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

Date & Time: Aug 29, 2002 at 1856 LT
Type of aircraft:
Operator:
Registration:
RA-28932
Survivors:
No
Schedule:
Khabarovsk – Poliny Osipenko – Ayan
MSN:
1AJ008-19
YOM:
1990
Flight number:
VTK359
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
16
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:
Operator:
Registration:
N635AW
Survivors:
Yes
Schedule:
Houston - Phoenix
MSN:
092
YOM:
1990
Flight number:
AWE794
Crew on board:
5
Crew fatalities:
Pax on board:
154
Pax fatalities:
Other fatalities:
Total fatalities:
0
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:
Operator:
Registration:
RA-33501
Flight Phase:
Survivors:
Yes
MSN:
1G228-53
YOM:
1988
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
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
Operator:
Registration:
9N-AFR
Survivors:
No
Site:
Schedule:
Jomsom - Pokhara
MSN:
762
YOM:
1981
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
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:
Operator:
Registration:
PT-WGE
Flight Phase:
Survivors:
Yes
Schedule:
Humaitá – Manaus
MSN:
120-004
YOM:
1986
Flight number:
RLE4847
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
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:
Operator:
Registration:
9Q-CHA
Survivors:
Yes
Schedule:
Kinshasa - Brussels
MSN:
193C-1227
YOM:
1982
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
188
Pax fatalities:
Other fatalities:
Total fatalities:
0
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
Operator:
Registration:
9N-AGF
Survivors:
No
Site:
Schedule:
Jumla - Surkhet
MSN:
828
YOM:
1985
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed Jumla at 1404LT on a 25-minutes flight to Surkhet with two passengers and two pilots on board. While descending to Surkhet, the crew encountered poor visibility due to bad weather conditions. At an altitude of 6,500 feet, the aircraft struck the slope of a mountain and crashed 10 km from Surkhet. All four occupants were killed.
Probable cause:
Controlled flight into terrain after the crew descended below the minimum prescribed altitude in poor visibility.

Crash of a Britten-Norman BN-2a-6 Islander in Long Bawan: 9 killed

Date & Time: Jul 16, 2002
Type of aircraft:
Operator:
Registration:
PK-TAR
Survivors:
Yes
Schedule:
Tarakan – Long Bawan
MSN:
860
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
On final approach to Long Bawan Airport, at an altitude of 5,400 feet, the twin engine aircraft collided with trees and crashed in a wooded area located 8 km short of runway. The wreckage was found six days later and a passenger was evacuated alive while all nine other occupants were killed. For unknown reasons, the crew was completing the approach at an insufficient altitude.

Crash of a Saab 2000 in Werneuchen

Date & Time: Jul 10, 2002 at 2042 LT
Type of aircraft:
Operator:
Registration:
HB-IZY
Survivors:
Yes
Schedule:
Basel - Hamburg
MSN:
2000-047
YOM:
1997
Flight number:
LX850
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2600
Captain / Total hours on type:
2350.00
Copilot / Total flying hours:
1940
Copilot / Total hours on type:
1732
Aircraft flight hours:
12303
Aircraft flight cycles:
12069
Circumstances:
The twin engine aircraft departed Basel-EuroAirport on a flight to Hamburg with 16 passengers and four crew members on board. While descending to Hamburg, weather conditions deteriorated rapidly and due to thunderstorm activity with heavy rain falls and strong winds, the crew was unable to land at Hamburg-Fuhlsbüttel Airport and decided to divert to Bremen. Unfortunately, weather conditions were so poor that the crew was unable to land in Bremen, Hanover and Berlin-Tegel Airport as well. Due to low fuel reserve, the crew informed ATC about his situation and was vectored to Werneuchen, a former Soviet military airfield some 60 km northeast of Berlin. Werneuchen's unlighted runway has a length of 2,400 metres but has no approach aids. ATC warned the crew about the presence of a one metre high earth embankment across the runway, some 900 metres past the runway threshold which was there to avoid illegal car races. The remaining runway was still used for general aviation. Due to limited visibility caused by poor weather conditions, the crew was unable to see and avoid the earth embankment. After landing, the aircraft impacted the earth embankment, causing the undercarriage to be torn off. The aircraft slid on its belly for few dozen metres before coming to rest in the middle of the runway. All 20 occupants evacuated the cabin, among them two were slightly injured. The aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Dimension and intensity of the storm front and dynamics of the weather conditions,
- Inadequate use of resources in decision-making during the flight (proactive),
- Loss of alternative landing facilities at increasing time pressure (reactive),
- Landing of the aircraft outside the operating area of an aerodrome,
- Collision with the embankment due to the non-detection of an obstacle.
Systemic causes:
- Inadequate information on weather conditions and development before and during the flight,
- Inadequate information on the Werneuchen Special Airfield due to an ambiguous map display as well as misleading or lack of communication,
- Inadequate labeling/marking of the operational and non-operational areas of the airport.
Final Report:

Crash of a Britten-Norman BN-2B-26 Islander in Anholt

Date & Time: Jun 14, 2002 at 1945 LT
Type of aircraft:
Operator:
Registration:
OY-CFV
Flight Phase:
Survivors:
Yes
Schedule:
Anholt - Roskilde
MSN:
2174
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
759
Captain / Total hours on type:
131.00
Circumstances:
Before takeoff from Anholt Airfield, the pilot failed to position the elevator trim in the neutral position. During the takeoff roll, because the elevator trim remained in a 1,5 unit nose down position, the pilot was unable to rotate so he rejected takeoff. A second attempt to takeoff was abandoned few minutes later for the same reason. During a third attempt to take off, with a tailwind component near the limit, the aircraft lifted off when the stall warning alarm sounded. The pilot lowered the nose to gain speed when the right main gear impacted a sand dune. Out of control, the aircraft crash landed and came to rest. All eight occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- The elevator trim was not correctly configured to neutral prior to takeoff,
- The pilot failed to abort the takeoff after the first attempted rotation, when the aircraft did not respond normally to elevator command,
- The takeoff was initiated with a tailwind component that was close to the maximum permissible value.
Final Report: