Phase:
Survivors:
Yes
Schedule:
Tanjung Redep - Samarinda
MSN:
50
YOM:
1987
Flight number:
TGN162
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Copilot / Total flying hours:
2000
Aircraft flight hours:
34414
Aircraft flight cycles:
42107
Circumstances:
On 11 February 2010, an Avions de Transport Regional ATR 42-300 aircraft, registered PK-YRP, was being operated by Trigana Air Service on a scheduled passenger service between Kalimarau Airport Berau (BEJ) and Samarinda (SRI) as flight TGN162. There were 52 persons on board; two pilots, one engineer, two flight attendants, one flight dispatcher and 46 passengers (43 adults, one child, and two infants). The aircraft departed from Berau at 0230 UTC1 and climbed to Flight Level 140. Balikpapan approach cleared the crew to track from en-route Way Point LOLOT direct to Samarinda. After transferring to Temindung Tower, Samarinda, the crew was cleared to track direct to left downwind for runway 04. The controller informed them that the wind was 060/12 knots. The crew did not report any abnormalities and the aircraft operation appeared to be normal. During the final approach for runway 04, the left ECU light illuminated followed by low oil pressure and torque indications. The Pilot in Command decided to go around, divert to Balikpapan, and carry out the QRH engine shut-down procedure. They commenced the climb to 4000 ft with the left engine inoperative. Approximately 16 Nm from Balikpapan Airport, while climbing through 3,800 feet, the right ECU light illuminated, immediately followed by low oil pressure and low torque indications. The right engine then failed. The crew broadcast a MAYDAY to Balikpapan Approach and decided to conduct a forced landing into a clear field in the Samboja area, about 16 Nm from the Balikpapan Airport. The PIC gave instructions to the Flight Attendant to prepare the passengers for an emergency landing. After the aircraft came to a stop the PIC initiated an evacuation.
Probable cause:
The both engine were lack of fuel before flame out, it was indicated the fuel management was out of control during flight that might be a misleading of fuel quantity indication. The proper analysis could not be carried out due to both FDR and CVR were un-operated.
Final Report:

Crash of a Yakovlev Yak-40 in Luanda

Date & Time: Jan 31, 2010 at 1513 LT
Type of aircraft:
Operator:
Registration:
D2-FES
Survivors:
Yes
Schedule:
Cabinda – Luanda
MSN:
9341431
YOM:
1973
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
34
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Cabinda, the aircraft landed on runway 25 when all three gears collapsed. The aircraft slid on its belly for few dozen metres before coming to rest by taxiway Bravo. While all 37 occupants were uninjured, the aircraft was damaged beyond repair.

Crash of an Embraer EMB-110C Bandeirante in Senador José Porfirio: 2 killed

Date & Time: Jan 25, 2010 at 1320 LT
Operator:
Registration:
PT-TAF
Survivors:
Yes
Schedule:
Belém - Senador José Porfirio
MSN:
110-103
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12350
Captain / Total hours on type:
3887.00
Copilot / Total flying hours:
701
Copilot / Total hours on type:
265
Circumstances:
Following an uneventful flight from Belém, the crew started the descent to Senador José Porfirio-Wilma Rebelo Airport in marginal weather conditions. On approach, the crew noticed an elevation of the left engine turbine temperature. The captain reduced the power on both engines and elected to make an emergency landing when the aircraft stalled and crashed in an open field located 4 km short of runway. The captain and a passenger were killed. All eight other occupants were killed, three seriously. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- Weather conditions made it difficult for the crew to locate the runway;
- The crew failed to follow the emergency procedures and was unable to keep the aircraft level;
- The captain did not feather the left propeller, which resulted in increased drag and reduced aircraft speed;
- The engine maintenance did not meet the engine manufacturer's requirements;
- No technical overhaul of the left engine had been carried out despite the fact that the 12-year calendar limit set by the manufacturer had been exceeded;
- A nipple mounted on the left propeller governor was not intended for aeronautical use;
- The poor seal caused by the improper connection allowed the pressure to drop, resulting in a loss of power on the left engine;
- Poor organizational culture by the operator, which compromised the safety of the operation;
- The company did not have an effective supervision program;
- Poor judgment on part of the captain;
- Poor aircraft maintenance.
Final Report:

Crash of a Boeing 737-8AS off Beyrouth: 90 killed

Date & Time: Jan 25, 2010 at 0241 LT
Type of aircraft:
Operator:
Registration:
ET-ANB
Flight Phase:
Survivors:
No
Schedule:
Beirut - Addis Ababa
MSN:
29935/1061
YOM:
2002
Flight number:
ET409
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
90
Captain / Total flying hours:
10233
Captain / Total hours on type:
188.00
Copilot / Total flying hours:
673
Copilot / Total hours on type:
350
Aircraft flight hours:
26459
Aircraft flight cycles:
17823
Circumstances:
On 25 January 2010, at 00:41:30 UTC, Ethiopian Airlines flight ET 409, a Boeing 737-800 registered ET-ANB, crashed into the Mediterranean Sea about 5 NM South West of Beirut Rafic Hariri International Airport (BRHIA), Beirut, Lebanon. ET 409 was being operated under the provisions of the Ethiopian Civil Aviation Regulations (ECAR) and as a scheduled international flight between BRHIA and Addis Ababa Bole International Airport (ADD) - Ethiopia. It departed Beirut with 90 persons on board: 2 flight crew (a Captain and a First Officer), 5 cabin crew, an IFSO and 82 regular passengers. The flight departed at night on an instrument flight plan. Low clouds, isolated cumulonimbus (CB) and thunderstorms were reported in the area. The flight was initially cleared by ATC on a LATEB 1 D departure then the clearance was changed before take-off to an “immediate right turn direct Chekka”. After take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315°. ET 409 acknowledged and heading 315° was selected on the Mode Control Panel (MCP). As the aircraft was on a right turn, Control suggested to ET 409 to follow heading 270° “due to weather”. However, ET 409 continued right turn beyond the selected heading of 315° and Control immediately instructed them to “turn left now heading 270°”. ET 409 acknowledged, the crew selected 270° on the MCP and initiated a left turn. ET 409 continued the left turn beyond the instructed/selected heading of 270° despite several calls from ATC to turn right heading 270° and acknowledgment from the crew. ET 409 reached a southerly track before sharply turning left until it disappeared from the radar screen and crashed into the sea 4‟ 59” after the initiation of the take-off roll (4‟17” in the air). The aircraft impacted the water surface around 5 NM South West of BRHIA and all occupants were fatally injured. Search and Rescue (S&R) operations were immediately initiated. The DFDR and CVR were retrieved from the sea bed and were read, as per the Lebanese Government decision, at the BEA facility at Le Bourget, France. The recorders data revealed that ET 409 encountered during flight two stick shakers for a period of 27” and 26”. They also recorded 11 “Bank Angle” aural warnings at different times during the flight and an over-speed clacker towards the end of the flight. The maximum recorded AOA was 32°, maximum recorded bank angle was 118° left, maximum recorded speed was 407.5 knots, maximum recorded G load was 4.76 and maximum recorded nose down pitch value 63.1°. The DFDR recording stopped at 00:41:28 with the aircraft at 1291‟. The last radar screen recording was at 00:41:28 with the aircraft at 1300‟. The last CVR recording was a loud noise just prior to 00:41:30.
Probable cause:
Probable Causes:
1- The flight crew's mismanagement of the aircraft's speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.
2- The flight crew failure to abide by CRM principles of mutual support and calling deviations hindered any timely intervention and correction.
Contributing Factors:
1- The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.
2- The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.
3- The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and lead to loss of situational awareness.
4- The relative inexperience of the Flight Crew on type combined with their unfamiliarity with the airport contributed, most likely, to increase the Flight Crew workload and stress.
5- The consecutive flying (188 hours in 51 days) on a new type with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the captain's performance.
6- The heavy meal discussed by the crew prior to take-off has affected their quality of sleep prior to that flight.
7- The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed in the increase of the crew workload and stress level.
8- Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.
9- The F/O reluctance to intervene did not help in confirming a case of captain's subtle incapacitation and/or to take over control of the aircraft as stipulated in the operator's SOP.
Final Report:

Crash of a Tupolev TU-154M in Mashhad

Date & Time: Jan 24, 2010 at 0720 LT
Type of aircraft:
Operator:
Registration:
RA-85787
Survivors:
Yes
Schedule:
Abadan - Machhad
MSN:
93A971
YOM:
1993
Flight number:
TBM6437
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The three engine aircraft departed Abadan for a night flight to Mashhad. Due to poor weather conditions at destination, the crew diverted to Isfahan Airport. The aircraft departed Isfahan Airport at 0535LT bound to Mashhad. While on an ILS approach in thick fog, the aircraft was in a nose high attitude when the base of the empennage struck the runway surface and separated. On impact, the undercarriage were torn off. Out of control, the aircraft slid for few dozen metres, veered off runway and came to rest with both wings partially torn off, bursting into flames. At least 46 occupants were injured while the aircraft was partially destroyed by fire. Vertical visibility was 200 feet at the time of the accident due to fog.
Probable cause:
The following findings were reported:
- The visibility was below minimums,
- The crew continued the approach despite the aircraft attitude was incorrect,
- The crew failed to initiate a go-around procedure.

Ground accident of a Saab 340A in Nassau

Date & Time: Jan 7, 2010 at 1145 LT
Type of aircraft:
Operator:
Registration:
C6-SBE
Flight Phase:
Survivors:
Yes
Schedule:
Nassau - Marsh Harbour
MSN:
99
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two crew took place in the cockpit to prepare the aircraft for a scheduled commercial service to Marsh Harbour. In unknown circumstances, all three landing gear retracted, causing the aircraft to fall on the ground. Both occupants were uninjured while the aircraft was damaged beyond repair. It is unknown if the retraction of the undercarriage was the consequence of a mechanical failure or a mishandling from the crew.