Ground accident of a Boeing 727-247 in Pointe-Noire

Date & Time: Jan 25, 2008
Type of aircraft:
Registration:
9L-LEF
Flight Phase:
Survivors:
Yes
MSN:
21482/1341
YOM:
1978
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While parked at Pointe-Noire Airport, the aircraft was struck by an Antonov AN-12 registered EK-11660 and operated by Aéro-Service that just completed a cargo flight from Brazzaville with 6 crew members on board. Following a normal landing, the crew of the AN-12 vacated the runway and while approaching the apron, they lost control of the aircraft that collided with the parked Boeing 727. All six crew members on board the AN-12 were injured, both pilots seriously. Both aircraft were damaged beyond repair. The Boeing 727 was empty at the time of the ground collision.
Probable cause:
It is believed that the loss of control was the consequence of a brakes failure.

Crash of a Boeing 777-236ER in London

Date & Time: Jan 17, 2008 at 1242 LT
Type of aircraft:
Operator:
Registration:
G-YMMM
Survivors:
Yes
Schedule:
Beijing - London
MSN:
30314/342
YOM:
2001
Flight number:
BA038
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12700
Captain / Total hours on type:
8450.00
Copilot / Total flying hours:
9000
Copilot / Total hours on type:
7000
Aircraft flight hours:
28675
Aircraft flight cycles:
3957
Circumstances:
G-YMMM was on a scheduled return flight from Beijing, China, to London (Heathrow) with a flight crew consisting of a commander and two co-pilots; the additional co-pilot enabled the crew to take in-flight rest. There had been no reported defects with G-YMMM during the outboard flight from London (Heathrow) to Beijing, China. The flight plan for the return sector, produced by the aircraft’s operator, required an initial climb to 10,400 m (FL341) with a descent to 9,600 m (FL315) because of predicted ‘Extreme Cold’ at POLHO (a waypoint that lies on the border between China and Mongolia). Having checked the flight plan and the weather in more detail the crew agreed on a total fuel load for the flight of 79,000 kg. The startup, taxi, takeoff at 0209 hrs and the departure were all uneventful. During the climb, Air Traffic Control (ATC) requested that G-YMMM climb to an initial cruise altitude of 10,600 m (FL348). The crew accepted this altitude and, due to the predicted low temperatures, briefed that they would monitor the fuel temperature en route. The initial climb to altitude was completed using the autopilot set in the Vertical Navigation (VNAV) mode. Approximately 350 nm north of Moscow the aircraft climbed to FL380; this step climb was carried out using the Vertical Speed (VS) mode of the autoflight system. Another climb was then carried out whilst the aircraft was over Sweden, this time to FL400, and again this was completed in VS mode. During the flight the crew monitored the fuel temperature displayed on the Engine Indication and Crew Alerting System (EICAS) and noted that the minimum indicated fuel temperature en route was -34˚C. At no time did the low fuel temperature warning annunciate. The flight continued uneventfully until the later stages of the approach into Heathrow. The commander was flying at this time and during the descent, from FL400, the aircraft entered the hold at Lambourne at FL110; it remained in the hold for approximately five minutes, during which it descended to FL90. The aircraft was radar vectored for an Instrument Landing System (ILS) approach to Runway 27L at Heathrow and subsequently stabilised on the ILS with the autopilot and autothrottle engaged. At 1,000 ft aal, and 83 seconds before touchdown, the aircraft was fully configured for the landing, with the landing gear down and flap 30 selected. At approximately 800 ft aal the co-pilot took control of the aircraft, in accordance with the briefed procedure. The landing was to be under manual control and the co-pilot intended to disconnect the autopilot at 600 ft aal. Shortly after the co-pilot had assumed control, the autothrottles commanded an increase in thrust from both engines. The engines initially responded but, at a height of about 720 ft, 57 seconds before touchdown, the thrust of the right engine reduced. Some seven seconds later, the thrust reduced on the left engine to a similar level. The engines did not shut down and both engines continued to produce thrust above flight idle, but less than the commanded thrust. At this time, and 48 seconds before touchdown, the co-pilot noted that the thrust lever positions had begun to ‘split’. On passing 500 ft agl there was an automatic call of the Radio Altimeter height, at this time Heathrow Tower gave the aircraft a landing clearance, which the crew acknowledged. Some 34 seconds before touchdown, at 430 ft agl, the commander announced that the approach was stable, to which the co-pilot responded “just”. Seven seconds later, the co-pilot noticed that the airspeed was reducing below the expected approach speed of 135 kt. On the Cockpit Voice Recorder (CVR) the flight crew were heard to comment that the engines were at idle power and they attempted to identify what was causing the loss of thrust. The engines failed to respond to further demands for increased thrust from the autothrottle and manual movement of the thrust levers to fully forward. The airspeed reduced as the autopilot attempted to maintain the ILS glide slope. When the airspeed reached 115 kt the ‘airspeed low’ warning was annunciated, along with a master caution aural warning. The airspeed stabilised for a short period, so in an attempt to reduce drag the commander retracted the flaps from flap 30 to flap 25. In addition, he moved what he believed to be an engine starter/ignition switch on the overhead panel. The airspeed continued to reduce and by 200 ft it had decreased to about 108 kt. Ten seconds before touchdown the stick shaker operated, indicating that the aircraft was nearing a stall and in response the co-pilot pushed the control column forward. This caused the autopilot to disconnect as well as reducing the aircraft’s nose-high pitch attitude. In the last few seconds before impact, the commander attempted to start the APU and on realising that a crash was imminent he transmitted a ‘MAYDAY’ call. As the aircraft approached the ground the co-pilot pulled back on the control column, but the aircraft struck the ground in the grass undershoot for 27L approximately 330 m short of the paved runway surface and 110 m inside the airfield perimeter fence. During the impact and short round roll the nose landing gear (NLG) and both the main landing gears (MLG) collapsed. The right MLG separated from the aircraft but the left MLG remained attached. The aircraft came to rest on the paved surface in the undershoot area of Runway 27L. The commander attempted to initiate an evacuation by making an evacuation call, which he believed was on the cabin Passenger Announcement (PA) system but which he inadvertently transmitted on the Heathrow Tower frequency. During this period the co-pilot started the actions from his evacuation checklist. Heathrow Tower advised the commander that his call had been on the tower frequency so the commander repeated the evacuation call over the aircraft’s PA system before completing his evacuation checklist. The flight crew then left the flight deck and exited the aircraft via the escape slides at Doors 1L and 1R. The cabin crew supervised the emergency evacuation of the cabin and all occupants left the aircraft via the slides, all of which operated correctly. One passenger was seriously injured, having suffered a broken leg, as a result of detached items from the right MLG penetrating the fuselage. Heathrow Tower initiated their accident plan, with a crash message sent at 1242:22 hrs and fire crews were on scene 1 minute and 43 seconds later. The evacuation was completed shortly after the arrival of the fire vehicles. After the aircraft came to rest there was a significant fuel leak from the engines and an oxygen leak from the disrupted passenger oxygen bottles, but there was no fire. Fuel continued to leak from the engine fuel pipes until the spar valves were manually closed.
Probable cause:
Whilst on approach to London (Heathrow) from Beijing, China, at 720 feet agl, the right engine of G-YMMM ceased responding to autothrottle commands for increased power and instead the power reduced to 1.03 Engine Pressure Ratio (EPR). Seven seconds later the left engine power reduced to 1.02 EPR. This reduction led to a loss of airspeed and the aircraft touching down some 330 m short of the paved surface of Runway 27L at London Heathrow. The investigation identified that the reduction in thrust was due to restricted fuel flow to both engines. It was determined that this restriction occurred on the right engine at its FOHE. For the left engine, the investigation concluded that the restriction most likely occurred at its FOHE. However, due to limitations in available recorded data, it was not possible totally to eliminate the possibility of a restriction elsewhere in the fuel system, although the testing and data mining activity carried out for this investigation suggested that this was very unlikely. Further, the likelihood of a separate restriction mechanism occurring within seven seconds of that for the right engine was determined to be very low.
The investigation identified the following probable causal factors that led to the fuel flow restrictions:
1) Accreted ice from within the fuel system released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines.
2) Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the ‘sticky range’.
3) The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below -10°C and a fuel flow above flight idle.
4) Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time.
Final Report:

Crash of a Let L-410UVP-E3 off Los Roques: 14 killed

Date & Time: Jan 4, 2008 at 0910 LT
Type of aircraft:
Operator:
Registration:
YV2081
Flight Phase:
Survivors:
No
Schedule:
Caracas – Los Roques
MSN:
87 20 15
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
At 0858LT, while cruising at an altitude of 7,500 feet some 83 km from the destination, the crew reported his position to ATC. About 10 minutes later, while cruising at an altitude of 3,000 feet, the captain declared an emergency following a double engine failure. The aircraft lost height and crashed in the sea some 29 km off Los Roques Airport. Few debris were found floating on water and all 14 occupants were killed, among them 8 Italians, one Swiss and five Venezuelans. At the time of the accident, weather conditions were poor. On 19 June 2013, an Italian-Venezuelan search team found the wreckage at a depth of 974 metres.
Probable cause:
Double engine failure for unknown reasons.

Crash of a NAMC YS-11A-500 in Masbate

Date & Time: Jan 2, 2008 at 0735 LT
Type of aircraft:
Operator:
Registration:
RP-C3592
Survivors:
Yes
Schedule:
Manila - Masbate
MSN:
2108
YOM:
1969
Flight number:
RIT321
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Masbate Airport, the twin engine aircraft was unable to stop within the remaining distance. It overran, veered to the right and collided with a concrete wall. All 47 occupants escaped uninjured while the aircraft was damaged beyond repair. At the time of the accident, wind was from 040 at 11 knots gusting to 14 knots.

Crash of a Fokker 100 in Tehran

Date & Time: Jan 2, 2008 at 0732 LT
Type of aircraft:
Operator:
Registration:
EP-IDB
Flight Phase:
Survivors:
Yes
Schedule:
Tehran - Shiraz
MSN:
11299
YOM:
1990
Flight number:
IR235
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
105
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
30732
Aircraft flight cycles:
33933
Circumstances:
While preparing the flight at Tehran-Mehrabad Airport, the copilot proceeded with a walk around check of the airplane. As the OAT was near freezing level and there were some light snow showers, he requested a deicing. Nevertheless, as there were already a few number of aircraft waiting for deicing, the captain decided to takeoff without deicing. At 0731LT, the crew was cleared for takeoff and started the takeoff procedure. After liftoff, the aircraft started to roll to the left then to the right. Losing altitude, the left wing impacted ground and the aircraft crash landed, coming to rest and bursting into flames. All 113 occupants were rescued, among them 11 were seriously injured including four crew members.
Probable cause:
It was determined that the accident was the consequence of an aerodynamic stall after lift off due to a loss of lift because the wings were contaminated and that the aircraft had not been deiced prior to takeoff.
The following contributing factors were identified:
- Poor crew resources management,
- Poor flight preparation,
- Lack of knowledge about winter operations on part of the operator.

Crash of a Cessna 208B Grand Caravan in Corozal

Date & Time: Dec 4, 2007
Type of aircraft:
Operator:
Registration:
V3-HFS
Flight Phase:
Survivors:
Yes
Schedule:
Corozal – San Pedro
MSN:
208B-0579
YOM:
1996
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 25 at Corozal Airport, the pilot decided to abandon the takeoff procedure. Unable to stop within the remaining distance, the single engine aircraft overran, went through a fence and came to rest against trees. All 12 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a McDonnell Douglas MD-83 in Isparta: 57 killed

Date & Time: Nov 30, 2007 at 0136 LT
Type of aircraft:
Operator:
Registration:
TC-AKM
Survivors:
No
Site:
Schedule:
Istanbul - Isparta
MSN:
53185/2090
YOM:
1994
Flight number:
KK4203
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
57
Circumstances:
The aircraft departed Istanbul-Atatürk Airport at 0051LT on a schedule service to Isparta, carrying 50 passengers and 7 crew members. After being cleared to proceed to a VOR/DME approach to Isparta Airport runway 05, the crew was supposed to fly over IPT VOR then to follow a 223° heading. But the crew failed to input the arrival procedures in the FMS and started the approach by night over rising terrain. As the EGPWS failed to activate, the crew did not realize his altitude was insufficient when the aircraft collided with trees and crashed in a mountainous area located near Çukurören, about 12 km west of Isparta Airport. The aircraft was destroyed and all 57 occupants were killed.
Probable cause:
The following findings were identified:
- The crew failed to follow the published procedures,
- The crew failed to adhere to SOP's,
- The EGPWS system failed to activate and to warn the crew about the insufficient altitude,
- The EGPWS failed 86 times during the last 235 flights and was removed from another aircraft to be installed on TC-AKM 10 days prior to the accident,
- Lack of visibility due to the night,
- The CVR system was unserviceable,
- The DFDR system was partially unserviceable and recorded the last 15 minutes of flight only,
- Lack of crew training,
- The captain followed only 20 of the requested 32 hours training,
- The copilot followed a 32-hours training program in Sofia but this was not documented,
- A probable lack of situational awareness on part of the crew.

Crash of an Airbus A340-642 in Quito

Date & Time: Nov 9, 2007 at 1706 LT
Type of aircraft:
Operator:
Registration:
EC-JOH
Survivors:
Yes
Schedule:
Madrid - Quito
MSN:
731
YOM:
2006
Flight number:
IB6463
Country:
Crew on board:
14
Crew fatalities:
Pax on board:
345
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14024
Captain / Total hours on type:
2375.00
Copilot / Total flying hours:
10095
Copilot / Total hours on type:
1742
Aircraft flight hours:
8704
Aircraft flight cycles:
965
Circumstances:
Following an uneventful flight from Madrid, the crew contacted Quito Approach at 1650LT and received descent instructions in preparation for an instrument approach no. 4 (VOR QIT DME/ILS) for runway 35. During the descent the crew were notified that preceding flights had reported braking action medium to poor. The flight crew selected auto braking to 'High'. At 17:05, the crew reported the runway in sight, after which the controller stated that the wind was 170° at 4 knots, the runway was wet and reported braking action was poor. The flight was cleared to land. The pilot in command, following the procedures established by Iberia, decided to leave the ILS glide path and captured the path of the PAPI lights. The aircraft touched down 200 metres past the threshold at a 3.09g side load. The spoilers deployed automatically and main gear tyres 3 and 8 blew. The flap lever was moved involuntarily by the copilot, from the full position to position 2. The crew applied full manual braking and select reverse thrust. The Auto Brake function failed, after which the crew disconnected the antiskid braking system and continued to apply manual braking. The aircraft passed the end of runway 35, with a ground speed of 90 knots, hit the ILS localizer and stopped 232 meters further. Passengers and crew were evacuated using the slide at door 2R, thirty minutes after the aircraft stopped. All occupants escaped uninjured while the aircraft was considered as damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew who decided to continue the approach to Quito Airport, knowing the poor runway conditions, poor weather conditions and the aircraft weight, and his failure to initiate a go-around procedure while forcing the aircraft to intercept the PAPI, causing the aircraft to be unstabilized.
Contributing factors:
- On the date of the incident, the crew did not have specific regulations and operating procedures (the briefing of the operator for the airport in Quito was inappropriate to the existent conditions).
- The fact that the crew still being experienced similar airports in Quito and had not experienced similar weather situations, circumstances that would have allowed a strategy of approximation consistent with the terms of this operation, in particular as regards:
- Calculations in flight for landing runway length,
- Minimum altitude to start the maneuver of changing the path of ILS to PAPI,
- Carrying out a very detailed briefing that allowed unwanted deviations on approach,
- The weather conditions existing at the time of landing (visibility, tail wind and moderate rain).

Crash of a Cessna 208B Grand Caravan in Culiacán Rosales

Date & Time: Nov 5, 2007 at 0850 LT
Type of aircraft:
Operator:
Registration:
XA-UBC
Flight Phase:
Survivors:
Yes
Schedule:
Culiacán Rosales – Cabo San Lucas
MSN:
208B-1046
YOM:
2004
Flight number:
CFV126
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from runway 02, the pilot initiated a 180 turn when the aircraft stalled and crashed in an open field located one km from the airport, coming to rest upside down. All 15 occupants were injured and the aircraft was destroyed.

Crash of a Boeing 737-230 in Malang

Date & Time: Nov 1, 2007 at 1324 LT
Type of aircraft:
Operator:
Registration:
PK-RIL
Survivors:
Yes
Schedule:
Jakarta – Malang
MSN:
22137/788
YOM:
1981
Flight number:
RI260
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
89
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19357
Captain / Total hours on type:
10667.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
1528
Aircraft flight hours:
57823
Circumstances:
On 1 November 2007, a Boeing Company B737-200 aircraft, registered PK-RIL, operated by PT. Mandala Airlines as flight number MDL 260, was on a scheduled passenger flight from Jakarta Soekarno-Hatta International Airport, Jakarta, to Abdurrachman Saleh Airport, Malang, East Java. The pilot in command (PIC) was the handling pilot, and the copilot was the support/monitoring pilot. There were 94 persons on board the aircraft, consisting of two pilots, three cabin crew, and 89 passengers. The aircraft landed at Malang at 1324 Western Indonesian Standard Time (06:24 Coordinated Universal Time (UTC). It was reported to have been raining heavily when the aircraft landed on runway 35 at Malang. The aircraft bounced twice after the initial severe hard landing, and the lower drag strut of the nose landing gear fractured, resulting in the rearwards collapse of the nose landing gear and separation of the lower nose landing gear shock strut and wheel assembly. The aircraft’s nose then contacted the runway, and the aircraft came to rest 290 metres before the departure end of runway 17. The crew subsequently reported that during the visual segment of the landing approach, they realized that the aircraft was too high with reference to the precision approach path indicator (PAPI) for runway 35. The PIC increased the aircraft’s rate of descent (ROD) to capture the PAPI. The high ROD was not arrested, and as a consequence, the severe hard landing occurred which substantially damaged the aircraft. No one of the passengers or crew was injured.
Probable cause:
The flight crew did not appear to have an awareness that the aircraft was above the desired approach path to runway 35 at Malang until they sighted the visual approach slope indication lighting system. The pilot in command continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions. Non-adherence by the flight crew to stabilized approach procedures, which resulted in the initial severe hard landing at Malang, together with the omission of a high bounced landing recovery, resulted in substantial damage to the aircraft. The following findings were identified:
- The PIC allowed the approach at Malang to become unstabilized and did not correct that condition.
- The PIC continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions.
- Neither pilot responded appropriately to the ground proximity warning system voice aural ‘SINK RATE’ or ‘PULL UP’ warnings that sounded during the final approach to Malang.
- The PIC did not initiate action to recover from the high bounced landing following the initial severe hard landing impact.
- The PIC did not ensure that effective crew coordination was maintained during the landing approach.
Final Report: