Crash of a Cessna 208B Grand Caravan off La Tortuga

Date & Time: Aug 26, 2009 at 0814 LT
Type of aircraft:
Operator:
Registration:
YV1183
Flight Phase:
Survivors:
Yes
Schedule:
Los Roques - Porlamar
MSN:
208B-0690
YOM:
1998
Flight number:
TUY202
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
21109
Captain / Total hours on type:
2216.00
Copilot / Total flying hours:
1986
Copilot / Total hours on type:
48
Aircraft flight hours:
8392
Aircraft flight cycles:
8897
Circumstances:
The single engine aircraft departed Los Roques Airport at 0734LT on a schedule service to Porlamar, carrying 11 passengers and two pilots. At 0804LT, while cruising at an altitude of 11,500 feet, the engine exploded the vibrated. The crew shut down the engine, declared an emergency and reduced his altitude. Ten minutes later, in a 30° flaps down configuration, the crew ditched the aircraft at low speed about 7,4 km north of La Tortuga Island. All 13 occupants were quickly rescued and the aircraft was damaged beyond repair.
Probable cause:
Engine failure after the disintegration of several blades on the compressor disk. Technical analysis were unable to determine the exact cause of this disintegration.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Kokoda: 13 killed

Date & Time: Aug 11, 2009 at 1114 LT
Operator:
Registration:
P2-MCB
Survivors:
No
Site:
Schedule:
Port Moresby - Kokoda
MSN:
441
YOM:
1975
Flight number:
CG4684
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
2270
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
2150
Copilot / Total hours on type:
1940
Aircraft flight hours:
46700
Circumstances:
On 11 August 2009, a de Havilland Canada DHC-6 Twin Otter aircraft, registered P2-MCB, with two pilots and 11 passengers, was being operated on a scheduled regular public transport service from Port Moresby to Kokoda Airstrip, Papua New Guinea (PNG). At about 1113, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5,780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors. Prior to the accident the crew were manoeuvring the aircraft within the Kokoda Gap, probably in an attempt to maintain visual flight in reported cloudy conditions. The investigation concluded that the accident was probably the result of controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, involving a de Havilland Canada DHC-6-300 Twin Otter aircraft, registered P2-MCB, and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• Visual flight in the Kokoda Gap was made difficult by the extensive cloud coverage in the area.
• The crew attempted to continue the descent visually within the Kokoda Gap despite the weather conditions not being conducive to visual flight.
• It was probable that while manoeuvring at low level near the junction of the Kokoda Gap and Kokoda Valley, the aircraft entered instrument meteorological conditions.
• The aircraft collided with terrain in controlled flight.
Other safety factors:
• The copilot was assessed during normal proficiency checks for instrument approach procedures but was not qualified for flight in instrument meteorological conditions.
• The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
• The Civil Aviation Safety Authority Papua New Guinea surveillance of the operator did not identify the operations by the operator in contravention of Rule 91.112.
• The lack of a reliable mandatory occurrence reporting arrangement minimized the likelihood of an informed response to Papua New Guinea-specific safety risks.
• There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG).
• The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Other key findings:
• The investigation was unable to discount the possible incapacitation of the copilot as a factor in the accident.
• Although not required by the aviation rules at the time of the accident, the adoption of threat and error management training for flight crews, and of the methodology by operators would provide a tool to identify and mitigate operational risk as follows:
– by flight crews, when flight planning and during flight; and
– by operators, when developing their operational procedures.
Final Report:

Crash of an ATR72-212A in Koh Samui: 1 killed

Date & Time: Aug 4, 2009 at 1430 LT
Type of aircraft:
Operator:
Registration:
HS-PGL
Survivors:
Yes
Schedule:
Krabi – Koh Samui
MSN:
670
YOM:
2001
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
68
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following an uneventful flight from Krabi, the crew started the approach to Koh Samui Airport. Conditions at destination were marginal with stormy weather, winds and turbulences. Upon landing on runway 35, the aircraft bounced then landed a second time. It deviated from the centerline to the left, veered off runway, rolled through a grassy area and eventually collided with the concrete structure of the airport tower. The captain was killed and the copilot was seriously injured as the cockpit area was destroyed upon impact. 26 other people were injured.

Incident with a Boeing 707-3J9C in Ahwaz

Date & Time: Aug 3, 2009 at 1000 LT
Type of aircraft:
Operator:
Registration:
EP-SHK
Flight Phase:
Survivors:
Yes
Schedule:
Ahwaz - Tehran
MSN:
21128/917
YOM:
1976
Flight number:
IRZ124
Location:
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
162
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take off from Ahwaz Airport, while in initial climb, the engine n°2 suffered an uncontained failure. The crew informed ATC about the situation and was cleared for an immediate return. The aircraft landed safely 10 minutes later and was stopped on the main runway. All 174 occupants were rescued, among them two passengers were slightly injured. The aircraft was considered as damaged beyond repair as n°1 engine and the left wing were also damaged due to debris from the n°2 engine's compressor.
Probable cause:
It appears that a stage of the high pressure compressor in the n°2 engine disintegrated during initial climb. Elements punctured the nacelle and hit the left wing and the n°1 engine. After the n°2 engine failed, the n°1 engine lost power.

Crash of a De Havilland DHC-6 Twin Otter 300 near Oksibil: 15 killed

Date & Time: Aug 2, 2009 at 1100 LT
Operator:
Registration:
PK-NVC
Flight Phase:
Survivors:
No
Site:
Schedule:
Jayapura - Oksibil
MSN:
626
YOM:
1979
Flight number:
MZ9760D
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
8387
Captain / Total hours on type:
8387.00
Copilot / Total flying hours:
1207
Copilot / Total hours on type:
1207
Aircraft flight hours:
27336
Circumstances:
On the morning of Sunday, 2 August 2009, a de Havilland DHC-6 Twin Otter aircraft, registered PK-NVC, operated by PT. Merpati Nusantara Airlines as flight number MZ-7960D, departed from Sentani Airport, Jayapura for Oksibil Airport. The flight was planned in accordance with the visual flight rules (VFR). There were 15 persons on board; two pilots, one engineer, 10 adult passengers and two infants. The estimated flight time was 50 minutes. The fuel on board was sufficient for 2 hours and 50 minutes flight time. About 15 minutes prior to the estimated time of arrival at Oksibil the crew of another aircraft informed the Twin Otter crew that the weather in the Oksibil area was partly cloudy. There were no further reports of radio transmissions from the Twin Otter, and it did not arrive at Oksibil. A search was initiated at the time the aircraft would have run out of fuel. On the morning of 4 August 2009, searchers located the wreckage of the Twin Otter at an elevation of about 9,300 feet about 6 Nm from Oksibil. The aircraft was destroyed by impact forces, and all of the occupants were fatally injured.
Probable cause:
The pilots did not maintain visual flight procedures when flying below lowest safe altitude, and the aircraft was flown into cloud in the vicinity of gap north west of Oksibil. In conclusion, the accident was consistent with controlled flight into terrain.
Final Report:

Crash of an Ilyushin II-62M in Mashhad: 16 killed

Date & Time: Jul 25, 2009 at 1805 LT
Type of aircraft:
Operator:
Registration:
UP-I6208
Survivors:
Yes
Schedule:
Tehran - Mashhad
MSN:
19 51 5 2 5
YOM:
1989
Flight number:
IRX1525
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
14200
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
8294
Copilot / Total hours on type:
1319
Aircraft flight hours:
13573
Aircraft flight cycles:
3987
Circumstances:
At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline with registration, UP-I6208 and flight IRX1525 of Aria Airline flight with 169 passengers from Mehrabad International Airport/ Tehran, and it has landed at 18:05 local time on RWY 13 L in Mashhad International Airport; then it has run off from end of the runway, without considerable reduction in aircraft speed and it collided with wall of the airport and it was stopped after approximately 185 m. The mentioned aircraft has been leased by Aria Airline as ACMI, according to contract No. 002/IL-62M/ACMI. Subsequently, the ground safety unit of the airport has attended in place of occurring accident, by breaking protective fences and barbed wires of the airport, and then they evacuated passengers and extinguished fire outside of aircraft by carrying out necessary actions. 16 people were killed, 11 crew members and five passengers. All other occupants were rescued, among them 30 were injured. Accident site inspection revealed that the aircraft position had coordinates N 36,218º E 59,666º, at a road in the vicinity of the aerodrome, 1km away from the RWY-31R threshold (130º MH or 133, 5º TH) of the Mashhad airport with the azimuth of 125º (true). Power line along the road was destroyed by the right aircraft wing. Wing fuel tanks of the right wing were damaged evidenced by fuel leaking. Main and emergency exits were open. An inflatable slide was dropped down from the port side. No evidences of fire on board and at the accident site were found. First tracks of intensive braking (black tire tracks) were found at the concrete at a distance of 550 m from the departure threshold of RWY31R. The track of the main gear wheels was going along the RWY in its left part, and diverging further to the right beyond the departure threshold. At about 100m away from the threshold at the end portion of the braking way, a net barrier was found (textile aerodrome emergency braking unit).The aircraft ran over the RWY when moving along the right side of the stop way, 300m long. Beyond the end of the RWY landing gear wheels track could be clearly seen passing over a rough partly grassed surface, and crossing a dirt road. At a distance of 100m from the RWY end, where the right gear crossed the road, a destroyed tire tube was found, which presumably belonged to the right gear front wheel. At a distance of 160m from the RWY end smashed approach lights were found, and after that point the gear wheel track started to diverge to the left from the RWY centerline. The front gear wheel track further merged with the left gear wheel track and extended joining the forward airframe track. At a distance of 320 m from the RWY end another line of broken approach lights were found. Airframe structures were found before the approach lights (along the aircraft way). From that point small aircraft structure pieces were found along the whole aircraft path. 40m past the destroyed approach lights line a ditch of 0,5…1m in depth was found (with an underground pipeline) which was crossing this area from the south to the north. The south-eastern part of the aerodrome was fenced with a brick wall of 2,5m high and 0,4m thick with a concrete strip foundation. It went along the RWY there. The aircraft collided with the fence at a distance of 820m from the departure threshold (520m past the stop way end) with a heading of 105 degrees. The fence was destroyed throughout 70m. Debris of the nose part of the airframe, cockpit, passenger seats, aircraft cabin parts were found behind the fence. Earlier aerodrome employees, police and medical services found at the site and evacuated crew bodies, as well as killed and injured passengers. After the collision with the fence the aircraft kept moving for 160 m with a heading of 105 degrees and came to a stop at the road.
Probable cause:
The following findings were identified:
- The crew was not trained &acquainted with flight conditions in the Iran territory with an Iranian instructor pilot and the operation unit of Aria Airline has acted so weak regarding those mentioned subjects.
- The approach speed of aircraft was higher than recommended available airport charts & aircraft weight, however it was controllable if the crew could proceed to land correctively.
- The crew had not done correct procedure according to the aircraft Standard Operation Procedure (SOP) to use related check lists. (Descend-Approach-Landing)
- There was lack of precise coordination between flight crew on their self responsibility during the approach and landing.
- The flight crew did not pay attention to EGPWS warning, and did not take corrective action.
- The crew did not use engine reverser and spoiler systems correctly to reduce aircraft speed during the landing and consequently it caused to loose long Runway distance.
- The flight crew had not good English language proficiency. And they were poor in England language conversation.
- The Capitan of the aircraft as the pilot in command had not sufficient force and efficient management in the cockpit. (lack of Cockpit Resource Management).
- There were unauthorized actions of flight engineer for shifting engine reversers as well as lack of mutual oversight by crew members in checklist accomplishment during approach and landing.
- The crew has had disagreement about “Go around” due to unsuitable landing situations.
- Presence of General Director of airline in the cockpit had adverse psychological effect on crew efficiency behaviors.
- The DETA airline did not use correct procedure to extend engines No; 1-2-4 life time from Ukrainian company (Aerotechservice co.) and the technical manager of ARIA airline did not control and
supervise the matter accordingly.

Main Cause :
Considering those items in factual information and analysis, the main cause of this accident is “weak Cockpit management between the crew” to use correct landing techniques same as releasing Engine trust reversers – Engine shut down in unsuitable time - ….

Contributive Factors :
Some of contributive factors for this accident occurrence are noted as:
- The copilot and the flight engineer had self activity& decision without the (PIC) coordination.
- The cockpit crew was careless and not paying proper attention toward EGPWS warning.
- Psychological adverse effect on cockpit crew because of presence of General Director of Aria airline

Violation & other deficiencies:
The accident investigation team encountered some violations and deficiencies with ICAO Standards and Iran Local Authority regulation (CAO) which are descript as:
- Poor and in-sufficient supervision controlled of operation &technical manger of Aria Airline.
- The DETA airline has not used proper procedure to receive life time extension of engine and has not passed necessary information to Iranian and Kazakhstan Authorities.
- It has not been designed a headset for flight engineer to make more coordination between the crew, by the aircraft design bureau.
- The crew was not familiar with Iranian AIP completely.
- The total on board persons was not according to written load sheet.
Final Report:

Crash of a Tupolev TU-154M near Qazvin: 168 killed

Date & Time: Jul 15, 2009 at 1133 LT
Type of aircraft:
Operator:
Registration:
EP-CPG
Flight Phase:
Survivors:
No
Schedule:
Tehran - Yerevan
MSN:
87A-748
YOM:
1987
Flight number:
RV7908
Location:
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
168
Aircraft flight hours:
26593
Aircraft flight cycles:
16248
Circumstances:
The three engine aircraft departed Tehran-Imam Khomeiny Airport at 1117LT on a regular schedule flight to Yerevan, carrying 158 passengers and 10 crew members. Sixteen minutes after takeoff, while cruising over Qazvin at FL340, the aircraft suddenly changed its heading to 270° and then entered a rapid descent, losing 20,000 feet in 90 seconds. In a near vertical attitude, the aircraft crashed in an open field, causing a large crater. The aircraft disintegrated on impact and all 168 occupants were killed.
Probable cause:
Failure of the first stage of the high compressor disk on the left engine while the aircraft was flying at FL340, due to fatigue cracks. Debris punctured the engine nacelle, and several hydraulic and fuel lines were cut while all control systems were unserviceable. A huge fire spread on the left side of the airplane and the airplane entered an uncontrolled descent until impact.
Final Report:

Crash of a Britten Norman BN-2A Trislander III-1 on Great Barrier Island

Date & Time: Jul 5, 2009 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZK-LOU
Flight Phase:
Survivors:
Yes
Schedule:
Great Barrier Island - Auckland
MSN:
322
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
868
Captain / Total hours on type:
28.00
Circumstances:
At about 1300 on Sunday 5 July 2009, ZK-LOU, a 3-engined Britten Norman BN2A Mk III Trislander operated by Great Barrier Airlines (the company), took off from Great Barrier Aerodrome at Claris on Great Barrier Island on a regular service to Auckland International Airport. On board were 10 passengers and a pilot, all of whom were wearing their seat belts. That morning the pilot had flown a different Trislander from Auckland International Airport to Claris and swapped it for ZK-LOU for the return flight because it was needed for pilot training back in Auckland. Another company pilot had that morning flown ZK-LOU to Claris from North Shore Aerodrome. He had completed a full engine run-up for the first departure of the day, as was usual, and said he noticed nothing unusual with the aeroplane during the approximate 30-minute flight. For the return flight the pilot said he completed the normal after-start checks in ZK-LOU and noticed nothing abnormal. He did not do another full engine run-up because it was not required. He taxied the aeroplane to the start of sealed runway 28, applied full power while holding the aeroplane on brakes and rechecked that the engine gauges were indicating normally before starting the take-off roll. The aeroplane took off without incident, but the pilot said when it was climbing through about 500 feet he heard an unusual “pattering” sound. He also heard the propellers going out of synchronisation, so he attempted to resynchronise them with the propeller controls. He checked the engine’s gauges and noticed that the right engine manifold pressure and engine rotation speed had dropped, so he adjusted the engine and propeller controls to increase engine power. At that time there was a loud bang and he heard a passenger scream. Looking back to his right the pilot saw that the entire propeller assembly for the right engine was missing and that there was a lot of oil spray around the engine cowling. The pilot turned the aeroplane left and completed the engine failure and shutdown checks. He transmitted a distress call on the local area frequency and asked the other company pilot, who was airborne behind him, to alert the local company office that he was returning to Claris. The company office manager and other company pilot noticed nothing unusual with ZK-LOU as it taxied and took off. The other pilot was not concerned until he saw what looked like white smoke and debris emanate from the aeroplane as though it had struck a flock of birds. Despite the failure, ZK-LOU continued to climb, so the pilot said he levelled at about 800 feet and reduced power on the 2 serviceable engines, completed a left turn and crossed over the aerodrome and positioned right downwind for runway 28. There was quite a strong headwind for the landing, so the pilot elected to do a flapless landing and keep the power and speed up a little because of the possibility of some wind shear. The pilot and other personnel said that the cloud was scattered at about 2500 feet, that there were a few showers in the area and that the wind was about 15 to 20 knots along runway 28. The visibility was reported as good. After landing, the pilot stopped the aeroplane on the runway and checked on the passengers before taxiing to the apron. At the apron he shut down the other engines and helped the passengers to the terminal, where they were offered drinks. The company chief executive, who lived locally, and a local doctor attended to the passengers. Three of the passengers received some minor abrasions and scrapes from shattered Perspex and broken interior lining when the propeller struck the side of the fuselage.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The engine propeller assembly separated from the right engine of ZK-LOU in flight and struck the fuselage when the crankshaft failed at the flange that connected it to the propeller hub.
- High-cycle fatigue cracking on the flange that had developed during normal operations from undetected corrosion had reached a critical stage and allowed the flange to fail in overload.
- The crankshaft had inadvertently passed its overhaul service life by around 11% when the failure occurred, but the company had not realized this because of an anomaly in the recorded overseas service hours prior to importation of the engine to New Zealand. Ordinarily, the crankshaft would have been retired before a failure was likely.
- The crankshaft was an older design that has since been progressively superseded by those with flanges less prone to cracking.
- There was no requirement for a specific periodic crack check of the older-design crankshaft flanges, but this has been addressed by the CAA issuing a Continuing Airworthiness Notice on the issue.
- The CAA audit of the company had examined whether its engine overhaul periods were correct, but the audit could not have been expected to discover the anomaly in the overseas-recorded engine hours.
- This failure highlighted the need by potential purchasers of overseas components to follow the guidelines outlined in CAA Advisory Circular 00-1 to scrutinize overseas component records to ensure that the reported in-service hours are accurate.
Final Report:

Crash of an Airbus A310-324 off Moroni: 152 killed

Date & Time: Jun 30, 2009 at 0154 LT
Type of aircraft:
Operator:
Registration:
7O-ADJ
Survivors:
Yes
Schedule:
Sanaa - Moroni
MSN:
535
YOM:
1990
Flight number:
IY626
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
142
Pax fatalities:
Other fatalities:
Total fatalities:
152
Captain / Total flying hours:
7936
Captain / Total hours on type:
5314.00
Copilot / Total flying hours:
3641
Copilot / Total hours on type:
3076
Aircraft flight hours:
53587
Aircraft flight cycles:
18129
Circumstances:
Following an uneventful flight from Sana'a, the crew started a night approach to Moroni-Prince Saïd Ibrahim Airport runway 02. Weather conditions were considered as good with a 10 km visibility, an OAT of 24° C. and a wind from 180° gusting to 25 knots for runway 20. For unknown reasons, the crew initiated a go-around procedure when the aircraft entered an uncontrolled descent and crashed in the sea about 6 km from the airport. A young girl aged 12 was found alive few hours later while 152 other occupants were killed. Both CVR and DFDR were found almost two months later at a depth of 1,200 metres. The final report was published in June 2013.
Probable cause:
The accident was caused by inappropriate actions on part of the crew on flight controls which brought the aircraft into a stall that could not be recovered. These actions were successive to an unstabilized visual approach during which several alarms related to the proximity of the ground, the aircraft configuration and approach to stall sounded. Crew's attention was focused on the management of the path of the aircraft and the location of the runway, and they probably did not have enough mental resources available in this stressful situation, to respond adequately to these different alarms.
Contributing to the accident were the following factors:
- Weather conditions at the airport with winds gusting to 30 knots,
- Lack of training or pre-flight briefing of the crew in accordance with the Yemenia company operations manual, given the reluctance of the pilot to execute the MVI [Visual Maneuvering with Prescribed track] (none of the documents submitted in the investigation shows this training),
- The non-execution of the MVI maneuver by the crew (the plane left the LOC axis after the published point which is 5.2 NM), implying that the crew delayed the turn to reach the right hand downwind leg.
- The non-application by the crew of the procedure following the PULL UP-alarm.
Final Report:

Crash of a Xian MA60 in Caticlan

Date & Time: Jun 25, 2009 at 0755 LT
Type of aircraft:
Operator:
Registration:
RP-C8892
Survivors:
Yes
Schedule:
Manila - Caticlan
MSN:
07 03
YOM:
2008
Flight number:
EZD863
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
55
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Manila, the crew started the descent to Caticlan Airport and was informed that runway 06 was in use due to the wind component. For unknown reasons, the captain decided to land on runway 24. The approach was too long and the aircraft landed too far down the runway, about 950 metres past the runway threshold. Unable to stop within the remaining distance, it overran and came to rest in a grassy area against the perimeter fence. All 59 occupants escaped uninjured while the aircraft was damaged beyond repair.