Crash of a Yakovlev Yak-40 in Osh

Date & Time: Oct 21, 2001
Type of aircraft:
Operator:
Registration:
EX-87470
Flight Phase:
Survivors:
Yes
Schedule:
Osh – Bishkek
MSN:
9441537
YOM:
1974
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Osh Airport, the captain decided to abort for unknown reasons. Unable to stop within the remaining distance, the aircraft verran and came to rest in a ravine. All 36 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of an Airbus A300B4-203 in Dubai

Date & Time: Oct 17, 2001 at 1409 LT
Type of aircraft:
Operator:
Registration:
AP-BCJ
Survivors:
Yes
Schedule:
Islamabad – Peshawar – Dubai
MSN:
268
YOM:
1983
Flight number:
PK231
Location:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
193
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Dubai Airport, the right main landing gear collapsed. The aircraft skidded for few dozen metres then veered off runway to the right and came to rest in a sandy area. All 205 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Cessna 208 Caravan I in Dillingham: 10 killed

Date & Time: Oct 10, 2001 at 0926 LT
Type of aircraft:
Operator:
Registration:
N9530F
Flight Phase:
Survivors:
No
Schedule:
Dillingham – King Salmon
MSN:
208-0088
YOM:
1986
Flight number:
KS350
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
3100
Captain / Total hours on type:
869.00
Aircraft flight hours:
10080
Circumstances:
The airplane was parked outside on the ramp the night before the accident and was subjected to rain, snow, and temperatures that dropped below 32 degrees F. Other pilots whose airplanes were also parked outside overnight stated that about 1/4 to 1/2 inch of snow/frost covered a layer of ice on their airplanes the morning of the accident. Because of these conditions, ramp personnel deiced the accident airplane with a heated mixture of glycol and water. The PenAir ramp supervisor who conducted the deicing stated that he believed the upper surface of the wing was clear of ice but that he did not physically touch the wing to check for the presence of ice. Investigators were unable to determine whether the accident pilot visually or physically checked the wing and tail surfaces for contamination after the accident airplane was deiced. However, the airplane's high-wing configuration would have hindered the pilot's ability to see residual clear ice on the surface of the wing after the deicing procedures. Company records indicate that the certificated commercial pilot completed his initial CE-208 flight training 2 months before the accident and had accumulated a total of 74 hours in this make and model of airplane. The airplane, with the pilot and nine passengers onboard, crashed shortly after takeoff from runway 01. A witness observed that the airplane's flight appeared to be normal until the airplane suddenly pitched up, rolled 90 degrees to the left, and yawed to the left. The airplane then descended nose-down until it disappeared from view. Data from the engine monitoring system revealed that the maximum altitude obtained during the accident flight was about 651 feet mean sea level. The airplane crashed in a level attitude. Investigators found no evidence of pre-impact failures in the structure, flight control systems, or instruments. Further, examination of the engine and propeller revealed no pre-impact failures and that the engine was running when the airplane hit the ground.
Probable cause:
An in-flight loss of control resulting from upper surface ice contamination that the pilot-in-command failed to detect during his preflight inspection of the airplane. Contributing to the accident was the lack of a preflight inspection requirement for CE-208 pilots to examine at close range the upper surface of the wing for ice contamination when ground icing conditions exist.
Final Report:

Crash of a McDonnell Douglas MD-87 in Milan: 114 killed

Date & Time: Oct 8, 2001 at 0810 LT
Type of aircraft:
Operator:
Registration:
SE-DMA
Flight Phase:
Survivors:
No
Schedule:
Milan - Copenhagen
MSN:
53009
YOM:
1991
Flight number:
SK686
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
104
Pax fatalities:
Other fatalities:
Total fatalities:
110
Captain / Total flying hours:
5842
Captain / Total hours on type:
232.00
Copilot / Total flying hours:
4355
Copilot / Total hours on type:
1978
Aircraft flight hours:
25573
Aircraft flight cycles:
16562
Circumstances:
A brand new Cessna 525A CitationJet 2, D-IEVX, arrived at Milan-Linate following a flight from Köln. The Cessna was to carry out a return flight to Paris-Le Bourget, carrying two pilots, a Cessna sales manager and a prospective customer. The plane arrived at 06:59 and was taxied to the General aviation apron, also known as 'West apron'. It was a foggy morning at Milan and one of the passenger flights parked on the North apron was SAS MD-87 "Lage Viking" which was being prepared for flight SK686 to Copenhagen, scheduled to depart at 07:35. At 07:41, the pilot of the MD-87 contacted Linate Ground Control for his engine start clearance, as the boarding of 104 passengers had been completed. The Ground controller cleared the pilot to start engines and advised that the slot time for takeoff of the flight was at 08:16. Thirteen minutes later flight 686 was cleared to taxi to runway 36R: "Scandinavian 686 taxi to the holding position Cat III, QNH 1013 and please call me back entering the main taxiway." A few minutes later, the Cessna pilot requested permission to start the engines. The ground controller then gave start-up clearance. The ground controller then requested flight 686 to contact the Tower controller. From this moment on the crew of the MD-87 and the crew of the Cessna were tuned on two different radio frequencies. At 08:05 the pilots of the Cessna received taxi clearance: "Delta Victor Xray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the ... main runway extension." The pilot acknowledged by saying: "Roger via Romeo 5 and ... 1013, and call you back before reaching main runway." The Cessna started to taxi from the General Aviation parking position, following the yellow taxi line. After reaching the position where the yellow taxi line splits into two diverging directions, the pilot erroneously took the taxi line to right and entered taxiway R6. At 08:09 the Ground controller cleared the Cessna to continue its taxi on the North apron. At the same time the Tower controller cleared the MD-87 for takeoff: "...Scandinavian 686 Linate, clear for take off 36, the wind is calm report rolling, when airborne squawk ident." The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87 was speeding down the runway, the Cessna crossed the runway holding sign and entered the active runway 18L/36R. At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were extending the shock absorbers but the main wheels were still on the ground at an airspeed of 146 knots (270,5 km/h). At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and reacted with additional large nose-up elevator. At that moment the MD-87 collided with the CitationJet. The right wing of the MD-87 sustained damage at the leading edge and the right hand main landing gear leg broke off. It damaged the right flap and struck the no. 2 engine which then separated from the pylon. The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne for a total of 12 seconds, reaching an estimated height of about 35 feet (11 meters). The left hand engine suffered a noticeable thrust reduction as a result of debris ingestion, which became insufficient to sustain flight. The airspeed had increased up to 166 knots (307,6 km/h), but the MD-87 descended abruptly making contact with the runway with the left hand maingear, the truncated right hand maingear leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust and after ground contact the engine reverse levers were activated and deployed (on the left hand engine only). Maximum available reverse thrust was selected and the brakes applied. The plane skidded past the grass overrun area, across a service road, crashing sideways into a baggage handling building, which partly collapsed. This building was located 20 m/67 feet to the right of the runway, and 460 m/1500 feet from the runway end.
Probable cause:
After analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. The obvious consideration is that the human factor related action of the Cessna crew - during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The following list highlights immediate and systemic causes that led to the accident:
- The visibility was low, between 50 and 100 meters;
- The traffic volume was high;
- The lack of adequate visual aids;
- The Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- The failure to check the Cessna crew qualification;
- The nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- The Cessna crew was not aided properly with correct publications (AIP Italy - Jeppesen), lights (red bar lights and taxiway lights), markings (in deformity with standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- Official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- Operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- Radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- Radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- The ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- Instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
Furthermore:
- The aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognize especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- No functional Safety Management System was in operation;
- The competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- The LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 4976.
The combined effect of these factors, contemporaneously present on the 8th of October 2001 at Milano Linate, have neutralized any possible error corrective action and therefore allowed the accident.
Final Report:

Crash of a Tupolev TU-154M in the in Black Sea: 78 killed

Date & Time: Oct 4, 2001 at 1344 LT
Type of aircraft:
Operator:
Registration:
RA-85693
Flight Phase:
Survivors:
No
Schedule:
Tel Aviv - Novosibirsk
MSN:
91A866
YOM:
1991
Flight number:
SBI1812
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
66
Pax fatalities:
Other fatalities:
Total fatalities:
78
Aircraft flight hours:
16705
Aircraft flight cycles:
7281
Circumstances:
While cruising at an altitude of 36,000 feet over the Black Sea on a weekly schedule service from Tel Aviv to Novosibirsk, the aircraft disappeared from radar screens at 1344LT. The crew did not send any distress call. The aircraft entered an uncontrolled descent and crashed in the sea about 185 km off Adler, and sank to a depth of 2,000 metres. All 78 occupants were killed. Ten days after the crash, the President of Ukraine confirmed officially that the aircraft has been shot down by a surface-to-air missile (Type S200) as the Ukrainian Army was completing exercices off Feodosia, south Crimea.
Probable cause:
The catastrophe involving Tu-154M RA-85693 occurred during the execution, by crew of the Sibir airline, of passenger charter flight # 1812 from Tel Aviv to Novosibirsk. During travel along international flight path B-145 at an altitude of 11,100 m, the aircraft was struck by the 5B14Sh warhead of a 5B28 missile from an S-200B surface-to-air missile system, launched from a position near the town of Feodosia on the Crimean Peninsula, with coordinates 45°03'48"N. Lat. and 36°05'07"E. Long.

Crash of a Yakovlev Yak-40 in Tigil

Date & Time: Sep 23, 2001
Type of aircraft:
Operator:
Registration:
RA-87481
Survivors:
Yes
MSN:
9 44 09 38
YOM:
1974
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft landed hard and bounced several times before landing firmly. On touchdown, the nose gear collapsed and the airplane slid for few dozen metres before coming to rest. All 21 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Ilyushin II-86 in Dubai

Date & Time: Sep 21, 2001 at 2009 LT
Type of aircraft:
Operator:
Registration:
RA-86074
Survivors:
Yes
Schedule:
Moscow - Dubai
MSN:
51483205041
YOM:
1985
Flight number:
SU521
Location:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
307
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
23711
Aircraft flight cycles:
7132
Circumstances:
Following an uneventful flight from Moscow, the crew started a night approach to Dubai Intl Airport. Despite this was a non standard procedure, the captain requested that the landing gear circuit breaker be switched off so he could extend the flaps earlier and prior to gear extension. Later on approach, the flight engineer completed the checklist and mistakenly confirmed that gear were down after the crew forgot to turn the circuit breaker on again. The captain continued the approach without proceeding to a verification/confirmation that gear were down, causing the aircraft to land on its belly. It slid for few dozen metres and came to rest with both engines n°2 and 3 on fire as well as the rear part of the cargo compartment. All 321 occupants were evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Poor approach configuration on part of the crew and violation of published standard operational procedures. Lack of crew coordination and poor crew resources management were considered as contributing factors.

Crash of a Let L-410UVP-E in Guatemala City: 8 killed

Date & Time: Sep 18, 2001 at 0642 LT
Type of aircraft:
Operator:
Registration:
TG-CFE
Flight Phase:
Survivors:
Yes
Schedule:
Guatemala City – San Pedro Sula
MSN:
86 17 05
YOM:
1986
Flight number:
ATL870
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
8
Aircraft flight hours:
2467
Aircraft flight cycles:
4001
Circumstances:
After takeoff from runway 01 at Guatemala City-La Aurora Airport, while climbing to a height of 200 feet, the twin engine aircraft rolled left and right then stalled and crashed beside the runway, about 550 metres from its end. The copilot and four passengers were injured while eight other occupants including the captain were killed. The aircraft was totally destroyed.
Probable cause:
It was determined that the aircraft stalled during initial climb because the passengers seats were not properly allocated, causing the center of gravity to be outside the permissible limit. The following contributing factors were identified:
- The Atlantic Airlines company, at the date of the accident, did not have sufficiently trained administrative and operational personnel for a safe operation.
- The poor allocation of the passengers inside the cabin affected lift, causing the aircraft to stall. Due to its low height, it was impossible to expect a stall recovery. This shows that the aircraft collapsed completely without move on the ground and being destroyed by the weight of the engines and their wings that were full of fuel.
- Lack of crew training, especially the copilot who was not rated on this type of aircraft. Thus, he was not able to assist the captain in an emergency situation but only reading the checklist.
- The engines were operating normal at the time of impact and they were running in normal takeoff conditions.
- No evidence of mechanical failure was found.
- The accident shows that the aircraft was operating normally, but that due to aerodynamic circumstances, it entered a stall and crashed on the ground abruptly and uncontrollably.

Crash of a Boeing 737-2C3 in Goiânia

Date & Time: Sep 16, 2001 at 1053 LT
Type of aircraft:
Operator:
Registration:
PP-CJN
Survivors:
Yes
Schedule:
São Paulo – Goiânia
MSN:
21012
YOM:
1974
Flight number:
RG2240
Location:
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
62
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
68500
Aircraft flight cycles:
65500
Circumstances:
On final approach to Goiânia-Santa Genoveva Airport, the crew encountered poor weather conditions with a limited visibility due to rain. The aircraft landed about 500 metres past the runway threshold but as it was misaligned, the right main gear touched down on the left side of the runway. The crew attempted to steer the plane back onto the runway when the right main gear collapsed. The aircraft went out of control, lost its right engine then its nose gear and came to rest on the runway. All 67 occupants evacuated safely.
Probable cause:
Wrong approach configuration on part of the crew who continued the approach while the aircraft was not properly aligned with the runway centerline.

Crash of a Boeing 757-222 in Shanksville: 45 killed

Date & Time: Sep 11, 2001 at 1030 LT
Type of aircraft:
Operator:
Registration:
N591UA
Flight Phase:
Survivors:
No
Schedule:
Newark - San Francisco
MSN:
28142
YOM:
1996
Flight number:
UA093
Crew on board:
7
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
45
Aircraft flight hours:
18435
Aircraft flight cycles:
6968
Circumstances:
The Boeing 757 departed Newark Airport at 0847LT on a regular schedule service to San Francisco, carrying 37 passengers and a crew of seven. Few minutes later, the aircraft was hijacked by terrorists who modified the flight path and apparently attempted to fly over Washington DC. At 1030LT, the aircraft crashed in an open field located about 4 km north of Shanksville. The aircraft disintegrated on impact and all 45 occupants were killed. The terrorist attacks of September 11, 2001 are under the jurisdiction of the Federal Bureau of Investigation. The Safety Board provided requested technical assistance to the FBI, and this material generated by the NTSB is under the control of the FBI. The Safety Board does not plan to issue a report or open a public docket.
Probable cause:
The Safety Board did not determine the probable cause and does not plan to issue a report or open a public docket. The terrorist attacks of September 11, 2001 are under the jurisdiction of the Federal Bureau of Investigation. The Safety Board provided requested technical assistance to the FBI, and any material generated by the NTSB is under the control of the FBI.