Scheduled Revenue Flight

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.

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.

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.

Following an uneventful flight from Yangon, the crew completed the approach to Sittwe Airport in poor weather conditions. The aircraft landed hard on runway 11, causing the right main gear to collapse. The right wing struck the ground and was partially sheared off. The aircraft went out of control, veered off runway to the left and came to rest against a fence. Three occupants, among them the captain, were slightly injured and the aircraft was damaged beyond repair. At the time of the accident, the runway threshold and edge lights as well as the VASIS were unserviceable.

On Sunday 31 May 2009, the Airbus A330-203 registered F-GZCP operated by Air France was programmed to perform scheduled flight AF 447 between Rio de Janeiro-Galeão and Paris Charles de Gaulle. Twelve crew members (3 flight crew, 9 cabin crew) and 216 passengers were on board. The departure was planned for 22 h 00. At around 22 h 10, the crew was cleared to start up engines and leave the stand. Takeoff took place at 22 h 29. The Captain was Pilot Not Flying (PNF); one of the copilots was Pilot Flying (PF). At the start of the Cockpit Voice Recorder (CVR) recording, shortly after midnight, the aeroplane was in cruise at flight level 350. Autopilot 2 and auto-thrust were engaged. Auto fuel transfer in the “trim tank” was carried out during the climb. The flight was calm. At 1 h 35, the aeroplane arrived at INTOL point and the crew left the Recife frequency to change to HF communication with the Atlántico Oceanic control centre. A SELCAL test was successfully carried out, but attempts to establish an ADS-C connection with DAKAR Oceanic failed. Shortly afterwards, the co-pilot modified the scale on his Navigation Display (ND) from 320 NM to 160 NM and noted “…a thing straight ahead”. The Captain confirmed and the crew again discussed the fact that the high temperature meant that they could not climb to flight level 370. At 1 h 45, the aeroplane entered a slightly turbulent zone, just before SALPU point. Note: At about 0 h 30 the crew had received information from the OCC about the presence of a convective zone linked to the inter-tropical convergence zone (ITCZ) between SALPU and TASIL. The crew dimmed the lighting in the cockpit and switched on the lights “to see”. The co-pilot noted that they were “entering the cloud layer” and that it would have been good to be able to climb. A few minutes later, the turbulence increased slightly in strength. Shortly after 1 h 52, the turbulence stopped. The co-pilot again drew the Captain’s attention to the REC MAX value, which had then reached flight level (FL) 375. A short time later, the Captain woke the second co-pilot and said “[…] he’s going to take my place”. At around 2 h 00, after leaving his seat, the Captain attended the briefing between the two co-pilots, during which the PF (seated on the right) said specifically that “well the little bit of turbulence that you just saw we should find the same ahead we’re in the cloud layer unfortunately we can’t climb much for the moment because the temperature is falling more slowly than forecast” and that “the logon with DAKAR failed”. Then the Captain left the cockpit. The aeroplane approached the ORARO point. It was flying at flight level 350 and at Mach 0.82. The pitch attitude was about 2.5 degrees. The weight and balance of the aeroplane were around 205 tonnes and 29%. The two copilots again discussed the temperature and the REC MAX. The turbulence increased slightly. At 2 h 06, the PF called the cabin crew, telling them that “in two minutes we ought to be in an area where it will start moving about a bit more than now you’ll have to watch out there” and he added “I’ll call you when we’re out of it”. At around 2 h 08, the PNF proposed “go to the left a bit […]”. The HDG mode was activated and the selected heading decreased by about 12 degrees in relation to the route. The PNF changed the gain adjustment on his weather radar to maximum, after noticing that it was in calibrated mode. The crew decided to reduce the speed to about Mach 0.8 and engine de-icing was turned on. At 2 h 10 min 05, the autopilot then the auto-thrust disconnected and the PF said “I have the controls”. The aeroplane began to roll to the right and the PF made a nose-up and left input. The stall warning triggered briefly twice in a row. The recorded parameters showed a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS). The flight control law reconfigured from normal to alternate. The Flight Directors (FD) were not disconnected by the crew, but the crossbars disappeared. Note: Only the speeds displayed on the left side and on the ISIS are recorded on the FDR; the speed displayed on the right side is not recorded. At 2 h 10 min 16, the PNF said “we’ve lost the speeds ” then “alternate law protections”. The PF made rapid and high amplitude roll control inputs, more or less from stop to stop. He also made a nose-up input that increased the aeroplane’s pitch attitude up to 11° in ten seconds. Between 2 h 10 min 18 and 2 h 10 min 25, the PNF read out the ECAM messages in a disorganized manner. He mentioned the loss of autothrust and the reconfiguration to alternate law. The thrust lock function was deactivated. The PNF called out and turned on the wing anti-icing. The PNF said that the aeroplane was climbing and asked the PF several times to descend. The latter then made several nose-down inputs that resulted in a reduction in the pitch attitude and the vertical speed. The aeroplane was then at about 37,000 ft and continued to climb. At about 2 h 10 min 36, the speed displayed on the left side became valid again and was then 223 kt; the ISIS speed was still erroneous. The aeroplane had lost about 50 kt since the autopilot disconnection and the beginning of the climb. The speed displayed on the left side was incorrect for 29 seconds. At 2 h 10 min 47, the thrust controls were pulled back slightly to 2/3 of the IDLE/CLB notch (85% of N1). Two seconds later, the pitch attitude came back to a little above 6°, the roll was controlled and the angle of attack was slightly less than 5°. The aeroplane’s pitch attitude increased progressively beyond 10 degrees and the plane started to climb. From 2 h 10 min 50, the PNF called the Captain several times. At 2 h 10 min 51, the stall warning triggered again, in a continuous manner. The thrust levers were positioned in the TO/GA detent and the PF made nose-up inputs. The recorded angle of attack, of around 6 degrees at the triggering of the stall warning, continued to increase. The trimmable horizontal stabilizer (THS) began a nose-up movement and moved from 3 to 13 degrees pitch-up in about 1 minute and remained in the latter position until the end of the flight. Around fifteen seconds later, the ADR3 being selected on the right side PFD, the speed on the PF side became valid again at the same time as that displayed on the ISIS. It was then at 185kt and the three displayed airspeeds were consistent. The PF continued to make nose-up inputs. The aeroplane’s altitude reached its maximum of about 38,000 ft; its pitch attitude and angle of attack were 16 degrees. At 2 h 11 min 37, the PNF said “controls to the left”, took over priority without any callout and continued to handle the aeroplane. The PF almost immediately took back priority without any callout and continued piloting. At around 2 h 11 min 42, the Captain re-entered the cockpit. During the following seconds, all of the recorded speeds became invalid and the stall warning stopped, after having sounded continuously for 54 seconds. The altitude was then about 35,000 ft, the angle of attack exceeded 40 degrees and the vertical speed was about -10,000 ft/min. The aeroplane’s pitch attitude did not exceed 15 degrees and the engines’ N1’s were close to 100%. The aeroplane was subject to roll oscillations to the right that sometimes reached 40 degrees. The PF made an input on the side-stick to the left stop and nose-up, which lasted about 30 seconds. At 2 h 12 min 02, the PF said, “I have no more displays”, and the PNF “we have no valid indications”. At that moment, the thrust levers were in the IDLE detent and the engines’ N1’s were at 55%. Around fifteen seconds later, the PF made pitch-down inputs. In the following moments, the angle of attack decreased, the speeds became valid again and the stall warning triggered again. At 2 h 13 min 32, the PF said, “[we’re going to arrive] at level one hundred”. About fifteen seconds later, simultaneous inputs by both pilots on the side-sticks were recorded and the PF said, “go ahead you have the controls”. The angle of attack, when it was valid, always remained above 35 degrees. From 2 h 14 min 17, the Ground Proximity Warning System (GPWS) “sink rate” and then “pull up” warnings sounded. The recordings stopped at 2 h 14 min 28. The last recorded values were a vertical speed of -10,912 ft/min, a ground speed of 107 kt, pitch attitude of 16.2 degrees nose-up, roll angle of 5.3 degrees left and a magnetic heading of 270 degrees. No emergency message was transmitted by the crew. The wreckage was found at a depth of 3,900 metres on 2 April 2011 at about 6.5 NM on the radial 019 from the last position transmitted by the aeroplane. Both CVR and DFDR were found 23 months after the accident, in May 2011 at a depth of 3,900 metres. The final report was published in July 2012.

On approach to Guadalajara-Miguel Hidalgo y Costilla Airport, the pilots encountered technical problems with the landing gear and elected to perform a low pass in front of the tower. ATC confirmed that the landing gear were not fully deployed and locked. The captain decided to perform a wheels up landing. After touchdown on runway 28, the aircraft slid for few dozen metres before coming to rest. The left engine was destroyed by fire and the aircraft was damaged beyond repair. All 116 occupants escaped uninjured.

Lion Mentari Airline (Lion Air) as flight number LNI-793, departed from Sultan Hasanuddin Airport (WAAA), Makassar, Ujung Pandang, Sulawesi at 0636 UTC for Soekarno-Hatta International Airport (WIII), Jakarta. The estimated flight hour from Makassar to Jakarta was 2 hours. The crew consisted of two pilots and four flight attendants. There were 166 adult passengers. The copilot was the pilot flying for the sector, and the pilot in command (PIC) was the support/monitoring pilot. During the approach to runway 25L at Jakarta, the weather at the airport was reported as wind direction 200 degrees, wind speed 20 knots, visibility 1,000 meters, and rain. The PIC reported that he decided to take over control from the copilot. The PIC later reported that he had the runway in sight passing through 1,000 feet on descent, and he disengaged the autopilot at 400 feet. At about 50 feet the aircraft drifted to the right and the PIC initiated corrective action to regain the centreline. The aircraft touched down to the left of the runway 25L centerline and then commenced to drift to the right. The PIC reported that he immediately commenced corrective action by using thrust reverser, but the aircraft increasingly crabbed along the runway with the tail to the right of runway heading. The investigation subsequently found that the right thrust reverser was deployed, but left thrust reverser was not deployed. The aircraft stopped at 0835 on the right side of the runway 25L, 1,095 meters from the departure end of the runway on a heading of 152 degrees; 90 degrees to the runway 25L track. The main landing gear wheels collapsed, and still attached to the aircraft, were on the shoulder of the runway and the nose wheel was on the runway. The passengers and crew disembarked via the front right escape slide and right emergency exit windows. None of the occupants were injured

Turkish Airlines Flight 1951, a Boeing 737-800, departed Istanbul-Atatürk International Airport (IST) for a flight to Amsterdam-Schiphol International Airport (AMS), The Netherlands. The flight crew consisted of three pilots: a line training captain who occupied the left seat, a first officer under line training in the right seat and an additional first officer who occupied the flight deck jump seat. The first officer under line training was the pilot flying. The en route part of the flight was uneventful. The flight was descending for Schiphol and passed overhead Flevoland at about 8500 ft. At that time the aural landing gear warning sounded. The aircraft continued and was then directed by Air Traffic Control towards runway 18R for an ILS approach and landing. The standard procedure for runway 18R prescribes that the aircraft is lined up at least 8 NM from the runway threshold at an altitude of 2000 feet. The glidepath is then approached and intercepted from below. Lining up at a distance between 5 and 8 NM is allowed when permitted by ATC. Flight 1951 was vectored for a line up at approximately 6 NM at an altitude of 2000 feet. The glide slope was now approached from above. The crew performed the approach with one of the two autopilot and autothrottle engaged. The landing gear was selected down and flaps 15 were set. While descending through 1950 feet, the radio altimeter value suddenly changed to -8 feet. And again the aural landing gear warning sounded. This could be seen on the captain’s (left-hand) primary flight display. The first officer’s (right-hand) primary flight display, by contrast, indicated the correct height, as provided by the right-hand system. The left hand radio altimeter system, however, categorised the erroneous altitude reading as a correct one, and did not record any error. In turn, this meant that it was the erroneous altitude reading that was used by various aircraft systems, including the autothrottle. The crew were unaware of this, and could not have known about it. The manuals for use during the flight did not contain any procedures for errors in the radio altimeter system. In addition, the training that the pilots had undergone did not include any detailed system information that would have allowed them to understand the significance of the problem. When the aircraft started to follow the glidepath because of the incorrect altitude reading, the autothrottle moved into the ‘retard flare’ mode. This mode is normally only activated in the final phase of the landing, below 27 feet. This was possible because the other preconditions had also been met, including flaps at (minimum) position 15. The thrust from both engines was accordingly reduced to a minimum value (approach idle). This mode was shown on the primary flight displays as ‘RETARD’. However, the right-hand autopilot, which was activated, was receiving the correct altitude from the right-hand radio altimeter system. Thus the autopilot attempted to keep the aircraft flying on the glide path for as long as possible. This meant that the aircraft’s nose continued to rise, creating an increasing angle of attack of the wings. This was necessary in order to maintain the same lift as the airspeed reduced. In the first instance, the pilots’ only indication that the autothrottle would no longer maintain the pre-selected speed of 144 knots was the RETARD display. When the speed fell below this value at a height of 750 feet, they would have been able to see this on the airspeed indicator on the primary flight displays. When subsequently, the airspeed reached 126 knots, the frame of the airspeed indicator also changed colour and started to flash. The artificial horizon also showed that the nose attitude of the aircraft was becoming far too high. The cockpit crew did not respond to these indications and warnings. The reduction in speed and excessively high pitch attitude of the aircraft were not recognised until the approach to stall warning (stick shaker) went off at an altitude of 460 feet. The first officer responded immediately to the stick shaker by pushing the control column forward and also pushing the throttle levers forward. The captain however, also responded to the stick shaker commencing by taking over control. Assumingly the result of this was that the first officer’s selection of thrust was interrupted. The result of this was that the autothrottle, which was not yet switched off, immediately pulled the throttle levers back again to the position where the engines were not providing any significant thrust. Once the captain had taken over control, the autothrottle was disconnected, but no thrust was selected at that point. Nine seconds after the commencement of the first approach to stall warning, the throttle levers were pushed fully forward, but at that point the aircraft had already stalled and the height remaining, of about 350 feet, was insufficient for a recovery. According to the last recorded data of the digital flight data recorder the aircraft was in a 22° ANU and 10° Left Wing Down (LWD) position at the moment of impact. The airplane impacted farmland. The horizontal stabilizer and both main landing gear legs were separated from the aircraft and located near the initial impact point. The left and right engines had detached from the aircraft. The aft fuselage, with vertical stabilizer, was broken circumferentially forward of the aft passenger doors and had sustained significant damage. The fuselage had ruptured at the right side forward of the wings. The forward fuselage section, which contained the cockpit and seat rows 1 to 7, had been significantly disrupted. The rear fuselage section was broken circumferentially around row 28.

The scheduled commuter flight was about 10 miles north of the destination airport, operating under a special visual-flight-rules clearance, and descending for landing in instrument meteorological conditions. According to the pilot he started a gradual descent over an area of featureless, snow-covered, down-sloping terrain in whiteout and flat light conditions. During the descent a localized snow shower momentarily reduced the pilot’s forward visibility and he was unable to discern any terrain features. The airplane collided with terrain in an all-white snow/ice field and sustained substantial damage. At the time of the accident the destination airport was reporting visibility of 1.5 statute miles in light snow and mist, broken layers at 900 and 1,600 feet, and 3,200 feet overcast, with a temperature and dew point of 25 degrees Fahrenheit. The pilot reported that there were no pre accident mechanical problems with the airplane and that the accident could have been avoided if the flight had been operated under an instrument-flight-rules flight plan.

Following a normal touchdown, the fracture of the nose landing gear main fitting allowed the nose gear to collapse rearwards and penetrate the lower fuselage, causing significant damage to the equipment bay and the battery to become disconnected. The penetration of the fuselage allowed smoke and fumes produced by the consequent release of hydraulic fluid to enter the cockpit and passenger cabin. With the battery disconnected and after the engines were shut down, all power to the aircraft PA systems was lost and the remote cockpit door release mechanism became inoperative. No pre-accident defects were identified with the manual cockpit door release mechanism or the PA system.