Crash of a De Havilland DHC-6 Twin Otter 300 off North Ari Atoll

Date & Time: Jul 14, 2008 at 1230 LT
Operator:
Registration:
8Q-MAS
Survivors:
Yes
Schedule:
Male - North Ari Atoll
MSN:
445
YOM:
1975
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3150
Captain / Total hours on type:
430.00
Copilot / Total flying hours:
2880
Copilot / Total hours on type:
127
Aircraft flight hours:
49129
Circumstances:
14th July 2008 was a Monday; the busiest day of the week where there is an average of 150-200 movements. 8Q-MAS completed six sectors prior to the accident, with the same flight crew. Sixteen pieces of baggage were loaded, in the aft cabin, with total weight of 458 lbs. The flight manifest signed by Pilot in Command indicated that the aircraft was loaded up to 11874 lbs. The aircraft was boarded with 14 passengers (7 females, 6 males and 1 child) and the flight manifest used approved weights of 77 lbs Child, 181 lbs for male and 141 lbs for female to calculate the aircraft weight. The aircraft had 930 lbs of fuel. This particular aircraft was a short nose twin otter aircraft, with main loading in aft cabin. The MAT seaplane operation was based on a day VFR, non-schedule and a self dispatch system. All pre-flight duties were completed by the crew. The weather was windy and sea was rough. The aircraft departed at 12.11 hrs from MAT dock at Male International Airport, Water Aerodrome to Adaaran Club Bathala with 14 passengers total: 10 passengers to Adaaran Club Bathala, 2 passengers to Nika Maldives and 2 Passengers to W Retreat and Spa (Fesdu). The estimated flight time to destination was 20 minutes. The W Retreat and Spa Maldives Resort’s Speed Boat (Angelina) (a 34 ft Triana Express) was moored at a buoy (located at 04 04’ 43.6” N, 072 56’ 37.1” E) used by MAT to moor the aircrafts for night stops. The floating platform was located (04 04’ 43.5”N, 072 56’ 38.8”E) east of the buoy. The distance between the floating platform and buoy is around 165 feet. Around 12:30 the aircraft approached for landing near the floating platform. The wind was on a westerly direction 20 to 25 knots and the aircraft approached for a westbound landing. The aircraft made an orbit over the lagoon to inspect the water. The aircraft did a touchdown and was cutting the wave tops to find an appropriate location to stop, when it hit a big wave and was airborne. The aircraft veered to the left. The PIC declared to do a go around. The crew action was 10 degree flap, full throttle and Max Prop RPM. On climb the aircraft collided with the Speed Boat and the aircraft veered to the right and PIC was able to land on LH float.
Probable cause:
Causal Factors:
• The crew’s decision to land on rough waters without giving due considerations for a rejected landing and obstacles nearby was a causal factor.
• The Speed Boat moored to a buoy, close to the landing area was also a causal factor.
Final Report:

Crash of a Let L-410UVP-E9 in Kichwa Tembo

Date & Time: Jul 10, 2008 at 0820 LT
Type of aircraft:
Operator:
Registration:
5Y-VVB
Flight Phase:
Survivors:
Yes
MSN:
96 27 04
YOM:
1996
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, the copilot noticed abnormal parameters on the right engine and a possible failure. The captain confirmed and rejected the take off procedure. The twin engine aircraft was unable to stop within the remaining runway 08, overran, collided with a termite mound and came to rest 140 metres further on. All 13 occupants escaped uninjured while the aircraft was damaged beyond economical repair.

Explosion of a Tupolev TU-154M in Saint Petersburg

Date & Time: Jun 30, 2008 at 1548 LT
Type of aircraft:
Operator:
Registration:
RA-85667
Flight Phase:
Survivors:
Yes
Schedule:
Saint Petersburg - Moscow
MSN:
89A825
YOM:
1989
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, at a speed of 32 knots, the engine n°1 (a Soloviev D-30KU-154-II) exploded. The crew abandoned the takeoff procedure and started an emergency braking manoeuvre. The aircraft was stopped on the main runway and all 112 occupants evacuated safely. The aircraft was considered as damaged beyond repair as several compressor elements punctured the engine n°1 nacelle, hit the fuselage and n°2 engine structure. A fire erupted on the left engine and destroyed the nacelle and a part of APU as well.
Probable cause:
Left engine compressor disintegration during the takeoff roll.

Crash of an Airbus A310-324 in Khartoum: 30 killed

Date & Time: Jun 10, 2008 at 2026 LT
Type of aircraft:
Operator:
Registration:
ST-ATN
Survivors:
Yes
Schedule:
Amman – Damascus – Khartoum
MSN:
548
YOM:
1990
Flight number:
SD109
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
203
Pax fatalities:
Other fatalities:
Total fatalities:
30
Captain / Total flying hours:
14180
Captain / Total hours on type:
3088.00
Copilot / Total flying hours:
9879
Copilot / Total hours on type:
3347
Aircraft flight hours:
53233
Aircraft flight cycles:
21524
Circumstances:
The Airbus 310 serial number 548 owned by Sudan Airways Was entered in Sudan Civil Register on 15/09/2007 , designated registration marks ST-ATN in accordance to registration certificate No. 0493 dated 15/09/2007 and issued with Certificate of airworthiness No AWP/COA/0203/2007 dated 19/09/2007. On the morning of 10th June at 8:30 hrs (local time 05:30 UTC) after arriving from Cairo with a deactivated no 1 engine reverse as being a carry forward defect and being labeled according to MEL, the captain accepted the aircraft to carry out its scheduled flight to Amman via Damascus. The trip en-route to Amman was uneventful. Same day in the afternoon, the Airbus A310, ST-ATN, was en-route flying from Damascus (Syria) to Khartoum (Sudan) with 203 passengers and 11 crew members on board. The Airbus approached Khartoum in the afternoon and due to bad weather conditions, the captain decided to divert to Port Sudan. The aircraft landed Port Sudan Airport normally and was refuelled with 20 tons of Jet A1. As mentioned by the Captain that he was in contact with Khartoum enquiring about the weather. After staying on ground at Port Sudan for about 1:15 hour, and being informed that the weather was getting better, the Captain decided to return back to Khartoum. A310, ST-ATN, took off to Khartoum where the captain initiated a night approach for the runway 36 as pilot flying. He got the clearance to land after the controller provided him with wind information (320° / 7 Kt) and runway condition (wet). The left engine thrust reverser was unserviceable and inhibited as per Minimum Equipment List (MEL) procedures. The aircraft landed smoothly about 17:26 UTC. R/W 36 landing and within 900 meters range from the threshold of R/W 36 as stated by the flying pilot. The captain reported that he experienced some difficulties in maintaining the aircraft on the centre line just after setting both thrust levers in the reverse position. Then he did not succeed in slowing down the aircraft nor could stop it before the end of the runway. The aircraft longitudinally overran the runway and came to a stop 215 meters after the runway end. Then it caught fire on its right side. The right hand slides could not be deployed, the crew and the passengers evacuated the aircraft from the left front slide, twenty nine passengers and one cabin crew were fatally injured.
Probable cause:
The accident was due to a long flaring distance (900 meters from R/W threshold) on a wet slippery runway without selecting Auto brake and with one deactivated engine reverse in such rainy conditions. The remaining available landing distance turned out to be too short to allow the captain to stop the aircraft before the end of the runway.
Contributing factors:
The wind information was not appropriate as it was tailwind at time of landing. The crew was not aware about the aircraft ground speed and the tailwind.
Final Report:

Crash of a Cessna 208B Grand Caravan near La Junta: 1 killed

Date & Time: Jun 7, 2008 at 1350 LT
Type of aircraft:
Operator:
Registration:
CC-CTR
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Puerto Montt – La Junta
MSN:
208B-1137
YOM:
2005
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15132
Captain / Total hours on type:
283.00
Circumstances:
The single engine aircraft departed Puerto Montt-El Tepual Airport at 1315LT on a flight to La Junta, carrying 9 passengers and one pilot. En route, the pilot reported to ATC his ETA at La Junta at 1425LT. Few minutes later, while cruising under VFR mode in IMC conditions, the aircraft impacted trees and crashed on a wooded area located on Mt Estero Yeco. The wreckage was found four days later, on June 11, at an altitude of 3,300 feet and 18 km west of La Junta Airport. All 9 passengers were rescued while the pilot was killed.
Probable cause:
The decision of the pilot to continue the flight under VFR mode in IMC conditions. As a result, he lost visual references and was unable to maintain a safe separation with the ground, causing the aircraft to impact terrain. Inadequate planning by the pilot by not considering the existing weather conditions en route and at destination was considered as a contributing factor.
Final Report:

Crash of an Airbus A320-233 in Tegucigalpa: 5 killed

Date & Time: May 30, 2008 at 0940 LT
Type of aircraft:
Operator:
Registration:
EI-TAF
Survivors:
Yes
Schedule:
San Salvador – Tegucigalpa – Miami
MSN:
1374
YOM:
2000
Flight number:
TA390
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
118
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
11899
Captain / Total hours on type:
8514.00
Copilot / Total flying hours:
1607
Copilot / Total hours on type:
250
Aircraft flight hours:
21957
Aircraft flight cycles:
9992
Circumstances:
A TACA Airlines Airbus A320, flight TA390, with Irish Registry EI-TAF, with 135 passengers and crew on board, overran at the end of the runway during landing at Tegucigalpa caused the deaths of three people on board and two on the ground. The government of Honduras delegated the conduct of investigation to the Salvadoran Civil Aviation Authorities, as provided for in Annex 13 to the Chicago Convention. In accordance with international agreements, France sent two investigators from the BEA (Bureau d'Enquêtes et d'Analyses), accompanied by five technical advisors from Airbus; United States sent two investigators from the NTSB (National Transportation Safety Board), accompanied by one advisor from FAA (Federal Aviation Administration) and one technical Advisor from IAE (International Aero Engine); and Ireland sent one investigator. Both flight recorders (CVR and DFDR) were recovered and taken to the NTSB in order to perform the read out. The following data result from the analysis done by the BEA and Airbus of the accident recorders, which have been processed within the NTSB facilities under the leadership of the in-charge Authorities. It is confirmed that the aircraft was dispatched without any deferred MEL item. Prior to landing, the wind information given by the ATC to the crew was 190°/10kt and ATC also confirmed that the runway was wet. The Captain was the Pilot Flying (PF). Landing configuration was established with Slats/Flaps fully extended, gear down, ground spoilers armed, autobrake selected to MED. The aircraft landing weight was 63.5t (max landing weight 64.5t), Vapp 137kt. The aircraft was cleared to land on runway 02 and landed with Autopilot and Flight Directors OFF, and autothrust engaged in managed speed mode. At time of touch down, IAS was 139kt and Ground Speed (GS) was 159kt (estimated tailwind was 12kt from DFDR data analysis). The aircraft landed on runway 02 (Runway 02 is 3297 feet high and has a displaced threshold of 213m). The Landing Distance Available (LDA) for runway 02 is of 1649m. The touch down occurred at approximately 400m from the runway 02 displaced threshold. Immediately after touchdown, the crew selected MAX REV, and both engine reversers and the Ground Spoilers (G/S) deployed normally. The nosewheel touch down occurred 7s after the Main Landing Gear (MLG) following PF inputs. The crew applied manual braking 4s after MLG touch down and commanded maximum pedal braking in 10s (14s after MLG touch down). At 70 knots Indicated Airspeed Speed (IAS), upon Pilot Non Flying (PNF) call-out, the PF selected IDLE REV. The remaining distance to the runway end was approximately 190m. The aircraft overran the runway at 54kt and dropped down the 20 m embankment sustaining severe damage on impact with the ground. The landing performance analysis confirms that the landing performances are consistent with runway condition and crew actions.
Probable cause:
Contributing factors:
- Wrong approach configuration,
- Excessive speed upon landing,
- The aircraft landed too far down the runway with a tailwind component,
- On approach, the crew failed to recalculate the aircraft weight for landing and the landing distance,
- The non precision approach was completed in poor weather conditions, which increased the cockpit crew workload,
- The absence of a stopping zone at the end of runway 02 contributed to the severity of the occurrence,
- The runway surface was wet and not equipped with a water drainage system, which reduced the braking coefficient.
Final Report:

Crash of a BAe 146-200 in Bucharest

Date & Time: Apr 22, 2008 at 1817 LT
Type of aircraft:
Operator:
Registration:
YR-BEB
Survivors:
Yes
Schedule:
Timişoara – Bucharest
MSN:
E2220
YOM:
1993
Flight number:
RMV204
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Timişoara, the crew initiated the approach to Bucharest-Otopeni-Henri Coanda Airport in poor weather conditions. After touchdown, the crew encountered difficulties to stop the aircraft. On a wet runway surface, the aircraft deviated to the right, causing the right main gear to be torn off while contacting soft ground. The airplane came to rest, straddling on the runway edge. All 73 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of an Embraer EMB-110P1 Bandeirante in Coari

Date & Time: Apr 21, 2008 at 1500 LT
Operator:
Registration:
PT-OCV
Survivors:
Yes
Schedule:
Manaus – Carauari
MSN:
110-359
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16442
Captain / Total hours on type:
2519.00
Copilot / Total flying hours:
1132
Copilot / Total hours on type:
364
Circumstances:
The twin engine aircraft departed Manaus-Eduardo Gomes Airport on a flight to Carauari, carrying 15 passengers and two pilots. About 50 minutes into the flight, while cruising at an altitude of 8,500 feet, the right engine failed. The crew elected several times to restart it but without success. After the crew informed ATC about his situation, he was cleared to divert to Coari Airport located about 37 km from his position. Because the aircraft was overloaded and one engine was inoperative, the crew was approaching Coari Airport runway 28 with a speed higher than the reference speed. The aircraft landed too far down the runway, about 700 metres past the runway 28 threshold (runway 28 is 1,600 metres long). After touchdown, directional control was lost. The airplane veered off runway to the left and while contacting a drainage ditch, the undercarriage were torn off and the aircraft came to rest 20 metres further. All 17 occupants were evacuated, among them nine were injured. The aircraft was damaged beyond repair.
Probable cause:
The failure of the right engine was the result of the failure of the fuel pump due to poor maintenance and a possible use beyond prescribed limits. The presence of iron oxide inside and outside the fuel pump as well as the lack of cleanliness of the internal components indicates a probable lack of maintenance. When the right engine stopped running, the generator No. 1 was then responsible for powering the aircraft's electrical system. As the latter was not in good working order, the primary generator could not withstand the overload and ceased to function, leaving only the battery to power the entire electrical system. To maintain power to critical systems, the crew would have had to select the backup power system. Since after the engine stopped, there was no monitoring of the electrical system, the pilots only realized the failure of the electrical system when they attempted to extend the landing gears. The emergency hydraulic system was then used to lower the gears, after which the crew did not return the system selection valve to the 'normal' position, resulting in the brakes and the steering systems to be inoperative after landing. The chain of failures may be associated with not reading the checklist when performing procedures after the engine failure.
The following contributing factors were identified:
- Poor flight preparation,
- The crew failed to follow the SOP's, and took the decision to initiate the flight with an aircraft that was overloaded by 503 kilos,
- When the emergency situation presented itself to the crew, they failed to follow the checklist,
- On an organizational level, the company did not have an effective personnel training system in place, so that the crew did not have sufficient skills to respond to emergency situations,
- Because the aircraft was overloaded and that one engine was inoperative, the crew was forced to complete the approach with a speed higher than the reference speed,
- An improper use of the controls allowed the aircraft to land 700 meters past the runway 28 threshold, reducing the landing distance available,
- The crew focused their attention on the failure of the right engine and did not identify the failure of the electrical system, which delayed their tasks assignment, all made worse by the failure to comply with the checklist,
- The operations cleared the crew to start the flight despite the fact that the aircraft was overloaded on takeoff based on weight and balance documents,
- The crew did not prepare the flight according to published procedures and did not consider the total weight of the aircraft in relation to the number of passengers on board and the volume of fuelin the tanks, which resulted in an aircraft to be overloaded by 503 kilos and contributed to the failure of the right engine,
- A lack of maintenance on the part of the operator.
Final Report:

Crash of an Ilyushin II-62M in Saint Domingo

Date & Time: Apr 20, 2008 at 1430 LT
Type of aircraft:
Operator:
Registration:
CU-T1283
Survivors:
Yes
Schedule:
Santo Domingo - Havana
MSN:
4053823
YOM:
1991
Flight number:
CU201
Crew on board:
8
Crew fatalities:
Pax on board:
109
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Few minute after takeoff from Santo Domingo-Las Américas Airport, while cruising at an altitude of 25,000 feet, some 83 km from Santo Domingo, the captain informed ATC about the explosion of the engine n°2 and that a cabin decompression occurred. The crew was cleared for an immediate return and the aircraft landed uneventful few minutes later. All 117 occupants evacuated safely. However, the aircraft was considered as damaged beyond repair due to severe damages to the engines n°2 and n°1 as well as the fuselage because debris of the engine n°2 punctured the fuselage and came to rest in the cabin.

Crash of a Douglas DC-9-51 in Goma: 40 killed

Date & Time: Apr 15, 2008 at 1430 LT
Type of aircraft:
Operator:
Registration:
9Q-CHN
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Goma – Kisangani
MSN:
47731/860
YOM:
1977
Location:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
40
Circumstances:
During the takeoff roll from runway 18 at Goma Airport, the crew started the rotation but the aircraft failed to respond. The aircraft continued, overran and crashed in the Birere District, about 100 metres past the runway end, bursting into flames. Three passengers were killed as well as 37 people on the ground. All other occupants were injured. The aircraft was totally destroyed by impact forces and a post crash fire.
Probable cause:
It is possible that one of the engine or maybe both suffered a loss of power during takeoff after the aircraft passed through a puddle.