Crash of an ATR42-300 in São Paulo

Date & Time: Jul 16, 2007 at 1242 LT
Type of aircraft:
Operator:
Registration:
PT-MFK
Survivors:
Yes
Schedule:
Araçatuba – Bauru – São Paulo
MSN:
225
YOM:
1991
Flight number:
PTN4763
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7420
Captain / Total hours on type:
4993.00
Copilot / Total flying hours:
947
Copilot / Total hours on type:
797
Circumstances:
The aircraft departed Araçatuba on a flight to São Paulo with an intermediate stop in Bauru, carrying 21 passengers and a crew of four. After touchdown on wet runway 17R at Congonhas Airport, the crew started the braking procedure when the aircraft deviated to the left and veered off runway. While contacting soft ground, the aircraft collided with a concrete block housing the electrical device supplying the runway light system. On impact, the nose gear was torn off and the aircraft came to rest. All 25 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Loss of control upon landing after the aircraft suffered aquaplaning. The following contributing factors were identified:
- A light rain caused the presence of water on the runway, enabling the occurrence of hydroplaning.
- The accumulation of water on the surface of the runway, as a result of inadequate drainage, lack of "grooving", enabled the hydroplaning.
- The pilot applied full pressure on the right pedal, generating a force to the left that contributed to the departure off the runway.
- During hydroplaning, the pilot should not apply pedal to the opposite side to which the aircraft slides; this fact was not covered during the instruction of the pilot.
- In the face of hydroplaning, the pilot applied the right pedal, aggravating the departure of the aircraft to the left.
Final Report:

Crash of an ATR72-212A in Indore

Date & Time: Jul 1, 2007 at 1946 LT
Type of aircraft:
Operator:
Registration:
VT-JCE
Survivors:
Yes
Schedule:
Bhopal - Indore
MSN:
640
YOM:
2000
Flight number:
JAI3307
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
49
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10169
Circumstances:
The flight up-till approach to land at Indore was normal. On coming to the runway the aircraft touched down moderately hard and bounced high. The pilots were perhaps determined to salvage the abnormal situation and added power to the engines with intention to cushion the sink-rate and settle the runway. On the contrary, the aircraft came hard on the runway and bounced once again. This got followed with a series of bounces in succession. While bouncing the aircraft migrated from the runway and finally came to full halt on right side close to the airport boundary wall. There was no fire in the accident. All 53 occupants evacuated safely.
Probable cause:
The pilot-in-command in absence of bounce recovery guidance adopted self-perceived technique and kept on adding engine power along with aircraft pitch manipulations to salvage the aircraft from the bounce on landing, and gravely damaged the aircraft structure.
Final Report:

Crash of a Boeing 737-2M2 in M'Banza Congo: 6 killed

Date & Time: Jun 28, 2007 at 1332 LT
Type of aircraft:
Operator:
Registration:
D2-TBP
Survivors:
Yes
Schedule:
Luanda – M’Banza Congo – Negage – Luanda
MSN:
23220/1084
YOM:
1985
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
71
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
After landing on runway 16/34 (1,800 metres long) at M'Banza Congo Airport, the aircraft was unable to stop within the remaining distance. It overran, collided with cars and two houses and came to rest. A crew member, five passengers and one people on the ground were killed while 25 other passengers were injured. The aircraft was destroyed.
Probable cause:
It is believed that the aircraft landed too far down the runway, reducing the landing distance available.

Crash of an Antonov AN-24B near Sihanoukville: 22 killed

Date & Time: Jun 25, 2007 at 1040 LT
Type of aircraft:
Operator:
Registration:
XU-U4A
Survivors:
No
Site:
Schedule:
Siem Reap - Sihanoukville
MSN:
9 99 019 08
YOM:
1969
Flight number:
PMT241
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
22
Circumstances:
The aircraft departed Siem Reap Airport on a flight to Sihanoukville, carrying 16 passengers (13 South Korean and 3 Czech) and 6 crew members. While descending to Sihanoukville Airport in marginal weather conditions, the aircraft struck the slope of Mt Phnom Damrey located in the Elephant Mountain Range, about 50 km northeast of the Sihanoukville Airport. The aircraft was totally destroyed and all 22 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Let L-410UVP in Kamina: 1 killed

Date & Time: Jun 21, 2007
Type of aircraft:
Operator:
Registration:
9Q-CEU
Flight Phase:
Survivors:
Yes
Schedule:
Kamina – Lubumbashi
MSN:
84 12 14
YOM:
1984
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Kamina Airport, while in initial climb, the twin engine aircraft stalled and crashed in a swampy area. A parliamentary member of the DRC government was killed while all other occupants escaped with various injuries.

Crash of a Canadair RegionalJet CRJ-100ER in Toronto

Date & Time: May 20, 2007 at 1235 LT
Operator:
Registration:
C-FRIL
Survivors:
Yes
Schedule:
Moncton – Toronto
MSN:
7051
YOM:
1994
Flight number:
AC8911
Country:
Crew on board:
37
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft, with 3 crew members and 37 passengers on board, was operating as Air Canada Jazz Flight 8911 from Moncton, New Brunswick, to Toronto/Lester B. Pearson International Airport, Ontario. At 1235 eastern daylight time, the aircraft landed on Runway 06R with a 90º crosswind from the left, gusting from 13 to 23 knots. The aircraft first contacted the runway in a left-wing-down sideslip. The left main landing gear struck the runway first and the aircraft sustained a sharp lateral side load before bouncing. Once airborne again, the flight and ground spoilers deployed and the aircraft landed hard. Both main landing gear trunnion fittings failed and the landing gear collapsed. The aircraft remained upright, supported by the landing gear struts and wheels. The aircraft slid down the runway and exited via a taxiway, where the passengers deplaned. There was no fire. There were no injuries to the crew; some passengers reported minor injuries as a result of the hard landing.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On final approach, the captain diverted his attention from monitoring the flight, leaving most of the decision making and control of the aircraft to the first officer, who was significantly less experienced on the aircraft type. As a result, the first officer was not fully supervised during the late stages of the approach.
2. The first officer did not adhere to the Air Canada Jazz standard operating procedures (SOPs) in the handling of the autopilot and thrust levers on short final, which left the aircraft highly susceptible to a bounce, and without the bounce protection normally provided by the ground lift dump (GLD) system.
3. Neither the aircraft operating manual nor the training that both pilots had received mentioned the importance of conducting a balked or rejected landing when the aircraft bounces. Given the low-energy state of the aircraft at the time of the bounce, the first officer attempted to salvage the landing.
4. When the thrust levers were reduced to idle after the bounce, the GLD system activated. The resultant sink rate after the GLD system deployed was beyond the certification standard for the landing gear and resulted in the landing gear trunnion fitting failures.
5. There was insufficient quality control at the landing gear overhaul facility, which allowed non-airworthy equipment to enter into service. The condition of the shock struts would have contributed to the bounce.
Findings as to Risk:
1. Several passengers took carry-on items with them as they exited the aircraft, despite being instructed not to do so.
2. The location of the stored megaphone did not allow the flight attendant to have ready access after the passengers started moving to the exit door.
Final Report:

Crash of a Cessna 404 Titan II in Goroka

Date & Time: May 19, 2007
Type of aircraft:
Operator:
Registration:
P2-ALK
Survivors:
Yes
MSN:
404-0222
YOM:
1978
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the pilot started the approach to Goroka Airport in poor weather conditions. After landing on runway 17R, the aircraft was unable to stop within the remaining distance. It overran and came to rest few dozen metres further. All four occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 737-8AL near Douala: 114 killed

Date & Time: May 5, 2007 at 0008 LT
Type of aircraft:
Operator:
Registration:
5Y-KYA
Flight Phase:
Survivors:
No
Schedule:
Abidjan – Douala – Nairobi
MSN:
35069/2079
YOM:
2006
Flight number:
KQ507
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
114
Captain / Total flying hours:
8682
Copilot / Total flying hours:
831
Aircraft flight hours:
2100
Aircraft flight cycles:
734
Circumstances:
During the night of 4th May 2007, the B737-800, registration 5Y-KYA, operating as flight KQ507 from Abidjan international Airport, Ivory Coast, to the Jomo Kenyatta Airport in Nairobi (Kenya), made a scheduled stop-over at the Douala international Airport. The weather was stormy. The aircraft took off and climbed into the dark night. There were no external visual references, yet no instrument scanning was done by the crew. At 1000 feet climbing, the pilot flying released the flight controls for 55 seconds without having engaged the autopilot. The bank angle of the airplane increased continuously by itself very slowly up to 34° right and the captain appeared unaware of the airplane’s changing attitude. Just before the "Bank Angle" warning sounds, the captain grabbed the controls, appeared confused about the attitude of the airplane, and made corrections in an erratic manner increasing the bank angle to 50° right. At about 50° bank angle, the autopilot was engaged and the inclination tended to stabilize; then movements of the flight controls by the pilot resumed and the bank angle increased towards 70° right. A prolonged right rudder input brought the bank angle to beyond 90°. The aircraft descended in a spiral dive until it crashed at approximately 0008LT (May 5) in a mangrove swamp located 5,5 km southeast of Douala Airport. The aircraft disintegrated on impact and all 114 occupants were killed.
Probable cause:
The airplane crashed after loss of control by the crew as a result of spatial disorientation (non recognized or subtle type transitioning to recognized spatial disorientation), after a long slow roll, during which no instrument scanning was done, and in the absence of external visual references in a dark night. Inadequate operational control, lack of crew coordination, coupled with the non-adherence to procedures of flight monitoring, confusion in the utilization of the AP, have also contributed to cause this situation.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander in Kopinang: 3 killed

Date & Time: Apr 25, 2007 at 1405 LT
Type of aircraft:
Operator:
Registration:
8R-GET
Survivors:
Yes
Schedule:
Ogle – Kato – Kopinang – Mahdia – Ogle
MSN:
484
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Ogle on a schedule service to Kato, Kopinang and Mahdia. At Kato Airport, the pilot and passengers should wait more than two hours for weather improvement. The aircraft departed Kato at 1345LT on the leg to Kopinang with four passengers, two adults, a five-year old boy and an infant. Twenty minutes later, while on approach to Kopinang, the aircraft descended into trees and crashed in a dense wooded area located few km from the airfield. The wreckage was found few hours later. Two passengers were seriously injured while the pilot and two passengers including the infant were killed.

Crash of a De Havilland Dash-8-301 in Governor's Harbour

Date & Time: Apr 20, 2007 at 1708 LT
Operator:
Registration:
C6-BFN
Survivors:
Yes
Schedule:
Nassau – Governor’s Harbour
MSN:
159
YOM:
1989
Flight number:
UP353
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
48
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
29570
Aircraft flight cycles:
52653
Circumstances:
Following an uneventful flight (service UP353) from Nassau, the crew started the descent to Governor’s Harbour. After landing on runway 15, the left main gear collapsed. The aircraft slid for few dozen metres then turn slightly to the left and came to rest on the main runway. All 51 occupants evacuated safely, nevertheless, few passengers suffered minor injuries. The aircraft was damaged beyond repair.
Probable cause:
The probable Cause has been determined as an over-center Torque Link condition that culminated in a single cycle failure of the cylinder. The over center torque links condition occur as a result of the over extension of the shock strut.
Possible Contributory factors to the over extension of the shock strut includes:
Possible Cause for Loss of Damping
• The failure to install the dampening ring when the landing gear was assembled.
• Improper servicing of the landing gear shock strut with Mil-H-5606 hydraulic fluid plus nitrogen during initial assembly.
• Improper servicing of landing gear shock strut during line maintenance and inadequate post servicing follow up per AMM Chapter 12. See attached report Appendix A-30 From Bombardier
• Under-serviced shock strut (low oil volume)
• A broken damper ring
• No damper ring
• Disengaged damper ring.
Final Report: