Crash of a Yakovlev Yak-40 in Dnipropetrovsk

Date & Time: Apr 28, 2003
Type of aircraft:
Operator:
Registration:
UR-87918
Survivors:
Yes
MSN:
9 73 08 55
YOM:
1977
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On flare, the aircraft was unstable and rolled from right to left. When landing firmly on runway 09/27, the aircraft was not properly aligned and ran off runway to the right at a speed of 115 km/h. It eventually collided with a dike located 100 metres further. All 17 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Beechcraft 99A Airliner in Prince Albert

Date & Time: Apr 23, 2003 at 1802 LT
Type of aircraft:
Operator:
Registration:
C-FDYF
Survivors:
Yes
Schedule:
Saskatoon – Prince Albert
MSN:
U-110
YOM:
1969
Flight number:
TW602
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was on a scheduled flight from Saskatoon, Saskatchewan, to Prince Albert, Saskatchewan, with two pilots and four passengers on board. The aircraft was approximately 4000 feet above sea level when the crew selected the flaps for the approach to Prince Albert. A bang was heard from the rear of the fuselage. The aircraft commenced an uncommanded pitch-up to a near-vertical attitude, then stalled, nosed over, and began a spin to the left. The crew countered the spin but the aircraft continued to descend in a near-vertical dive. Through the application of full-up elevator and the manipulation of power settings, the pilots were able to bring the aircraft to a near-horizontal attitude. The crew extended the landing gear and issued a Mayday call, indicating that they were conducting a forced landing. The aircraft struck a knoll, tearing away the belly cargo pod and the landing gear. The aircraft bounced into the air and travelled approximately 180 metres, then contacted a barbed-wire fence and slid to a stop approximately 600 metres from the initial impact point. The crew and passengers suffered serious but non-life-threatening injuries. All of the occupants exited through the main cabin door at the rear of the aircraft. The accident occurred during daylight hours at 1802 central standard time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. During flight, the horizontal stabilizer trim actuator worked free of the mounting structure, and as a result, the flight crew lost pitch control of the aircraft.
2. During replacement of the horizontal stabilizer trim actuator, the upper attachment bolts were inserted through the airframe structure but did not pass through the upper mounting lugs of the
trim actuator.
3. The improperly installed bolts trapped the actuator mounting lug assemblies, suspending the weight of the actuator and giving the false impression that the bolts had been correctly installed.
4. Dual inspections, ground testing, and flight testing did not reveal the faulty attachment.
Findings as to Risk:
1. The nature of the installation presents a risk that qualified persons may inadvertently install Beech 99 and Beech 100 horizontal stabilizer trim actuators incorrectly. There are no published warnings to advise installers that there is a potential to install the actuator incorrectly.
Final Report:

Crash of a Yakovlev Yak-40 in Urganch

Date & Time: Apr 9, 2003
Type of aircraft:
Operator:
Registration:
UK-87367
Flight Phase:
Survivors:
Yes
MSN:
9341731
YOM:
1973
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During takeoff roll on runway 13/31, the crew noticed a loss of power on the left engine and decided to abort. The aircraft could not be stopped within the remaining distance and overran. It lost its right main gear and came to rest few dozen metres further. All occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 300 in Mulia: 4 killed

Date & Time: Mar 27, 2003 at 1230 LT
Operator:
Registration:
PK-WAY
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Mulia – Wamena
MSN:
261
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Shortly after takeoff from Mulia Airport, while climbing to an altitude of 7,000 feet, the twin engine aircraft struck the slope of a mountain and crashed. Both pilots and two passengers were killed while 12 other occupants were injured.

Crash of a Boeing 737-4B6 in Oujda

Date & Time: Mar 26, 2003
Type of aircraft:
Operator:
Registration:
CN-RNF
Survivors:
Yes
MSN:
27678
YOM:
1995
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
53
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During a night approach, the aircraft landed 20 metres to the right of runway 06 in a slight right bank. It continued to roll for several hundred metres before coming back onto the paved surface. Doing so, the nose gear collapsed and the aircraft came to rest. All 60 occupants escaped uninjured while the aircraft was damaged beyond repair. The visibility was reported to be 1,600 metres at the time of the accident.

Crash of an Airbus A321-131 in Tainan

Date & Time: Mar 22, 2003 at 2235 LT
Type of aircraft:
Operator:
Registration:
B-22603
Survivors:
Yes
Schedule:
Taipei - Tainan
MSN:
602
YOM:
1996
Flight number:
GE543
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
169
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
13516
Aircraft flight cycles:
18580
Circumstances:
After landing on runway 36R at Tainan Airport, while decelerating, the aircraft struck construction vehicles parked beside the runway. The crew was able to stop the aircraft on the main runway and all 175 occupants evacuated safely. Two workers on the ground were injured. The aircraft was damaged beyond repair.
Probable cause:
Inadequate planning and implementation in airport construction safety procedures by both the CAA and the military authority, inadequacy in landing approval when exceeding the curfew hour, insufficient cooperation and coordination between the CAA and the military base authorities prior to construction work, lack of awareness to a lit runway when entering an active runway without acknowledging the tower controllers.

Ground accident of an ATR42-300 in Rome

Date & Time: Mar 6, 2003 at 2050 LT
Type of aircraft:
Operator:
Registration:
I-ATRF
Flight Phase:
Survivors:
Yes
Schedule:
Rome - Rimini
MSN:
034
YOM:
1986
Flight number:
MTC403
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7685
Captain / Total hours on type:
1159.00
Copilot / Total flying hours:
740
Copilot / Total hours on type:
232
Aircraft flight hours:
27472
Aircraft flight cycles:
28492
Circumstances:
Following a normal taxi procedure at Rome-Fiumicino Airport, the crew was at the holding point of runway 25, ready for departure. On board were 42 passengers and a crew of three. Both engines were turning at 70% torque. When the crew released the brakes, the swinging lever of the left main gear failed. The aircraft sank on its belly and stopped. All 45 occupants evacuated safely and there were no injuries. The aircraft was damaged beyond repair.
Probable cause:
Failure of the swinging lever of the left main gear due to the presence of fatigue cracks.
Final Report:

Crash of a Boeing 737-2T4 in Tamanrasset: 102 killed

Date & Time: Mar 6, 2003 at 1515 LT
Type of aircraft:
Operator:
Registration:
7T-VEZ
Flight Phase:
Survivors:
Yes
Schedule:
Tamanrasset - Ghardaia - Algiers
MSN:
22700
YOM:
1983
Flight number:
AH6289
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
97
Pax fatalities:
Other fatalities:
Total fatalities:
102
Captain / Total flying hours:
10760
Captain / Total hours on type:
1087.00
Copilot / Total flying hours:
5219
Copilot / Total hours on type:
1292
Aircraft flight hours:
41472
Aircraft flight cycles:
27184
Circumstances:
The aircraft was taking off from Tamanrasset to undertake, with a three-hour delay, scheduled flight DAH 6289 to Ghardaïa and Algiers. Six crew members (two flight crew and four cabin crew) and 97 passengers were on board. The co-pilot was pilot flying. No technical exemptions or deferred maintenance items applied to the airplane; on departure from Algiers it had been subject to routine maintenance for a minor technical problem, a hydraulic pump having been changed in the circuit B landing gear bay. The speeds decided on by the crew were V1 = 144 kt, VR = 146 kt, V2 = 150 kt. The EPR displayed was 2.18, that is to say nominal maximum thrust on take-off. At 14 h 01 min 37 s, the crew requested start-up clearance. At 14 h 08 min 36 s, the tower cleared the airplane to taxi, enter and taxi up runway 02. The wind was 330 at 12 kt. At 14 h 12 min 30 s, the co-pilot called out “we’re ready”. At 14 h 12 min 31 s, the tower cleared flight 6289 to line up and take off. At 14 h 13 min 36 s, flight DAH 6289 announced take-off. About five seconds after airplane rotation, at the moment when gear retraction was requested, a sharp thumping noise was recorded on the CVR. The airplane’s heading veered to the left, followed by a track correction. The Captain announced that he was taking over the controls. A short time later, the co-pilot told the control tower “we have a small problem”. The airplane continued to climb and reached a recorded height of about 400 ft. The speed dropped progressively from 160 kt during airplane lift-off to stall speed at the end of the recording. In fact, about ten seconds before, the noise of the stick shaker is heard on the CVR (which usually indicates that the airplane is 7% from its stall speed). The “Don’t Sink” aural warning, which normally indicates a loss of altitude during take-off when the airplane is below nine hundred feet, appeared about six seconds before the end of the recording. The airplane, with landing gear extended, struck the ground on its right side. A severe fire broke out immediately. The airplane slid along, losing various parts, struck and knocked over the airport perimeter fence then crossed a road before coming to a halt in flames. The control tower immediately sounded the alert.
Probable cause:
Probable causes:
The accident was caused by the loss of an engine during a critical phase of flight, the non-retraction of the landing gear after the engine failure, and the Captain, the PNF, taking over control of the airplane before having clearly identified the problem.
The following factors probably contributed to the accident:
• the perfunctory flight preparation, which meant that the crew were not equipped to face the situation that occurred at a critical moment of the flight;
• the coincidence between the moment the failure occurred and the request to retract the landing gear;
• the speed of the event that left the crew little time to recover the situation;
• maintaining an inappropriate rate of climb, taking into account the failure of one engine;
• the absence of any teamwork after the engine failure, which led to a failure to detect and correct parameters related to the conduct of the flight (speed, rate of climb, configuration, etc.);
• the takeoff weight being close to the maximum with a high aerodrome altitude and high temperature;
• the rocky environment around the aerodrome, unsuitable for an emergency landing.
Final Report:

Crash of a Boeing 737-2M9 in Rio Branco

Date & Time: Jan 26, 2003 at 1415 LT
Type of aircraft:
Operator:
Registration:
PP-SPJ
Survivors:
Yes
Schedule:
Belém – Manaus – Rio Branco
MSN:
21236
YOM:
1976
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
89
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7120
Captain / Total hours on type:
5271.00
Copilot / Total flying hours:
1348
Copilot / Total hours on type:
310
Aircraft flight hours:
54989
Circumstances:
Following an uneventful flight from Manaus, the crew started the descent to Rio Branco-Presidente Médici Airport runway 06 in marginal weather conditions with limited visibility due to fog. After passing the MDA at 1,150 feet, the crew continued the approach with an excessive rate of descent of 1,222 feet per minute. At a height of 57 feet, the aircraft struck trees located 360 metres short of runway 06 threshold. The engines lost power, the aircraft lost speed and height then struck the ground about 100 metres short of runway. Upon impact, the undercarriage were torn off and the aircraft slid on a distance of 600 metres before coming to rest. All 95 occupants escaped uninjured while the aircraft was destroyed.
Probable cause:
Poor approach configuration on part of the flying crew who continued the approach after passing the MDA at 1,150 feet while the aircraft was not stabilized and the crew did not establish a visual contact with the obstacles on short final. The following contributing factors were identified:
- Following the first impact with trees, branches and pieces of wood entered the engines, causing a loss of power followed by a loss of speed and altitude,
- Complacency on the part of the crew,
- Pressure and stress,
- Visual perception issues,
- Violation of the standard operating procedures,
- Loss of situational awareness,
- Lack of crew resources management,
- Poor approach and landing planning,
- Poor weather conditions,
- Relative low experience of the copilot.
Final Report:

Crash of an Airbus A319 in New York

Date & Time: Jan 19, 2003 at 0715 LT
Type of aircraft:
Operator:
Registration:
N313NB
Flight Phase:
Survivors:
Yes
MSN:
1186
YOM:
2000
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two maintenance technicians where on board Northwest Airlines' Airbus A319 N313NB which was taxied from a maintenance area to Gate 10. When they arrived in the vicinity of gate 10, the mechanic who was steering the plane, activated the parking brake and waited for ground personnel and a jetway operator to arrive. After the ground personnel arrived he released the parking brake. The airplane did not move and he advanced the throttles out of their idle detents "a couple of inches, about halfway." The airplane began to move at a "fairly decent speed," and he realized the throttles were still out of the idle detent position. He pulled the throttle back and applied brakes; however, the airplane did not slow and continued until it struck the concrete support column of the jetway, and the left wing contacted the right side of a Boeing 757-251 (N550NW, parked at gate 9). The nose gear sheared off the Airbus, and the right side of the Boeing sustained a 6-foot long, 2-foot wide gash, just aft of the R1 door. The mechanic estimated that the airplane was about halfway down the parking line when he pulled back the throttles. Initial review of the flight data recorder for the time period surrounding the accident revealed that about 10 seconds after the parking brake was released, the thrust lever angles for both engines were increased to about 17 degrees for about 8 seconds, before they were returned to the idle position. During that time, the engines N1 and N2 speeds increased to about 71, and 85 percent, respectively.
Probable cause:
Maintenance personnel failure to maintain aircraft control as a result of excessive throttle input.