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.

Crash of a Grumman G-21A Goose in Unalaska

Date & Time: Apr 9, 2008 at 1630 LT
Type of aircraft:
Operator:
Registration:
N741
Survivors:
Yes
Schedule:
Akutan - Unalaska
MSN:
B097
YOM:
1944
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7040
Captain / Total hours on type:
320.00
Aircraft flight hours:
12228
Circumstances:
The airline transport pilot was on an approach to land on Runway 30 at the conclusion of a visual flight rules (VFR)scheduled commuter flight. Through a series of radio microphone clicks, he activated threshold warning lights for vehicle traffic on a roadway that passes in front of the threshold of Runway 30. Gates that were supposed to work in concert with the lights and block the runway from vehicle traffic were not operative. On final approach, the pilot, who was aware that the gates were not working, noticed a large truck and trailer stopped adjacent to the landing threshold. As he neared the runway, he realized that the truck was moving in front of the threshold area. The pilot attempted to go around, but the airplane's belly struck the top of the trailer and the airplane descended out of control to the runway, sustaining structural damage. The truck driver reported that, as he approached the runway threshold, he saw the flashing red warning lights, but that the gates were not closed. He waited for about 45 seconds and looked for any landing traffic and, seeing none, drove onto the road in front of the threshold. As he did so, he felt the airplane impact the trailer, and saw it hit the runway. The accident truck's trailer is about 45 feet long and 13 feet tall. The Federal Aviation Administration (FAA) Facility Directory/Alaska Supplement recommends that pilots maintain a 25-foot minimum threshold crossing height. The NTSB's investigation revealed that the gate system had been out of service for more than a year due to budgetary constraints, and that there was no Notice to Airman (NOTAM) issued concerning the inoperative gate system. The FAA certificated airport is owned and operated by the State of Alaska. According to the Airport Certification Manual, the airport manager is responsible to inspect, maintain, and repair airport facilities to ensure safe operations. Additionally, the airport manager is responsible for publishing NOTAM's concerning hazardous conditions. A 10-year review of annual FAA certification and compliance inspection forms revealed no discrepancy listed for the inoperative gates until 16 days after the accident.
Probable cause:
The pilot's failure to maintain clearance from a truck while landing, and the vehicle operator's decision to ignore runway warning signals. Contributing to the accident was an inoperative vehicle gate system and the failure of airport management to adequately maintain the gate system and issue a NOTAM.
Final Report:

Crash of a PZL-Mielec AN-28 in Benzdorp: 19 killed

Date & Time: Apr 3, 2008 at 1100 LT
Type of aircraft:
Operator:
Registration:
PZ-TSO
Survivors:
No
Site:
Schedule:
Paramaribo – Lawa
MSN:
1AJ007-17
YOM:
1990
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Circumstances:
While approaching Lawa-Antino airport, the crew was informed that another airplane was on the runway at that time. The crew initiated a go-around procedure when the aircraft hit a wooded hillside and crashed, bursting into flames. All 19 occupants were killed.

Crash of a Dornier DO328-110 in Mannheim

Date & Time: Mar 19, 2008 at 1745 LT
Type of aircraft:
Operator:
Registration:
D-CTOB
Survivors:
Yes
Schedule:
Berlin - Mannheim
MSN:
3107
YOM:
1999
Flight number:
RUS1567
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
1700.00
Copilot / Total flying hours:
320
Copilot / Total hours on type:
130
Aircraft flight hours:
13029
Aircraft flight cycles:
13185
Circumstances:
Following an uneventful flight from Berlin-Tempelhof Airport, the crew started a LOC/DME approach to runway 27 at Mannheim Airport. The copilot was the pilot-in-command and reported to the captain he has difficulties to land in Mannheim. On approach, the aircraft descended below the prescribed altitude of 5,000 feet. At an altitude of 3,800 feet, some 100 feet below the Minimum Sector Altitude (MSA), the captain instructed the copilot to arrest the descent and climb back to 5,000 feet. After he was established on the localizer, the crew continued the approach. Shortly before landing, the aircraft floated over the runway and the touchdown zone and landed too far down the runway, about 530 metres past the runway threshold. After touchdown, the aircraft encountered difficulties to decelerate and was unable to stop within the remaining distance of 480 metres. It overran at a speed of 50 knots, lost its left main gear and came to rest against an embankment. All 27 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
 The following findings were identified:
- The throttle, after placement by the PIC (PF), could not be moved into 'ground idle' or reverse,
- The landing was not aborted after the plane had flown over the touchdown zone,
- The crew failed to initiate a go-around procedure,
- During the flare for landing, the engine throttles were not selected to 'flight idle', which was not noted by both pilots,
- The flight crew flew the approach not in accordance with SOPs, and thereby pushing and even exceeding the limits.
The following factors contributed to the accident:
- Many non-precision approaches and landings at Mannheim City were not performed according to air carriers OMs,
- The TRs and FOIs of the aircraft manufacturer were not incorporated into the OM/B and D of the air carrier,
- The practical training of the flight crew by the air carrier was inadequate in terms of preventing an erroneous operation of the throttle control on the basis of the manufacturer of the Do 328-100 issued instructions,
- The flight crew conducted a non-precision approach, which did not meet the procedural requirements of the OM of the air carrier and the AIP,
- The design of the power lever was not forgiving enough,
- The risks of existing problems in the operation of the power levers were not correctly identified and eliminated by by the relevant authorities and the relevant type certificate holder, in spite of several relevant events and various safety recommendations,
- The touchdown zone in Mannheim was not marked,
- The size and design of the safety area at the end of runway 27 was not sufficient to guarantee the operation of the flight within the safety levels set by ICAO and the legislator.
Final Report:

Crash of a Boeing 737-408 in Batam

Date & Time: Mar 10, 2008 at 1020 LT
Type of aircraft:
Operator:
Registration:
PK-KKT
Survivors:
Yes
Schedule:
Jakarta - Batam
MSN:
24353/1721
YOM:
1989
Flight number:
DHI292
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
171
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 10 March 2008, a Boeing Company 737-400 aircraft, registered PK-KKT, was being operated by Adam SkyConnection Airlines (Adam Air) as scheduled passenger flight with flight number DHI292. The flight departed Soekarno – Hatta Airport, Jakarta at 01:30 UTC with destination Hang Nadim Airport, Batam and the estimated time of arrival was 03:05 UTC. On board in this flight were 177 people consisted of two pilots, four flight attendants, and 171 passengers. The Pilot in Command (PIC) acted as pilot flying (PF) and the Second in Command (SIC) acted as pilot monitoring (PM). The flight until commencing descend was uneventful. Prior to descend, the flight crew received weather information indicating that the weather was fine. At 0302 UTC the flight crew contacted Hang Nadim tower controller and informed them that the visibility was 1,000 meters and they were sequence number three for landing runway 04. The flight crew of the aircraft on sequence number two informed to Hang Nadim tower controller that the runway was insight at an altitude of about 500 feet. The Hang Nadim tower controller forwarded the information to the flight crew of DHI 292, and followed this by issuing landing clearance, and additional information that the wind velocity was 360 degrees at 8 knots and heavy rain. The DHI 292 flight crew acknowledged the information. The landing configuration used flaps 40 degrees with landing speed of 136 knots. The flight crew were able to see the runway prior to the Decision Altitude (DA), however the PIC was convinced that continuing the approach to landing was unsafe and elected to go around. The Hang Nadim tower controller instructed the flight crew to climb to 3000 feet, maintain runway heading, and contact Singapore Approach. At 0319 UTC, DHI 292 was established on the localizer runway 04, and the Hang Nadim tower controller informed them that the visibility improved to 2,000 meters. While on final approach, the flight crew DHI 292 reported that the runway was in sight and the Hang Nadim tower controller issued a landing clearance. On touchdown, the crew felt that the main wheels barely touch the runway first. During the landing roll, as the ground speed decreased below 30 knots, the aircraft yawed to the right. The flight crew attempted to steer the aircraft back to centerline by applying full left rudder. The aircraft continued yaw to the right and came to stop on the runway shoulder at approximately 40 meters from the right side of the runway edge, and 2,760 meters from the runway 04 threshold. No one was injured in this accident. The aircraft was seriously damaged with the right main landing gear assembly detached and collapsing backward and damaging the right wing and flaps. The right engine was displaced from its attachment point.
Probable cause:
The Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR) data were downloaded. The CVR data showed that the aircraft was flying below the correct glide path indicated by a glide slope aural warning, and the crew had difficulty in recovering the condition. The CVR also recorded landing gear warning after touchdown which indicated the landing gear had collapsed. The FDR data showed that the vertical acceleration during landing was 2.97 g, however this amount of vertical acceleration should not damage the landing gear. The FDR data showed that just after touchdown, the right main landing gear collapsed. The FDR also recorded that the aircraft experienced hard landing and had bounced on a previous flight, and the value of the vertical acceleration recorded was 1.78 g. It was most likely that the hard landing and bounce had affected the strength of the landing gear. The examination of the failed landing gear also found corrosion on the fracture surface of the right main landing gear strut.
Final Report:

Crash of an ATR42-300 in Mérida: 46 killed

Date & Time: Feb 21, 2008 at 1700 LT
Type of aircraft:
Operator:
Registration:
YV1449
Flight Phase:
Survivors:
No
Site:
Schedule:
Mérida – Caracas
MSN:
28
YOM:
1986
Flight number:
BBR518
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
46
Circumstances:
After takeoff from Mérida-Alberto Carnevalli Airport runway 25, the aircraft climbed in clouds when it collided with a mountain located 10 km northwest of the airport. The aircraft disintegrated on impact and all 46 occupants were killed. The wreckage was found at an altitude of 4,100 metres.
Probable cause:
After departure from runway 25, the crew planned to use an unpublished procedure. Climbing through clouds a 180-degree turn was initiated. Using the unreliable magnetic compass, the flight made a 270 degree turn, heading towards rising terrain. The captain took over control from the copilot. When visual contact with terrain was regained, the crew noted they were heading for mountains. The captain tried to avoid rising terrain but the aircraft impacted the side of a mountain at 4,100 metres.

Crash of an ATR72-212 in Putao

Date & Time: Feb 19, 2008
Type of aircraft:
Operator:
Registration:
XY-AIE
Flight Phase:
Survivors:
Yes
Schedule:
Putao - Myitkyina
MSN:
458
YOM:
1995
Flight number:
JAB252
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
53
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, the captain noticed an asymmetrical engine thrust and decided to reject takeoff. Unable to stop within the remaining distance, the aircraft overran, rolled for about 30 metres and collided with an embankment, coming to rest broken in two. All 57 occupants evacuated safely.

Crash of a Canadair RegionalJet CRJ-100ER in Yerevan

Date & Time: Feb 14, 2008 at 0415 LT
Operator:
Registration:
EW-101PJ
Flight Phase:
Survivors:
Yes
Schedule:
Yerevan - Minsk
MSN:
7316
YOM:
1999
Flight number:
BRU1834
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
15563
Aircraft flight cycles:
14352
Circumstances:
A Canadair CRJ100ER passenger jet, operated by Belavia, was destroyed when crashed and burned on takeoff from Yerevan-Zvartnots Airport (EVN), Armenia. All three crew members and eighteen passengers survived the accident. The airplane arrived as flight BRU1833 from Minsk-2 International Airport (MSQ), Belarus at 02:05. Refueling was carried out in preparation for the return flight and the crew conducted the flight planning. After refueling the pilot carried out a tactile and visual inspection of all critical surfaces of the wing and visual inspection of the tail assembly. All the planes were clean and dry. The weather reported for the 04:00 was: wind 110 degrees at the ground 1 m/sec, visibility 3500 meters, haze, small clouds, vertical visibility of 800 meters, scattered clouds at 3000 m, a temperature of minus 3° C, dew point minus 4° C, pressure 1019 hPa. At 04:08 both engines were started. The engine air intake heating (cowl anti-ice) was switched on but the wing anti-icing system was not switched on. The crew taxied to runway 27 and were cleared for departure. During takeoff the airplane progressively banked left until the left wing tip contacted runway. The airplane went off the side with the airplane rolling the right. The right hand wing broke off and spilled fuel caught fire. The airplane came to rest upside down.
Probable cause:
The accident involving aircraft CRJ-100LR registration number EW-101PJ was the result of an asymmetric loss of lift of the wing during take-off, which led to the toppling of the aircraft immediately after liftoff from the runway, the left wing tip contacting the ground, the subsequent destruction and fire. The reason for the loss of lift of the wing at the actual weather conditions, was the formation of frost, which "pollutes" the surface of the wing. The cause of formation of frost, most likely, was the fuel icing, while the aircraft was parked at the airport and during taxiing for the return flight, resulting in a difference in temperature of the surrounding air and cold fuel in the tanks after the flight. The situation could be aggravated when exceeding the values recommended by the operations manual of the angular velocity when lifting the nose wheel during takeoff with "contaminated" wings when it is impossible to monitor this parameter instrumentally. Existing procedural methods of control of the aerodynamic surfaces of the aircraft before departure, along with the inefficiency, during takeoff, the existing system of protection from stalling due to increased sensitivity of the wing, even to a slight contamination of the leading edge, can not fully guarantee the prevention of similar accidents in future. An Airworthiness Directive on the need to include anti-icing systems on the wing in the final stage of taxiing at the actual weather conditions was issued by Transport Canada after the accident. This probably could have prevented the accident.