Crash of an Airbus A320-214 in New York

Date & Time: Jan 15, 2009 at 1531 LT
Type of aircraft:
Operator:
Registration:
N106US
Flight Phase:
Survivors:
Yes
Schedule:
New York - Charlotte
MSN:
1044
YOM:
1999
Flight number:
US1549
Crew on board:
5
Crew fatalities:
Pax on board:
150
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19663
Captain / Total hours on type:
4765.00
Copilot / Total flying hours:
15643
Copilot / Total hours on type:
37
Aircraft flight hours:
25241
Aircraft flight cycles:
16299
Circumstances:
Aircraft experienced an almost complete loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from La Guardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport, Charlotte, North Carolina, and had departed LGA about 2 minutes before the in-flight event occurred. The 150 passengers, including a lap held child, and 5 crew members evacuated the airplane via the forward and overwing exits. One flight attendant and four passengers were seriously injured, and the airplane was substantially damaged.
Probable cause:
The ingestion of large birds into each engine, which resulted in an almost total loss of thrust in both engines and the subsequent ditching on the Hudson River. Contributing to the fuselage damage and resulting unavailability of the aft slide/rafts were:
-the Federal Aviation Administration’s approval of ditching certification without determining whether pilots could attain the ditching parameters without engine thrust,
-the lack of industry flight crew training and guidance on ditching techniques,
-the captain’s resulting difficulty maintaining his intended airspeed on final approach due to the task saturation resulting from the emergency situation.
Contributing to the survivability of the accident was:
-the decision-making of the flight crew members and their crew resource management during the accident sequence,
-the fortuitous use of an airplane that was equipped for an extended overwater flight, including the availability of the forward slide/rafts, even though it was not required to be so equipped
-the performance of the cabin crew members while expediting the evacuation of the airplane,
-the proximity of the emergency responders to the accident site and their immediate and appropriate response to the accident.
Final Report:

Crash of an Antonov AN-24RV in Bosaso

Date & Time: Jan 13, 2009
Type of aircraft:
Operator:
Registration:
S9-KAS
Survivors:
Yes
Schedule:
Djibouti City - Bosaso
MSN:
4 73 094 06
YOM:
1974
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Djibouti City, the crew started the approach to Bosaso Airport. When the undercarriage were selected down, the crew realized that the nose gear was stuck in its wheel well. The crew elected to get it down manually but without success. The decision was taken to land in such configuration. Upon touchdown, the aircraft landed on its nose and slid for few dozen metres before coming to rest. All 15 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Xian MA60 in Caticlan

Date & Time: Jan 11, 2009 at 0658 LT
Type of aircraft:
Operator:
Registration:
RP-C8893
Survivors:
Yes
Schedule:
Manila - Caticlan
MSN:
07 04
YOM:
2008
Flight number:
EZD865
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2675
Captain / Total hours on type:
500.00
Circumstances:
On or about 0613LT 11 January 2009, flight 6K865 RP-C8893 departed NAIA (RPLL) for Caticlan Airport (RPVE) with 22 passengers and 5 crew members on board. The flight was uneventful until a go-around was initiated during the first approach, A second attempt to land was made which ended with the aircraft undershooting the runway. After the first touchdown the aircraft bounce and landed on the runway and veered to the left side of the runway due to the left landing gear failure upon the contact with the embankment before the road at the end of the runway. The aircraft settled down at the concrete wall of the ramp facing the passenger lounge of the Zest Air. Three (3) passengers suffered serious injuries, and 19 passengers with minor one, the crew member escape injuries except the Captain suffering slight injury. The aircraft was damaged beyond economical repair.
Probable cause:
- The captain’s low level of experience (2,675 hours) and less than 500 hours PIC.
- The critical runway conditions (950 M and gusty wind conditions No PAPI).
- The absence of crew coordination (monitoring and CRM).
Final Report:

Crash of a Boeing 737-524 in Denver

Date & Time: Dec 20, 2008 at 1818 LT
Type of aircraft:
Operator:
Registration:
N18611
Flight Phase:
Survivors:
Yes
Schedule:
Denver - Houston
MSN:
27324/2621
YOM:
1994
Flight number:
CO1404
Crew on board:
5
Crew fatalities:
Pax on board:
110
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13100
Captain / Total hours on type:
6300.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
1500
Aircraft flight hours:
40541
Aircraft flight cycles:
21511
Circumstances:
On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of whom were lap-held children) were uninjured. The airplane was substantially damaged. The scheduled, domestic passenger flight, operated under the provisions of 14 Code of Federal Regulations Part 121, was departing DEN and was destined for George Bush Intercontinental Airport, Houston, Texas. At the time of the accident, visual meteorological conditions prevailed, with strong and gusty winds out of the west. The flight operated on an instrument flight rules flight plan.
Probable cause:
The captain’s cessation of right rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the excursion, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience.
Contributing to the accident were the following factors:
1) an air traffic control system that did not require or facilitate the dissemination of key, available wind information to the air traffic controllers and pilots; and
2) inadequate crosswind training in the airline industry due to deficient simulator wind gust modeling.
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander in Espiritu Santo: 2 killed

Date & Time: Dec 19, 2008 at 1110 LT
Type of aircraft:
Operator:
Registration:
YJ-RV2
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Olpoi - Luganville
MSN:
172
YOM:
1970
Flight number:
AVN261
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8395
Captain / Total hours on type:
1300.00
Aircraft flight hours:
15314
Aircraft flight cycles:
26340
Circumstances:
On Friday 19 December 2008, YJ-RV2, a Britten-Norman Islander aeroplane, was scheduled to fly a routine commercial passenger service for Air Vanuatu (Domestic) Limited (the operator). The service was to start from Bauerfield International Airport, Port Vila and was to include 5 flights or legs, taking the aircraft north via an intermediate landing at Norsup and onto Pekoa International Airport (also known as Santo Airport) near Luganville on Espiritu Santo. At Santo Airport the aircraft was to be refuelled and after a stopover of about 2 hours the service was to continue north to Gaua and Mota Lava before returning to Santo where it was planned to terminate. The pilot arrived at the operator’s base at about 0700 and started his before-flight duties. The flight departed Bauerfield on schedule at 0730 and progressed normally to Santo. The operator’s agent at Santo had early Friday morning called the company operations office in Port Vila and asked if a flight from Santo to Lajmoli and return could be added to the service. The regular Thursday flight had been cancelled and 9 passengers had been left stranded at Lajmoli. The operations staff approved the request and the agent advised he would confirm with the pilot of YJ-RV2 when he arrived at Santo. At Santo the pilot was met by the agent and agreed to the request for the additional flight to Lajmoli. No interruption to the original schedule was envisaged as the flight should have returned to Santo well before the planned 1230 departure north to Gaua. The aircraft was checked and 246 litres of fuel were added. The aircraft departed Santo for Lajmoli at 1016 with the pilot and 4 passengers onboard. At Lajmoli, the local agent, aware that YJ-RV2 was inbound, weighed the passengers and their bags in preparation for the return flight. At 1043 YJ-RV2 landed at Lajmoli and the agent off-loaded the passengers and baggage while the pilot waited by the aircraft. The agent later reported that he informed the pilot of the planned load of 9 passengers and baggage, and that the aircraft would likely be at about maximum allowable weight. The pilot was reported to have advised the agent that he was happy to continue and instructed him to load the aircraft. The pilot remained near the aircraft while the agent loaded first the baggage then the passengers. The pilot instructed one of the passengers to enter the aircraft through the forward door and sit in the front-right seat next to the pilot. The agent added the weight of the passengers and baggage to the load sheet for the flight, but he wasn’t aware of the fuel weight so omitted this from the sheet. The load sheet, which included a passenger manifest, was returned to the pilot, who signed it. A copy was retained by the agent and later handed to the investigation team. At 1055 the pilot started the engines and taxied the aircraft for grass runway 14. YJ-RV2 took off at 1058 and at 1100 the pilot called Santo air traffic services on the high frequency (HF) radio,reporting airborne and climbing to 7000 feet. He gave an estimated time of arrival at Santo of 130. Witnesses, both on the ground at Lajmoli and passengers on board, later commented that the aircraft took longer to get airborne than normal and was slower to climb. The pilot followed the coastline south and approaching the village of Wunavae turned left inland. Passengers later commented that the aircraft flew in a direct line towards the rising hilly ground and, based on their previous flying experiences, crossed several ridges at a lower-than-normal height. The passengers also commented that the pilot increased power on the engines as they flew in an easterly direction. The passengers later spoken to (7) reported no significant turbulence and while there was perhaps some light cloud about, they were able to see the terrain ahead. The passengers recalled becoming increasingly concerned about the low height of the aircraft as it flew directly at a right-angle towards the last ridgeline before crossing over into Big Bay. Some of the passengers described the pilot closing the throttles and shutting down the engines as they approached the ridgeline. At about the same time they heard a loud buzzing sound, later identified as the aircraft’s stall warning. Shortly afterwards, the aircraft struck the trees and bush and quickly came to a halt. No communication was heard from the pilot during this time, although he was observed throughout making movements typical of someone who was awake. Within a couple of minutes of impacting into the bush, the passengers started vacating the aircraft. Fuel was smelled about the aircraft and seen dripping from the wing. The passengers were unable to rouse the pilot and front-seat passenger, who were trapped in the now-deformed front of the aircraft. A second passenger, who had suffered a severe head wound and suspected broken leg, was slower to vacate the aircraft and remained semi-conscious near its right side. The remaining 7 passengers assembled at the rear of the aircraft, near the rear left baggage door. Thinking that the pilot and front-seat passenger were dead, and fearing the aircraft might catch fire, they agreed to start walking downhill towards the coast and Wunavae village. The eighth passenger, now aware that the main group had departed downhill, attempted to follow but was unable to catch up owing to his injuries. At about 1115, Santo air traffic services called the pilot of YJ-RV2 to coordinate his arrival with those of several other aircraft also approaching Santo. The controller received no response, so requested other aircraft to call YJ-RV2 on various radio frequencies. Again there was no response. At 1130 the controller declared the aircraft overdue and informed the authorities and the operator. The crews of a company ATR 42 and a DH6 Twin Otter on scheduled local flights were asked to conduct an initial search for YJ-RV2, focusing on the direct track from Lajmoli to Santo. A third private aircraft also assisted in the search. At about 1245 the crew of the ATR 42 located the wreckage of YJ-RV2 at about 4000 feet (1200 m) in the mountainous area west of Big Bay. The crew was unable to fly close enough to confirm if there were any survivors. At 1500, a light helicopter based in Port Vila departed for Santo and the accident site. Inclement weather prevented the helicopter reaching the site that evening and rescue operations were halted until the next day. Additional support was also requested from New Caledonia, and a French military Super Puma helicopter and medical team arrived in Santo on Saturday morning. At about 0700 on Saturday 20 December, the first rescue personnel reached YJ-RV2 and confirmed that the pilot was dead and the front-seat passenger critically injured. There was no sign of the remaining 8 passengers. The critically injured passenger was initially evacuated to Luganville Hospital and was subsequently taken to Australia for further treatment. He died of his injuries on 1 January 2009. During Saturday morning a group of searchers from Wunavae village started walking towards the accident site looking for survivors. About mid-afternoon, the group of 7 passengers was located by the crew of the Super Puma some 3 to 4 km west of the accident site and airlifted to Santo for treatment. The last passenger was located by the villagers the following day and after a third night in the bush was airlifted to hospital.
Probable cause:
Findings:
Findings are listed in order of development and not in order of priority.
- The pilot was appropriately licensed to fly the aeroplane, but his route and aerodrome qualification had been allowed to lapse. However, this lapse was unlikely to have contributed to the accident.
- There was no evidence that the pilot was not fit to conduct the flight, but he was observed by the local agent and passengers to be less communicative than usual, both before and during the flight.
- The aeroplane had been maintained in accordance with approved standards and there was no evidence of mechanical failure that could have contributed to the accident.
- The weather was suitable for the pilot to maintain appropriate terrain separation visually.
- The aeroplane was overloaded by at least 7%, which affected its climb performance and made it unlikely that it would be able to cross the final ridge without deviating from the path flown by the
pilot.
- The aeroplane did not have sufficient height margin to approach the lee of the ridge where downdraughts were foreseeable, and the pilot had not approached the ridge from a direction that
would have afforded him an escape route when he decided to abort the crossing.
- The poor configuration of the seat belts in the aeroplane increased the risk of injury to the occupants, and may have contributed to the death of one passenger.
- The chances of survival for those passengers who survived the impact were reduced by their decision to leave the accident site.
Final Report:

Crash of a BAe 3112 Jetstream 31 in Fort Smith

Date & Time: Nov 27, 2008 at 1515 LT
Type of aircraft:
Operator:
Registration:
C-FNAY
Survivors:
Yes
Schedule:
Hay River - Fort Smith
MSN:
768
YOM:
1987
Flight number:
PLR734
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Northwestern Air BAe Jetstream 31 was operating as PLR734 on an instrument flight rules (IFR) flight from Hay River to Fort Smith, Northwest Territories. After conducting an IFR approach to Runway 11, PLR734 executed a missed approach and flew a full procedure approach for Runway 29. At approximately 0.2 nautical miles from the threshold, the crew sighted the approach strobe lights and continued for a landing. Prior to touchdown, the aircraft entered an aerodynamic stall and landed hard on the runway at 1515 mountain standard time. The aircraft remained on the runway despite the left main landing gear collapsing. The two flight crew members and three passengers were uninjured and evacuated the aircraft through the left main cabin door. There was no post-impact fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Though icing conditions were encountered, the airframe de-icing boots were not cycled nor was the Vref speed increased to offset the effects of aircraft icing.
2. An abrupt change in aircraft configuration, which included a reduction in power to flight idle and the addition of 35° flap, caused the aircraft’s speed to rapidly decrease.
3. The aircraft entered an aerodynamic stall due to the decreased performance caused by the icing. There was insufficient altitude to recover the aircraft prior to impact with the runway.
Finding as to Risk:
1. The company had not incorporated the British Aerospace Notice to Aircrew into its standard operating procedures (SOP) at the time of the occurrence. Therefore, crews were still required to make configuration changes late in the approach sequence, increasing the risk of an unstabilised approach.
Final Report:

Crash of a Boeing 737-8AS in Rome

Date & Time: Nov 10, 2008 at 0756 LT
Type of aircraft:
Operator:
Registration:
EI-DYG
Survivors:
Yes
Schedule:
Hahn - Rome
MSN:
33639/2557
YOM:
2008
Flight number:
FR4102
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9883
Captain / Total hours on type:
6045.00
Copilot / Total flying hours:
600
Copilot / Total hours on type:
400
Aircraft flight hours:
2419
Aircraft flight cycles:
1498
Circumstances:
The airplane departed Hahn Airport at 0630LT on a flight to Rome-Ciampino Airport, carrying 14 passengers and a crew of 8. The first officer was the Pilot Flying on the leg whilst the captain was the Pilot Monitoring. The flight was uneventful until the approach phase at the destination airport. The aircraft established the first radio contact with Ciampino Tower, communicating that it was 9 NM from the runway and stabilised on the ILS for runway 15. The aircraft, authorized and configured for the approach, was proceeding for landing, when, at a height of 136 ft and a distance of about 300 m from the runway, the captain noticed birds on the flight trajectory. He stated "Ahi", repeated in rapid sequence. At a distance of about 100 m from the runway, the TO/GA pushbutton was activated. The first officer acknowledged: "Go around, flaps 15", setting the go around attitude. At the same time as the TO/GA was activated, the aircraft collided with a thick flock of some 90 starlings. A loud bang was heard and both engines stalled. The aircraft climbed to 173 feet and then continued to lose height, despite the nose-up command. There was a progressive speed reduction and an increase of the angle of attack until the activation of the stick shaker, which was recorded at 21 feet. The aircraft hit the ground in aerodynamic stall conditions, near taxiway AC, about half way along the total length of the runway at a vertical acceleration of 2.66g. First contact with the runway occurred with the main landing gear properly extended and with the lower part of the fuselage tail section. The left main landing gear detached from its attachment during the landing run and the lower part of the left engine nacelle came into contact with the runway. The aircraft stopped near the threshold of runway 33. The fire brigade sprayed extinguishing foam around the area where the engine nacelle had come into contact with the runway. The captain then arranged for the disembarkation of the passengers and crew using a ladder truck from the right front door, with the addition of the right rear slide, later activated and used.
Probable cause:
The accident has been caused by an unexpected loss of both engines thrust as a consequence of a massive bird strike, during the go-around manoeuvre. The loss of thrust has prevented the aircrew from performing a successful go around and has led the aircraft to an unstabilized runway contact. The following factors have contributed to the event:
- The inadequate effectiveness of bird control and dispersal measures put in place by the airport operator at the time of the accident,
- The captain decision to perform a go around, when the aircraft was at approximately 7 seconds from touchdown. The above decision was significantly influenced by:
- The lack of instructions to flight crew concerning the most suitable procedures to adopt in the case of single or multiple bird strikes in the landing phase,
- The absence of specific training in the management, by the flight crew, of the "surprise" and "startle" effects in critical phases of the flight.
Final Report:

Crash of a Dornier DO328-100TP in Fakfak

Date & Time: Nov 6, 2008 at 1033 LT
Type of aircraft:
Operator:
Registration:
PK-TXL
Survivors:
Yes
Schedule:
Sorong - Fakfak
MSN:
3037
YOM:
1995
Flight number:
XAR9000
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10190
Captain / Total hours on type:
2365.00
Copilot / Total flying hours:
4673
Copilot / Total hours on type:
15
Aircraft flight hours:
24404
Aircraft flight cycles:
21916
Circumstances:
The aircraft touched down heavily approximately 5 meters before the touch-down area of runway 10 at Torea Airport, Fak-Fak at 01:33. The investigation found that the left main landing gear touched the ground first (5 meters before the end of the runway), and the right main landing gear touched the ground (4.5 meters from the end of the runway). It stopped on the runway, approximately 700 meters from the touch-down area. The left main landing gear fractured in two places; at the front pivot point, and the aft pivot point. The left fuselage contacted the runway surface 200 meters from the touch-down point and the aircraft slid with the left fuselage on the ground for a further 500 meters, before it stopped at the right edge of the runway. The wing tip and left propeller blade tips also touched the runway and were damaged. The passengers and crew disembarked normally; there were no injuries. Following an inspection of the landing gear and temporary replacement of the damaged left main landing gear, the aircraft was moved to the apron on 8 November 2008 at 04:00. The runway was closed for 5 days.
Probable cause:
The Digital Flight Data Recorder data showed evidence that the aircraft descended suddenly and rapidly when it was on short final approach before the aircraft was above the touchdown area. Propeller RPM was reduced suddenly and rapidly to 70% less than 10 seconds before ground contact. Given that the propellers are constant speed units, the sudden and rapid changes could not be explained other than the probability that a crew member had made the control inputs. The PIC (pilot monitoring/flight instructor) did not monitor the operation of the aircraft sufficiently to ensure timely and effective response to the pilot induced excessive sink rate.
Other Factors:
The airport did not meet the ICAO Annex 14 Standard with respect to the requirement to have runway end safety areas.
Final Report:

Crash of a Boeing 737-2H4 in Caracas

Date & Time: Oct 16, 2008 at 1530 LT
Type of aircraft:
Operator:
Registration:
YV162T
Survivors:
Yes
Schedule:
Puerto Ordaz – Caracas
MSN:
23055/970
YOM:
1983
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 28R at Caracas-Maiquetía-Simón Bolívar Airport, the aircraft deviated to the left. It eventually veered off runway to the left and went down a slope, coming to rest with its nose gear torn off. All 54 occupants evacuated safely and aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 300 in Lukla: 18 killed

Date & Time: Oct 8, 2008 at 0731 LT
Operator:
Registration:
9N-AFE
Survivors:
Yes
Schedule:
Kathmandu – Lukla
MSN:
720
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
8185
Captain / Total hours on type:
7180.00
Copilot / Total flying hours:
556
Copilot / Total hours on type:
341
Circumstances:
The aircraft departed Kathmandu-Tribhuvan Airport at 0651LT on a regular schedule service to the Lukla-Tenzing-Hillary Airport. On approach to runway 06, the crew encountered poor visibility due to foggy conditions. Despite the pilot did not establish any visual contact with the ground, he continued the approach when, on short final, the aircraft struck a rock and crashed just below the runway 06 threshold, bursting into flames. The captain was seriously injured while 18 other occupants were killed, among them 12 Germans, 2 Australians and 5 Nepalese.
Probable cause:
Controlled flight into terrain after the captain decided to continue the approach under VFR mode in IMC conditions.