Crash of an Airbus A320-214 in Bilbao

Date & Time: Feb 7, 2001 at 2309 LT
Type of aircraft:
Operator:
Registration:
EC-HKJ
Survivors:
Yes
Schedule:
Barcelona – Bilbao
MSN:
1278
YOM:
2000
Flight number:
IB1456
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10805
Copilot / Total flying hours:
423
Aircraft flight hours:
1149
Aircraft flight cycles:
869
Circumstances:
The aircraft was on its final approach to runway 30 of Bilbao Airport. The aircraft, operated by Iberia, was employed on flight IB1456, a scheduled domestic flight from Barcelona to Bilbao, with 136 passengers and 7 crew members on board. The expected flight time was 53 minutes. The current conditions in Bilbao were night VMC, with a 10 knots and southwest (SW) wind and gusts of up to 25 knots. Visibility was more than 10 km and there were scattered clouds above 5,600 feet. The sun had set four hours earlier and all electronic and visual aids in the airport were fully operational. There was no rain and the flight was conducted unter IFR rules. Since the takeoff from Barcelona at 2201LT, the flight had been uneventful. The pilot flying was seated on the right hand side, and he was in line flying under supervision. The captain seated on the left hand side was supervising the flight. A third flight crew member, seated in the jumpseat, was the first officer who had given his seat to the pilot under supervision on the right hand seat. On course to Bilbao, the aircraft flew over Pamplona at FL150, where they were informed of possible light turbulence. A about 25 NM from their destination and at 7,500 feet altitude, they crossed a small cumulus with strong turbulence. Descending through 6,000 feet and established on the Bilbao localizer they found winds of 55 knots. The ATC tower (TWR) of Bilbao cleared them to land on runway 30, and informed the decision height, 247 feet, under VMC conditions and continued the approach to land. One minute prior to touchdown, the tower informed of wind conditions of 240° 8 knots. The aircraft conditions during the approach were: weight, 62,380 kilos; centre of gravity, 28,66% MAC, full flaps. The reference speed (Vref) was 132 knots and the approach speed (Vapp), 142 knots. Autopilot was disconnected by the crew at 400 feet to continue the approach manually. In the last few seconds prior to touchdown, the vertical descent speed was very high, around 1,200 feet per minute (6 metres per second) and the 'sink rate' warning of the GPWS sounded twice. The aircraft did not react to the pitch-up order input applied by both pilots on the side-sticks, due to the design software logic that operates at these specific moments, and did not flare. Announcements of 'dual-input' warning were heard at the time. Then the captain, in view of the 'sink rate' warnings, selected TOGA power setting to go around and abort the landing. The pilot's actions on the flight controls could not avoid a hard touchdown of the aircraft in a slight nose down attitude, and the captain decided to continue the landing and to stop the aircraft. The aircraft slowed-down along 1,100 metres of the runway within the paved surface. It finally came to a stop with its horizontal axis at an angle of 60° to the right of the runway centerline. During the landing roll the nose landing gear collapsed, the four tires of the main gear burst and the engine nacelles, on which the aircraft was leaning after the collapse, dragged along the pavement. Once the aircraft came to a halt, the captain ordered its evacuation, which was carried out using all the exit doors and their slides. During the evacuation a cabin crew member and 24 passengers were injured. All injuries were considered minor except for one, a female passenger whose injuries were considered serious. Seven injured people were taken to hospital.
Probable cause:
The cause of the accident was the activation of the angle of attack protection system which, under a particular combination of vertical gusts and windshear and the simultaneous actions of both crew members on the sidesticks, not considered in the design, prevented the aeroplane from pitching up and flaring during the landing.
Final Report:

Crash of a Short 360-100 in Sheffield

Date & Time: Feb 4, 2001 at 1921 LT
Type of aircraft:
Operator:
Registration:
EI-BPD
Survivors:
Yes
Schedule:
Dublin – Sheffield
MSN:
3656
YOM:
1984
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
25
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4484
Captain / Total hours on type:
1392.00
Circumstances:
The crew were planned to fly a scheduled passenger flight from Dublin to Sheffield airport and the commander was the handling pilot for the flight. Both pilots had operated into Sheffield between five and ten times in the previous three months. The aircraft, which was serviceable, took off from Dublin at 1814 hrs and was routed to Sheffield via the VOR/DME navigation beacon at Wallasey at FL90. Prior to descent, the crew obtained the most recent information from the Automatic Terminal Information Service (ATIS); this report, timed at 1820 hrs, was identified as 'Information Hotel'. The reported conditions at Sheffield were: surface wind variable at 03 kt, visibility 4,000 metres in rain and snow, a few clouds at 600 feet, scattered cloud at 1,200 feet and broken cloud at 3,000 feet, the temperature and dew point were coincident at +1°C and the QNH was 989 hPa. Air traffic control was passed to the Sheffield approach controller when the aircraft was 12 nm from the overhead at which time it was descending to 5,000 feet on the QNH. The crew were informed that the current ATIS was now 'Information India' and the aircraft was cleared to descend to 3,000 feet when within 10 nm of the airport. 'Information India', timed at 1850 hrs, contained no significant changes from 'Information Hotel'. The aircraft weight for the landing was calculated to be 11,100 kg with an associated threshold speed of 103 kt. The aircraft was cleared for the ILS/DME procedure for Runway 28 and the crew requested the QFE which was 980 hPa. The decision height for the approach was 400 feet. During the initial stages of the manually flown ILS approach the commander's flight director warning flag appeared briefly but then disappeared and did not reappear during the remaining period of flight. The de-ice boots had been selected to 'ON' early in the descent when the aircraft had briefly encountered light icing. These de-ice boots were selected to 'OFF' when at 5 nm from the runway at which stage there were no indications of icing and the indicated outside air temperature was +5°C. (This is indicative of an actual air temperature of +2°C.) At 1918:11 hrs the crew reported that they were established on the localiser. When the aircraft intercepted the glidepath, the flaps were set to 15° correctly configuring the aircraft for the approach. The handling pilot recalled that initially the rate of descent was slightly higher than the expected 650 ft/min leading him to suspect the presence of a tailwind, however, the rate of descent returned to a more normal value when approximately 4 nm from the runway. The propellers were set to the maximum rpm at 1,200 feet agl. When the crew reported that they were inside 4 nm they were cleared to land and passed the surface wind, which was variable at 2 kt; they were also warned that the runway surface was wet. Both pilots saw the runway lights when approaching 400 feet agl; the flaps were selected to 30° and confirmed at that position. Both pilots believed that the airspeed was satisfactory but, as the commander checked back on the control column for the landing, the rate of descent increased noticeably and the aircraft landed firmly. Both pilots believed that the power levers were in the flight idle position and neither was aware of any unusual control inputs during the landing flare. Two separate witnesses saw the aircraft during the later stages of the approach and the subsequent landing, one of these witnesses was in the control tower and the other was standing in front of the passenger terminal. They both saw the aircraft come into view at a height of approximately 400 feet and apparently travelling faster than normal. They described the aircraft striking the ground very hard with the left wing low; both heard a loud noise coincident with the initial contact. They then reported that the aircraft bounced before hitting the ground again, this time with the nose wheel first, before bouncing once more. Crew statements and flight data evidence indicate that the aircraft lifted no more than 8 feet before settling on the runway and then remained on the ground. The aircraft was then seen to travel about half way along the runway before slewing to the left and running onto the grass. When the aircraft stopped the left wing tip appeared to be touching the grass. When the aircraft came to rest the tower controller asked the crew if they required assistance, this call was timed at 1921:15 hrs. The crew asked for the fire services to be placed on standby but the controller judged that the situation required an immediate and full emergency response and activated the fire and rescue services. The airfield fire services arrived at the aircraft at 1924 hrs and all the passengers had been evacuated by 1925 hrs. The South Yorkshire fire and rescue services arrived at 1933 hrs and assisted in ferrying passengers to the terminal building.
Probable cause:
Evidence from the CVR indicated that the flight was conducted in a thoroughly professional manner in accordance the operator's normal procedures until the final stages of the approach. The recorded data indicate that three seconds prior to touchdown the propeller blade angle changed from the flight range to the ground range. Coincident with this change the CVR recorded sounds consistent with the propellers 'disking' and the FDR indicated that the aircraft then decelerated longitudinally and accelerated downwards. The engineering investigation revealed that the propeller control rigging and the operation of the flight idle baulk were correct. Selection of ground fine requires the pilot to firstly release the flight idle baulk and then lift and pull the propeller levers further back, this combined action rapidly becomes a programmed motor skill in the routine of daily operations. It is therefore possible that the handling pilot unintentionally selected the propellers into the ground fine position whilst still in the air.
Final Report:

Crash of a Let L-410UVP in Maiduguri

Date & Time: Jan 23, 2001 at 2130 LT
Type of aircraft:
Operator:
Registration:
9L-LCG
Survivors:
Yes
Schedule:
Jos – Maiduguri
MSN:
85 15 31
YOM:
1985
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Jos on a charter flight to Maiduguri, carrying 14 passengers and four crew members for the Nigerian daily newspaper 'This Day'. After takeoff from Jos Airport, the crew was informed about good weather conditions at destination with a 9 km visibility that dropped few minutes later to 5 km. While approaching Maiduguri, the crew encountered poor weather conditions and ATC advised the crew to divert to another airport. The crew followed a holding pattern for few minutes for weather improvement but informed ATC that he was unable to divert due to insufficient fuel reserve. Eventually, the captain attempted an emergency landing 12 km from the airport. The aircraft crash landed in an open field and came to rest. All 18 occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
Forced landing due to the deterioration of the weather conditions with tropical storm. Poor flight preparation from the crew who miscalculated the fuel reserve for a possible alternate airport. It was also determined that the crew was unable to locate the runway because the intensity of the runway light system was too low.

Ground accident of a Boeing 727-287 in Buenos Aires

Date & Time: Jan 9, 2001 at 1720 LT
Type of aircraft:
Operator:
Registration:
CP-2323
Flight Phase:
Survivors:
Yes
Schedule:
Buenos Aires - Santa Cruz
MSN:
22605/1787
YOM:
1981
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was taxiing at Buenos Aires-Ezeiza-Ministro Pistarini Airport for a departure from runway 11 when the left main gear collapsed. All 146 occupants evacuated safely but the aircraft was considered as damaged beyond repair.
Probable cause:
It was determined that the left main landing gear collapsed because the forward trunnion bearing support fitting broke due to intergranular corrosion.

Crash of a BAe 4101 Jetstream 41 in Charlottesville

Date & Time: Dec 29, 2000 at 2234 LT
Type of aircraft:
Operator:
Registration:
N323UE
Survivors:
Yes
Schedule:
Washington DC – Charlottesville
MSN:
41059
YOM:
1995
Flight number:
UA331
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4050
Captain / Total hours on type:
1425.00
Copilot / Total flying hours:
4818
Copilot / Total hours on type:
68
Aircraft flight hours:
14456
Circumstances:
The twin-engine turboprop airplane touched down about 1,900 feet beyond the approach end of the 6,000-foot runway. During the rollout, the pilot reduced power by pulling the power levers aft, to the flight idle stop. He then depressed the latch levers, and pulled the power levers further aft, beyond the flight idle stop, through the beta range, into the reverse range. During the power reduction, the pilot noticed, and responded to a red beta light indication. Guidance from both the manufacturer and the operator prohibited the use of reverse thrust on the ground with a red beta light illuminated. The pilot pushed the power levers forward of the reverse range, and inadvertently continued through the beta range, where aerodynamic braking was optimum. The power levers continued beyond the flight idle gate into flight idle, a positive thrust setting. The airplane continued to the departure end of the runway in a skid, and departed the runway and taxiway in a skidding turn. The airplane dropped over a 60-foot embankment, and came to rest at the bottom. The computed landing distance for the airplane over a 50-foot obstacle was 3,900 feet, with braking and ground idle (beta) only; no reverse thrust applied. Ground-taxi testing after the accident revealed that the airplane could reach ground speeds upwards of 85 knots with the power levers at idle, and the condition levers in the flight position. Simulator testing, based on FDR data, consistently resulted in runway overruns. Examination of the airplane and component testing revealed no mechanical anomalies. Review of the beta light indicating system revealed that illumination of the red beta light on the ground was not an emergency situation, but only indicated a switch malfunction. In addition, a loss of the reverse capability would have had little effect on computed stopping distance, and none at all in the United States, where performance credit for reverse thrust was not permitted.
Probable cause:
The captain's improper application of power after responding to a beta warning light during landing rollout, which resulted in an excessive rollout speed and an inability to stop the airplane before it reached the end of the runway.
Final Report:

Ground fire of a Douglas DC-9-32 in Atlanta

Date & Time: Nov 29, 2000 at 1550 LT
Type of aircraft:
Operator:
Registration:
N826AT
Survivors:
Yes
Schedule:
Atlanta - Akron
MSN:
47359/495
YOM:
1969
Flight number:
FL956
Crew on board:
5
Crew fatalities:
Pax on board:
92
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
6000.00
Copilot / Total flying hours:
3100
Copilot / Total hours on type:
0
Aircraft flight hours:
78255
Aircraft flight cycles:
88367
Circumstances:
Shortly after takeoff, the airplane experienced electrical problems, including numerous tripped circuit breakers. The flight crew requested a return to airport. During the landing rollout, the lead flight attendant and air traffic control personnel reported to the flight crew that smoke was coming from the left side of the airplane; subsequently, the flight crew initiated an emergency evacuation on one of the taxiways. Examination of the airplane revealed fire damage to the left, forward areas of the fuselage, cabin, and forward cargo compartment. The greatest amount of fire damage was found just aft of the electrical disconnect panel located at fuselage station 237. There was no evidence that the drip shield normally installed over the disconnect panel was present at the time of the accident. Bluish stains caused by lavatory rinse fluid were observed on surfaces near the disconnect panel on the accident airplane and in the same areas on another of AirTran's DC-9 airplanes. Examination of one of the connectors from the disconnect panel on the accident airplane revealed light-blue and turquoise-green deposits on its internal surfaces and evidence of shorting between the connector pins. It could not be determined when the drip shield over the disconnect panel was removed; however, this likely contributed to the lavatory fluid contamination of the connectors. Following the accident, AirTran revised its lavatory servicing procedures to emphasize the importance of completely draining the waste tank to avoid overflows. Boeing issued an alert service bulletin recommending that operators of DC-9 airplanes visually inspect the connectors at the FS 237 disconnect panel for evidence of lavatory rinse fluid contamination and that they install a drip shield over the disconnect panel. Boeing also issued a service letter to operators to stress the importance of properly sealing floor panels and adhering to lavatory servicing procedures specified in its DC-9 Maintenance Manual. The Safety Board is aware of two incidents involving the military equivalent of the DC-9 that involved circumstances similar to the accident involving N826AT. Drip shields were installed above the FS 237 disconnect panels on both airplanes.
Probable cause:
The leakage of lavatory fluid from the airplane's forward lavatory onto electrical connectors, which caused shorting that led to a fire. Contributing to the accident were the inadequate servicing of the lavatory and the failure of maintenance to ensure reinstallation of the shield over the fuselage station 237 disconnect panel.
Final Report:

Crash of a Britten-Norman BN-2B-21 Islander in Datah Dawai

Date & Time: Nov 18, 2000 at 1053 LT
Type of aircraft:
Operator:
Registration:
PK-VIY
Flight Phase:
Survivors:
Yes
Schedule:
Datah Dawai - Samarinda
MSN:
2133
YOM:
1981
Flight number:
AW3130
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7560
Captain / Total hours on type:
3632.00
Aircraft flight hours:
21336
Aircraft flight cycles:
20374
Circumstances:
The aircraft departed from Datah Dawai Airport for a regular commercial flight with destination airport, Samarinda, East Kalimantan. There were 18 persons on board including the pilot. Minutes after airborne, the aircraft crashed at a location of about 2 km north of the runway 02 extension. The pilot and 11 passengers were found seriously injured, while six sustained minor injuries or none. Weather was reported clear at the time of the occurrence.
Probable cause:
The following findings were identified:
- There are no signs of engine failure prior to the impact,
- The aircraft exceeded its manufacturer's MTOW on the flight from Datah Dawai to Samarinda,
- The aircraft center of gravity is near the aft limit of the CG flight envelope,
- The PIC apparently has a wrong perception on takeoff procedure. He thought that the optimum takeoff performance could be achieved by taking-off with a higher velocity. Meanwhile, in achieving high velocity one has to roll closer to the obstacle, which forced the aircraft to maintain a higher rate of climb,
- The PIC and Datah Dawai ground crews have endangered his passengers by letting more passengers loaded into the aircraft than the number of seats available,
- The PIC and Datah Dawai ground crews have endangered their passengers by improperly calculating the weight of aircraft payload,
- The operator did not have proper supervision system that may prevent such practice to happen,
- The operator has never filled out Flight Clearance, for its Samarinda - Datah Dawai operation,
- There are a lot more passengers or demand than the capacity of the Pioneer Flight Samarinda - Datah Dawai,
- There are not enough flight operation documents published (such as visual track and single engine emergency return guidance) to fly safely in and out of Datah Dawai,
- The exceeding MTOW, small stability margin, PIC takeoff habit, and lack of published safety documents for the area are the contributing factors to the accident.
There were found indications of practices that fit into the category of negligence, willful misconduct and violations of existing flight safety rules and regulations.
Final Report:

Crash of an Antonov AN-26 in Luanda: 57 killed

Date & Time: Nov 15, 2000 at 1303 LT
Type of aircraft:
Operator:
Registration:
D2-FCG
Flight Phase:
Survivors:
No
Schedule:
Luanda - Namibe
MSN:
2 73 081 04
YOM:
1972
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
57
Circumstances:
Shortly after takeoff from Luanda-4 de Fevereiro Airport, while climbing to a height of about 200 feet, the aircraft banked left, lost height and crashed 5 km from the airport, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all 57 occupants were killed. The five crew members were four Ukrainian citizens and one Angolan.
Probable cause:
It is believed that the loss of control was the consequence of the failure of the left engine during climbout. The exact cause of the engine failure remains unknown but discrepancies were noted concerning operations, manifest and W&B documents (fuel and pax). Since last October 31, all Antonov AN-24, AN-26 and AN-32 flights were suspended in all Angolan airspace, except on the route Luanda - Namibe.

Crash of a Douglas DC-9-51 in Conakry

Date & Time: Nov 13, 2000 at 1813 LT
Type of aircraft:
Operator:
Registration:
9G-ADY
Survivors:
Yes
Schedule:
Accra – Abidjan – Monrovia – Freetown – Conakry
MSN:
47679
YOM:
1975
Flight number:
GH530
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
45600
Aircraft flight cycles:
64300
Circumstances:
While descending to Conakry-Gbessia Airport, the crew encountered technical problems with the undercarriage that could not be lowered. Several attempts were made to lower the gear manually but this was unsuccessful. The crew decided to complete a belly landing. After touchdown, the aircraft slid for few dozen metres and came to rest on the runway. All 50 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Boeing 747-2H7B in Paris

Date & Time: Nov 5, 2000 at 2157 LT
Type of aircraft:
Operator:
Registration:
TJ-CAB
Survivors:
Yes
Schedule:
Douala - Paris
MSN:
22378
YOM:
1981
Flight number:
UY070
Country:
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
187
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20250
Captain / Total hours on type:
12000.00
Copilot / Total flying hours:
14188
Copilot / Total hours on type:
9767
Aircraft flight hours:
48770
Aircraft flight cycles:
12872
Circumstances:
Following an uneventful flight from Douala, the crew started the descent to Paris-Roissy-CDG Airport by night and poor weather conditions. After touchdown on the wet runway 09R, the crew started the braking procedure when the aircraft went out of control, veered to the right off runway, crossed a grassy area, lost its nose gear and came to rest between both taxiways Z6 and Z7. All 203 occupants evacuated safely while the aircraft christened 'Mount Cameroon' was damaged beyond repair due to severe damages in the electronic bay because the nose landing gear penetrated the fuselage.
Probable cause:
The initial cause of the accident was the incomplete reduction of thrust on the left outer engine at the beginning of deceleration. This caused the de-activation of the automatic braking system and the non-extension of the n°1 thrust reverser. The inadvertent selection of full thrust on this engine after the landing created a high thrust asymmetry leading to the runway excursion. The lack of coordination and of joint control by the crew members, perhaps aggravated by the presence of third parties in the cockpit, contributed to the development of this situation.
Final Report: