Crash of a Canadair RegionalJet CRJ-200 in Lexington: 49 killed

Date & Time: Aug 27, 2006 at 0607 LT
Operator:
Registration:
N431CA
Flight Phase:
Survivors:
Yes
Schedule:
Lexington - Atlanta
MSN:
7472
YOM:
2001
Flight number:
DL5191
Crew on board:
3
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
49
Captain / Total flying hours:
4710
Captain / Total hours on type:
3082.00
Copilot / Total flying hours:
6564
Copilot / Total hours on type:
940
Aircraft flight hours:
12048
Aircraft flight cycles:
14536
Circumstances:
The aircraft crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed, and the first officer received serious injuries. The airplane was destroyed by impact forces and post crash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 and was en route to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Night visual meteorological conditions prevailed at the time of the accident.
Probable cause:
The flight crew members' failure to use available cues and aids to identify the airplane's location on the airport surface during taxi and their failure to cross-check and verify that the airplane was on the correct runway before takeoff. Contributing to the accident were the flight crew's non pertinent conversation during taxi, which resulted in a loss of positional awareness, and the Federal Aviation Administration's failure to require that all runway crossings be authorized only by specific air traffic control clearances.
Final Report:

Crash of a Tupolev TU-154M in Novgorodskoye: 170 killed

Date & Time: Aug 22, 2006 at 1539 LT
Type of aircraft:
Operator:
Registration:
RA-85185
Flight Phase:
Survivors:
No
Schedule:
Anapa - Saint Petersburg
MSN:
91A-894
YOM:
1991
Flight number:
FV612
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
160
Pax fatalities:
Other fatalities:
Total fatalities:
170
Aircraft flight hours:
24215
Circumstances:
The aircraft departed Anapa Airport at 1505LT and climbed to the assigned altitude of 11,700 metres. Due to the presence of stormy weather ahead, the crew was cleared to modify his route and changed heading to avoid the thunderstorm area with CB's up to 15 km. The aircraft encountered severe turbulences and climbed from 11,961 metres to 12,794 metres within 10 seconds, reaching a super critical angle of attack of 46° with a speed dropping from 350 km/h to zero, causing all three engines to stop. The crew was able to send a brief message then the aircraft entered an uncontrolled descent in a flat spin. At an altitude of 3,300 metres, the crew informed ATC that control was totally lost. The aircraft crashed in a prairie located near Novgorodskoye, about 45 km northwest of Donetsk. It was totally destroyed by impact forces and a post crash fire, and all 170 occupants were killed.
Probable cause:
The cause of the accident was a loss of control in manual flight mode after the aircraft reached a super critical angle of attack, causing a stall with the subsequent transition to a flat spin and collision with the ground with a large vertical velocity. The following contributing factors were identified:
- Poor crew coordination,
- Failure of the crew to follow the flight manual instructions to identify and prevent a stall condition,
- The crew training methods used were insufficient to demonstrate the dangers of manual flight at high altitudes.
Final Report:

Crash of a Fokker F27 Friendship 200 in Multan: 45 killed

Date & Time: Jul 10, 2006 at 1205 LT
Type of aircraft:
Operator:
Registration:
AP-BAL
Flight Phase:
Survivors:
No
Schedule:
Multan - Lahore
MSN:
10243
YOM:
1964
Flight number:
PK688
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
45
Captain / Total flying hours:
9320
Captain / Total hours on type:
138.00
Copilot / Total flying hours:
520
Copilot / Total hours on type:
303
Aircraft flight hours:
73591
Aircraft flight cycles:
83485
Circumstances:
On 10 July 2006, F-27 Fokker registration No AP-BAL, belonging to Pakistan International Airline was scheduled to fly from Multan to Lahore. The aircraft had 45 souls on board including four crew members. The Captain of the aircraft was Captain Hamid Qureshi. The aircraft took off for Lahore at 1205 hours Pakistan Standard Time (PST) from Multan Runway 36. Soon after takeoff, the aircraft was observed by the ATC and other eyewitnesses to be maintaining very low altitude and drifting right in a bank. ATC Control tower tried to establish contact with aircraft, but no contact was established. Subsequently a call from the local resident was received stating that an aircraft had crashed at about 2 km, NE of the Runway. All souls on board the aircraft sustained fatal injuries and the aircraft was completely burned.
Probable cause:
Accidents and losses are part of aviation business, but avoidable accidents hurt us the most. PIA or any other company can ill afford such losses. In this accident, while the aircraft had developed a problem in its right engine turbine, resulting in the engine failure, yet a professional handling by the aircrew could have saved 45 precious lives and a valuable aircraft. It is also felt that this accident may not be viewed as an isolated case of a pilot’s failure to handle the emergency. The problems were observed to be complex and deep routed and reflect towards the organization and her culture. The occurrence (right engine failure) took place due to improper assembly during overhaul. Quality Control system of PIA Engineering appears to be ineffective in detecting the weaknesses. The accident took place due to improper handling of the emergency by the air crew which reflected towards in adequacies of PIA Training/Assessment and Scheduling System. The CAA Airworthiness, too, can not be absolved of their responsibilities of regulating and monitoring the quality control system at PIAC Engineering.
Final Report:

Crash of an Airbus A310-324 in Irkutsk: 125 killed

Date & Time: Jul 9, 2006 at 0744 LT
Type of aircraft:
Operator:
Registration:
F-OGYP
Survivors:
Yes
Schedule:
Moscow - Irkutsk
MSN:
442
YOM:
1987
Flight number:
SBI778
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
195
Pax fatalities:
Other fatalities:
Total fatalities:
125
Captain / Total flying hours:
10611
Captain / Total hours on type:
1056.00
Copilot / Total flying hours:
9771
Copilot / Total hours on type:
158
Aircraft flight hours:
59865
Aircraft flight cycles:
12550
Circumstances:
On July 8, 2006 an А310 airplane with state registration number F-OGYP (France), leased by ОАО Aviakompania Sibir, and with a flight crew consisting of the Captain and the co-pilot, was flying scheduled passenger flight С7 778 from Domodedovo to Irkutsk. Apart from the two cockpit personnel, there were 6 flight attendants and 195 passengers on board (of these, 2 worked for the company), which included 181 nationals of Russia, 3 of Germany, 3 of the PRC, 2 of Poland, 3 of Belarus, 2 of Moldova and 1 of Azerbaijan. The airplane's payload according to the flight manifest was 19,800 kg (which included about 80 kg of hazardous freight - perfume), its take-off weight 140414 kg (maximum permissible – 150,000 kg), and center-of-gravity position 25.5% (the range of permissible center-of-gravity positions for take-off is 18% - 32%). Upon completion of the pre-flight preparation, the crew took off from Domodedovo airport at 17:17 (17:15 – as per schedule) and after climbing set a course for its destination airport of Irkutsk (alternate airport Bratsk). The flight proceeded without incident and at 22:17 the crew initiated descent for an approach and landing at Irkutsk airport. At 22:43:40 the airplane landed without misalignment on runway 30 at Irkutsk airport. Before the flight, in accordance with Sibir’s MEL, the maintenance personnel deactivated the thrust reverser on the airplane's left engine after hearing the crew's observation about this thrust reverser's malfunction during a previous flight. After touchdown all spoiler sections prepared ("armed") by the crew for utilization were deployed and the autobrake in Low mode, previously selected by the crew, was activated. The pilot moved the right engine (no. 2) thrust reverser forward. However, simultaneously with the subsequent reduction of the reverse mode of engine no. 2, engine no. 1 started to speed up (forward thrust), which led to an increase in airplane speed and the onset of torque that pulled the airplane to the right. The crew failed to perceive the cause of what was happening. In spite of intense wheel-braking efforts, the airplane used up the entire length of the runway and overshot its end at a speed of about 180 kph. The airplane then continued to travel on wet soil. At a distance of about 300 m from the departure threshold of the runway, the airplane collided with a concrete barrier of the aerodrome and then with some garages located directly behind the barrier, after which the airplane, now seriously damaged, stopped. As a result of the destruction of the fuel tanks the fuel ignited and fire penetrated the airplane's interior. As a result of the accident, 125 individuals died, including the two pilots and three of the flight attendants. The airplane was practically completely destroyed by the fire.
Probable cause:
The cause of Sibir A310 F-OGYP accident was the erroneous and uncontrolled actions by the crew during rollout after landing in a configuration with one engine reverser deactivated. After touchdown, the Captain, while acting on the reverse thrust lever of the right engine, inadvertently and uncontrollably moved the throttle lever for the left engine, whose thrust reverser was deactivated, from the "idle" to the significant forward thrust position. Inadequate monitoring and call-outs of airplane speed and engine parameters by the Co-pilot made it impossible for the crew to perform the necessary actions, either by moving the left throttle back to idle or shutting down the engines. The crew had enough time to recognize the situation. The airplane went off the runway at the high speed of ~180 km/h, hit the concrete fence and buildings, crashed and caught fire. 125 people died as a result of the accident.
Final Report:

Crash of a Swearingen SA227AC Metro III in Canberra

Date & Time: Jul 1, 2006
Type of aircraft:
Operator:
Registration:
VH-VEH
Survivors:
Yes
MSN:
AC-663B
YOM:
1986
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
By night, the twin engine aircraft landed hard at Canberra Airport. There were no injuries but the aircraft was damaged beyond repair.
Probable cause:
ATSB did not conduct any investigations on this event.

Crash of a De Havilland DHC-6 Twin Otter 300 in Jumla: 9 killed

Date & Time: Jun 21, 2006 at 1203 LT
Operator:
Registration:
9N-AEQ
Survivors:
No
Schedule:
Nepālganj – Surkhet – Jumla
MSN:
708
YOM:
1980
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
9
Aircraft flight hours:
23392
Aircraft flight cycles:
36092
Circumstances:
The twin engine aircraft departed Nepālganj Airport on a domestic service to Jumla with an intermediate stop in Surkhet, carrying six passengers, three crew members and a load consisting of bags containing grains for a total of 941 kilos. While approaching Jumla Airport, the crew was informed that runway 27 was in use with a wind from 240 at 4 knots. For unknown reasons, the captain started the approach to runway 09 at 1201LT. At an excessive speed, he missed the runway, initiated a go-around procedure and passed to the right of the tower. Then, he started a steep turn to the left when the aircraft lost height and speed and crashed in a field located 500 meters east of the airport, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all 9 occupants were killed.
Probable cause:
The crew's attempt to make a sudden go-around while close to runway 09 threshold with a very low circuit altitude and subsequent attempt to turn in a tight circuit with excessive angle of bank that led to a stall. The aircraft subsequently contacted terrain due to insufficient clearance available for effective stall recovery. The quick decisions to change runway added to the crew workload at a critical period which was aggravated by the breakdown of cockpit discipline. The other contributory factors leading to the accident were:
- Violation of company Standard Operating Procedures by flight crew,
- Insufficient monitoring of its flight training program and line operations by Yeti management,
- Inadequate oversight of Yeti Airlines by CAAN.

Crash of a Casa NC-212-AB4 Aviocar 200 in Banda Neira

Date & Time: Jun 5, 2006 at 1013 LT
Type of aircraft:
Operator:
Registration:
PK-NCL
Survivors:
Yes
Schedule:
Ambon - Bandanaira
MSN:
185/34N
YOM:
1981
Flight number:
MZ9971
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on wet runway 10/28 at Banda Neira Airport, the aircraft slid then veered off runway to the right. While contacting soft ground, the undercarriage collapsed and the aircraft came to rest, broken in two. All 18 occupants escaped with minor injuries. The accident occurred in heavy rain falls.

Crash of a BAe 3101 Jetstream 31EP in Bocas del Toro

Date & Time: Jun 1, 2006 at 0755 LT
Type of aircraft:
Operator:
Registration:
HP-1477PST
Survivors:
Yes
Schedule:
Panama City - Bocas del Toro
MSN:
760
YOM:
1985
Flight number:
PST680
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Panama City, the crew completed the approach and landing at Bocas del Toro Airport. After touchdown on a wet runway following heavy rain falls, the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest in bushes. All occupants were rescued, among them few were slightly injures. The aircraft was damaged beyond repair.

Crash of an Airbus A320-211 off Sochi: 113 killed

Date & Time: May 3, 2006 at 0213 LT
Type of aircraft:
Operator:
Registration:
EK-32009
Survivors:
No
Schedule:
Yerevan - Sochi
MSN:
547
YOM:
1995
Flight number:
RNV967
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
105
Pax fatalities:
Other fatalities:
Total fatalities:
113
Captain / Total flying hours:
5458
Captain / Total hours on type:
1436.00
Copilot / Total flying hours:
2185
Copilot / Total hours on type:
1022
Aircraft flight hours:
28234
Aircraft flight cycles:
14376
Circumstances:
On 2 May 2006 the Armavia A320, registered EK-32009, was undertaking passenger flight RNV 967 from Zvartnots (Yerevan, Armenia) to Adler (Sochi, Russia). Preliminary preparation of the crew was conducted on 23-24 May 2006 under the guidance of the airline’s Flight Director, in accordance with the requirements of ROLRGA RA-2000, Section 7.2.1. Pre-flight briefing of the crew was conducted on the day of departure, under the guidance of the Captain, in accordance with the requirements of ROLRGA RA-2000, Section 8.2.1 On 2 May 2006 at 19.30 the crew passed the pre-flight medical examination. The crew’s pre-flight rest period exceeded 24 hours. In accordance with ROLRGA RA-2000 and Work-Rest Norms for civil aircraft crews from the Republic of Armenia, each crew member is individually responsible for adherence to the pre-flight rest regime. It should be noted that it was difficult for the crew to take adequate rest during the day before the night flight, due to impairment of bio-rhythms. That is most likely why, in their cockpit conversations the crew members mentioned that they had not got enough sleep. In order to make their decision for departure, the crew obtained the observed weather data and the weather forecast for the takeoff, landing and alternate aerodromes that met the requirements for IFR flights. According to the documents submitted, the airplane takeoff weight and the centre of gravity were 62,712 kg and 29.9% mean aerodynamic chord, i.e. within the A320 FCOM limitations. There were 113 occupants on board: 105 passengers (including 5 children and 1 baby), 2 pilots, 5 flight attendants and 1 engineer. The airplane took off from Zvartnots airport at 20:47. Takeoff, climb and cruise were uneventful. The first communication between the Sochi approach controller and the crew took place at 21:10:20. At that moment the airplane was beyond the coverage area of Sochi aerodrome radar. Up until 21:17 the approach controller and the crew discussed the observed and forecast weather, and as a result the crew decided to return to Yerevan. At 21:26:37, after the decision had already been made, the crew asked the controller about the latest observed weather. At 21:30:49 the controller informed the crew that visibility was 3,600 m and the cloud ceiling 170 m. At 21.31.14 the crew decided to continue the flight to Sochi airport. The next communication with the approach controller was at 22:00:45. At that moment the airplane was descending to an altitude of 3,600 m heading to GUKIN point and was being tracked by the Sochi radar. The approach controller cleared the airplane for descent to 1,800 m and reported the observed weather at Sochi, as at 22:00, for runway 06, which was above the aerodrome minimum. Then the crew was handed over to the holding and tower controllers, and was cleared for descent to 600 m, as per aerodrome pressure QNH 1016 hPa, before entering the turn to final. While performing the turn to final, the runway extended centreline was overshot. Having eliminated the deviation, the airplane started descending along the glide slope, following the approach pattern. At 22:10:45 the crew reported extension of the landing gear and their readiness for landing. In response they were advised of the distance of 10 km and weather 4000 x 190, and were cleared for landing. However, about 30 seconds later, the controller advised the crew of the observed cloud ceiling at 100 m and instructed them to stop their descent and carry out a right turn and climb up to 600 m and also to get in touch with the holding controller. The last communication with the crew was at 22:12:35. After that the crew did not respond to any of the controller’s calls. At 22:13:03 the airplane struck the water, was destroyed and sank.
Probable cause:
The fatal crash of the Armavia A320 EK-32009 was a CFIT accident that happened due to collision with the water while carrying-out a climbing manoeuvre after an aborted approach to Sochi airport at night with weather conditions below the established minima for runway 06. While performing the climb with the autopilot disengaged, the Captain, being in a psychoemotional stress condition, made nose down control inputs due to the loss of pitch and roll awareness. This started the abnormal situation. Subsequently the Captain's inputs in the pitch channel were insufficient to prevent development of the abnormal situation into the catastrophic one. Along with the inadequate control inputs of the Captain, the contributing factors to development of the abnormal situation into the catastrophic one were also the lack of necessary monitoring of the aircraft descent parameters (pitch attitude, altitude, vertical speed) by the co-pilot and the absence of proper reaction by the crew to the EGPWS warning.
Final Report:

Crash of a Let L-410UVP-E20 near Rio Bonito: 19 killed

Date & Time: Mar 31, 2006 at 1739 LT
Type of aircraft:
Operator:
Registration:
PT-FSE
Flight Phase:
Survivors:
No
Site:
Schedule:
Macaé – Rio de Janeiro
MSN:
91 25 32
YOM:
1991
Flight number:
TIM6865
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
10000
Captain / Total hours on type:
39.00
Copilot / Total flying hours:
5220
Copilot / Total hours on type:
1719
Aircraft flight hours:
2739
Aircraft flight cycles:
3960
Circumstances:
The twin engine aircraft departed Macaé Airport at 1719LT on a flight to Rio de Janeiro-Santos Dumont Airport with 17 passengers and two pilots on board. Few minutes later, the copilot cancelled the IFR flight plan and continued under VFR mode at an altitude of 4,500 feet. Approaching São Pedro da Aldeia, the copilot was cleared to descend to 2,000 feet to avoid poor weather conditions. Later, while approaching Saquarema, the crew initiated a left turn to avoid clouds when shortly later, at an altitude of 1,920 feet, the aircraft struck the Pedra Bonita Peak. The wreckage was found six km southeast of Rio Bonito in a dense wooded area. The aircraft was totally destroyed and all 19 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue under VFR mode in IMC conditions. The following contributing factors were identified:
- Overconfidence on part of the captain who was familiar with the area,
- The organizational culture of the company proved to be complacent by not inhibiting the adoption of procedures incompatible with flight safety, such as the low altitude flights made by the instructor captain,
- There was inadequate assessment of the situation by the crew, causing them to fly at a lower altitude than the safe limits under visual conditions unsuitable for visual flight, resulting in the collision of the aircraft with high ground,
- The use of human resources for the operation of the aircraft was unsuitable because of failure to comply with operational standards, leading the crew to perform a passenger flight to the lower altitude limits of safety, under inadequate visual conditions,
- The preparation for the flight proved inadequate because the crew did not have a meteorological analysis of the appropriate level of flight performed, considering that the conditions for the region were overshadowing the Serra do Mar and surrounding areas of low clouds and / or mist, especially on the slopes of the mountain,
- The weather conditions prevailing in the region made visual flight impossible, resulting in the concealment of the elevation at which the aircraft crashed,
- The pilots intentionally not complying with rules of air traffic and civil aviation rules, without grounds, performing flight at low altitude, under conditions of visibility below the limits established for VFR flight, colliding with high grounD,
- The company has not taken appropriate supervisory measures, enabling the existence of a culture of undeveloped flight safety, which prevented advance identification of actions taken by the crew and injured misconception exists in the CRM business, which represented a potential risk to their operations, as well as by the failure of some educational measures provided for in its PPAA (Plan for the Prevention of Aeronautical Accidents).
Final Report: