Crash of a Yakovlev Yak-40 in Tashkent: 37 killed

Date & Time: Jan 13, 2004 at 1927 LT
Type of aircraft:
Operator:
Registration:
UK-87985
Survivors:
No
Schedule:
Termez - Tashkent
MSN:
9 54 08 44
YOM:
1975
Flight number:
UZB1154
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
37
Aircraft flight hours:
37000
Circumstances:
Following an uneventful flight from Termez, the crew started the descent to Tashkent-Yuzhny Airport by night and marginal weather conditions. The visibility was limited due to foggy conditions with an RVR between 600 and 900 metres for runway 08L. The captain continued the approach with an excessive rate of descent, causing the aircraft to pass below the MDA without any visual contact with the ground. At an altitude of 165-170 metres, the captain positioned the airplane in a flat attitude then continued the descent at a distance of 2 km from the runway threshold, but this time with an insufficient rate of descent. The aircraft passed over the runway threshold at a height of about 30-40 metres and flew over the runway for a distance of 3,3 km. The captain established a visual contact with the runway lights, elected to land but failed to realize he was in fact approaching the end of the runway which is 4 km long. He reduced both engines power to idle, activated the thrust reversers when he realized his mistake and attempted a go-around. The aircraft collided with a 2 metres high concrete wall located 260 metres past the runway end, lost its right wing and crashed in a drainage ditch located along the perimeter fence, bursting into flames. The aircraft was totally destroyed and all 37 occupants were killed, among them Richard Conroy, special UNO representative in Uzbekistan.
Probable cause:
The following factors were identified:
- The crew failed to maintain a correct approach pattern maybe following a wrong setting of the approach selector in SP mode instead of ILS mode,
- The crew decided to continue the approach without establishing any visual contact with the approach light and runway light system,
- The crew failed to comply with published procedures,
- The crew failed to initiate a go-around procedure.

Crash of a De Havilland DHC-6 Twin Otter in Sturt Island

Date & Time: Jan 5, 2004
Operator:
Registration:
P2-KSG
Flight Phase:
Survivors:
Yes
MSN:
509
YOM:
1976
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a grassy runway (780 metres long), the pilot noted standing water on the ground. He attempted to take off prematurely to avoid these puddles but the aircraft stalled and crash landed. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 727-223 in Cotonou: 141 killed

Date & Time: Dec 25, 2003 at 1459 LT
Type of aircraft:
Operator:
Registration:
3X-GDO
Flight Phase:
Survivors:
Yes
Schedule:
Conakry - Cotonou - Kufra - Beirut - Dubai
MSN:
21370
YOM:
1977
Flight number:
GIH141
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
153
Pax fatalities:
Other fatalities:
Total fatalities:
141
Captain / Total flying hours:
11000
Captain / Total hours on type:
8000.00
Aircraft flight hours:
67186
Aircraft flight cycles:
40452
Circumstances:
Flight GIH 141 was a weekly scheduled flight, performed by the Union des Transports Africains (UTA), between Conakry (Guinea), Cotonou (Benin), Beirut (Lebanon) and Dubai (United Arab Emirates). A stopover at Kufra (Libya) was planned between Cotonou and Beirut. Having departed from Conakry at 10 h 07 with eighty-six passengers, including three babies, and ten crew members, the Boeing 727-223 registered 3X-GDO landed at Cotonou Cadjèhoun on 25 December 2003 at 12 h 25. Nine passengers disembarked. Sixty-three persons, including two babies, checked in at the airport check-in desk. Ten others, including one baby, boarded from an aircraft that had arrived from Lomé (Togo). Passenger boarding and baggage loading took place in a climate of great confusion. The airplane was full. In the cockpit, two UTA executives were occupying the jump seats. Faced with the particularly large number and size of the hand baggage, the chief flight attendant informed the Captain of the situation. The ground handling company’s agents began loading the baggage in the aft hold when one of the operator’s agents, who remains unidentified, asked them to continue loading in the forward hold, which already contained baggage. When the operation was finished, the hold was full. During this time, the crew prepared the airplane for the second flight segment. The co-pilot was discussing his concerns with the UTA executives, reminding them of the importance of determining the precise weight of the loading of the airplane. The flight plan for Kufra, signed by the Captain, was filed with the ATC office but the meteorological dossier that had been prepared was not collected. Fuel was added to fill up the airplane’s tanks (14,244 liters, or 11.4 metric tons). The accompanying mechanics added some oil. The Captain determined the limitations for the flight and selected the following configuration: flaps 25°, air conditioning units shut down. At 13 h 47 min 55, the crew began the pre-flight checklist. Calm was restored in the cockpit. At 13 h 52 min 12, flight GIH 141 was cleared to roll. The co-pilot was pilot flying (PF). The elevator was set at 6 ¾, it was stated that the takeoff would be performed with full power applied with brakes on, followed by a climb at three degrees maximum to gain speed, with no turn after landing gear retraction. As the roll was beginning, a flight attendant informed the cockpit that passengers who wanted to sit near their friends were still standing and did not want to sit down. The airline’s Director General called the people in the cabin to order. Take-off thrust was requested at 13 h 58 min 01, brake release was performed at 13 h 58 min 15. The airplane accelerated. In the tower, the assistant controller noted that the take-off roll was long, though he did not pay any particular attention to it. At 13 h 59, a speed of a hundred and thirty-seven knots was reached. The Captain called out V1 and Vr. The co-pilot pulled back on the control column. This action initially had no effect on the airplane’s angle of attack. The Captain called « Rotate, rotate »; the co-pilot pulled back harder. The angle of attack only increased slowly. When the airplane had hardly left the ground, it struck the building containing the localizer on the extended runway centerline, at 13 h 59 min 11. The right main landing gear broke off and ripped off a part of the underwing flaps on the right wing. The airplane banked slightly to the right and crashed onto the beach. It broke into several pieces and ended up in the ocean. The two controllers present in the tower heard the noise and, looking in the direction of the takeoff, saw the airplane plunge towards the ground. Immediately afterwards, a cloud of dust and sand prevented anything else being seen. The fire brigade duty chief stated that the airplane seemed to have struck the localizer building. The firefighters went to the site and noticed the damage to the building and the presence of a casualty, a technician who was working there during the takeoff. Noticing some aircraft parts on the beach, they went there through a service gate beyond the installations. Some survivors were still in the wreckage, others were in the water or on the beach. Some inhabitants from the immediate vicinity crowded around, complicating the rescuers’ task. The town fire brigade, the Red Cross and the Cotonou SAMU, along with some members of the police, arrived some minutes later.
Probable cause:
The accident resulted from a direct cause:
• The difficulty that the flight crew encountered in performing the rotation with an overloaded airplane whose forward center of gravity was unknown to them; and two structural causes:
• The operator’s serious lack of competence, organization and regulatory documentation, which made it impossible for it both to organize the operation of the route correctly and to check the loading of the airplane;
• The inadequacy of the supervision exercised by the Guinean civil aviation authorities and, previously, by the authorities in Swaziland, in the context of safety oversight.
The following factors could have contributed to the accident:
• The need for air links with Beirut for the large communities of Lebanese origin in West Africa;
• The dispersal of effective responsibility between the various actors, in particular the role played by the owner of the airplane, which made supervision complicated;
• The failure by the operator, at Conakry and Cotonou, to call on service companies to supply information on the airplane’s loading;
• The Captain’s agreement to undertake the take-off with an airplane for which he had not been able to establish the weight;
• The short length of the runway at Cotonou;
• The time of day chosen for the departure of the flight, when it was particularly hot;
• The very wide margins, in particular in relation to the airplane’s weight, which appeared to exist, due to the use of an inappropriate document to establish the airplane’s weight and balance sheet;
• The existence of a non-frangible building one hundred and eighteen meters after the runway threshold.
Final Report:

Crash of a Boeing 737-3Y0 in Libreville

Date & Time: Dec 19, 2003 at 1844 LT
Type of aircraft:
Operator:
Registration:
TR-LFZ
Survivors:
Yes
Schedule:
Franceville – Libreville
MSN:
23750
YOM:
1987
Flight number:
GN471
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
125
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Libreville-Léon Mba Airport, the crew encountered poor weather conditions. Due to low visibility caused by heavy rain falls, a landing was not possible and the crew followed a holding pattern of about 30 minutes for weather improvement. After landing on runway 16 (3,000 metres long), the aircraft was unable to stop within the remaining distance. It overran at a speed of 100 knots, collided with a fence and came to rest 100 metres further. All 131 occupants evacuated safely while the aircraft was damaged beyond repair. It was reported that the left engine throttle lever was in a full forward position after touchdown while the right engine throttle lever was in the reverse position. The braking action was poor because the runway surface was poor and the crew did not initiate a go-around procedure.

Crash of a Boeing 737-200 in Lima

Date & Time: Dec 13, 2003 at 2248 LT
Type of aircraft:
Operator:
Registration:
OB-1544-P
Survivors:
Yes
Schedule:
Caracas - Lima
MSN:
20956
YOM:
1974
Flight number:
ACQ341
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
94
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25502
Copilot / Total flying hours:
2229
Aircraft flight hours:
62716
Aircraft flight cycles:
62162
Circumstances:
Following an uneventful flight from Caracas, the crew started the approach to Lima-Callao-Jorge Chávez Airport when the crew noted an asymmetric warning with the flaps. The crew decided to continue the approach but failed to lower the undercarriage. The aircraft belly landed at a speed of 190 knots and slid on runway 15 for 2,347 metres before coming to rest. All 100 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Failure of the crew to verify and check the Non Normal Checklist of the Quick Reference Handbook (QRH) due to technical problems at the time of approach and landing, causing the omission of the extension of the gear and subsequent contact of the aircraft with the runway with landing gear retracted. The following findings were identified:
- During the approach, an indication of flap asymmetry presented.
- Due to the tightness of the itinerary programmed by the company, the total flight hours and the flight's working day were within the limits of the maximum allowed by the RAP, which could have influenced (due to fatigue) the poor performance by the crew.
- The lack of recording of some parameters of the flight recorders (FDR and CVR) prevented the resolution of some important and useful details for the investigation.
- The flap asymmetry indication, due to an indication fault in the Flap Position Indicator caused by high electrical resistance originating from the winding inside the synchro transmitter of the right side Flap Position Transmitter.
- The omission of the use in the approach phase of the procedures described in the QRH for this type of abnormal situations.
- The lack of decision to carry out a Go Around, taking into account that the period of time to carry out the QRH procedures for this abnormal situation was not going to be enough.
- Overconfidence (complacency) during the approach phase under abnormal conditions (indication of flap asymmetry).
- Lack of Crew Resource Management during the approach and landing phases, especially under abnormal conditions.
- Lack of leadership during the abnormal situation presented.
- Lack of communication with the Control Tower about the abnormal conditions in which the approach and landing were to be carried out.
- Itinerary very adjusted to the limits of flight hours and working hours, established by the RAP.
Final Report:

Crash of a Fokker F28 Fellowship 4000 in Lokichoggio

Date & Time: Dec 7, 2003 at 1337 LT
Type of aircraft:
Operator:
Registration:
5Y-NNN
Survivors:
Yes
Schedule:
Nairobi – Lokichogio
MSN:
11231
YOM:
1986
Flight number:
HSA812
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Lokichogio Airport, the crew started the braking procedure when the tyre n°1 on the nose gear burst. Unable to stop within the remaining distance, the airplane overran, collided with a fence and came to rest in a ditch with its nose gear torn off. All 27 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Dornier DO228-202 in Bodø

Date & Time: Dec 4, 2003 at 0909 LT
Type of aircraft:
Operator:
Registration:
LN-HTA
Survivors:
Yes
Schedule:
Røst – Bodø
MSN:
8127
YOM:
1987
Flight number:
KAT603
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6400
Captain / Total hours on type:
700.00
Copilot / Total flying hours:
1450
Copilot / Total hours on type:
260
Aircraft flight hours:
11069
Circumstances:
Kato Airline flight KAT603, an aircraft of the type Dornier 228-202 with registration LN-HTA, was to fly a regular scheduled flight from Røst airport (ENRS) to Bodø airport (ENBO). There were two passengers and two pilots on board. There was a strong westerly wind, and when the plane approached Bodø extensive lightning activity developed quickly. The aircraft was struck by a very powerful lightning. The lightning struck the aircraft’s nose area and passed to the tail. Boundings between the fuselage and tail surface and a wire between the tail surface and the elevator were burned off. A powerful electric energy passed through the elevator rod in the tail section. A rod end came loose, resulting in a breach in the control rod. Thus the only connection between the control column in the cockpit and the elevator was lost. This aircraft type has electric pitch trim which adjusts the tail surface angle of attack and after a period the pilots regained limited control of the aircraft’s nose position by using this. When the lightning struck the aircraft, the pilots were blinded for approximately 30 seconds. They lost control of the aircraft for a period and the aircraft came very close to stalling. The pilots declared an emergency. The aircraft’s remaining systems were intact and the pilots succeeded in bringing the plane in for landing. During the first landing attempt the airspeed was somewhat high. The aircraft hit the ground in an approximate three-point position and bounced into the air. The pilots concluded that the landing was uncontrollable because the elevator was not working. The landing was aborted and the aircraft circled for a new attempt. Wind conditions were difficult and the next attempt was also unstable in terms of height and speed. At short final the aircraft nosed down and the pilots barely managed to flare a little before the aircraft hit the ground. The point of impact was a few metres before the runway and the aircraft slid onto the runway. Emergency services quickly arrived at the scene. The two pilots were seriously injured while both passengers suffered only minor physical injuries. No fuel leakage or fire occurred. The aircraft was written off.
Probable cause:
Significant investigation results:
a) The air traffic control service did not have equipment for integrated weather presentation on the radar display.
b) The aircraft’s weather radar did not indicate precipitation cells and was therefore not functioning correctly.
c) Up to 30% of the wires on individual bondings between the fuselage, horizontal stabilizer and elevator may have been broken before the lightning struck.
d) The aircraft was hit by lightning containing a very large amount of energy. The aircraft’s bondings were not able to conduct the electric energy from the lightning and the transfer rod from the cockpit to the elevator was broken.
e) As a result of the reduced control of the aircraft’s pitch and difficult wind conditions, the sink rate was not sufficiently stabilized on short final. The crew were unable to prevent the aircraft from hitting the ground.
Final Report:

Crash of a Fokker F27 Friendship 600 in Tarauacá

Date & Time: Oct 20, 2003 at 1132 LT
Type of aircraft:
Operator:
Registration:
PT-TVA
Survivors:
Yes
Schedule:
Cruzeiro do Sul – Tarauacá – Rio Branco
MSN:
10334
YOM:
1967
Flight number:
TVJ6167
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
3797.00
Copilot / Total hours on type:
2682
Aircraft flight hours:
55725
Aircraft flight cycles:
60270
Circumstances:
After landing at Tarauacá Airport, the crew started the braking procedure when control was lost. The aircraft veered off runway, collided with several obstacles and came to rest in a ditch. All 23 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control after landing after the crew selected the power levers on 'ground fine pitch', combined with the failure of the antiskid system due to poor maintenance. The operator was facing enormous financial difficulties which affected the motivation of the maintenance, flight and cabin crew, which was considered as a contributing factor.
Final Report:

Crash of a BAe 3102 Jetstream 31 in Wick

Date & Time: Sep 17, 2003 at 1447 LT
Type of aircraft:
Operator:
Registration:
G-EEST
Survivors:
Yes
Schedule:
Aberdeen – Wick
MSN:
781
YOM:
1987
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7885
Captain / Total hours on type:
1195.00
Copilot / Total flying hours:
6800
Copilot / Total hours on type:
1000
Aircraft flight hours:
17845
Aircraft flight cycles:
20730
Circumstances:
The aircraft was landing on Runway 31 at Wick Airport. It crossed the threshold at 130 kt which was 21 kt faster than the correct threshold speed. After the co-pilot closed the power levers the aircraft floated about six feet above the runway surface. The aircraft touched down and bounced before touching down a second time more heavily, cracking a wing spar and flexing the aircraft structure sufficient to allow the right propeller to contact the runway. The aircraft bounced again before touching down for the third and final time. The investigation determined that just before the first touchdown, one or both power levers were moved aft of the flight idle position. It was concluded that both the commander and co-pilot were making inputs on the flying controls from that moment onwards until after the second, heavy touchdown. There was no evidence of any technical fault on the aircraft and the weather conditions were well within the limitations set for the aircraft. No safety recommendations were made.
Probable cause:
It is reasonable to conclude that the manoeuvres conducted by G-EEST during the landing were the result of combined control inputs made by the commander and co-pilot. The evidence indicates that this period of combined control started at least 0.28 seconds before the first touchdown and finished at some stage after the second and damaging touchdown. After the first touchdown the aircraft became airborne in a high-drag, low-lift configuration which was intended for ground operation only and a 5.6g impact ensued on the second touchdown. There was no evidence of any technical fault on the aircraft that could have been a factor and the meteorological conditions were within the limitations set for the aircraft. A more complete understanding of the accident might have been possible with additional flight data parameters such as engine performance, aircraft pitch, and power lever position.
Final Report:

Crash of a Cessna 208B Grand Caravan near Summer Beaver: 8 killed

Date & Time: Sep 11, 2003 at 2130 LT
Type of aircraft:
Operator:
Registration:
C-FKAB
Survivors:
No
Schedule:
Pickle Lake - Summer Beaver
MSN:
208B-0305
YOM:
1992
Flight number:
WSG125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2351
Captain / Total hours on type:
946.00
Aircraft flight hours:
16770
Circumstances:
The aircraft departed Pickle Lake to Summer Beaver, Ontario, on a charter flight with seven passengers and one crew member. The flight proceeded on a direct routing to destination at 3500 feet above sea level under night visual flight conditions. On approaching Summer Beaver, the aircraft joined the circuit on a downwind leg for a landing on Runway 17. When the aircraft did not land, personnel at Summer Beaver contacted the Pickle Lake flight dispatch to inquire about the flight. The aircraft was declared missing following an unsuccessful radio search by the Pickle Lake flight dispatch staff. Search and rescue personnel found the wreckage in a wooded area three nautical miles northwest of Summer Beaver. The aircraft had been nearly consumed by a post-crash fire. All eight people on board had been fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
The aircraft departed controlled flight and struck terrain for undetermined reasons.
Findings as to Risk:
The company's flight-following procedures for flights operating in remote areas were impractical and were not consistently applied; this could compromise timely search and rescue operations following an accident.
Other Findings:
The aircraft did not carry flight recorders. Lack of information about the cause of this accident affects TSB's ability to identify related safety deficiencies and to issue safety communications intended to prevent accidents that could occur under similar circumstances.
Final Report: