Crash of a Boeing 737-3Y0 in Kaliningrad

Date & Time: Oct 1, 2008 at 2318 LT
Type of aircraft:
Operator:
Registration:
EI-DON
Survivors:
Yes
Schedule:
Barcelona - Kaliningrad
MSN:
23812/1511
YOM:
1988
Flight number:
KNI794
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5372
Captain / Total hours on type:
1258.00
Copilot / Total flying hours:
1010
Copilot / Total hours on type:
1010
Aircraft flight hours:
48514
Aircraft flight cycles:
39949
Circumstances:
The accident aircraft Boeing 737-3Y0 EI-DON, was operated by KD Avia on a flight from Kaliningrad, Russia to Barcelona, Spain and return. Flight KD793 to Barcelona was uneventful. The return flight, KD794, departed at 16:18 with 138 passengers and six crew members on board. The copilot was Pilot Flying, the captain was Pilot Monitoring. The en route part of the flight was uneventful. As the flight was descending to Kaliningrad at night in heavy rains and with gusty crosswind. During the descent flaps were first selected at 1° and thereafter to 5°. As the flaps were transitioning to this position, a flap asymmetry warning caught the attention of the crew. At 19:00 hours the captain took over control and selected flaps to 2°, the position at which there was no asymmetry warning. The crew then contacted the controller at Kaliningrad and reported that they had flap problems. As the descent was continued, the copilot performed the necessary calculations for a landing with flaps at 2°. At 19:09 the cabin crew was warned to prepare for a high-speed landing. Using the QRH to work the flap issue, the co-pilot activated the 'flap inhibit' and 'gear inhibit' switches. This "incorrect" action effectively disconnected the ground-proximity warning system (GPWS). At 19:11 it was established that the landing speed would be Vref +30, leading to a planned landing speed of 161 knots. At 19:14 the Landing Gear Warning Horn sounded due to the combination of power and flaps setting with the fact that the landing gear had not been selected down. This warning was cancelled by the crew. When the engine power was reduced to idle, the Landing Gear Warning Horn sounded again. This time the crew did not pay attention to the warning and continued to land. The airplane performed a gear up landing, sliding for 1440 m before coming to rest on the runway. The flap asymmetry issue was caused by a faulty Flap Position Transmitter. The flaps had extended to the commanded position, but the system incorrectly detected an asymmetry issue. This issue had occurred previously on EI-DON. The sensor had been replaced prior to departure from Kaliningrad that same day.
Probable cause:
The crash was caused by aircraft landing with not extended landing gear that resulted in aircraft structure and engines damage and it was caused by combination of the following adverse factors:
- Erroneous deactivation of GPWS gear warning (voice) system that was caused by failure to perform QRH recommendations on flaps warning deactivation during their asymmetrical extension;
- Presence of QRH manual on board of Boeing-737-300 EI-DON aircraft containing in Additional Deferred Item clause of Trailing Edge Flap Asymmetry chapter recommendation to the crew which are not specialized for the board configuration;
- Violation of the "Crew operating procedure of Boeing-737-300 aircraft" and non-compliance with QRH recommendations («LANDING CHECKLIST» section) with the result that the crew did not extend landing gear and did not monitor their position;
- Stereotyping on actuation of Landing Gear Warning Horn aural warning during approach as a result of which the crew deactivated it repeatedly without monitoring of landing gear position;
- Inadequate coordination of the crew resulted in lack of monitoring of compliance with FCOM and QRH requirements at occurrence and development of abnormal situation;
Appropriate safety recommendations based on the investigation results were developed.
Following this accident, both pilots lost their licence and KD Avia's AOC was revoked by Russian authorities in September 2009. The same month, KD Avia bankrupted.
Final Report:

Crash of a Fokker F28 Fellowship 4000 in Quito

Date & Time: Sep 22, 2008 at 1115 LT
Type of aircraft:
Operator:
Registration:
HC-CDT
Flight Phase:
Survivors:
Yes
Schedule:
Quito – Coca
MSN:
11222
YOM:
1985
Flight number:
ICD504
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
62
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9292
Captain / Total hours on type:
109.00
Copilot / Total flying hours:
3889
Copilot / Total hours on type:
380
Aircraft flight hours:
42422
Aircraft flight cycles:
47727
Circumstances:
During the takeoff roll from runway 25 at Quito-Mariscal Sucre Airport, the crew noted a fire alarm connected to the forward cargo compartment. The captain decided to abandon the takeoff procedure and initiated an emergency braking manoeuvre. Unable to stop within the remaining distance, the aircraft overran, collided with the ILS antenna, went down an embankment then impacted a brick wall and came to rest 300 metres past the runway end. All 66 occupants were rescued, among them eight passengers were injured. The aircraft was damaged beyond repair.
Probable cause:
Failure of the crew to follow the published procedures following a fire alarm, as stated in the Operations Manual and the late application of the procedures once the decision to abort the takeoff was taken.
Contributing factors:
- Complacency on part of the crew who failed to proceed with a pre-takeoff briefing,
- A fact that influenced the lack of appropriate action from the crew to successfully tackle any emergency,
- Lack of crew resources management,
- The braking coefficient was low because the runway surface was wet.
Final Report:

Crash of a Boeing 737-505 in Perm: 88 killed

Date & Time: Sep 14, 2008 at 0510 LT
Type of aircraft:
Operator:
Registration:
VP-BKO
Survivors:
No
Schedule:
Moscow - Perm
MSN:
25792/2353
YOM:
1992
Flight number:
AUL821
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
88
Captain / Total flying hours:
3900
Captain / Total hours on type:
1190.00
Copilot / Total flying hours:
8900
Copilot / Total hours on type:
236
Aircraft flight hours:
44533
Aircraft flight cycles:
35104
Circumstances:
On September 13, 2008 an Aeroflot –Nord flight crew (Captain and copilot), were conducting a scheduled domestic passenger flight n°AFL821 on a B737-505 aircraft, registration VP-BKO, from Moscow (Sheremetyevo, UUEE) to Perm (Bolshoye Savino, USPP). Apart from the two-member flight crew there were 4 flight attendants and 82 passengers on board, which makes a total of 88 people, including 66 citizens of the Russian Federation, 8 citizens of Azerbaijan, 1 citizen of Byelorussia, 1 of Germany, 1 of Italy, 1 of China, 1 of Latvia, 1 of Turkey, 1 of Uzbekistan, 5 citizens of Ukraine and 2 of France. According to the load sheet, the aircraft payload (cargo and passengers) was 8079 kg. The takeoff weight was ~54000 kg (with the max TOW of 60554 kg), the CG was at 20.61 % MAC, which was within the B-737-500 FCOM limitations. The calculated landing weight was 49700 kg (with the maximum of 49895 kg), and the CG was at 21.9 % MAC, which was also within the B737-500 FCOM limitations. The pre-flight briefing was conducted in due time and in compliance with the standard procedures. All the crew members passed medical check at the medical office of Aeroflot – Russian Airlines on September 13, 2008 at 1948 hrs and got permissions to fly. On the basis of the dispatch information (aircraft condition, aeronautical information, weather information, aircraft load data and operational flight plan) the PIC at 1955 hrs made a decision to fly. The takeoff was performed at 2113 without delay. The climb and level flight at FL290, 9,100 metres were conducted without any deviations. At 2245 hrs the crew started descent from the flight level to waypoint Mendeleyevo (940 MN). After passing over Mendeleyevo, in compliance with the Perm Approach Control instruction, the aircraft flew via the outer marker (705 PX) of Runway 21 which is the initial approach fix (IAF) for Runway 21 (heading 212° magnetic). After passing over the RWY with heading 110° M, the crew, following the Controller’s instruction, turned right for back course and started maneuvering for ILS approach to Runway 21. After the base turn, approaching the landing course at 600 m with both autopilot and autothrottle disengaged, the aircraft started climbing up to 1300 m, rolled 360° over the left wing and collided with the ground. The aircraft was totally destroyed and partly burnt in the ground fire. All passengers and crew members on board died due to the ground impact. The accident occurred at 2310 hrs 12.4 km from aerodrome reference point (ARP) of Perm Airport, azimuth 60° M. Accident site elevation is 153 m.
Probable cause:
The immediate cause of the accident was spatial disorientation of the crew, especially the Captain who was the pilot flying at the final stage of the flight, which led to the left flip-over, a steep descent and the crash of the aircraft. The spatial disorientation was experienced during the night time operation in clouds, with both autopilot and autothrottle disengaged. Contributing to the development of the spatial disorientation and failure to recover from it was a lack of proficiency in aircraft handling, crew resource management and of skills associated with upset recovery using "western"-type attitude indications that are found on foreign and modern Russian made aircraft. This type of indication differs from the one used on aircraft types previously flown by the crew (Tupolev 134, Antonov 2). The cause above was determined on the basis of flight recorders and ATC recorder data analysis, examination of the airframe and engine wreckage, results of the accident flight simulation, findings of the independent expertise conducted by test pilots from State Research Institute of Civil Aviation and Gromov Flight Research Institute as well as line pilots, and also on the basis of all the works conducted with participation of experts from Bermuda, France, Russia, UK and USA in the course of the investigation. The systemic cause of the accident was insufficient management by the airline of flight and maintenance operations of the Boeing 737 type of aircraft. These deficiencies in the aircraft maintenance also revealed through safety inspections conducted by the Russian Transport Oversight Authority and the Russian CAA after the accident. Deficiencies in the aircraft maintenance led to a situation when flights were performed for a long time with a throttle stagger that exceeded the limitations in the AMM and when the maintenance staff did not follow the AMM recommended troubleshooting procedures. The need to manage the throttle stagger during the approach increased crew workload. The forensic medical examination performed in the State Healthcare Center of Special Status “Perm Regional Forensic Expertise Bureau” confirmed the presence of ethyl alcohol in the Captain’s body before his death. The captain’s recent work schedule during the time period before the accident was conducive to fatigue and did not comply with national regulations.
Final Report:

Crash of a Cessna 208B Grand Caravan off Belize City

Date & Time: Sep 7, 2008 at 0940 LT
Type of aircraft:
Operator:
Registration:
V3-HFQ
Flight Phase:
Survivors:
Yes
Schedule:
Belize City - Belize City
MSN:
208B-0575
YOM:
1996
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Belize City-Sir Barry Bowen Municipal Airport on a short flight to the Belize City-Philip S. W. Goldson International Airport with 4 US citizens and one pilot on board. While cruising along the shore, the engine failed. The pilot reduced his altitude and attempted to land on a beach when the aircraft crashed in the sea and came to rest in two feet of water, broken in two. All five occupants escaped with minor injuries.
Probable cause:
Engine failure for unknown reasons.

Crash of a Boeing 737-2H6 in Jambi: 1 killed

Date & Time: Aug 27, 2008 at 1634 LT
Type of aircraft:
Operator:
Registration:
PK-CJG
Survivors:
Yes
Schedule:
Jakarta - Jambi
MSN:
23320/1120
YOM:
1985
Flight number:
SJY062
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7794
Captain / Total hours on type:
6238.00
Copilot / Total flying hours:
5254
Copilot / Total hours on type:
4143
Aircraft flight hours:
49996
Aircraft flight cycles:
54687
Circumstances:
On 27 August 2008, a Boeing 737-200 aircraft, registered PK-CJG, was being operated on a scheduled passenger service from Soekarno-Hatta International Airport, Jakarta to Sultan Thaha Airport, Jambi with flight number SJY062. On board the flight were two pilots, four flight attendants, and 124 passengers. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight time from Jakarta to Jambi was estimated to be about one hour and the aircraft was dispatched with approximately 4 hours of fuel endurance. The number one electrical engine driven generator was unserviceable, as such the Auxiliary Power Unit (APU) generator was used during the flight to maintain two generators operation. Prior to descent into Jambi, the PIC conducted the crew briefing and stated a plan for Makinga straight-in approach to runway 31 with flap 40°, reviewed the go-around procedures and stated that Palembang was the alternate airport.There was no abnormality recorded nor reported until the PIC commenced the approach to Jambi. At 09:18 UTC, the SIC contacted Thaha Tower controller and reported that the aircraft was descending and passing FL160 and had been cleared by Palembang Approach control to descend to 12,000 feet. The Thaha Tower controller issued a clearance to descend to 2500 feet and advised that runway 31 was in use. The SIC asked about the weather conditions and was informed that the wind was calm, rain over the field and low cloud on final approach to runway 31. The PIC flew the aircraft direct to intercept the final approach to runway 31. While descending through 2500 feet, and about 8 miles from the VOR, the flap one degree and flap 5° were selected. Subsequently the landing gear was extended and flap 15° was selected. 13 seconds after flap 15 selection, the pilots noticed that the hydraulic system A low pressure warning light illuminated, and also the hydraulic system A quantity indicator showed zero. The PIC commanded the SIC to check the threshold speed for the existing configuration of landing, weight and with flap 15°. The SIC called out that the threshold speed was 134 kts and the PIC decided to continue with the landing. The PIC continued the approach and advised the SIC that he aimed to fly the aircraft slightly below the normal glide path in order to get more distance available for the landing roll. The aircraft touched down at 0930 UTC and during the landing roll, the PIC had difficulty selecting the thrust reversers. The PIC the applied manual braking. During the subsequent interview, the crew reported that initially they felt a deceleration then afterward a gradual loss of deceleration. The PIC reapplied the brakes and exclaimed to the SIC about the braking condition, then the SIC also applied the brakes to maximum in responding to the situation. The aircraft drifted to the right of the runway centre line about 200 meters prior to departing off the end of the runway, and stopped about 120 meters from the end of the runway 31 in a field about 6 meters below the runway level. Three farmers who were working in that area were hit by the aircraft. One was fatally injured and the other two were seriously injured. The pilots reported that, after the aircraft came to a stop, they executed the Emergency on Ground Procedure. The PIC could not put both start levers to the cut-off position, and also could not pull the engines and APU fire warning levers. The PIC also noticed that the speed brake lever did not extend. The radio communications and the interphone were also not working. The flight attendants noticed a significant impact before the aircraft stopped. They waited for any emergency command from the PIC before ordering the evacuation. However, the passengers started to evacuate the aircraft through the right over-wing exit window before commanded by the flight attendants. The flight attendants subsequently executed the evacuation procedure without command from the PIC. The left aft cabin door was blocked by the left main landing gear that had detached from the aircraft and the flight attendants were unable to open the door. The right main landing gear and both engines were also detached from the aircraft. The Airport Rescue and Fire Fighting (ARFF) come to the crash site and activated the extinguishing agent while the passengers were evacuating the aircraft. The PIC, SIC and FA1 were the last persons to evacuate the aircraft. The APU was still running after all passengers and crew evacuation completed, afterward one company engineer went to the cockpit and switched off the APU. All crew and passengers safely evacuated the aircraft. No significant property damage was reported.
Probable cause:
Contributing Factors:
- When the aircraft approach for runway 31, the Loss of Hydraulic System A occurred at approximately at 1,600 feet. At this stage, there was sufficient time for pilots to conduct a missed approach and review the procedures and determine all the consequences prior to landing the aircraft.
- The smooth touchdown with a speed 27 kts greater than Vref and the absence of speed brake selection, led to the aircraft not decelerating as expected.
Final Report:

Crash of a Boeing 737-219 in Bishkek: 65 killed

Date & Time: Aug 24, 2008 at 2044 LT
Type of aircraft:
Operator:
Registration:
EX-009
Survivors:
Yes
Schedule:
Bichkek - Tehran
MSN:
22088/676
YOM:
1980
Flight number:
IRC6895
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
85
Pax fatalities:
Other fatalities:
Total fatalities:
65
Captain / Total flying hours:
18250
Captain / Total hours on type:
2337.00
Copilot / Total flying hours:
4531
Copilot / Total hours on type:
881
Aircraft flight hours:
60014
Aircraft flight cycles:
56196
Circumstances:
On 24 August, 2008 the Boeing 737-200 aircraft registered ЕХ-009 and operated by a crew including a PIC and a Co-pilot of Itek Air was flying a scheduled passenger flight IRC 6895 from Bishkek to Tehran. Also on board there was the cabin crew (3 persons) as well as 85 passengers including two service passengers: a maintenance engineer and a representative of the Iran Aseman Airlines. Flight IRC 6895 was executed in compliance with the leasing agreement No. 023/05 of 15 July, 2005 for the Boeing 737-200 ЕХ-009 between the Kyrgyz airline, Itek Air, and the Iran Aseman Airlines. The crew passed a medical examination in the ground medical office of Manas Airport. The crew did not have any complaints of their health. The crew received a complete preflight briefing. The weather at the departure airport Manas, the destination airport and at alternate aerodromes was favourable for the flight. Total fuel was 12000 kg, the takeoff weight was 48371 kg with the CG at 24,8% MAC, which was within the B737-200 AFM limitations. After the climb to approximately 3000 m the crew informed the ATC about a pressurization system fault and decided to return to the aerodrome of departure. While they were descending for visual approach the aircraft collided with the ground, was damaged on impact and burnt. As a result of the crash and the following ground fire 64 passengers died. The passenger who was transferred on 29 August, 2008 to the burn resuscitation department of the Moscow Sklifasovsky Research Institute died of burn disease complicated by pneumonia on 23 October, 2008, two months after he got burn injuries. Thus, his death is connected with the injuries received due to the accident.
Probable cause:
The cause of the Itek Air B737-200 ЕХ-009 accident during the air-turn back due to the cabin not pressurizing (probably caused by the jamming of the left forward door seal) was that the crew allowed the aircraft to descend at night to a lower than the minimum descent altitude for visual approach which resulted in the crash with damage to the aircraft followed by the fire and fatalities. The combination of the following factors contributed to the accident:
- Deviations from the Boeing 737-200 SOP and PF/PM task sharing principles;
- Non-adherence to visual approach rules, as the crew did not keep visual contact with the runway and/or ground references and did not follow the prescribed procedures after they lost visual contact;
- Loss of altitude control during the missed approach (which was performed because the PIC incorrectly evaluated the aircraft position in comparison with the required descent flight path when he decided to perform visual straight-in approach);
- Non-adherence to the prescribed procedures after the TAWS warning was triggered.
Final Report:

Crash of a Cessna 208A Caravan I in Cabañas: 11 killed

Date & Time: Aug 24, 2008 at 0941 LT
Type of aircraft:
Operator:
Registration:
TG-JCS
Flight Phase:
Survivors:
Yes
Schedule:
Guatemala City - El Estor
MSN:
208-0327
YOM:
2001
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
3057
Copilot / Total flying hours:
2596
Circumstances:
The single engine aircraft departed Guatemala City-La Aurora Airport at 0923LT on a flight to El Estor with 12 passengers and two pilots on board. About 18 minutes into the flight, the crew encountered engine problems. The captain contacted ATC and declared an emergency. The crew reduced his altitude and attempted an emergency landing when the aircraft crashed in an open field, bursting into flames. Three passengers were seriously injured while 11 other occupants including both pilots were killed.
Probable cause:
The sudden engine failure during flight, forcing the pilot to make an emergency landing, the aircraft impacting unsuitable terrain at a descent angle. The engine power loss was caused by the fracture of more than one compressor turbine blade, the impact of the blades in the inner parts general causing damage on the internal mechanism of the turbine station. The gas generator was rotating at low speed with the propeller feathered on the first impact with the ground. The high concentration of fire in the compressor section and in the combustion chamber, possibly indicate that several attempts were made on the engine to cause the compressor to continue working after losing the blades.
Final Report:

Crash of a De Havilland DHC-8-301 in Barranquilla

Date & Time: Aug 23, 2008 at 1715 LT
Operator:
Registration:
HK-3952
Survivors:
Yes
Schedule:
Willemstad – Barranquilla
MSN:
169
YOM:
1989
Flight number:
ARE051
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7003
Captain / Total hours on type:
6691.00
Copilot / Total hours on type:
781
Aircraft flight hours:
31260
Circumstances:
Following an uneventful flight from Willemstad-Hato Airport, the crew started the approach to Barranquilla-Ernesto Cortissoz Airport runway 23. The aircraft landed 770 metres past the runway threshold. After touchdown, the crew noticed vibrations coming from the right side of the aircraft when the right main gear collapsed. The aircraft slid for few dozen metres before coming to rest on the main runway. All 31 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Fracture of the ring of the mechanical stop of the shock absorber on the right main gear, turning the whole gear into a solid structure incapable of absorbing the landing loads, due to the non-incorporation of the Airworthiness Directive AD-2006-14 in the general repair of the main gear.
Final Report:

Crash of a McDonnell Douglas MD-82 in Madrid: 154 killed

Date & Time: Aug 20, 2008 at 1424 LT
Type of aircraft:
Operator:
Registration:
EC-HFP
Flight Phase:
Survivors:
Yes
Schedule:
Madrid - Las Palmas
MSN:
53148/2072
YOM:
1993
Flight number:
JKK5022
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
166
Pax fatalities:
Other fatalities:
Total fatalities:
154
Captain / Total flying hours:
8476
Captain / Total hours on type:
5776.00
Copilot / Total flying hours:
1276
Copilot / Total hours on type:
1054
Aircraft flight hours:
31963
Aircraft flight cycles:
28133
Circumstances:
An MD-82 passenger plane, registered EC-HFP, was destroyed when it crashed on takeoff at Madrid-Barajas Airport (MAD), Spain. Of the aircraft’s occupants, 154 were killed, including all six crew members. Eighteen passengers were seriously injured. The MD-82 aircraft operated Spanair flight JK5022 from Madrid-Barajas (MAD) to Gran Canaria (LPA). The estimated departure time was 13:00. The aircraft was authorized by control for engine start-up at 13:06:15. It then taxied to runway 36L from parking stand T21, which it occupied on the apron of terminal T2 at Barajas. The flaps were extended 11°. Once at the runway threshold, the aircraft was cleared for takeoff at 13:24:57. The crew informed the control tower at 13:26:27 that they had a problem and that they had to exit the runway. At 13:33:12, they communicated that they were returning to the stand. The crew had detected an overheating Ram Air Temperature (RAT) probe. The aircraft returned to the apron, parking on remote stand R11 of the terminal T2 parking area. The crew stopped the engines and requested assistance from maintenance technicians to solve the problem. The mechanic confirmed the malfunction described in the ATLB, checked the RAT probe heating section of the Minimum Equipment List (MEL) and opened the electrical circuit breaker that connected the heating element. Once complete, it was proposed and accepted that the aircraft be dispatched. The aircraft was topped off with 1080 liters of kerosene and at 14:08:01 it was cleared for engine start-up and to taxi to runway 36L for takeoff. The crew continued with the tasks to prepare the airplane for the flight. The conversations on the cockpit voice recorder revealed certain expressions corresponding to the before engine start checklists, the normal start list, the after start checklist and the taxi checklist. During the taxi run, the aircraft was in contact with the south sector ground control first and then with the central sector. On the final taxi segment the crew concluded its checks with the takeoff imminent checklist. At 14:23:14, with the aircraft situated at the head of runway 36L, it was cleared for takeoff. Along with the clearance, the control tower informed the aircraft that the wind was from 210° at 5 knots. At 14:23:19, the crew released the brakes for takeoff. Engine power had been increased a few seconds earlier and at 14:23:28 its value was 1.4 EPR. Power continued to increase to a maximum value of 1.95 EPR during the aircraft’s ground run. The CVR recording shows the crew calling out "V1" at 14:24:06, at which time the DFDR recorded a value of 147 knots for calibrated airspeed (CAS), and "rotate" at 14:24:08, at a recorded CAS of 154 knots. The DFDR recorded the signal change from ground mode to air mode from the nose gear strut ground sensor. The stall warning stick shaker was activated at 14:24:14 and on three occasions the stall horn and synthetic voice sounded in the cockpit: "[horn] stall, [horn] stall, [horn] stall". Impact with the ground took place at 14:24:23. During the entire takeoff run until the end of the CVR recording, no noises were recorded involving the takeoff warning system (TOWS) advising of an inadequate takeoff configuration. During the entire period from engine start-up while at parking stand R11 to the end of the DFDR recording, the values for the two flap position sensors situated on the wings were 0°. The length of the takeoff run was approximately 1950 m. Once airborne, the aircraft rose to an altitude of 40 feet above the ground before it descended and impacted the ground. During its trajectory in the air, the aircraft took on a slight left roll attitude, followed by a fast 20° roll to the right, another slight roll to the left and another abrupt roll to the right of 32°. The maximum pitch angle recorded during this process was 18°. The aircraft’s tail cone was the first part to impact the ground, almost simultaneously with the right wing tip and the right engine cowlings. The marks from these impacts were found on the right side of the runway strip as seen from the direction of the takeoff, at a distance of 60 m, measured perpendicular to the runway centerline, and 3207.5 m away from the threshold, measured in the direction of the runway. The aircraft then traveled across the ground an additional 448 m until it reached the side of the runway strip, tracing out an almost linear path at a 16° angle with the runway. It lost contact with the ground after reaching an embankment/drop-off beyond the strip, with the marks resuming 150 m away, on the airport perimeter road, whose elevation is 5.50 m lower than the runway strip. The aircraft continued moving along this irregular terrain until it reached the bed of the Vega stream, by which point the main structure was already in an advanced state of disintegration. It is here that it caught on fire. The distance from the initial impact site on the ground to the farthest point where the wreckage was found was 1093 m.
Probable cause:
The crew lost control of the airplane as a consequence of entering a stall immediately after takeoff due to an improper airplane configuration involving the non-deployment of the slats/flaps following a series of mistakes and omissions, along with the absence of the improper takeoff configuration warning.
The crew did not identify the stall warnings and did not correct said situation after takeoff. They momentarily retarded the engine throttles, increased the pitch angle and did not correct the bank angle, leading to a deterioration of the stall condition.
The crew did not detect the configuration error because they did not properly use the checklists, which contain items to select and verify the position of the flaps/slats, when preparing the flight. Specifically:
- They did not carry out the action to select the flaps/slats with the associated control lever (in the "After Start" checklist);
- They did not cross check the position of the lever or the status of the flap and slat indicating lights when executing the" After Start" checklist;
- They omitted the check of the flaps and slats during the "Takeoff briefing" item on the "Taxi" checklist;
- The visual check done when executing the "Final items" on the "Takeoff imminent" checklist was not a real check of the position of the flaps and slats, as displayed on the instruments in the cockpit.
The CIAIAC has identified the following contributing factors:
- The absence of an improper takeoff configuration warning resulting from the failure of the TOWS to operate, which thus did not warn the crew that the airplane's takeoff configuration was not appropriate. The reason for the failure of the TOWS to function could not be reliably established.
- Improper crew resource management (CRM), which did not prevent the deviation from procedures in the presence of unscheduled interruptions to flight preparations.
Final Report:

Crash of a Boeing 737-282 in Port Harcourt

Date & Time: Jul 14, 2008 at 1844 LT
Type of aircraft:
Operator:
Registration:
5N-BIG
Survivors:
Yes
Schedule:
Lagos – Port Harcourt
MSN:
23044/973
YOM:
1983
Flight number:
NCH138
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8688
Captain / Total hours on type:
452.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
2500
Aircraft flight hours:
55508
Aircraft flight cycles:
36263
Circumstances:
On 14th July, 2008 at 16:49 h, a Boeing 737–282 aircraft with nationality and registration marks 5N-BIG, operated by Chanchangi Airlines Ltd, commenced a scheduled domestic flight from Murtala Muhammed International Airport, (DNMM) with call sign NCH138 for Port Harcourt International Airport (DNPO). Instrument Flight Rules (IFR) flight plan was filed for the flight. There were 47 persons on board (41 passengers, 2 flight crew and 4 flight attendants) and 3 hours fuel endurance. The Captain was the Pilot Flying (PF) and The First Officer (FO) was the Pilot Monitoring (PM). The FO stated that NCH138 was initially scheduled to depart at 15:30 h, but the flight was delayed due to loading of passenger baggage. The Captain stated that NCH138 was cleared to FL290 and the flight continued normally. According to the DNPO Air Traffic Control (ATC) watch supervisor on duty, NCH138 contacted DNPO Approach Control (APP) at 17:05 h with flight information estimating POT at 17:50 h. NCH138 was issued an inbound clearance to POT1 VOR2 with the following weather information for 17:00 h as: Wind calm, Visibility 10 km, Broken clouds 270 m, Scattered clouds 600 m, Cumulonimbus clouds scattered, temperature 25/24°C, Thunderstorms, Temporarily Variable 8 kt, gusting 18 kt, Visibility 3000 m, Thunderstorms and rain, and expect runway (RWY) 21 for landing. According to the First Officer NCH138 requested descent into POT at about 100 NM. The Captain added that due to ATC delay, the descent commenced at about 80 NM. The Control Tower Watch Supervisor stated that at 18:00 h, NCH138 requested to hold over POT at 3500 ft for weather improvement, because there was rain overhead the station with build-up closing in at the threshold of RWY 21. At about 15 NM, between radials 180° and 210°, NCH138 reported breaking out of weather. At 18:19 h, NCH138 requested weather information from the Tower. Tower advised the flight crew that RWY 03 was better for landing. At this time, NCH138 requested RWY 03 for approach and Approach Control cleared NCH138 for the approach to RWY 03. At 18:27 h, the flight crew reported established on approach to RWY 03, leaving 2000 ft. The Approach Control then transferred NCH138 to DNPO Tower for landing instructions. At 18:28 h, the Tower instructed NCH138 to report field in sight. The flight crew acknowledged and reported RWY 03 in sight. Tower cleared NCH138 to land on RWY 03 and NCH138 was cautioned that the runway was wet. At 18:34 h, NCH138 executed and reported a missed approach. NCH138 requested a climb to 3500 ft. NCH138 was cleared to climb and instructed to report overhead POT. At 18:39 h, NCH138 requested a descent and clearance for an approach to RWY 21. Approach Control cleared NCH138 to descend to 2000 ft and report to Tower when established on the approach and also to report leaving 2000 ft. At 18:42 h, NCH138 reported inbound maintaining 2000 ft. The Approach Control requested the distance from the runway and sought consent of NCH138 for Arik 514 at the holding point to take off. NCH138 declined, as they were about 10 miles to touchdown. At 18:45 h, NCH138 reported five miles to touchdown. Approach Control acknowledged and instructed NCH138 to report field in sight and thereafter handed over to Tower on 119.2 MHz. When contacting the Tower, NCH138 was cleared to land on RWY 21, wind 0100 /10 kt and was advised to exercise caution due to wet runway. NCH138 acknowledged the clearance. NCH138 landed hard and bounced three times on the runway. According to the ATC controller, after touch down the aircraft rolled in an s-pattern before it overran the runway. NCH138 made a 180° turn with the right engine hitting the ground. The aircraft came to a final stop on the left side and 10 m beyond the stopway. The accident occurred at night in Instrument Meteorological Conditions (IMC). The Aerodrome Rescue and Fire Fighting Service (ARFFS) arrived the scene and commenced rescue operations immediately. All occupants on board were evacuated; one passenger sustaining a minor injury.
Probable cause:
The decision to land following an unstabilized approach (high rate of descent and high approach speed. A go-around was not initiated.
Contributory factors:
1. The deteriorating weather conditions with a line squall prevented a diversion to the alternates.
2. The runway was wet with significant patches of standing water.
Final Report: