Scheduled Revenue Flight

Flight Type:

Survivors:

Site:

Schedule:

Salvador – São Paulo

MSN:

11441

YOM:

1993

Flight number:

JJ3499

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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:

Fokker 100

Operator:

Registration:

PT-MQH

Flight Phase:

Flight

Flight Type:

Survivors:

Site:

Plain, Valley

Schedule:

São Paulo – Campo Grande

MSN:

11512

YOM:

1994

Flight number:

JJ3804

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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:

Crash of a PZL-Mielec AN-28 in Ayan: 16 killed

Date & Time: Aug 29, 2002 at 1856 LT

Type of aircraft:

PZL-Mielec AN-28

Operator:

Registration:

RA-28932

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Khabarovsk – Poliny Osipenko – Ayan

MSN:

1AJ008-19

YOM:

1990

Flight number:

VTK359

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The aircraft was completing a flight from Khabarovsk to Ayan with an intermediate stop in Poliny Osipenko, carrying 14 passengers and two pilots. Before takeoff from Poliny Osipenko, the crew was informed about weather conditions at Ayan with a visibility up to 5 km. But while approaching the destination, the crew realized that weather conditions deteriorated rapidly with poor visibility due to low stratus and fog. The crew initiated the descent prematurely and after the first turn, the aircraft was already at an insufficient altitude of 800 metres instead of the required 950 metres. At a speed of 283 km/h, the aircraft descended too low and deviated to the right of the approach pattern by 2,3 km when it entered an area of low stratus at an altitude of 320 metres. In a visibility reduced to 50 metres, the crew lost visual contact with the ground but the captain decided to continue the approach. At a height of 188 metres, the aircraft impacted a hill (226 metres high) located near the shore of the Okhotsk Sea. The aircraft was destroyed by impact forces and a post crash fire and all 16 occupants were killed.

Probable cause:

Controlled flight into terrain following after the crew initiated the descent prematurely and failed to follow the published procedures. The following contributing factors were identified:
- The approach was continued in below minima weather conditions,
- Failure of the crew to get a current weather report for Ayan and the alternate airport,
- The decision of the captain to continue the approach at decision height without any visual contact with the ground and his failure to initiate a go-around procedure,
- Failure of the crew to follow the established approach pattern,
- Failure of the meteorological observer to issue updated weather bulletin,
- Absence of radio navigational aids at Ayan Airport,
- Lack of interaction between ATC and meteorological observer at Ayan Airport when aircraft are approaching in adverse weather conditions.

Crash of an Airbus A320-231 in Phoenix

Date & Time: Aug 28, 2002 at 1843 LT

Type of aircraft:

Airbus A320

Operator:

Registration:

N635AW

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Houston - Phoenix

MSN:

092

YOM:

1990

Flight number:

AWE794

Location:

Phoenix-Sky Harbor

Arizona

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

154

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

19500

Captain / Total hours on type:

7000.00

Copilot / Total flying hours:

11000

Copilot / Total hours on type:

800

Aircraft flight hours:

40084

Aircraft flight cycles:

18530

Circumstances:

After an asymmetrical deployment of the thrust reversers during landing rollout deceleration, the captain failed to maintain directional control of the airplane and it veered off the runway, collapsing the nose gear and damaging the forward fuselage. Several days before the flight the #1 thrust reverser had been rendered inoperative and mechanically locked in the stowed position by maintenance personnel. In accordance with approved minimum equipment list (MEL) procedures, the airplane was allowed to continue in service with a conspicuous placard noting the inoperative status of the #1 reverser placed next to the engine's thrust lever. When this crew picked up the airplane at the departure airport, the inbound crew briefed the captain on the status of the #1 thrust reverser. The captain was the flying pilot for this leg of the flight and the airplane touched down on the centerline of the runway about 1,200 feet beyond its threshold. The captain moved both thrust levers into the reverse position and the airplane began yawing right. In an effort at maintaining directional control, the captain then moved the #1 thrust lever out of reverse and inadvertently moved it to the Take-Off/Go-Around (TOGA) position, while leaving the #2 thrust lever in the full reverse position. The thrust asymmetry created by the left engine at TOGA power with the right engine in full reverse greatly increased the right yaw forces, and they were not adequately compensated for by the crew's application of rudder and brake inputs. Upon veering off the side of the runway onto the dirt infield, the nose gear strut collapsed. The airplane slid to a stop in a nose down pitch attitude, about 7,650 feet from the threshold. There was no fire. Company procedures required the flying pilot (the captain) to give an approach and landing briefing to the non flying pilot (first officer). The captain did not brief the first officer regarding the thrust reverser's MEL'd status, nor was he specifically required to do so by the company operations manual. Also, the first officer did not remind the captain of its status, nor was there a specific requirement to do so. The operations manual did state that the approach briefing should include, among other things, "the landing flap setting...target airspeed...autobrake level (if desired) consistent with runway length, desired stopping distance, and any special problems." The airline's crew resource management procedures tasked the non flying pilot to be supportive of the flying pilot and backup his performance if pertinent items were omitted from the approach briefing. The maintenance, repair history, and functionality of various components associated with the airplane's directional control systems were evaluated, including the brake system, the nose landing gear strut and wheels, the brakes, the antiskid system, the thrust levers and reversers, and the throttle control unit. No discrepancies were found regarding these components.

Probable cause:

The captain's failure to maintain directional control and his inadvertent application of asymmetrical engine thrust while attempting to move the #1 thrust lever out of reverse. A factor in the accident was the crew's inadequate coordination and crew resource management.

Final Report:

Crash of a PZL-Mielec AN-2R in Kashtak

Date & Time: Aug 26, 2002

Type of aircraft:

PZL-Mielec AN-2

Operator:

Dauriya

Registration:

RA-33501

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

De Havilland DHC-6 Twin Otter

MSN:

1G228-53

YOM:

1988

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The crew was forced to make an emergency landing at Kashtak Airfield near Chita. There were no casualties but the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 300 in Pokhara: 18 killed

Date & Time: Aug 22, 2002 at 1005 LT

Type of aircraft:

Operator:

Registration:

9N-AFR

Flight Phase:

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Jomsom - Pokhara

MSN:

762

YOM:

1981

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The twin engine aircraft departed Jomsom Airport at 0941LT for a 25-minutes flight to Pokhara, carrying three crew members and 15 passengers, 13 Germans, one American and one British. While descending to Pokhara Airport, the crew encountered poor weather conditions with low clouds. At an altitude of 4,600 feet, the aircraft struck the slope of a mountain located 6 km southwest of the airport, near the village of Kristi Nachnechaur. The aircraft was totally destroyed by impact forces and all 18 occupants were killed. There was no fire.

Probable cause:

Controlled flight into terrain after the crew descended too low in poor visibility without maintaining visual clearance with the ground.

Ground accident of an Embraer EMB-120RT Brasília in Manaus

Date & Time: Aug 13, 2002 at 1225 LT

Type of aircraft:

Embraer EMB-120 Brasília

Operator:

Registration:

PT-WGE

Flight Phase:

Taxiing

Flight Type:

Survivors:

Site:

Schedule:

Humaitá – Manaus

MSN:

120-004

YOM:

1986

Flight number:

RLE4847

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

13474

Captain / Total hours on type:

518.00

Copilot / Total flying hours:

4110

Copilot / Total hours on type:

3660

Aircraft flight hours:

26756

Circumstances:

Following an uneventful flight from Humaitá, the crew completed the landing at Manaus-Eduardo Gomes Airport. After taxi, the crew was approaching the apron when he feathered the propellers and applied the brakes as they wanted to stop the aircraft. There was no deceleration despite both crew applied brakes. The copilot suggested to use reverse thrust but this was not possible as the propellers were already feathered. Out of control, the aircraft struck a brick building, damaging the left engine, and the right landing gear fell into a drainage ditch, approximately one meter deep. All 25 occupants evacuated safely while the aircraft was damaged beyond repair.

Probable cause:

The following factors were identified:
- The crew did not have sufficient training to enable the desired assertiveness for the correct use of aircraft resources, which would probably have prevented the accident, since, instead of applying the emergency brake, they applied reverse with the feathered props, contrary to the procedure provided for in the Aircraft Manual.
- The maintenance services were not efficient, as they did not comply with the Aircraft Maintenance Manual in relation to the dimensional adjustment of the Hub Cap Drive Clips' drive clips, and the Service Bulletin incorporated stickers to the outer doors of the main landing gear, as a reminder to the mechanic to check the clearances.
- The copilot failed to apply the reverse pitch on the propellers as they were feathered, and at that moment the emergency brake should be commanded to brake the aircraft.
- The company failed to adequately check the execution of the actions provided for in the Aircraft Maintenance Manual regarding the 'Antiskid' system and to verify the application of all service bulletins issued by the manufacturer.

Final Report:

Crash of a Lockheed L-1011 TriStar 250 in Kinshasa

Date & Time: Aug 8, 2002

Type of aircraft:

Lockheed L-1011 TriStar

Operator:

Registration:

9Q-CHA

Flight Phase:

Flight Type:

Survivors:

Site:

Democratic Republic of Congo

Schedule:

Kinshasa - Brussels

MSN:

193C-1227

YOM:

1982

Location:

Kinshasa-N'Djili

Kinshasa City Province

Country:

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

188

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

71317

Aircraft flight cycles:

21669

Circumstances:

The aircraft departed Kinshasa-N'Djili Airport on a regular schedule flight to Brussels with 188 passengers and 12 crew members on board. While cruising at an altitude of 25,000 feet over Gabon, the crew contacted ATC and reported the failure of the engine n°3. He was cleared to return to Kinshasa for an emergency landing. Upon touchdown, all tyres burst and the aircraft skidded on the runway before coming to rest. All 200 occupants evacuated safely while the aircraft was damaged beyond repair.

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

Date & Time: Jul 17, 2002 at 1422 LT

Type of aircraft:

De Havilland DHC-6 Twin Otter

Operator:

Registration:

9N-AGF

Flight Phase:

Flight Type: