Crash of a McDonnell Douglas MD-82 in Kish Island

Date & Time: Mar 16, 2007
Type of aircraft:
Operator:
Registration:
LZ-LDD
Survivors:
Yes
Schedule:
Dubai - Kish Island
MSN:
49218/1274
YOM:
1986
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
154
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft landed hard at Kish Island Airport and was considered as damaged beyond repair. All 158 occupants escaped uninjured.

Crash of an Airbus A310 in Dubai

Date & Time: Mar 12, 2007 at 0630 LT
Type of aircraft:
Operator:
Registration:
S2-ADE
Flight Phase:
Survivors:
Yes
Schedule:
London - Dubai - Dhaka
MSN:
698
YOM:
1996
Flight number:
BG006
Location:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
236
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from Dubai Intl Airport runway 12L, after V1 speed, the crew heard a loud bang then noticed severe vibrations when the nose gear collapsed. The captain abandoned the takeoff procedure and initiated an emergency braking manoeuvre. The aircraft slid on its nose for few hundred metres and came to rest just before the end of the runway, slightly to the left of the centerline. All 250 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Failure of the nose gear during the takeoff roll after it impacted a half wheel rim which was broken off during the takeoff from a previous aircraft.

Crash of a Boeing 737-497 in Yogyakarta: 21 killed

Date & Time: Mar 7, 2007 at 0758 LT
Type of aircraft:
Operator:
Registration:
PK-GZC
Survivors:
Yes
Schedule:
Jakarta - Yogyakarta
MSN:
25664
YOM:
1992
Flight number:
GIA200
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
133
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
13421
Captain / Total hours on type:
3703.00
Copilot / Total flying hours:
1528
Copilot / Total hours on type:
1353
Aircraft flight hours:
35207
Aircraft flight cycles:
37360
Circumstances:
On 7 March 2007, a Boeing Company 737-497 aircraft, registered PK-GZC, was being operated by Garuda Indonesia on an instrument flight rules (IFR), scheduled passenger service, as flight number GA200 from Soekarno-Hatta Airport, Jakarta to Adisutjipto Airport, Yogyakarta. There were two pilots, five flight attendants, and 133 passengers on board. The pilot in command (PIC) and copilot commenced duty in Jakarta at about 21:30 Coordinated Universal Time (UTC), or 04:30 local time, for the flight to Yogyakarta. Prior to departing Jakarta, during the push back, the PIC contacted the ground engineers and informed them that the number-1 (left) engine thrust reverser fault light on the cockpit instruments had illuminated. The engineers reset the thrust reverser in the engine accessories unit and the fault light extinguished. The scheduled departure time was 23:00. The aircraft took off from Jakarta at 23:17, and the PIC was the pilot flying for the sector to Yogyakarta. The copilot was the monitoring/support pilot. During the cruise, just before top of descent, the crew was instructed by Jakarta Control to ‘maintain level 270 and contact Yogya Approach 123.4’. The copilot acknowledged; ‘contact Yogya 123.4, Indonesia 200’. The PIC started to give a crew briefing at 23:43 stating: ‘in case of holding, heading of 096’. The briefing was interrupted by a radio transmission from Yogya Approach, giving GA200 a clearance to Yogyakarta via airway W 17 for runway 09, and a requirement to report when leaving flight level 270. When radio communication was completed, the PIC continued with the crew briefing for an ILS approach, stating:
When clear approach ILS runway 09, course 088. (C) Frequency 1091, aerodrome elevation three hundred fifty, (C) leaving two thousand five hundred by 6 point 6 DME ILS, (C) to check four DME one thousand six hundred seventy, (C) crossing two DME one thousand thirty seven. Decision Altitude ILS Cat I, five eight seven, two three seven both set, approach flap forty, auto brake two. Speed one three six, one five one, two twenty. Timing from final approach-fix to VOR 6 DME. (C) With airspeed approximately one four one, two minutes thirty six. (C) In case localizer, MDA seven hundred, localizer, miss approach, at point six. (C) DME ILS India Juliet oscar golf. (C) On landing, to the left standby parking stand. Go-around missed approach climb one thousand five hundred turn left. To holding fix via Yogya VOR, continue climb four thousand feet, to cross Yogya at or above two thousand five hundred DME eight. (C).
Twelve minutes and 17 seconds later, Yogya Approach cleared GA200 ‘for visual approach runway zero nine, proceed to long final, report runway in sight’. The copilot acknowledged the clearance and asked for confirmation that they were cleared to descend to circuit altitude, Yogya Approach replied ‘descend to two thousand five hundred initially’. The crew informed the investigation that they were conducting an Instrument Landing System (ILS) approach to runway 09, in visual meteorological conditions (VMC). However they did not inform Yogya Approach or Yogyakarta Tower that they were flying the 09 ILS approach. At 23:58:10, the aircraft overran the departure end of runway 09 at Yogyakarta Airport. The PIC reported that as the aircraft was about to leave the runway, he shut down both engines. The aircraft crossed a road, and impacted an embankment before stopping in a rice paddy field 252 meters from the threshold of runway 27 (departure end of runway 09). The aircraft was destroyed by the impact forces and an intense, fuel-fed, post impact fire. There were 119 survivors. One flight attendant and 20 passengers were fatally injured. One flight attendant and 11 passengers were seriously injured.
Probable cause:
Causes:
1) Flight crew communication and coordination was less than effective after the aircraft passed 2,336 feet on descent after flap 1 was selected. Therefore the safety of the flight was compromised.
2) The PIC flew the aircraft at an excessively high airspeed and steep descent during the approach. The crew did not abort the approach when stabilized approach criteria were not met.
3) The pilot in command did not act on the 15 GPWS alerts and warnings, and the two calls from the copilot to go around.
4) The copilot did not follow company instructions and take control of the aircraft from the pilot in command when he saw that the pilot in command repeatedly ignored warnings to go around.
5) Garuda did not provide simulator training for its Boeing 737 flight crews covering vital actions and required responses to GPWS and EGPWS alerts and warnings such as ‘TOO LOW TERRAIN’ and ‘WHOOP, WHOOP PULL UP’.
Other Factors:
1) The airport did not meet the ICAO Standard with respect to runway end safety areas.
2) The airport did not meet the ICAO Standard with respect to rescue and fire fighting equipment and services for operation outside the airport perimeter and in swampy terrain.
Final Report:

Crash of a Boeing 737-33A in Surabaya

Date & Time: Feb 21, 2007 at 1525 LT
Type of aircraft:
Operator:
Registration:
PK-KKV
Survivors:
Yes
Schedule:
Jakarta - Surabaya
MSN:
27284/2606
YOM:
1994
Flight number:
DHI172
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
148
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
37936
Aircraft flight cycles:
23824
Circumstances:
The aircraft was on a scheduled passenger flight from Soekarno-Hatta Airport, Jakarta to Juanda Airport, Surabaya, East Java. There were 155 persons on board, consist of 7 crew and 148 passengers. During the flight there was no abnormality declare by the flight crew. Weather condition at Surabaya was thunderstorm and rain, wind 240/7 knots with visibility 8,000 meters. The CVR revealed that there was conversation in the cockpit that was not related to the progress of the flight, the conversation was relating to the company fuel policy and training program until 2000 feet. The CVR did not reveal approach briefing and any checklist reading. On final approach of runway 28 passing 800 feet approach light insight and landing clearance was received. Prior to touchdown, control of the aircraft was transferred from co-pilot to PIC. The CVR recorded that the Ground Proximity Warning Systems (GPWS) warned “Sink Rate” and “Pull Up”. The right wheel track was found out of the runway for about 4 meter away and return to the runway. The aircraft stopped for about 100 meters from taxiway N3. After aircraft touched down, the fuselage aft of passenger seat row 16 was bended down. The passengers were panic. Flight attendants evacuated the passengers via all exits available and door slides were inflated. The two passengers were minor injured, and the aircraft suffered severe damage.
Probable cause:
From the findings, it is concluded that the aircraft experienced excessive sink rate upon the touch-down. The aircraft was in unstable approach even at below 200 feet. The high vertical acceleration caused severe damage to the aircraft structure. The flight crew did not comply to several procedures published by the Boeing company. The flight crew did not respond to the GPWS alert and warnings.
Final Report:

Crash of a Beechcraft 200C Super King Air off East Bay Cay: 1 killed

Date & Time: Feb 6, 2007 at 1842 LT
Operator:
Registration:
VQ-TIU
Flight Phase:
Survivors:
Yes
Schedule:
East Bay Cay - Grand Turk
MSN:
BL-131
YOM:
1988
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8500
Captain / Total hours on type:
394.00
Aircraft flight hours:
24578
Aircraft flight cycles:
31684
Circumstances:
The aircraft was parked on the small apron at North Caicos Airport while the pilot went home to collect some personal items. One of the intended passengers saw the aircraft arrive. He remained in the vicinity until the pilot returned, and reported that the aircraft was unattended in the intervening time. When the pilot returned, four of the five passengers were gathered near the aircraft, and the last passenger arrived soon afterwards. The pilot, a local man well-known to the passengers, appeared to be his normal self and in good spirits. As most inter-island travel in the TCI is by air, the passengers were also familiar with the operator’s aircraft and used to travelling by air. Some had flown frequently on VQ-TIU. The pilot supervised embarkation and gave an emergency briefing. One passenger reported that the pilot made a mobile telephone call, which he presumed to be to Air Traffic Control (ATC) at Providenciales to notify them of the proposed flight. Prior to seating himself at the controls, the pilot told the passengers that they may expect some turbulence. The aircraft taxied onto the runway at its eastern end and along its length for a departure from Runway 08. It was about one hour after sunset and outside the airport’s normal operating hours, so there were no ATC personnel on duty. The runway lights were operated by the operator’s station manager. The aircraft took off at 1840 hrs. Soon after takeoff the aircraft was seen to start a turn to the right, which was consistent with its routing to Grand Turk, some 54 nm to the south-east. However, the aircraft reached a relatively large angle of bank and started to descend. The descent continued until it crashed with significant forward speed into an area of very shallow water. The aircraft broke up on impact, with the fuselage section coming to rest nearly inverted but comparatively intact. All those on board survived the impact sequence with varying degrees of injury. However, the pilot died before he could receive specialist medical treatment.
Probable cause:
The investigation identified the following causal factors:
1. The aircraft adopted an excessive degree of right bank soon after takeoff. This led to a descending, turning flight path which persisted until the aircraft was too low to make a safe recovery.
2. The pilot probably became spatially disoriented and was unable to recognise or correct the situation in time to prevent the accident.
The investigation identified the following contributory factors:
1. The environmental conditions were conducive to a spatial disorientation event.
2. The pilot had probably consumed alcohol prior to the flight, which made him more prone to becoming disorientated.
3. The flight was operated single-pilot when two pilots were required under applicable regulations. The presence of a second pilot would have provided a significant measure of protection against the effects of the flying pilot becoming disoriented.
Final Report:

Crash of a Fokker 100 in Pau: 1 killed

Date & Time: Jan 25, 2007 at 1124 LT
Type of aircraft:
Operator:
Registration:
F-GMPG
Flight Phase:
Survivors:
Yes
Schedule:
Pau - Paris
MSN:
11362
YOM:
1991
Flight number:
AF7775
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6135
Captain / Total hours on type:
2948.00
Copilot / Total flying hours:
6295
Copilot / Total hours on type:
287
Aircraft flight hours:
28586
Aircraft flight cycles:
34886
Circumstances:
Following a normal takeoff acceleration on runway 13 at Pau-Pyrénées Airport, the pilot-in-command started the rotation when the aircraft immediately rolled to the left. Then it rolled to the right and to the left again, lost height, struck the ground and bounced. At a speed of about 160 knots, the crew reduced the engine power when the aircraft rolled to the right of the runway, struck the perimeter fence then collided with a truck driving along a road. Upon touchdown, both main landing gears were torn off and the aircraft slid on its belly before coming to rest in an open field located 535 metres past the runway end. All 54 occupants evacuated safely while the aircraft was damaged beyond repair. The truck's driver was killed while his colleague was seriously injured.
Probable cause:
The accident resulted from a loss of control caused by the presence of ice contamination on the surface of the wings associated with insufficient consideration of the weather during the stopover, and by the rapid rotation pitch, a reflex reaction to a flight of birds.
Contributing factors:
- Limited awareness within the aviation community regarding the risks associated with the icing on the ground and changes in the performance of the aircraft involved in this phenomenon;
- The sensitivity of small aircraft not equipped with burners to the effects of ice on the ground;
- Insufficient awareness of the crew of procedures for the tactile verification of the condition of the surfaces in icing conditions and the lack of implementation by the operator of an adapted organization;
- The ordinary aspect of the flight including the weather encountered, which was not likely to incite the crew to particular vigilance.
Final Report:

Crash of a BAe 3112 Jetstream 31 in Fort Saint John

Date & Time: Jan 9, 2007 at 1133 LT
Type of aircraft:
Operator:
Registration:
C-FBIP
Survivors:
Yes
Schedule:
Grande Prairie – Fort Saint John
MSN:
820
YOM:
1988
Flight number:
PEA905
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
275
Copilot / Total hours on type:
20
Circumstances:
The aircraft was conducting an instrument approach to Runway 29 at Fort St. John, British Columbia, on a scheduled instrument flight rules flight from Grande Prairie, Alberta. At 1133 mountain standard time, the aircraft touched down 320 feet short of the runway, striking approach and runway threshold lights. The right main and nose landing gear collapsed and the aircraft came to rest on the right side of the runway, 380 feet from the threshold. There were no injuries to the 2 pilots and 10 passengers. At the time of the occurrence, runway visual range was fluctuating between 1800 and 2800 feet in snow and blowing snow, with winds gusting to 40 knots.
Probable cause:
Findings as to Causes and Contributing Factors:
1. A late full flap selection at 300 feet above ground level (agl) likely destabilized the aircraft’s pitch attitude, descent rate and speed in the critical final stage of the precision approach, resulting in an increased descent rate before reaching the runway threshold.
2. After the approach lights were sighted at low altitude, both pilots discontinued monitoring of instruments including the glide slope indicator. A significant deviation below the optimum glide slope in low visibility went unnoticed by the crew until the aircraft descended into the approach lights.
Finding as to Risk:
1. The crew rounded the decision height (DH) figure for the instrument landing system (ILS) approach downward, and did not apply a cold temperature correction factor. The combined error could have resulted in a descent of 74 feet below the DH on an ILS approach to minimums, with a risk of undershoot.
Other Finding:
1. The cockpit voice recorder (CVR) was returned to service following an intelligibility test that indicated that the first officer’s hot boom microphone intercom channel did not record. Although the first officer voice was recorded by other means, a potential existed for loss of information, which was key to the investigation.
Final Report:

Crash of a Boeing 737-4Q8 off Ujung Pandang: 102 killed

Date & Time: Jan 1, 2007 at 1459 LT
Type of aircraft:
Operator:
Registration:
PK-KKW
Flight Phase:
Survivors:
No
Schedule:
Jakarta – Surabaya – Manado
MSN:
24070
YOM:
1989
Flight number:
DHI574
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
102
Captain / Total flying hours:
13356
Captain / Total hours on type:
3856.00
Copilot / Total flying hours:
4200
Copilot / Total hours on type:
998
Aircraft flight hours:
45371
Aircraft flight cycles:
26725
Circumstances:
On 1 January 2007, a Boeing Company 737-4Q8 aircraft, registered PK-KKW, operated by Adam SkyConnection Airlines (AdamAir) as flight number DHI574, was on a scheduled passenger flight from Surabaya (SUB), East Java to Manado (MDC), Sulawesi, at FL350 (35,000 feet) when it disappeared from radar. The aircraft departed from Djuanda Airport, Surabaya at 05:59 Coordinated Universal Time (UTC) under the instrument flight rules (IFR), with an estimated time of arrival (ETA) at Sam Ratulangi Airport, Manado of 08:14. The fuel endurance on departure from Surabaya was hours 30 minutes, and the crew had flight planned for an alternate of Gorontalo (GTO). The pilot in command (PIC) was the pilot flying for the sector to Manado and the copilot was the monitoring/support pilot. There were 102 people on board; two pilots, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants.
Probable cause:
The following findings were identified:
1) Flight crew coordination was less than effective. The PIC did not manage the task sharing; crew resource management practices were not followed.
2) The crew focused their attention on troubleshooting the Inertial Reference System (IRS) failure and neither pilot was flying the aircraft.
3) After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented.
4) The AdamAir syllabus of pilot training did not cover complete or partial IRS failure.
5) The pilots had not received training in aircraft upset recovery, including spatial disorientation.
Other Causal Factors:
1) At the time of the accident, AdamAir had not resolved the airworthiness problems with the IRS that had been reoccurring on their Boeing 737 fleet for more than 3 months.
2) The AdamAir maintenance engineering supervision and oversight was not effective and did not ensure that repetitive defects were rectified.
Final Report:

Crash of a PZL-Mielec AN-2R near Shaburovo

Date & Time: Dec 26, 2006
Type of aircraft:
Operator:
Registration:
RA-33565
Flight Phase:
Survivors:
Yes
Schedule:
Puksinka - Vagel
MSN:
1G230-02
YOM:
1988
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On a flight from Puksinka to Vagel, while flying at an altitude of 300 metres, the engine lost power. The crew reduced his altitude and attempted an emergency landing when the aircraft collided with trees and crashed in a wooded area located near Shaburovo, coming to rest hanging in trees about 2 metres above the ground. All 3 crew and 10 passengers survived but the occupants sustained various injuries from jumping down from the plane that was damaged beyond repair.
Probable cause:
Engine problems for unknown reasons. At the time of the accident, the aircraft was operated above the MTOW.

Crash of a Boeing 737-4Y0 in Ujung Pandang

Date & Time: Dec 24, 2006 at 2035 LT
Type of aircraft:
Operator:
Registration:
PK-LIJ
Survivors:
Yes
Schedule:
Jakarta - Ujung Pandang
MSN:
24682
YOM:
1990
Flight number:
LNI792
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Jakarta, the crew started the descent to Makassar (Ujung Pandang) Airport. On approach to runway 31, flaps were selected down from 15° to 30° when the captain observed an asymmetrical condition between both flaps and decided to set back at 15° and to continue the approach in such conditions. The aircraft landed hard to the left of the runway centerline and bounced twice. Out of control, it veered off runway, lost its right main gear and came to rest few dozen metres further. All 164 occupants evacuated safely while the aircraft was damaged beyond repair as the left main gear punctured the fuel tank and the fuselage was deformed.
Probable cause:
The exact cause of the asymmetrical flaps condition on approach is undetermined. Since all the conditions were clearly not met, the pilots should have made the decision to initiate a go-around procedure.