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:

Crash of a Cessna 208B Grand Caravan in Cuenca: 5 killed

Date & Time: Mar 24, 2006 at 1102 LT
Type of aircraft:
Operator:
Registration:
HC-BXD
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Cuenca – Macas
MSN:
208B-0591
YOM:
1997
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
11250
Copilot / Total flying hours:
8007
Aircraft flight hours:
5736
Aircraft flight cycles:
10332
Circumstances:
Shortly after takeoff from runway 05 at Cuenca-Mariscal La Mar Airport, while climbing to a height of 300 feet, the engine failed. The airplane lost height, causing the nose wheel to struck the roof of a building. Out of control, the aircraft crashed onto a building occupied by a rubber company. Five passengers were killed while nine other occupants were seriously injured. There were no injuries on the ground. The aircraft was destroyed.
Probable cause:
Investigations revealed that one or more blades located on the turbine compressor failed as a result of deformation due to excessive high temperatures. It was also reported that the company's maintenance failed to follow the engine maintenance program that had not been inspected in accordance with the procedures published by the engine manufacturer. The Hot Section Inspection (HSI) should be performed at 3,600 flight hours but the airplane accumulated 200 additional hours since without the required checks.
Final Report:

Crash of an ATR72-212A in Bangalore

Date & Time: Mar 11, 2006 at 1017 LT
Type of aircraft:
Operator:
Registration:
VT-DKC
Survivors:
Yes
Schedule:
Coimbatore – Bangalore
MSN:
721
YOM:
2005
Flight number:
DN108
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft landed hard on runway 27 at Bangalore-Hindustan Airport. After touchdown, it veered off runway and came to rest. All 44 occupants escaped uninjured while the aircraft was damaged beyond repair. Brand new, it was delivered four months ago.

Crash of a McDonnell Douglas MD-82 in Surabaya

Date & Time: Mar 4, 2006 at 1625 LT
Type of aircraft:
Operator:
Registration:
PK-LMW
Survivors:
Yes
Schedule:
Denpasar – Surabaya
MSN:
49443/1291
YOM:
1986
Flight number:
JT8987
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Prior to departure from Bali to Surabaya, the crew was informed that the left engine's thrust reverser system was out of service. Following an uneventful flight, the crew completed a normal approach to runway 10 then landed according to procedures. After touchdown, the crew activated the thrust reverser when the airplane deviated to the right. The crew elected to counteract but the aircraft veered off runway, lost its undercarriage and came to rest in a grassy area. All 144 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a BAe 3102 Jetstream 31 in Cap Haïtien

Date & Time: Jan 31, 2006
Type of aircraft:
Operator:
Registration:
HH-DPL
Flight Phase:
Survivors:
Yes
MSN:
769
YOM:
1987
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Cap Haïtien Airport, the captain decided to abandon the takeoff procedure. Unable to stop within the remaining distance, the aircraft overran. The left hand side of the fuselage was punctured by propeller parts coming from the left engine. All occupants escaped uninjured while the aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere in January 2006.

Crash of a Cessna 208B Grand Caravan near Port Alberni: 3 killed

Date & Time: Jan 21, 2006 at 1420 LT
Type of aircraft:
Operator:
Registration:
C-GRXZ
Flight Phase:
Survivors:
Yes
Schedule:
Tofino – Vancouver
MSN:
208B-0469
YOM:
1995
Flight number:
RXX604
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2480
Captain / Total hours on type:
750.00
Circumstances:
The Cessna 208B aircraft (registration C-GRXZ, serial number 208B0469) was en route at 9000 feet above sea level, from Tofino, British Columbia, to Vancouver International Airport, British Columbia, when the engine failed. The pilot began a glide in the direction of the Port Alberni Regional Airport before attempting an emergency landing on a logging road. The aircraft struck trees during a steep right-hand turn and crashed. The accident occurred at about 1420 Pacific standard time, approximately 11 nm south-southeast of the Port Alberni Regional Airport. Five passengers survived with serious injuries; the pilot and the other two passengers were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The engine lost power when a compressor turbine blade failed as a result of the overstress extension of a fatigue-generated crack. The fracture initiated at a metallurgical anomaly in the parent blade material and progressed, eventually resulting in blade failure due to overstress rupture.
2. The combination of aircraft position at the time of the engine failure, the lack of equipment enabling the pilot to locate and identify high terrain, and the resultant manoeuvring required to avoid entering instrument flight conditions likely prevented the pilot from attempting to glide to the nearest airfield.
Findings as to Risk:
1. Single-engine instrument flight rules (SEIFR) operations in designated mountainous regions have unique obstacle risks in the event of an engine failure. Canadian equipment requirements for such operations do not currently include independent terrain mapping, such as terrain awareness and warning systems (TAWS).
2. Airline operators are not currently required to conduct any additional route evaluation or structuring to ensure that the risk of an off-field landing is minimized during SEIFR operations.
3. Pilots involved in commercial SEIFR operations do not receive training in how to conduct a forced landing under instrument flight conditions; such training would likely improve a pilotís ability to respond to an engine failure when operating in instrument meteorological conditions (IMC).
4. Mean time between failure (MTBF) calculations do not take into account In Flight Shut Downs (IFSDs) not directly attributable to the engine itself; it may be more appropriate to monitor all IFSD events.
5. The design of the Cessna 208B Caravan fuel shutoff valves increases the risk that the valves will open on impact, allowing fuel spillage and increasing the potential for fire.
Other Finding:
1. Sonicblue Airways was not providing downloaded engine parameter data for engine condition trend monitoring (ECTM) evaluation at appropriate intervals.
Final Report:

Crash of an Antonov AN-140-100 off Nardaran: 23 killed

Date & Time: Dec 23, 2005 at 2240 LT
Type of aircraft:
Operator:
Registration:
4K-AZ48
Flight Phase:
Survivors:
No
Schedule:
Baku - Aktau
MSN:
36525307036
YOM:
2004
Flight number:
AHY217
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
23
Circumstances:
On a flight from Baku to Aktau in difficult weather conditions at night when took off with caged gyro horizons, so the crew lost spatial orientation. The aircraft entered a steep right downward spiral and crashed on the shore of the Caspian Sea near Nardaran, some 35 km northeast of Baku, less than five minutes after takeoff. All 5 crew and 18 passengers were killed, among them were 15 Azeris, one Briton, one Australian, one Turkish, one Georgian and 4 Kazakh.
Probable cause:
The gyro horizons failed after takeoff due to a malfunction caused by the fact that some counterfeit assemblies and instruments had been installed by KhGAPP during the production of the aircraft. While cruising at night and poor visibility, the crew lost situational awareness and suffered a spatial disorientation, causing the aircraft to enter an uncontrolled descent and to crash into the sea. The lack of visual references on ground was considered as a contributing factor.

Crash of a Grumman G-73 Turbo Mallard off Miami: 20 killed

Date & Time: Dec 19, 2005 at 1439 LT
Type of aircraft:
Operator:
Registration:
N2969
Flight Phase:
Survivors:
No
Schedule:
Miami - Bimini
MSN:
J-27
YOM:
1947
Flight number:
OP101
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
20
Captain / Total flying hours:
2830
Captain / Total hours on type:
1630.00
Copilot / Total flying hours:
1420
Copilot / Total hours on type:
71
Aircraft flight hours:
31226
Aircraft flight cycles:
39743
Circumstances:
On December 19, 2005, about 1439 eastern standard time, a Grumman Turbo Mallard (G-73T) amphibious airplane, N2969, operated by Flying Boat, Inc., doing business as Chalk’s Ocean Airways flight 101, crashed into a shipping channel adjacent to the Port of Miami, Florida, shortly after takeoff from the Miami Seaplane Base. Flight 101 was a regularly scheduled passenger flight to Bimini, Bahamas, with 2 flight crewmembers and 18 passengers on board. The airplane’s right wing separated during flight. All 20 people aboard the airplane were killed, and the airplane was destroyed by impact forces. Flight 101 was operating under the provisions of 14 Code of Federal Regulations Part 121 on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Probable cause:
The in-flight failure and separation of the right wing during normal flight, which resulted from:
1) The failure of the Chalk’s Ocean Airways maintenance program to identify and properly repair fatigue cracks in the right wing and
2) The failure of the Federal Aviation Administration (FAA) to detect and correct deficiencies in the company’s maintenance program.
Final Report: