Crash of an Embraer 135 in George

Date & Time: Dec 7, 2009 at 1101 LT
Type of aircraft:
Operator:
Registration:
ZS-SJW
Survivors:
Yes
Schedule:
Cape Town - George
MSN:
145-423
YOM:
2001
Flight number:
SA8625
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11973
Captain / Total hours on type:
2905.00
Copilot / Total flying hours:
2336
Copilot / Total hours on type:
864
Aircraft flight hours:
21291
Aircraft flight cycles:
17003
Circumstances:
Flight SA8625 departed from Cape Town International Airport on a domestic scheduled flight to George Airport (FAGG) with three crew members and 32 passengers on board. The weather at FAGG was overcast with light rain, and the aircraft was cleared for an instrument landing system approach for runway 11. It touched down between the third and fourth landing marker. According to the air traffic controller, the landing itself appeared normal, but the aircraft did not vacate the runway to the left as it should have. Instead, it veered to the right, overran the runway and rolled on past the ILS localiser. Realising that something was wrong, he activated the crash alarm. The cockpit crew did not broadcast any messages to indicate that they were experiencing a problem. The aircraft collided with eleven approach lights before bursting through the aerodrome perimeter fence and coming to rest in a nose-down attitude on the R404 public road. Several motorists stopped and helped the passengers, who evacuated the aircraft through the service door (right front) and left mid-fuselage emergency exit. The aerodrome fire and rescue personnel arrived within minutes and assisted with the evacuation of the cockpit crew, who were trapped in the cockpit. Ten occupants were admitted to a local hospital for a check-up and released after a few hours. No serious injuries were reported.
Probable cause:
The crew were unable to decelerate the aircraft to a safe stop due to ineffective braking of the aircraft on a wet runway surface, resulting in an overrun.
Contributory factors:
- The aircraft crossed the runway threshold at 50 ft AGL at 143 KIAS, which was 15 kt above the calculated VREF speed.
- Although the aircraft initially touched down within the touchdown zone the transition back into air mode of 1.5 seconds followed by a 4 second delay in applying the brakes after the aircraft remained in permanent ground mode should be considered as a significant contributory factor to this accident as it was imperative to decelerate the aircraft as soon as possible.
- Two of the four main tyres displayed limited to no tyre tread. This was considered to have degraded the displacement of water from the tyre footprint, which had a significant effect on the braking effectiveness of the aircraft during the landing rollout on the wet runway surface.
Several non-compliance procedures were not followed.
Final Report:

Crash of a Fokker 100 in Kupang

Date & Time: Dec 2, 2009 at 2215 LT
Type of aircraft:
Operator:
Registration:
PK-MJD
Survivors:
Yes
Schedule:
Ujung Pandang - Kupang
MSN:
11474
YOM:
1993
Flight number:
MZ5840
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
88
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18776
Copilot / Total flying hours:
7074
Aircraft flight hours:
29637
Aircraft flight cycles:
29450
Circumstances:
PK-MJD was on passenger schedule flight from Sultan Hasanuddin Airport, Makassar with destination El Tari Airport, Kupang, East Nusa Tenggara. The flight number was Merpati 5840 and carried 94 person on board consist of 88 passengers including four children and four infants, two pilot and four flight attendant. A maintenance engineer was on-board in this flight. Acting as pilot flying was the Second in Command (SIC) while the Pilot in Command acted as Pilot Monitoring. On approach, the pilot selected landing gear to down position. The left main landing gear indicator light was showed red, its means that the left main landing gear was not in down position and unsafe for landing. The pilot reported to the Air Traffic Controller (ATC) for a go-around and requested an area for holding to solve the problem. The ATC gave a clearance to hold over Kupang bay. The pilot tried to solve the problem by conducting the procedure according to the emergency checklist, including selected the landing gear by alternate selector. The pilot then requested to the ATC to fly at low altitude over the airport and asked to the ATC to observe the landing gear condition. The pilot also asked through the company radio for an engineer on-ground to observe visually the landing gear condition. The pilot then returned to the holding area, repeated the procedure but unsuccessful. Both pilots and engineer had a discussion and decided to attempt un-procedural method to make the landing gear down. Prior making these efforts the pilot announced to the passengers about the problem and their attempts that might be unpleasant to the passengers. After all attempts to lower the landing gear had failed, the pilot decided to land with the left main landing gear in up position. The pilot also asked the flight attendant to prepare for an abnormal landing. The ATC were prepared the airport fire fighting and ambulance, and also contacted the local police, armed forces, and hospitals and asking for additional ambulances. The ATC then informed the pilot that the ground support was ready. On short final the pilot instructed ‘brace for impact’ and the FA repeated that instruction to all passengers. The aircraft touched down at the touch down zone on runway 07. The pilot flying held the left wing as long as possible and kept the aircraft on the centre line, and the pilot monitoring shut down both engines. The aircraft stopped at about 1,200 meters from the beginning of runway 07, on the left shoulder of the runway and the FA instructed to the passengers to keep calm and to evacuate the aircraft. The pilot continued the procedures for emergency. The evacuation was performed through all door and window exits. No one was injured on this serious incident.
Probable cause:
The debris trapped in the chamber between the orifice and the stopper of the restrictor check valve, it caused the orifice closed. This condition was resulted the hydraulic flow from the actuator blocked and caused the left main landing gear jammed at up position.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Lyall Haarbour: 6 killed

Date & Time: Nov 28, 2009 at 1603 LT
Type of aircraft:
Operator:
Registration:
C-GTMC
Flight Phase:
Survivors:
Yes
Schedule:
Vancouver - Mayne Island - Pender Island - Lyall Harbour - Vancouver
MSN:
1171
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2800
Captain / Total hours on type:
2350.00
Circumstances:
The Seair Seaplanes Beaver was departing Lyall Harbour, Saturna Island, for the water aerodrome at the Vancouver International Airport, British Columbia. After an unsuccessful attempt at taking off downwind, the pilot took off into the wind towards Lyall Harbour. At approximately 1603 Pacific Standard Time, the aircraft became airborne, but remained below the surrounding terrain. The aircraft turned left, then descended and collided with the water. Persons nearby responded immediately; however, by the time they arrived at the aircraft, the cabin was below the surface of the water. There were 8 persons on board; the pilot and an adult passenger survived and suffered serious injuries. No signal from the emergency locator transmitter was heard.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The combined effects of the atmospheric conditions and bank angle increased the load factor, causing an aerodynamic stall.
2. Due to the absence of a functioning stall warning system, in addition to the benign stalling characteristics of the Beaver, the pilot was not warned of the impending stall.
3. Because the aircraft was loaded in a manner that exceeded the aft CG limit, full stall recovery was compromised.
4. The altitude from which recovery was attempted was insufficient to arrest descent, causing the aircraft to strike the water.
5. Impact damage jammed 2 of the 4 doors, restricting egress from the sinking aircraft.
6. The pilot’s seat failed and he was unrestrained, contributing to the seriousness of his injuries and limiting his ability to assist passengers.
Findings as to Risk:
1. There is a risk that pilots will inadvertently stall aircraft if the stall warning system is unserviceable or if the audio warnings have been modified to reduce noise levels.
2. Pilots who do not undergo underwater egress training are at greater risk of not escaping submerged aircraft.
3. The lack of alternate emergency exits, such as jettisonable windows, increases the risk that passengers and pilots will be unable to escape a submerged aircraft due to structural damage to primary exits following an impact with the water.
4. If passengers are not provided with explicit safety briefings on how to egress the aircraft when submerged, there is increased risk that they will be unable to escape following an impact with the water.
5. Passengers and pilots not wearing some type of flotation device prior to an impact with the water are at increased risk of drowning once they have escaped the aircraft.
Final Report:

Crash of a McDonnell Douglas MD-82 in Goma

Date & Time: Nov 19, 2009 at 1100 LT
Type of aircraft:
Operator:
Registration:
9Q-CAB
Survivors:
Yes
Schedule:
Kinshasa - Goma
MSN:
49702/1479
YOM:
1988
Flight number:
E93711
Location:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
111
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 36 at Goma Airport, the aircraft failed to stop within the remaining distance. It overran and came to rest in a rocky lava field. At least 20 passengers were injured while the aircraft was damaged beyond repair. At the time of the accident, the runway was wet.

Crash of a Canadair RegionalJet CRJ-100ER in Kigali: 1 killed

Date & Time: Nov 12, 2009 at 1315 LT
Operator:
Registration:
5Y-JLD
Flight Phase:
Survivors:
Yes
Schedule:
Kigali - Entebbe
MSN:
7197
YOM:
1997
Flight number:
WB205
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
11478
Captain / Total hours on type:
1110.00
Copilot / Total flying hours:
1558
Copilot / Total hours on type:
533
Aircraft flight hours:
17140
Aircraft flight cycles:
17025
Circumstances:
Shortly after takeoff, when the Copilot pulled back the thrust levers of both engines to the desired positions, the thrust lever on left engine could not move and the engine remained in full power. The Pilot in Command (PIC) then informed Air Traffic Controller (ATC) that the aircraft had a technical problem and requested to return to the airport. The crew managed to land safely with the Copilot and accompanying company maintenance engineer struggling to control the left engine which was on high power setting and the PIC controlling the aircraft using only the right hand engine. The aircraft taxied to parking bay number 4 with the left engine still in full power. The captain applied the parking brake and the aircraft stopped for a while and before putting on the chocks, the aircraft started moving forward at a high speed through the jet blast fence and crashed into Control Tower building. A passenger was killed, six people were injured, three seriously.
Probable cause:
The flight crew’s failure to identify corrective action and their lack of knowledge of applicable airplane and engine systems in response to a jammed thrust lever, which resulted in the number 1 engine operating at high power and the airplane configured in an unsafe condition that led to the need to apply heavy braking during landing. Also causal was the flightcrew failure to recognize the safety hazard that existed from overheated brakes and the potential consequence on the braking action needed to park the airplane. Contributing factors included the possible failure by maintenance crew to correctly stow the upper core cowl support strut after maintenance, Flight crew’s failure to follow standard operating procedures, the company’s failure to be availed to manufacturer safety literature on the subject, and the susceptibility of the cowl core support shaft to interfere with the throttle control mechanism when the core strut is not in its stowed position.
Final Report:

Crash of an ATR72-212 in Mumbai

Date & Time: Nov 10, 2009 at 1640 LT
Type of aircraft:
Operator:
Registration:
VT-KAC
Survivors:
Yes
Schedule:
Bhavnagar - Mumbai
MSN:
729
YOM:
2006
Flight number:
IT4124
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7160
Captain / Total hours on type:
2241.00
Copilot / Total flying hours:
973
Copilot / Total hours on type:
613
Aircraft flight hours:
9318
Circumstances:
As per the NOTAM, Runway 14/32 was under permanent maintenance on every Tuesdays since 10/11/2009 runway 27 was available only after runway intersection as runway 27A. To carry out operations on this reduced runway 27 a NOTAM ‘G’ No. G 0128/08 was issued by AAI on the same day of accident i.e. 10-11-2009 and designated as runway 27A for visual approach only. As per the NOTAM Landing Distance Available (LDA)/take off Distance available (TODA) was 1703 m. The weather conditions prevailing at the time of accident was winds 070/07 knots visibility 2800 m with feeble rain. Prior to Kingfisher aircraft, Air India aircraft IC-164, Airbus 319 had landed and reported to ATC that it had aquaplaned and broken two runway edge lights. The ATC acknowledged it and sent runway inspection vehicle to inspect the runway. The ATC person was not familiar with the terminology of ‘aquaplaning’ and not realizing the seriousness of it, cleared kingfisher aircraft for landing. At the time of accident there were water patches on the runway. ATC also did not transmit to the Kingfisher aircraft the information regarding aquaplaning reported by the previous aircraft. The DFDR readout revealed that kingfisher aircraft was not on profile as per localizer procedure laid down in NOTAM ‘G’ and was high and fast. The aircraft landed late on the runway and the runway length available was around 1000 m from the touchdown point. In the prevailing weather conditions this runway length was just sufficient to stop the aircraft on the runway. During landing the kingfisher aircraft aquaplaned and did not decelerate even though reversers and full manual braking was applied by both the cockpit crew. The aircraft started skidding toward the left of center line. On nearing the runway end, the pilot initiated a 45 ° right turn, after crossing ‘N 10’ Taxi track, the aircraft rolled into unpaved wet area. Aircraft rolled over drainage pipes & finally came to a stop near open drain. There was no fire. All the passenger safely deplaned after the accident.
Probable cause:
The accident occurred due to an unstabilized approach and decision of crew not to carry out a ‘Go-around’.
Contributory Factors:
i) Water patches on the runway 27
ii) Inability of the ATCO to communicate the aircraft about aquaplaning of the previous aircraft
iii) Lack of input from the copilot.
Final Report:

Crash of a Xian MA60 in Harare

Date & Time: Nov 3, 2009 at 1936 LT
Type of aircraft:
Operator:
Registration:
Z-WPJ
Flight Phase:
Survivors:
Yes
Schedule:
Harare - Bulawayo
MSN:
03 01
YOM:
2005
Flight number:
UM239
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
34
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Harare Airport, the aircraft was bout to lift off when it collided with five warthogs, causing the left main gear to be torn off. Out of control, the aircraft veered off runway to the left and came to rest. All 38 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Loss of control during takeoff following a collision with five warthogs.

Crash of a Britten-Norman BN-2A-8 Islander off Kralendijk: 1 killed

Date & Time: Oct 22, 2009 at 1017 LT
Type of aircraft:
Operator:
Registration:
PJ-SUN
Survivors:
Yes
Schedule:
Willemstad – Kralendijk
MSN:
377
YOM:
1973
Flight number:
DVR014
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1738
Captain / Total hours on type:
565.00
Aircraft flight hours:
16670
Circumstances:
On 22 October the pilot concerned got up at 05.00 and drove towards the airport at about 05.30. After preparing the aircraft, with registration PJ-SUN, he piloted two return flights from Curaçao International Airport (hereinafter to be referred to as Hato airport) to Bonaire International Airport (hereinafter to be referred to as Flamingo airport). No problems occurred during these four flights. The departure for the next flight, “DVR014”, was planned at 09.30. The nine passengers booked for this flight, who had already had their luggage weighed, had to wait before they could board because the pilot had ordered the aircraft to be refuelled prior to this flight. The refuelling invoice of flight DVR014 specifies that fuel was taken up between 09.28 and 09.38. The luggage of these passengers and some additional cargo consisting of a few boxes had already been loaded on to the aircraft. The passengers were welcomed by the pilot when they boarded. The pilot informed them they should keep their waist belts fastened during the flight and that the safety cards were located in the seat pockets. From the passenger statements it can be deduced that these instructions were not heard by all of the passengers. The pilot and the passenger seated next to him fastened their waist and shoulder belts. Approximately ten minutes after the estimated time of departure, after having received the required approval from the Hato Tower air traffic control tower (hereinafter to be referred to as Hato Tower) via the on-board radio the engines were started without any problems. The flight manual engine ground checks were not extensively performed because these are part of the first flight of the day engine checks in accordance with the General Operating Manual. Around 09.47 the PJ-SUN took off for a flight with visual flight rules (VFR) to Bonaire. After take-off the aircraft climbed to flight level 035 (FL035). Some of the passengers had flown for some years, several times in a week with Divi Divi Air. From the passenger statements it can be deduced that the pilot brought the aircraft into level flight at FL035 and reduced the power from climb power to cruise power. The passenger next to the pilot stated that engine power ceased the moment that the pilot was adjusting (one of) the levers on the throttle quadrant. Some passengers reported they felt a jolt that moment. Some passengers reported the engine sputtered shortly before it ceased. No sound from which a mechanical problem was heard and no smoke was detected. Passengers stated that the pilot increased the left engine power, feathered the right propeller and trimmed away the forces to the rudder pedals due to the failure of the right engine. They also reported that the pilot attempted to restart the right engine two or three times but to no avail. Around 09.52 the pilot reported to the Hato Tower controller: Divi 014 requesting to switch to Flamingo, priority landing with Flamingo, have lost one of the engines. The controller acknowledged this message. The pilot continued the flight to Bonaire flying with the left engine running and contacted Flamingo Tower air traffic control (hereinafter to be referred to as Flamingo Tower) at 09.57 and reported: 014, Islander inbound from Curaçao, showing, I got one engine out, so we are landing with one engine, no emergency at this stage, I’m maintaining altitude at, 3000 feet, we request priority to landing runway 10, currently 24 miles out, estimating at, 18. The Flamingo Tower controller authorized the approach to runway 10. The air traffic controller requested the pilot to report when he left 3000 feet altitude, which he immediately did. The radar data shows that the PJ-SUN descended approximately 140 feet per minute on average from the moment the engine failed up to the emergency landing. According to the statements of a few of the passengers, the aircraft pitch attitude increased during the descent of the aircraft and it was higher than usual. The indicated airspeed on the airspeed indicator was lower than when flying with two working engines. The pilot did not inform the passengers regarding the failure of the right engine or his intentions. A few passengers were concerned and started to put on the life jackets having retrieved them from under their seats. The passenger next to the pilot could not find his life jacket, while others had some trouble opening the plastic bags of the life jackets. They also agreed on a course of action for leaving the aircraft in case of an emergency landing in the water. At 10.08 the pilot informed the Flamingo Tower that he was approaching and was ten nautical miles away, flying at 1000 feet and expected to land in ten minutes. At 10.12 the pilot reported the distance to be eight nautical miles and that he was having trouble with the altitude which was 600 feet at that moment. The traffic controller authorized the landing. At 10.14 the pilot reported to be six nautical miles away and flying at an altitude of 300 feet. During the last radio contact at 10.15 the pilot indicated to be at five nautical miles distance flying at 200 feet and that he was still losing altitude. The pilot was going to perform an emergency landing near Klein Bonaire. The aircraft subsequently turned a little to the left towards Klein Bonaire. According to a few passengers, the pilot turned around towards them and indicated with hand signals that the aircraft was about to land and he gave a thumbs-up signal to ask whether everyone was ready for the approaching emergency landing. There were life jackets for all people on-board. The pilot, the passenger seated next to him and two passengers seated in the back row did not have their life jackets on. The passengers in rows two through to four had put on their life jackets. One passenger had put on his life jacket back to front. According to the statements of the passengers, the stall warning (loud tone) was activated on and off during this last part of the flight. A short time before the emergency landing until the moment of impact with the water the stall warning was continuously audible. From the statements of the passengers it follows the all cabin doors were closed throughout the descent and the landing. The passenger’ statements differ in describing the last part of the flight until the impact of the aircraft with the water surface. One passenger stated that the aircraft fell down from a low height and impacted the water with a blow. Other passengers mentioned a high or low aircraft pitch attitude during impact. Most of the passengers stated that during impact the left wing was slightly down. The aircraft hit the water at 10.17 at a distance of approximately 0.7 nautical miles from Klein Bonaire and 3.5 nautical miles west of Bonaire. The left front door broke off from the cabin and other parts of the aircraft on impact. The aircraft was lying horizontally in the water. The height of the waves was estimated 0.5 meter by one of the passengers. The cabin soon filled with water because the left front door had broken off and the windscreen had shattered. The passenger behind the pilot was trapped, but was able to free herself from this position. All nine passengers were able to leave the aircraft without assistance using the left front door opening and the emergency exits. A few passengers sat for a short time on the wings before the aircraft sank. The passengers formed a circle in the water. The passengers who were not wearing life jackets kept afloat by holding onto the other passengers. One passenger reported that the pilot hit his head on the vertical door/window frame in the cockpit or the instrument panel at impact causing him to lose consciousness and may even have been wounded. The attempts of one or two passengers to free the pilot from his seat were unsuccessful. A few minutes after the accident, the aircraft sank with the pilot still on-board. Approximately five minutes after the emergency landing, two boats with recreational divers who were nearby arrived on the scene. Divers from the first boat tried to localise the sunken aircraft based on indications from the passengers. The people on the other boat took nine passengers out of the water and set course to Kralendijk where they arrived at approximately 10.37. The police and other emergency services personnel were awaiting the passengers on the quay. Six passengers were transported to the hospital where they were discharged after an examination. The other three went their own way.
Probable cause:
The following factors were identified:
1. After one of the two engines failed, the flight continued to Bonaire. By not returning to the nearby situated departure airport, the safest flight operation was not chosen.
- Continuing to fly after engine failure was contrary to the general principle for twin-engine aircraft as set down in the CARNA, that is, to land at the nearest suitable airport.
2. The aircraft could not maintain horizontal flight when it continued with the flight and an emergency landing at sea became unavoidable.
- The aircraft departed with an overload of 9% when compared to the maximum structural take-off weight of 6600 lb. The pilot who was himself responsible (self-dispatch and release) for the loading of the aircraft was aware of the overloading or could have been aware of this. A non-acceptable risk was taken by continuing the flight under these conditions where the aircraft could not maintain altitude due to the overloading.
3. The pilot did not act as could be expected when executing the flight and preparing for the emergency landing.
- The landing was executed with flaps up and, therefore, the aircraft had a higher landing speed.
- The pilot ensured insufficiently that the passengers had understood the safety instructions after boarding.
- The pilot undertook insufficient attempts to inform passengers about the approaching emergency landing at sea after the engine failure and, therefore, they could not prepare themselves sufficiently.

Contributing factors:
Divi Divi Air
4. Divi Divi Air management paid insufficient supervision to the safety of amongst others the flight operation with the Britten-Norman Islanders. This resulted in insufficient attention to the risks of overloading.
Findings:
- The maximum structural take-off weight of 6600 lb was used as limit during the flight operation. Although this was accepted by the oversight authority, formal consent was not
granted for this.
- A standard average passenger weight of 160 lb was used on the load and balance sheet while the actual average passenger weight was significantly higher. This meant that passenger weight was often lower on paper than was the case in reality.
- A take-off weight of exactly 6600 lb completed on the load and balance sheet occurred in 32% of the investigated flights. This is a strong indication that the luggage and fuel weights completed were incorrect in these cases and that, in reality, the maximum structural take-off weight of 6600 lb was exceeded.
- Exceedances of the maximum structural landing weight of 6300 lb occurred in 61% of the investigated flights.
- The exceedance of the maximum allowed take-off weight took place on all three of the Britten-Norman Islander aircraft in use and with different pilots.
- Insufficient attention was paid to aircraft weight limitations during training.
- Lack of internal supervision with regard to the load and balance programme.
- Combining management tasks at Divi Divi Air, which may have meant that insufficient details were defined regarding the related responsibilities.
5. The safety equipment and instructions on-board the Britten-Norman Islander aircraft currently being used were not in order.
Findings:
- Due to the high noise level in the cabin during the flight it is difficult to communicate with the passengers during an emergency situation.
- The safety instruction cards did not include an illustration of the pouches under the seats nor instructions on how to open these pouches. The life jacket was shown with two and not a single waist belt and the life jackets had a different back than the actual life jackets on-board.
Directorate of Civil Aviation Netherlands Antilles (currently the Curaçao Civil Aviation Authority)
6. The Directorate of Civil Aviation’s oversight on the operational management of Divi Divi Air was insufficient in relation to the air operator certificate involving the Britten-Norman Islander aircraft in use.
Findings:
- The operational restrictions that formed the basis for using 6600 lb were missing in the air operator certificate, in the certificate of airworthiness of the PJ-SUN and in the approved General Operating Manual of Divi Divi Air. The restrictions entail that flying is only allowed during daylight, under visual meteorological conditions, and when a route is flown from where a safe emergency landing can be executed in case of engine failure.
- The required (demonstrable) relation with the actual average passenger weight was missing in relation to the used standard passenger weight for drawing up the load and balance sheet.
- The failure of Divi Divi Air’s internal supervision system for the load and balance programme.
- Not noticing deviations between the (approved) safety instruction cards and the life jackets on-board during annual inspections.
- The standard average passenger weight of 176 lb set after the accident offers insufficient security that the exceedance of the maximum allowed take-off weight of flights with Antillean airline companies that fly with the Britten-Norman Islander will not occur.

Other factors:
Recording system of radio communication with Hato Tower
7. The recording system used for the radio communication with Hato Tower cannot be used to record the actual time. This means that the timeline related to the radio communication with Hato Tower cannot be exactly determined.
The alerting and the emergency services on Bonaire
8. There was limited coordination between the different emergency services and, therefore, they did not operate optimally.
Findings:
- The incident site command (Copi) that should have taken charge of the emergency services in accordance with the Bonaire island territory crisis plan was not formed.
- Insufficient multidisciplinary drills have been organized and assessed for executive officials who have a task to perform in accordance with the Bonaire island territory crisis plan and the airport aircraft accident crisis response plan in controlling disasters and serious accidents. They were, therefore, insufficiently prepared for their task.
9. The fire service and police boats could not be deployed for a longer period of time.
Final Report:

Crash of a PZL-Mielec AN-28 in Kwamalasamutu

Date & Time: Oct 15, 2009 at 1400 LT
Type of aircraft:
Operator:
Registration:
PZ-TST
Survivors:
Yes
Schedule:
Paramaribo - Kwamalasamutu
MSN:
1AJ008-04
YOM:
1990
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at the Kwamalasamutu Airstrip, the twin engine aircraft went out of control, lost its undercarriage and came to rest. Three passengers were slightly injured while the captain was seriously injured. All four other occupants escaped unhurt. The aircraft was damaged beyond repair.

Crash of an Antonov AN-24RV in Zarafshon

Date & Time: Aug 31, 2009
Type of aircraft:
Operator:
Registration:
UK-46658
Flight Phase:
Survivors:
Yes
MSN:
4 73 093 04
YOM:
1974
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from Zarafshon Airport, the undercarriage were prematurely retracted by the crew. The aircraft sank on its belly and slid for few dozen metres before coming to rest. There were no injuries but the aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere in August 2009.
Probable cause:
Premature retraction of the landing gear during the takeoff procedure.