Crash of a NAMC YS-11A-213 in Sapporo

Date & Time: Feb 16, 2000 at 1243 LT
Type of aircraft:
Operator:
Registration:
JA8727
Survivors:
Yes
Schedule:
Hakodate - Sapporo
MSN:
2095
YOM:
1969
Flight number:
EL354
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Sapporo-Okadama, the aircraft was too high on the glide and approached at an excessive speed. It landed too far down a snow covered runway and was unable to stop within the remaining distance. It overran, collided with snow bank and came to rest. All 41 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew who completed the approach at an excessive speed and above the glide, causing the aircraft to land too far down the runway. The following findings were identified:
- The aircraft speed was 23 knots higher than the reference speed above threshold,
- Excessive speed upon touchdown,
- The braking action was reduced because the runway surface was contaminated with snow,
- The aircraft was unable to stop within the remaining distance,
- The crew failed to initiate a go-around procedure while the landing was obviously missed,
- Marginal weather conditions,
- Poor crew coordination,
- Poor airspeed monitoring on part of the flying crew.

Ground accident of an Airbus A300B4-203 in Dakar

Date & Time: Feb 12, 2000 at 0056 LT
Type of aircraft:
Operator:
Registration:
TU-TAT
Flight Phase:
Survivors:
Yes
Schedule:
Dakar - Paris
MSN:
282
YOM:
1983
Flight number:
RK304
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
171
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
38400
Aircraft flight cycles:
19600
Circumstances:
While taxiing for departure at Dakar-Yoff Airport, the left main gear unsafe alarm came on in the cockpit panel. The captain decided to return to the apron to proceed to an inspection when the left main gear collapsed. The engine n°1 struck the ground and partially torn off. A fire erupted and quickly spread to the left wing. All 182 occupants evacuated safely but the aircraft was considered as damaged beyond repair. It just came out from a C Check maintenance program.
Probable cause:
A crossing of the flexible tubing of the hydraulic connection controlling the locking of the left gear failed, causing the left main gear to retract.

Crash of a Piper PA-31T3-T1040 Cheyenne in Wales

Date & Time: Feb 9, 2000 at 1205 LT
Type of aircraft:
Operator:
Registration:
N110JK
Survivors:
Yes
Schedule:
Nome – Wales
MSN:
31-8375005
YOM:
1983
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4600
Captain / Total hours on type:
195.00
Aircraft flight hours:
12385
Circumstances:
The airline transport certificated pilot was landing a twin-engine turboprop airplane at a remote airport on a scheduled air taxi flight. Rising hilly terrain is located east of the airport. The pilot said that during the approach for landing, he noticed the airport wind sock indicating a wind from the east about 25 knots. When the pilot descended to 500 feet, about mid-base, the airplane encountered moderate turbulence and an increased rate of descent. He added engine power to arrest the descent. As he turned toward the runway, the airplane encountered 3 to 4 rolling oscillations with a bank angle up to 90 degrees while descending toward the runway. According to a company mechanic who traveled to the scene, it appeared that the airplane struck the runway about 1,200 feet from the approach end with the left wing and left elevator, while yawed about 45 degrees to the left of the runway centerline. The airplane then slid off the left side of the runway. After the collision, the pilot evacuated the passengers, and noticed the airport wind sock was indicating a tailwind. The Airport/Facility Directory contains the following in the airport remarks: 'Unattended. Easterly winds may cause severe turbulence in vicinity of runway.'
Probable cause:
The pilot's inadequate evaluation of the weather conditions, and his inadvertent flight into adverse weather conditions. Factors in the accident were terrain induced turbulence and a tailwind.
Final Report:

Ground fire of an Airbus A300B2-203 in Tehran

Date & Time: Feb 1, 2000 at 1030 LT
Type of aircraft:
Operator:
Registration:
EP-IBR
Flight Phase:
Survivors:
Yes
MSN:
61
YOM:
1979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Aircraft flight hours:
33700
Aircraft flight cycles:
28100
Circumstances:
The aircraft was towed at Tehran-Mehrabad Airport when it was struck by a IRIAF Lockheed C-130 Hercules that crashed on takeoff. At impact, both aircraft exploded and were totally destroyed by a post crash fire. All six crew members on board the Hercules were killed as well as three people who were on board the Airbus.
Probable cause:
It is believed that the Hercules went out of control upon takeoff following an engine failure.

