Crash of a Britten-Norman BN-2A-21 Islander in Tarakan: 7 killed

Date & Time: Nov 7, 2002 at 1027 LT
Type of aircraft:
Operator:
Registration:
PK-VIZ
Survivors:
Yes
Schedule:
Tarakan - Long Bawan
MSN:
697
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Shortly after takeoff from Tarakan Airport, en route to Long Bawan, the pilot encountered engine problems and decided to return. On approach, the aircraft stalled and crashed on the top of a hill located 1,500 metres short of runway. Three passengers were injured while seven other occupants were killed.
Probable cause:
Engine failure for unknown reasons.

Crash of a Fokker 50 in Luxembourg: 20 killed

Date & Time: Nov 6, 2002 at 1006 LT
Type of aircraft:
Operator:
Registration:
LX-LGB
Survivors:
Yes
Schedule:
Berlin – Luxembourg
MSN:
20221
YOM:
1991
Flight number:
LG9642
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
20
Captain / Total flying hours:
4242
Captain / Total hours on type:
2864.00
Copilot / Total flying hours:
1156
Copilot / Total hours on type:
443
Aircraft flight hours:
21836
Aircraft flight cycles:
24068
Circumstances:
The Fokker 27 Mk050 registered LX-LGB and operated by Luxair left Berlin on 6 November 2002 at 07h 40min on flight LG 9642/LH 2420 with destination Luxembourg. Cruising level was at FL180. At 08h 50min, Frankfurt Control asked the crew to stop descent at FL 90, direct to Diekirch and at 08h 52min the flight was transferred to Luxembourg Approach. They were instructed to enter the Diekirch hold at FL90, to expect later on vectors for an ILS 24 and were given the latest RVR readings. At 08h 59min, well before reaching the Diekirch hold, the aircraft was recleared to 3000ft QNH and to turn left heading one three zero. At this time the aircraft flew in the clear sky above a fog layer. RVR was two hundred seventy five meters. The crew evoked a go-around if the RVR was not three hundred meters whilst passing ELU (it’s minima for a category II approach). At 09h04 min 36s, the aircraft passed overhead ELU maintaining 3000ft QNH. At 09h04 min 57s, the ATC controller transmitted an RVR of three hundred meters. Power was further reduced, flaps 10 were selected and the landing gear was lowered. Immediately after the landing gear was lowered, the pitch angle of the two propellers simultaneously reached a value that is lower than the minimum values for flight. This propeller pitch setting involves a rapid decrease of speed and altitude. During the following seconds, the left engine stopped and then the right engine stopped. The flight data recorders, no longer powered ceased functioning. At 09h05 min 42s (radar time base), the aircraft disappeared from the radar screen. It was immediately found in a field seven hundred meters to the north of runway centreline 24 and three point five kilometres to the east of the threshold. Six people were critically injured while 16 others were killed. Within the following hours, four of the survivors died from their injuries. The only two survivors were a passenger, a French citizen, and the captain.
Probable cause:
The initial cause of the accident is the crew’s acceptance of the approach clearance although they were not prepared to it, namely the absence of preparation of a go-around. It led the crew to perform a series of improvised actions that ended in the prohibited override of the primary stop on the power levers and leading to an irreversible loss of control.
Contributory factors can be listed as follows:
1. A lack of preparation for the landing, initiated by unnecessary occupations resulting from an obtained RVR value, which was below their company approved minima, created a disorganisation in the cockpit, leading to uncoordinated actions by each crewmember.
2. Some procedures as laid down in the operations manual were not followed at some stage of the approach. All this did not directly cause the accident, but created an environment whereby individual actions were initiated to make a landing possible.
3. Routine and the will to arrive at destination may have put the crew in a psychological state of mind, which could have been the origin of the deviations from standard procedures as noticed.
4. The priority in the approach sequence given to the crew by ATC, which facilitated the traffic handling for the controller who was not aware of the operational consequences.
5. The low reliability of the installed secondary stop safety device that was favoured by the non-application of service bulletin ABSC SB Fo50-32-4. Also the mode of distribution of the safety information (Fokker Aircraft B.V. – Service letter 137) to the operator as well as the operator’s internal distribution to the crews, that did not guarantee that the crews were aware of the potential loss of secondary stop on propeller pitch control.
6. Latent shortcomings in the Authority and the organisational structure of the operator, in combination with poor application of SOPs by the crew.
Final Report:

Crash of a PZL-Mielec AN-2TP in Sovetskiy

Date & Time: Nov 6, 2002
Type of aircraft:
Registration:
RA-70140
Flight Phase:
Survivors:
Yes
Schedule:
Sovetsky – Svetly
MSN:
1G137-14
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Some passengers were late and the crew apparently hurried the departure to avoid a night flight to Svetly. Doing so, the crew failed to prepare the flight properly and did not proceed to any engine runup prior to taxi and takeoff. During the taxi manoeuvre, the aircraft suffered controllability problems so the crew selected the propeller lever to the fine pitch position. The takeoff procedure was initiated without checks and the crew forgot that the propeller lever was not in the takeoff position. After liftoff, at a height of 3-5 metres, the aircraft encountered difficulties to gain height and speed. The crew attempted an emergency landing when the aircraft collided with trees and crashed in a wooded area. All 15 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Poor flight preparation on part of the crew who failed to follow the pre taxi and the pre takeoff checklist. The aircraft was unable to gain sufficient speed and height after takeoff because the propeller lever was not in the correct position.

Crash of a Fokker F27 Friendship 500RF in Sligo

Date & Time: Nov 2, 2002 at 1702 LT
Type of aircraft:
Operator:
Registration:
G-ECAT
Survivors:
Yes
Schedule:
Dublin - Sligo
MSN:
10672
YOM:
1984
Flight number:
ECY406
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
36
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5710
Captain / Total hours on type:
1176.00
Copilot / Total flying hours:
20117
Copilot / Total hours on type:
787
Aircraft flight hours:
27452
Circumstances:
The aircraft, a Fokker F27-500, registration G-ECAT, departed Dublin at 16.05 hrs (local time) for the 4th leg of a Public Service Obligation (PSO) rotation between Sligo in the North West of Ireland and Dublin. The aircraft had earlier departed Sligo for Dublin at 10.00 hrs, returned to Sligo at 12.30 hrs and departed once again for Dublin on time at 14.30 hrs. The Operator held the PSO contract to provide regular air service between Sligo and Dublin and also between Donegal (EIDL) and Dublin. The accident flight was delayed for 10 minutes as the flight to Donegal had been cancelled due to strong crosswinds at Donegal and arrangements had been made to fly these passengers to Sligo and bus them onwards to Donegal. The en-route segment of this flight was uneventful. At 16.22 hrs G-ECAT called Sligo on Tower frequency 122.10 Mhz and requested the latest weather conditions for Sligo. The Tower Controller transmitted the 16.30 hrs actual for Sligo, as presented at Section 1.7 Meteorological Information. At 16.50 hrs, the aircraft was handed over from Shannon Control to Sligo Tower, descending to 3,500 ft to the SLG beacon for NDB/DME approach to RWY 11. Sligo Tower then transmitted the Donegal weather, as presented at Section 1.7 Meteorological Information. At 16.53 hrs, the aircraft called overhead the SLG beacon and was cleared by Sligo Tower for the approach. At 17.00 hrs, G-ECAT reported at the Final Approach Fix (FAF) and was cleared to land by the Tower, giving a wind of 120 degrees 15 kt, gusting 29 kt. At 17.01 hrs, just prior to landing, G-ECAT was given a wind check of 120 degrees 15 kt, gusting 31 kt. At 17.02 hrs the aircraft made an initial touchdown at approximately the mid-point of the runway and appeared to a number of witnesses not to immediately decelerate. The aircraft continued down the runway until it departed the paved surface at the right hand side of the threshold of RWY 29. On seeing the aircraft pass the apron taxiway/runway intersection at an abnormally high speed, the Tower Controller immediately sounded the crash alarm. The aircraft continued on through a prepared run-off area at the end of the runway, for a further 50 metres, before coming to rest (17.02:30 hrs) with the main wheels embedded in boulders that formed part of an embankment leading down to the sea. The main wheels were approximately one metre short of where the boulders fall away into the sea. The nose wheel, cockpit and forward section of the fuselage cleared the top of the boulder embankment and the aircraft tilted approximately 15-20 degrees nose down onto the outgoing tide. Full tide was due at 04.00 hrs the following day at a depth of 3.9 meters. The Tower Controller immediately contacted the Shannon ATC Station Manager advising of the runway excursion and called 999 to request Gardaí, Fire Brigade and Ambulance assistance.
Probable cause:
The probable cause of this accident was a fast, low approach, leading to the aircraft landing late, beyond the normal touch down point, thereby making it impossible to stop the aircraft on the remaining runway available.
Contributory cause:
1. The lack of an adequate overrun area before an aircraft, failing to stop on the runway, enters the sea.
2. The lack of experience of the Operator in scheduled air operations.
3. The changing operational management structure and uncertain nature of the direction of the company with regard to aircraft type and network development.
Final Report:

Crash of a Douglas DC-9-32 in Monterrey

Date & Time: Oct 31, 2002 at 2215 LT
Type of aircraft:
Operator:
Registration:
XA-AMF
Survivors:
Yes
Schedule:
Guadalajara – Monterrey
MSN:
48130
YOM:
1980
Flight number:
AM254
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach and landing at Monterrey-General Mariano Escobido Airport were completed by night and poor weather conditions with limited visibility due to heavy rain falls and mist. At the time of the accident, runway 29 threshold was displaced by 900 metres, reducing the landing distance available from 3,000 metres to 2,100 metres due to construction works. Following a wrong approach configuration, the aircraft landed too far down a wet runway and was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest 60 metres further with the right partially torn off. 11 passengers were injured while 79 other occupants were unhurt.

Ground accident of an Avro RJ85 in Memphis

Date & Time: Oct 15, 2002 at 1224 LT
Type of aircraft:
Operator:
Registration:
N528XJ
Flight Phase:
Survivors:
Yes
MSN:
E2353
YOM:
1999
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following maintenance at Memphis Airport facilities, a crew of two technicians was ferrying the aircraft from the hangar to the main terminal. While approaching the C2 gate, the aircraft could not be stopped in time and collided with the jet bridge. Both occupants escaped with minor injuries while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-7-102 in Manila

Date & Time: Sep 5, 2002 at 1820 LT
Operator:
Registration:
RP-C2788
Survivors:
Yes
Schedule:
Manila - Caticlan
MSN:
89
YOM:
1982
Flight number:
RIT897
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
45
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft departed Manila-Ninoy Aquino Airport at 1536LT on a schedule flight to Caticlan with 45 passengers and four crew members. On approach to Caticlan, the crew encountered technical problems with the hydraulic system and could not lowered the right main gear that remained stuck in its wheel well. The captain decided to return to Manila and followed a holding pattern to burn fuel. After touchdown on runway 24, the aircraft went out of control, veered off runway to the right and came to rest in a grassy area. All 49 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The hydraulic pump on engine n°3 and 4 failed, causing a loss of hydraulic pressure on the secondary hydraulic system that dropped almost to zero.

Crash of an Embraer EMB-120ER Brasília in Rio Branco: 23 killed

Date & Time: Aug 30, 2002 at 1800 LT
Type of aircraft:
Operator:
Registration:
PT-WRQ
Survivors:
Yes
Schedule:
Cruzeiro do Sul – Tarauacá – Rio Branco
MSN:
120-043
YOM:
1987
Flight number:
RLE4823
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
9315
Captain / Total hours on type:
4560.00
Copilot / Total flying hours:
4242
Copilot / Total hours on type:
3585
Circumstances:
Following an uneventful flight from Tarauacá, the crew started the descent to Rio Branco-Presidente Médici Airport in limited visibility due to the night and rain falls. On final, the aircraft descended below the MDA and, at a speed of 130 knots, struck the ground and crashed in a field located 4 km short of runway 06. The aircraft was totally destroyed. Eight passengers were rescued while 23 other occupants were killed, among them the Brazilian politician Ildefonço Cardeiro.
Probable cause:
The exact cause of the accident could not be determined with certainty. However, it is believed that the accident was the consequence of a controlled flight into terrain after the crew continued the approach in poor weather conditions and descended below the MDA until the aircraft, in a flaps and gear down configuration, impacted ground. The following contributing factors were identified:
- A difference of 70 feet in the settings was noted between both pilot's altimeters,
- Poor crew coordination,
- Complacency on part of the flying crew caused several deviations from procedures during the approach,
- Lack of crew resources management,
- The crew failed to check the altitude during the final stage of the approach,
- Poor weather conditions.
Final Report:

Crash of a Fokker 100 in Campinas

Date & Time: Aug 30, 2002 at 1205 LT
Type of aircraft:
Operator:
Registration:
PT-MRL
Survivors:
Yes
Schedule:
Salvador – São Paulo
MSN:
11441
YOM:
1993
Flight number:
JJ3499
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
3600.00
Copilot / Total flying hours:
4300
Copilot / Total hours on type:
145
Circumstances:
The aircraft departed Salvador-Deputado Luís Eduardo Magalhães Airport at 0846LT on a schedule service JJ3499 to São Paulo-Guarulhos Airport, carrying 33 passengers and five crew members. En route, while cruising at an altitude of 35,000 feet, the crew encountered technical problems with the primary hydraulic system. He contacted ATC and was cleared to divert to Campinas-Viracopos Airport for an emergency landing. On approach, the crew was unable to lower the undercarriage that remained blocked in their wheel well. The crew elected to lower the gear manually and several troubleshootings were unsuccessful. The decision was taken to complete a belly landing on runway 33. After touchdown, the aircraft slid for few dozen metres and eventually came to rest. All 38 occupants evacuated safely and the aircraft was damaged beyond repair. It was later transferred to the TAM Museum.
Probable cause:
A loss of hydraulic fluids occurred on a hose separating a fitting from a pump on the right engine, causing the malfunction of the primary hydraulic system and resulting in the degradation of the mechanical system of the landing gear control command.
Final Report:

Crash of a Fokker 100 in Birigui

Date & Time: Aug 30, 2002 at 1045 LT
Type of aircraft:
Operator:
Registration:
PT-MQH
Flight Phase:
Survivors:
Yes
Schedule:
São Paulo – Campo Grande
MSN:
11512
YOM:
1994
Flight number:
JJ3804
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7300
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
4000
Copilot / Total hours on type:
1200
Circumstances:
The aircraft departed São Paulo-Guarulhos Airport on a schedule flight (JJ3804) to Campo Grande, carrying 24 passengers and five crew members. Less than an hour into the flight, while cruising at FL350, the crew encountered technical problems with the fuel system, declared an emergency and was cleared to divert to Araçatuba Airport. On approach, at an altitude of 1,639 feet, both engines failed. The captain realized he could not reach Araçatuba Airport so he attempted an emergency landing in a prairie located 29,5 km from the airport. Upon landing, the aircraft lost its undercarriage, slid on the ground, killed a cow and came to rest. All 29 occupants evacuated, among them four were slightly injured. The aircraft was damaged beyond repair.
Probable cause:
While cruising at FL350, the crew noticed a technical problem with the 'fuel filter' and a 'fuel pressure low' was observed on the right engine. Following a check of the flight manual, the crew reported a fuel transfer issue and attempted an emergency diversion. It was determined that both engine stopped following the rupture of a fuel line connected to the right engine, causing a major fuel leak. The disconnection of the fuel line was the consequence of the rupture of a aluminium ring.
Final Report: