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.

Crash of a Fokker 50 in Kenana

Date & Time: Dec 12, 2006
Type of aircraft:
Operator:
Registration:
ST-ASJ
Survivors:
Yes
MSN:
20246
YOM:
1992
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing, the nose gear collapsed. The aircraft went out of control and veered off runway. While contacting soft ground, the left main gear collapsed as well, causing the left propeller to struck the ground. A propeller blade separated and penetrated the fuselage, and the aircraft came to rest on its belly. All occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Rockwell Shrike Commander 500S off Kingstown: 2 killed

Date & Time: Nov 19, 2006 at 1853 LT
Operator:
Registration:
J8-VAX
Survivors:
No
Schedule:
Canouan - Kingstown
MSN:
500-1869-45
YOM:
1969
Flight number:
SVD360
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Canouan Island Airport at 1842LT on a short flight to Kingstown, Saint Vincent & Grenadines, carrying one passenger and one pilot. Shortly after takeoff, the pilot was instructed to report once passing over Bequia Island. Few minutes later, after passing Bequia Island, the pilot contacted ATC and reported he was at the altitude of 1,100 feet with an ETA in Kingstown in four minutes. At 1853LT, the aircraft crashed in unknown circumstances in the sea. The next morning, few debris were found floating on water and no trace of both occupants was ever found. The passenger was the Director of American Eagle for the Canouan Island. All SAR operations were abandoned few days later and the wreckage was not found.
Probable cause:
Due to the absence of evidences, the cause of the accident could not be determined.

Crash of a Swearingen SA226AC Metro II in Norway House

Date & Time: Nov 8, 2006 at 0834 LT
Type of aircraft:
Operator:
Registration:
C-FTNV
Survivors:
Yes
Schedule:
Winnipeg – Norway House
MSN:
TC-239E
YOM:
1977
Flight number:
PAG105
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Captain / Total hours on type:
4500.00
Copilot / Total flying hours:
4000
Copilot / Total hours on type:
15
Circumstances:
The aircraft was on a flight from Winnipeg, Manitoba, to Norway House, Manitoba, with two crew members and seven passengers on board. After touchdown on Runway 05, when propeller reverse was selected, the aircraft veered to the left. The crew attempted to regain directional control; however, the aircraft departed the left side of the runway surface, entered an area of loose snow, traversed a shallow ditch, climbed a rocky embankment, and came to rest on its belly with all three landing gears collapsed. The crew and passengers exited the aircraft through the main door stairway and the over-wing exits. There were no reported injuries. The accident occurred during daylight hours at 0834 central standard time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The left engine fuel control support assembly failed in fatigue and released one of three attachment bolts, which resulted in a slight displacement of the fuel control and changed the propeller control dimension. As a result, Beta pressure was achieved and propeller reverse was available for the left engine before it was available for the right engine.
2. The pilot selected thrust reverse without confirmation that the Beta lights were on for both engines, and the aircraft veered from the runway, most likely as a result of temporary asymmetric thrust.
Finding as to Risk:
1. There is no requirement to include the Beta light call as part of the pre-landing briefing. Briefing this item would remind the pilots of the need to confirm Beta light activation for both engines before application of thrust reverse.
Final Report:

Crash of a Cessna 207A Stationair 8 II off High Bluff

Date & Time: Nov 7, 2006 at 0715 LT
Operator:
Registration:
V3-HDT
Flight Phase:
Survivors:
Yes
Schedule:
Orange Walk – Corozal
MSN:
207-0716
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Orange Walk Airport at 0700LT for a 30 miles flight to Corozal, North Belize. After 15 minutes, the pilot encountered engine problems and elected to ditch the aircraft about 4 miles south of High Bluff. The aircraft sank in shallow water (about 5 feet deep). All 6 occupants were rescued by the crew of a boat.
Probable cause:
Engine failure in flight for unknown reasons. The engine was recently overhauled.

Crash of a Cessna 208B Grand Caravan in Punta Pájaros

Date & Time: Oct 30, 2006 at 1430 LT
Type of aircraft:
Operator:
Registration:
XA-UBL
Survivors:
Yes
Schedule:
Cancún – Punta Pájaros
MSN:
208B-1042
YOM:
2004
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Punta Pájaros Airport, the crew encountered poor weather conditions (stormy weather). He initiated a go-around and was trying to gain height when the single engine aircraft collided with bushes and crashed in a lagoon. All 14 occupants evacuated with minor injuries while the aircraft was damaged beyond repair. Weather conditions were marginal at the time of the accident.

Crash of a Boeing 737-2B7 in Abuja: 96 killed

Date & Time: Oct 29, 2006 at 1130 LT
Type of aircraft:
Operator:
Registration:
5N-BFK
Flight Phase:
Survivors:
Yes
Schedule:
Abuja – Sokoto
MSN:
22891
YOM:
1983
Flight number:
ADK053
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
100
Pax fatalities:
Other fatalities:
Total fatalities:
96
Captain / Total flying hours:
8545
Captain / Total hours on type:
353.00
Copilot / Total flying hours:
6497
Aircraft flight hours:
56411
Aircraft flight cycles:
44465
Circumstances:
The B737-200 aircraft which night-stopped at Calabar on Saturday the 28th of October, 2006, departed for Lagos in the morning of the 29th of October, 2006, and landed in Lagos at 0825 hrs. While on ground in Lagos, it uplifted some fuel. There was only cabin crew change. The aircraft departed Lagos on scheduled passenger service as ADK 063 at 0929 hrs and landed in Abuja at 1020 hrs. The aircraft uplifted 5000 litres of fuel and had 11000kg fuel for departure as ADK 053, a scheduled service to Sokoto. After boarding, it started raining and this compelled the crew to close the aircraft doors. Shortly after the rain had subsided, the doors were opened for the ground personnel to disembark. The crew then requested for start-up clearance. At 1115 hrs the aircraft was given a start up clearance for Sokoto. At 1121 hrs, the aircraft was given taxi clearance to holding position Runway 22. The pilot immediately requested for the wind, which was given as “210 variable at 8 kts”. Shortly after, the Control Tower transmitted the wind as south-westerly at 15 kts. While taxiing, the control tower advised Flight ADK 053 of gusty wind. The wind was initially given as 35 kts and then changed to 28 kts within 1 minute. At 1125 hrs while the aircraft was at the holding point, the crew was again advised of South-Westerly wind at 15 kts. At this juncture, the pilot of Virgin Nigeria 042 was heard on the radio saying “it looks like 35 kts to me” and then stated that he was going to wait for improvement in the weather, which he did. Thereafter, the ADK 053 crew requested for takeoff clearance and was cleared with right turn-out on course. Flight ADK 053 was airborne at 1129 hrs and was transferred to the Approach Control on 119.8MHZ but there was no acknowledgement from the crew. After three unsuccessful attempts to contact the aircraft, the Tower advised the Approach Control to call ADK 053. Other aircraft on the apron (Virgin Nigeria 042 and Trade Wings 2401), which were on that frequency were also asked to assist in contacting the aircraft but all attempts were unsuccessful. Kano and Lagos Area Controls were requested to contact ADK 053, but there was no response from the aircraft. Abuja Flight Communication Centre was then advised to inform National Emergency Management Agency (NEMA) in Kano about the loss of contact with the aircraft. At 1138 hrs, Flight Communication Centre called the Control Tower that someone came from a nearby village (Tungar Madaki) near the radar site and reported that a plane had crashed in their village. A search party from the airport was dispatched and they found and confirmed that the plane had crashed shortly after takeoff. The accident resulted in 96 fatalities out of 105 persons on board (POB). The accident occured at latitude N 08 59.691’ longitude E 007 14.772’ on an elevation of 1123 ft (ASL). The time of the accident was 1130 hrs during daylight and in rain.
Probable cause:
Causal Factor:
The pilot’s decision to take-off in known adverse weather conditions and failure to execute the proper windshear recovery procedure resulted in operating the aircraft outside the safe flight regime, causing the aircraft to stall very close to the ground from which recovery was not possible.
Contributory Factors:
1) Inability of the flight crew to apply windshear recovery procedures and the use of inappropriate equipment for windshear recovery procedure during simulator recurrency. Lack of company Standard Operating Procedures (SOP) for flight operations in adverse weather conditions.
2) The coordination of responsibilities between the pilot-flying (PF) and pilot not flying(PNF) during their encounter with adverse weather situation was inconsistent with Standard Operating Procedures (SOP) for the duties of the pilot-flying (PF) and pilot not flying(PNF) resulting in the inadequate control of the aircraft.
Final Report:

Crash of a Boeing 737-2T4 in Tarakan

Date & Time: Oct 3, 2006 at 1120 LT
Type of aircraft:
Operator:
Registration:
PK-RIE
Survivors:
Yes
Schedule:
Balikpapan – Tarakan
MSN:
22804
YOM:
1983
Flight number:
RI394
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
104
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Tarakan-Juwata Airport, the crew was informed of the poor visibility due smoke emanating from forest fire. After touchdown on runway 06/24 which is 1,845 metres long, the aircraft went out of control, veered off runway, lost its undercarriage and one engine and came to rest. All 110 occupants escaped uninjured while the aircraft was damaged beyond repair. At the time of the accident, the visibility was reported to be about 400 metres, below minimums.