Crash of a McDonnell Douglas MD-83 off Anacapa Island: 88 killed

Date & Time: Jan 31, 2000 at 1620 LT
Type of aircraft:
Operator:
Registration:
N963AS
Flight Phase:
Survivors:
No
Schedule:
Puerto Vallarta - San Francisco - Seattle - Anchorage
MSN:
53077
YOM:
1992
Flight number:
AS261
Crew on board:
5
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
88
Captain / Total flying hours:
10460
Captain / Total hours on type:
4150.00
Copilot / Total flying hours:
8140
Copilot / Total hours on type:
8060
Aircraft flight hours:
26584
Aircraft flight cycles:
14315
Circumstances:
On January 31, 2000, about 1621 Pacific standard time, Alaska Airlines, Inc., flight 261, a McDonnell Douglas MD-83, N963AS, crashed into the Pacific Ocean about 2.7 miles north of Anacapa Island, California. The 2 pilots, 3 cabin crewmembers, and 83 passengers on board were killed, and the airplane was destroyed by impact forces. Flight 261 was operating as a scheduled international passenger flight under the provisions of 14 Code of Federal Regulations Part 121 from Lic Gustavo Diaz Ordaz International Airport, Puerto Vallarta, Mexico, to Seattle-Tacoma International Airport, Seattle, Washington, with an intermediate stop planned at San Francisco International Airport, San Francisco, California. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
Probable cause:
A loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly's acme nut threads. The thread failure was caused by excessive wear resulting from Alaska Airlines' insufficient lubrication of the jackscrew assembly. Contributing to the accident were Alaska Airlines' extended lubrication interval and the Federal Aviation Administration's (FAA) approval of that extension, which increased the likelihood that a missed or inadequate lubrication would result in excessive wear of the acme nut threads, and Alaska Airlines' extended end play check interval and the FAA's approval of that extension, which allowed the excessive wear of the acme nut threads to progress to failure without the opportunity for detection. Also contributing to the accident was the absence on the McDonnell Douglas MD-80 of a fail-safe mechanism to prevent the catastrophic effects of total acme nut thread loss.
Final Report:

Crash of an Airbus A310-304 off Abidjan: 169 killed

Date & Time: Jan 30, 2000 at 2109 LT
Type of aircraft:
Operator:
Registration:
5Y-BEN
Flight Phase:
Survivors:
Yes
Schedule:
Abidjan - Lagos - Nairobi
MSN:
426
YOM:
1986
Flight number:
KQ431
Location:
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
169
Pax fatalities:
Other fatalities:
Total fatalities:
169
Captain / Total flying hours:
8663
Captain / Total hours on type:
1664.00
Copilot / Total flying hours:
7295
Copilot / Total hours on type:
5768
Aircraft flight hours:
58115
Aircraft flight cycles:
15026
Circumstances:
On Sunday 30 January 2000, the Kenya Airways Airbus 310-304, registered 5Y−BEN, was undertaking the scheduled international flight KQ 431 transporting passengers from Abidjan to Nairobi, via Lagos. On board there were 10 crewmembers and 169 passengers. On the same day, in the afternoon, 5Y-BEN had flown in from Nairobi and landed at Félix Houphouët-Boigny International Airport in Abidjan at 15 h 15. The unfavorable meteorological at Lagos had obliged the pilot, after a thirty minutes hold at Lagos, to divert to Abidjan. The relief crew, which had arrived two days previously on flight KQ 430 on Friday 28 January 2000, at 15 h 44, took over on board 5Y-BEN, to undertake flight KQ 431 from Abidjan to Nairobi, via Lagos. Departure was scheduled for 21 h 00, in accordance with the initial program. The copilot was pilot flying, the Captain was pilot not flying. At 20 h 55 min 22 s, the crew established contact with Abidjan Airport control tower and asked for start-up clearance. This was granted. At 20 h 56 min 09 s, the Captain ordered the checklist to be performed and announced the type of take-off by saying "Flex sixty" at 20 h 56 min 19 s. At 21 h 00 min 18 s, three minutes and nineteen seconds after the start-up of the first engine (engine n° 2), the Captain announced over the interphone that linked him with the ground mechanic “we have two normal start-ups”. At 21 h 01 min 07 s, the crew of 5Y-BEN asked for clearance to taxi. The tower controller put them on standby. A few seconds later, he cleared them to taxi. At 21 h 02 min 33 s, the Captain ordered the Copilot to set the flaps at 15°. Later, at 21 h 04 min 50 s , the copilot announced "trim: 0.9 nose up, Slats/flaps 15/15". The airplane began to taxi at 21 h 07 min 35 s, the tower controller informed the crew of the latest wind, cleared them to take off and asked the crew the call back when they reached flight level 40. At 21 h 07 min 45 s, the copilot read back the clearance. This was the last communication between the crew and the control tower. At 21 h 08 min 08 s, the copilot announced "Take-off checklist completed … cleared for take-off". At 21 h 08 min 18 s, the Captain applied take-off power and announced "thrust, SRS, and runway" then, nine seconds later “100 knots”. At 21 h 08 min 50 s, the Captain announced "V1 and Rotate(4)", then two seconds later "Positive". The airplane took off. At 21 h 08 min 57 s, the copilot announced "Positive rate of climb, gear up". Less than two seconds later the stall warning sounded. At 21 h 09 min 07 s, the automatic call out (AC) announced 300 feet. At 21 h 09 min 14 s, the copilot asked "what’s the problem?". From 21 h 09 min 16 s, the AC announced successively 200, 100, 50, 30, 20 and 10 feet. Meanwhile, at 21 h 09 min 18 s, the copilot ordered the aural warning to be cut. Two seconds later, the GPWS sounded the “Whoop...” alarm followed, a half a second later, by the AC announcement of 50 feet. At 21 h 09 min 22 s, an aural master warning started, immediately followed by an order from the Captain to climb: "Go up!", though this was preceded six tenths of a second by the AC announcement of 10 feet. At 21 h 09 min 23.9 s, end of the master warning, followed immediately within a tenth of a second by the noise of the impact. The time of the accident is presumed to be 21 h 09 min 24 s.
Probable cause:
The Commission of Inquiry concluded that the cause of the accident to flight KQ 431 on 30 January 2000 was a collision with the sea that resulted from the pilot flying applying one part of the procedure, by pushing forward on the control column to stop the stick shaker, following the initiation of a stall warning on rotation, while the airplane was not in a true stall situation. In fact, the FCOM used by the airline states that whenever a stall warning is encountered at low altitude (stick shaker activation), it should be considered as an immediate threat to the maintenance of a safe flight path. It specifies that at the first sign of an imminent stall or at the time of a stick shaker activation, the following actions must be undertaken simultaneously: thrust levers ion TOGA position, reduction of pitch attitude, wings level, check that speed brakes are retracted. The investigation showed that the pilot flying reduced the pitch attitude but did not apply TOGA thrust on the engines. The investigation was unable to determine if the crew performed the other two actions: leveling the wings and checking that the speed brakes were retracted.
The following elements contributed to the accident:
• the pilot flying’s action on the control column put the airplane into a descent without the crew realizing it, despite the radio altimeter callouts;
• the GPWS warnings that could have alerted the crew to an imminent contact with the sea were masked by the priority stall and overspeed warnings, in accordance
with the rules on the prioritization of warnings;
• the conditions for a takeoff performed towards the sea and at night provided no external visual references that would have allowed the crew to be aware of the
direct proximity of the sea.
Final Report:

Crash of a Saab 340B in Nassenwil: 10 killed

Date & Time: Jan 10, 2000 at 1756 LT
Type of aircraft:
Operator:
Registration:
HB-AKK
Flight Phase:
Survivors:
No
Schedule:
Zurich - Dresden
MSN:
213
YOM:
1990
Flight number:
LX498
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
8452
Captain / Total hours on type:
1870.00
Copilot / Total flying hours:
2332
Copilot / Total hours on type:
1162
Aircraft flight hours:
21676
Aircraft flight cycles:
20589
Circumstances:
Aircraft HB-AKK had landed in Zurich on 10 January 2000 as Crossair flight CRX 842 from Guernsey and reached stand F74 at 16:00 UTC, which is located near to the threshold of runway 28. The aircraft was then prepared for the next flight at this stand. According to statements from the Swissport ground personnel the preparation of the aircraft took place without any special occurrence. During its time on the ground, the aircraft was supplied with electric power by a ground power unit (GPU). An air-conditioning truck was not used and the aircraft was not de-iced. The crew prepared for the flight using the computer-aided briefing system. The following description of the history of the flight was reconstructed with the help of recordings from the cockpit voice recorder (CVR), digital flight data recorder (DFDR), voice radio communications and ATC radar (cf. Annex 1). According to the available recordings, the commander, as planned by the crew, was pilot flying (PF) and the first officer was pilot non flying (PNF) throughout the flight. At 16:39:14 UTC, flight CRX 498 to Dresden received from clearance delivery (DEL) the following ATC-clearance: "runway two eight, Dresden, Zurich East One Yankee Departure, squawk three zero zero four". The crew was then instructed to change to the apron (APR) frequency. Permission to start engines was given at 16:45:00 UTC by APR. At 16:49:22 UTC the first officer signaled readiness to taxi to APR. While the crew waited for taxi clearance, a few points of the taxi checklist were performed. At 16:50:30 UTC APR cleared flight CRX 498 to follow a Swissair Airbus A320 (SWR 014) to the holding position of runway 28. In accordance with this clearance, CRX 498 started to move. The flight crew performed the outstanding items on the taxi checklist and contacted the tower (TWR), which gave line-up clearance at 16:52:36 UTC. Take-off clearance was given at 16:54:00 UTC: "Crossair four nine eight, wind three zero zero degrees, three knots, cleared take-off runway two eight". According to the automatic terminal information service (ATIS) at 16:50 UTC the following meteorological conditions existed: wind 290° at 2 knots, visibility 6 km in drizzle, broken, cloud base at 500 feet above ground level, temperature 2 °C, dew point 1 °C, QNH 1032 hPa. The aircraft began its take-off roll at 16:54:10 UTC in darkness. The landing lights were on and the flaps were fully retracted. After take-off at 16:54:31 UTC the landing gear was retracted. Then, on the commander's order, the flight director (FD) was switched on and the NAV mode was armed. Both pilots confirmed that the long range navigation system number 1 (LRN 1) was following the track (LRN 1 captured). The commander controlled the aircraft in a stable climb with a pitch of 15° attitude nose up (ANU) and a speed of 136 knots indicated airspeed (KIAS). For the remaining flight, the autopilot was never engaged. Since the cloud base was indicated as 500 ft above ground level (AGL), it can be assumed that the aircraft, once above an altitude of approx. 1900 ft above mean sea level (AMSL) entered instrument meteorological conditions (IMC). The initial flight path, at a heading of 276°, followed the centre line of the runway. After the request from TWR, CRX 498 switched to the departure control frequency (DEP) at 16:55:07 UTC. The radar recording then showed a deviation in the flight path by 5° to the south. However, this slight deviation was reduced before waypoint DME 2.1 KLO was reached by initiating a right turn. At 16:55:15 UTC flight CRX 498 was cleared to climb to flight level 110. At 16:55:39 UTC, Zurich departure issued the instruction to turn to VOR ZUE: "four nine eight, turn left to Zurich East". The first officer confirmed by radio: "turning left to Zurich East, Crossair four niner eight". At the same time the aircraft reached waypoint DME 2.1 KLO. At this point the departure procedure ZUE1Y specifies a left turn, in order to capture and follow radial 255 of VOR KLO. At 16:55:45 the bank angle to the left reached a maximum of 16.9° on a compass heading of 270°. At 16:55:47 UTC the first officer informed the commander that the LRN system was programmed from the present position to ZUE: "from present, LRN is to Zurich East, yeah". The commander confirmed with: "checked". The left turn instruction from DEP was not mentioned. After the aircraft had remained briefly at a 16° bank angle to the left, it began to roll to the right. From 16:55:47 UTC the bank angle rate amounted to 3°/s to the right. In this phase the first officer was very busy carrying out the orders routinely issued by the commander ("CTOT/APR off, yaw damper on, bleed air on"). All relevant flight parameters in this phase indicated a stable climb with a pitch of 13-14° ANU. The communication being conducted internally did not give any indication of difficulties of any kind. At 16:55:55 UTC, at a bank angle of 8.4° to the right, the bank angle rate increased and the nose of the aircraft began to drop from 14.2° to 10.8° ANU. At 16:56:00 UTC the right bank angle attained a value of 31.0°, when the commander gave the order to set climb power: "set climb power". The first officer confirmed with a whispered "coming" and began to set the climb power – a procedure which takes quite some time. Between 16:56:03 UTC and 16:56:10 UTC the commander stabilized the bank angle to the right between 39° and 42° by corresponding flight control inputs. The pitch reduced further and stabilized at a value of 1° ANU at 16:56:06 UTC as a result of corresponding elevator inputs for four seconds. As a consequence, the trajectory reached its maximum altitude of 4720 ft AMSL. According to information from the crew of the preceding flight SWR 014 the cloud top at that time was approx. 5000 ft AMSL. The speed of the aircraft involved in the accident increased to 158 KIAS. 16:56:10 UTC marked the beginning of a nine-second period which was characterized by destabilization of the attitude. It featured uncoordinated deflections of the ailerons to the left and right. Meanwhile, the elevator remained practically in the neutral position. Since the rightward deflections of the aileron were dominant, the bank angle increased from 42° to 80° to the right. Given the neutral position of the elevator, because of the high bank angle the pitch increased to 25° attitude nose down (AND). The aircraft therefore quickly lost altitude and its speed increased to 207 KIAS. At 16:56:12 UTC the first officer made the commander aware that they should turn left to ZUE: "turning left to Zurich East, we should left". At 16:56:15 UTC, at a bank angle of 65.8° to the right, the commander muttered unclearly: "ohna-na". Three seconds later at 16:56:18 UTC, DEP requested confirmation that the aircraft was turning to the left: "Crossair four nine eight, confirm you are turning left". The first officer responded immediately: "moment please, standby". DEP then instructed the crew to continue the right turn: "ok, continue right to Zurich East." In the final phase of flight, beginning at 16:56:20 UTC, the aircraft went into a spiral dive. As a result of massive aileron deflections, the aircraft attained a maximum bank angle of 137° to the right. The engines still provided high power, since setting of climb power had not yet been terminated. At a speed of 250 KIAS the over speed warning horn sounded. At 16:56:24 UTC the first officer vigorously warned the commander to turn left: "turning left, left, left, left... left!" At the end of the data recording at 16:56:25 UTC the aircraft still exhibited a bank angle of 76° to the right. The nose of the aircraft had dropped to 63° AND at an air speed of 285 KIAS. Several witnesses observed the aircraft breaking out of the clouds in a steep descent and performing a right turn. At 16:56:27.2 UTC the aircraft crashed in an open field near Au, Nassenwil, ZH. None of the three crew members and seven passengers survived the impact.
Probable cause:
The accident is attributable to a collision with the ground, after the flight crew had lost control of the aircraft for the following reasons:
• The flight crew reacted inappropriately to the change in departure clearance SID ZUE 1Y by ATC.
• The co-pilot made an entry in the FMS, without being instructed to do so by the commander, which related to the change to the SID ZUE 1 standard instrument departure. In doing so, he omitted to select a turn direction.
• The commander dispensed with use of the autopilot under instrument flight conditions and during the work-intensive climb phase of the flight.
• The commander took the aircraft into a spiral dive to the right because, with a probability bordering on certainty, he had lost spatial orientation.
• The first officer took only inadequate measures to prevent or recover from the spiral dive.
The following factors may have contributed to the accident:
• The commander remained unilaterally firm in perceptions which suggested a left turn direction to him.
• When interpreting the attitude display instruments under stress, the commander resorted to a reaction pattern (heuristics) which he had learned earlier.
• The commander’s capacity for analysis and critical assessment of the situation were possibly limited as a result of the effects of medication.
• After the change to standard instrument departure SID ZUE 1Y the crew set inappropriate priorities for their tasks and their concentration remained one-sided.
• The commander was not systematically acquainted by Crossair with the specific features of western systems and cockpit procedures.
Final Report:

Crash of an Embraer EMB-110P1A Bandeirante in Abuja: 2 killed

Date & Time: Jan 5, 2000 at 1325 LT
Operator:
Registration:
5N-AXL
Survivors:
Yes
Schedule:
Lagos - Abuja - Ilorin
MSN:
110-455
YOM:
1984
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On final approach to Abuja-Nnamdi Azikiwe Airport runway 22, the crew declared an emergency and reported smoke in the cockpit and cabin. Shortly later, the aircraft stalled and crashed 120 metres short of runway. A passenger and one people on the ground were killed while 12 other occupants were injured.

Crash of a De Havilland DHC-6 Twin Otter 300 in Simara: 10 killed

Date & Time: Dec 25, 1999 at 1502 LT
Operator:
Registration:
9N-AFL
Flight Phase:
Survivors:
No
Site:
Schedule:
Simara - Kathmandu
MSN:
796
YOM:
1982
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
The twin engine aircraft departed Simara Airport at 1457LT on a schedule flight to Kathmandu with 10 people on board. Three minutes after takeoff, while climbing in marginal weather conditions, the aircraft struck the slope of Mt Burja Lek located few km from the airport. The aircraft disintegrated on impact and all 10 occupants were killed. At the time of the accident, the visibility was estimated to be 5 km with low ceiling.
Probable cause:
Controlled flight into terrain after the crew failed to follow the correct route after takeoff and continued at an insufficient altitude until the aircraft collided with terrain.

Crash of a Cessna T207A Skywagon in Bethel

Date & Time: Dec 24, 1999 at 1045 LT
Operator:
Registration:
N1864
Flight Phase:
Survivors:
Yes
Schedule:
Bethel – Chefornak
MSN:
207-0526
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2507
Captain / Total hours on type:
1080.00
Aircraft flight hours:
9809
Circumstances:
The certificated commercial pilot, with five passengers aboard, was departing runway 18 on a scheduled commuter flight. The pilot stated that the flight's original departure time was delayed for two hours due to ice fog, and low visibility. He said that just after takeoff, the engine surged followed by a loss of power. The airplane collided with snow-covered terrain during an off-airport emergency landing, and sustained substantial damage to the propeller, fuselage, and wings. Following retrieval of the airplane, an FAA airworthiness inspector examined the airplane, and found no mechanical anomalies. While still attached to the airplane, the engine was started and run at idle. The engine later produced full power on an engine test stand. A pilot-rated Alaska State Trooper, with extensive experience in the accident airplane make and model, examined the airplane soon after the accident. He said the wings, horizontal stabilizer, and elevators had an accumulation of frost.
Probable cause:
The pilot's failure to remove frost from the airplane prior to flight, and an inadvertent stall/mush.
Final Report: