Crash of a Boeing 737-85C in Manila

Date & Time: Aug 16, 2018 at 2355 LT
Type of aircraft:
Operator:
Registration:
B-5498
Survivors:
Yes
Schedule:
Xiamen – Manila
MSN:
37574/3160
YOM:
2010
Flight number:
MF8667
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On August 16, 2018, about 1555UTC/2355H local time, a Boeing 737-800 type of aircraft with Registry No. B-5498 operating as flight CXA 8667 sustained substantial damage following a runway excursion after second approach while landing on Runway 24 of Ninoy Aquino International Airport (NAIA), Manila, Philippines. The flight was a scheduled commercial passenger from Xiamen, China and operated by Xiamen Airlines. The one hundred fifty-seven (157) passengers and two (2) pilots together with the five (5) cabin crew and one air security officer did not sustain any injuries while the aircraft was substantially damaged. An instrument flight rules flight plan was filed. Instrument Meteorological Conditions (IMC) prevailed at the time of the accident. During the first approach, the Captain who was the pilot flying aborted the landing at 30 feet Radio Altitude (RA) due to insufficient visual reference. A second approach was considered and carried out after briefing the First Officer (FO) of the possibility of another aborted landing should the flight encounter similar conditions. The briefing included a diversion to their planned alternate airfield. The flight was “stabilized” on the second approach with flaps set at 30 degrees landing position, all landing gears extended and speed brake lever appropriately set in the ARM position. On passing 1,002 feet Radio Altitude (RA), the autopilot was disengaged; followed by the disengagement of the auto-throttle, three (3) seconds later. The ILS localizer lateral path and Glide slope vertical path were accurately tracked and no deviations were recorded. The “reference” landing speed for flaps 30 for the expected aircraft gross weight at the time of landing was 145 knots and a target speed of 150 knots was set on the Mode Control Panel (MCP). The vertical descent rate recorded during the approach was commensurate with the recommended descent rate for the profile angle and ground speed; and was maintained throughout the approach passing through the Decision Altitude (DA) of 375 feet down to 50 feet radio altitude (RA). As the aircraft passed over the threshold, the localizer deviation was established around zero dot but indicated the airplane began to drift to the left of the centerline followed by the First Officer (FO) making a call out of “Go-Around” but was answered by the Captain “No”. The throttle levers for both engines were started to be reduced to idle position at 30 feet RA and became fully idle while passing five (5) feet RA. At this point, the aircraft was in de-crab position prior to flare. At 13 feet RA, the aircraft was rolling left and continuously drifting left of the runway center line. At 10 feet RA another call for go-around was made by the FO but was again answered by the Captain with “No” and “It’s Okay”. At this point, computed airspeed was approximately 6 knots above MCP selected speed and RA was approaching zero feet. Just prior to touchdown, computed airspeed decreased by 4 knots and the airplane touched down at 151 knots (VREF+6). The wind was recorded at 274.7 degrees at 8.5 knots. Data from the aircraft’s flight data recorder showed that the aircraft touched down almost on both main gears, to the left of the runway centerline, about 741 meters from the threshold of runway 24. Deployment of the speed brakes was recorded and auto brakes engagement was also recorded. The auto brakes subsequently disengaged but the cause was undetermined. Upon touchdown, the aircraft continued on its left-wards trajectory while the aircraft heading was held almost constant at 241 degrees. After the aircraft departed the left edge of the runway, all landing gears collided with several concrete electric junction boxes that were erected parallel outside the confines of the runway pavement. The aircraft was travelling at about 147 knots as it exited the paved surface of the runway and came to rest at approximately 1,500 meters from the threshold of Runway 24, with a geographical position of 14°30’23.7” N; 121°0’59.1” E and a heading of 120 degrees. Throughout the above sequence of events from touchdown until the aircraft came to a full stop, the CVR recorded 2 more calls of “GO-AROUND” made by the FO. Throughout the landing sequence, the thrust reversers for both engines were not deployed. Throttle Lever Position (TLP) were recorded and there was no evidence of reverse thrust being selected or deployment of reversers. After the aircraft came to a complete stop, the pilots carried out all memory items and the refence items in the evacuation non-normal checklist, which includes extending the flaps to a 40 degrees position. The aircraft suffered total loss of communication and a failure in passenger address system possibly due to the damage caused by the nose gear collapsing rearwards and damaging the equipment in the E/E compartment or the E-buss wires connecting the Very High Frequency (VHF) 1 radio directly to the battery was broken. The Captain then directed the FO to go out of the cockpit to announce the emergency evacuation. The cabin crew started the evacuation of the passengers utilizing the emergency slides of the left and right forward doors. There were no reported injuries sustained by the passengers, cabin crew, flight crew or the security officer.
Probable cause:
Primary causal factors:
a. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference.
- The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline.
- The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation.
b. The Captain failed to apply sound CRM practices.
- The Captain did not heed to the First Officer call for a Go-Around.
Contributory factors:
a. Failure to apply appropriate TEM strategies. Failure of the Flight Crew to discuss and apply appropriate Threat and Error Management (TEM) strategies for the following:
- Inclement weather.
- Cross wind conditions during approach to land.
- Possibility of low-level wind shear.
- NOTAM information on unserviceable runway lights.
b. Inadequate Company Policy on Go-Around:
- Company’s Standard Operation Procedures were less than adequate in terms of providing guidance to the flight crew for call out of "Go-Around" during landing phase of the flight.
c. Runway strip inconsistent with CAAP MOS for Aerodrome and ICAO Annex 14:
- The uneven surface and concrete obstacles contributed to the damage sustained by the aircraft.
Final Report:

Crash of an Embraer ERJ-190AR in Durango

Date & Time: Jul 31, 2018 at 1523 LT
Type of aircraft:
Operator:
Registration:
XA-GAL
Flight Phase:
Survivors:
Yes
Schedule:
Durango – Mexico City
MSN:
190-00173
YOM:
2008
Flight number:
AM2431
Location:
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
98
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
1064.00
Copilot / Total flying hours:
1973
Copilot / Total hours on type:
460
Aircraft flight hours:
27257
Aircraft flight cycles:
18200
Circumstances:
The takeoff from Durango-Guadalupe Victoria Airport was initiated in poor weather conditions as a thunderstorm just passed over the airport five minutes prior to the accident. The takeoff from runway 03 was completed with a wind from 047° at 33 knots. Eight seconds after liftoff, the aircraft climbed to a height of 8 feet with a speed of 145 knots. At this time, the wind came from 103° at 11 knots. The aircraft continued to climb to 30 feet when the wind changed with a tailwind component of 22 knots from 030°. The aircraft started to descend and impacted ground, causing both engines to be torn off. The aircraft continued, overran and slid for 380 metres before coming to rest, bursting into flames. All 103 occupants were evacuated and 39 were injured, 14 seriously. The aircraft was totally destroyed by a post crash fire. At the time of the accident, weather conditions were poor with thunderstorm activity, heavy rain falls and strong winds. Notable variations in wind components were noticed at the time of the accident.
Probable cause:
Impact against the runway caused by loss of control of the aircraft in the final phase of the take-off run by low altitude windshear that caused a loss of speed and lift. The following contributing factors were reported:
- Decrease in situational awareness of the flight crew when the commander was performing unauthorized instructional tasks without being qualified to provide flight instruction and to assign copilot and Pilot Flying duties to a an uncertified and unlicensed pilot,
- Failure to detect variations in the indicator displayed by the airspeed indicator on the PFD during the take-off run,
- Lack of adherence to sterile cabin procedures and operational procedures (TVC; Changes of runway and/or take off conditions after door closings; Take off in adverse windshear conditions) established in the Flight Operations Manual, the Dispatch Manual and the Standard Operating Procedures,
- Lack of adherence to published procedure,
- Lack of adherence to Aerodrome and meteorological information procedures,
- Lack of supervision on part of Tower personnel at Durango Airport.
Final Report:

Crash of a PZL-Mielec AN-2R in Kamako: 5 killed

Date & Time: Jul 27, 2018 at 1000 LT
Type of aircraft:
Operator:
Registration:
9S-GFS
Flight Phase:
Survivors:
Yes
Schedule:
Kamako – Nsumbula – Diboko – Tshikapa
MSN:
1G201-29
YOM:
1983
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
4371
Aircraft flight cycles:
2585
Circumstances:
The single engine airplane departed Kamako Airport on a flight to Tshikapa with intermediate stops in Nsumbula and Diboko, carrying five passengers and two pilots. After takeoff, while climbint to a height of about 3,500 feet, the crew spotted birds in the vicinity when the engine lost power. The captain decided to return to Kamako but as he was unable to maintain a safe altitude, he attempted an emergency landing when the aircraft crashed in a marshy field located 3 km from the airport, bursting into flames. The captain and a passenger survived while five other occupants were killed.
Probable cause:
It is believed that the engine lost power following a collision with a flock of birds, but the extent of damages could not be determined.
Final Report:

Crash of a Cessna 208B Grand Caravan in Mt Aberdare: 10 killed

Date & Time: Jun 5, 2018 at 1702 LT
Type of aircraft:
Operator:
Registration:
5Y-CAC
Flight Phase:
Survivors:
No
Site:
Schedule:
Kitale – Nairobi
MSN:
208B-0525
YOM:
1996
Flight number:
EXZ102
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
2352
Circumstances:
The aircraft took-off from Kitale Airstrip (HKKT) at 16.05 hours and set course to Jomo Kenyatta International Airport (HKJK) after climbing to FL 110 with ten onboard. Once established, there were slight peripheral variations in groundspeed and track. The aircraft Flight Level was sustained at 110 with some occasional deviations. Aircraft height above ground level (AGL) varied between 1,102 feet and 4,187 feet. One minute before its impact with the cliff, the aircraft was at 11,100 feet or 3,000 feet AGL, 159 knots ground speed, and tracking radial 338 NV. Immediately before radar signal was lost, the elevation of the highest ground level was 12,876 feet, the aircraft altitude was 11,200 feet, the ground speed was 156 knots, and track was radial 339 NV. Information retrieved from the Radar transcript recorded various parameters of the aircraft from 1605hrs up to 1702hrs, the time radar signal was lost. This information was consistent with information extracted from the on-board equipment the ST3400 and the aera GPS. The radar system transmits information including aircraft position in relation to NV VOR, Flight Level or altitude, ground speed, vertical speed and heading. Information retrieved from the GPS captured the last recorded time, date and location as 14:00:52, on 06/05/2018 and elevation 3,555.57 metres. The aircraft impacted the bamboo-covered terrain at an elevation of 3,645 metres at 0.36’56’’S 36 42’44’’ where the wreckage was sited. The aircraft was totally destroyed by impact forces and all 10 occupants were killed.
Probable cause:
The flight crew's inadequate flight planning and the decision to fly instrument flight rules (IFR) at an altitude below the published Minimum Sector Altitude in the Standard Instrument Arrival Chart under instrument meteorological conditions (IMC), and their failure to perform an immediate escape maneuver following TAWS alert, which resulted in controlled flight into terrain (CFIT).
Contributing Factors:
1. Contributing to the accident were the operator's inadequate crew resource management (CRM) training, inadequate procedures for operational control and flight release.
2. Also contributing to the accident was the Kenya Civil Aviation Authority's failure to hold the operator accountable for correcting known operational deficiencies and ensuring compliance with its operational control procedures.
3. There was no requirement for crew to be trained in CFIT avoidance ground training tailored to the company’s operations that need to address current CFIT-avoidance technologies.
4. Use of non-documented procedure and Clearance by the ATC to fly below the published minimum sector altitude.
5. Lack of situational awareness by the radar safety controller while monitoring flights within the radar service section.
Final Report:

Crash of an Airbus A330-243 in Jeddah

Date & Time: May 21, 2018 at 2150 LT
Type of aircraft:
Operator:
Registration:
TC-OCH
Survivors:
Yes
Schedule:
Madinah - Dhaka
MSN:
437
YOM:
2001
Flight number:
SV3818
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
142
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Madinah-Mohammad Bin Abdulazziz Airport at 1724LT on a schedule service to Dhaka with 142 passengers and 10 crew members on board. At 1746LT, while cruising at FL370, the crew informed ATC about a malfunction of the green hydraulic system followed by a 'green hydraulic system reservoir low level' warning. The crew decided to return to Madinah but this was not possible due to deteriorating weather conditions, so it was decided to divert to Jeddah-King Abdulazziz Airport. Several attempts to lower the nose gear were unsuccessful and only both main landing gear seemed to be down. After a circuit to burn fuel, the crew was cleared to descent and expected to make a low pass over runway 16C but neither the control tower nor ground staff were able to confirm the nose gear extension. Eventually, the crew was cleared to land on runway 34R with the nose gear retracted. The aircraft landed 700 metres past the runway threshold and the nose landed 1,350 metres further, causing both engine nacelles to hit the runway surface. The airplane slid for few hundred metres and came to rest 700 metres from the runway end. All 152 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Boeing 737-201 in Havana: 112 killed

Date & Time: May 18, 2018 at 1210 LT
Type of aircraft:
Operator:
Registration:
XA-UHZ
Flight Phase:
Survivors:
Yes
Schedule:
Havana – Holguín
MSN:
21816/592
YOM:
1979
Flight number:
DMJ972
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
107
Pax fatalities:
Other fatalities:
Total fatalities:
112
Captain / Total flying hours:
16655
Copilot / Total flying hours:
2314
Aircraft flight hours:
69596
Aircraft flight cycles:
70651
Circumstances:
After takeoff from runway 06 at Havana-José Martí Airport, while in initial climb, the undercarriage were raised when the aircraft entered an excessive nose-up angle of 30°. It rolled to the right then descended until it struck power cables and a railway track before it disintegrated in a field located less than one km east from the airport. Three female passengers were seriously injured while 110 other occupants were killed, among them 102 Cubans, 6 Mexicans (crew) and 2 Argentinians. Three days after the accident, one of the three survivors died from her injuries. A second survivor died one week later, on May 25. The aircraft was operated by Cubana de Aviacíon under a wet lease contract from the Mexican operator Global Air (Damojh Aéreolíneas), and the service was operated under callsign DMJ972.
Probable cause:
Loss of control of the aircraft during initial climb following a chain of human errors in the preparation of the flight and the weight and balance calculation. It was determined that the crew calculated the CofG to be 17,4% while it was actually 28,5%, about 0,5% below the rear limit of 29%. Consequently, the horizontal stabilizer trim was set at 5 3/4 units instead of 3 1/4 units. This caused the aircraft to enter an excessive nose up attitude immediately after liftoff.
The following contributing factors were identified:
- Inconsistencies in crew training,
- Errors in weight and balance calculations,
- Low operational standards manifested in flight.
Final Report:

Crash of a De Havilland DHC-8-Q402 Dash-8 in Kathmandu: 51 killed

Date & Time: Mar 12, 2018 at 1419 LT
Operator:
Registration:
S2-AGU
Survivors:
Yes
Schedule:
Dhaka - Kathmandu
MSN:
4041
YOM:
2001
Flight number:
BS211
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
51
Captain / Total flying hours:
5518
Captain / Total hours on type:
2824.00
Copilot / Total flying hours:
390
Copilot / Total hours on type:
240
Aircraft flight hours:
21419
Aircraft flight cycles:
28649
Circumstances:
On March 12, 2018, a US Bangla Airlines, Bombardier DHC-8-402, S2-AGU, flight number BS211 departed Hazrat Shahjalal International Airport, Dhaka, Bangladesh at 06:51 UTC on a schedule flight to Tribhuvan International Airport (TIA), Kathmandu, Nepal. The aircraft overflew part of Bangladesh and Indian airspace en-route to Nepal. At 0641, Dhaka Ground Control contacted the aircraft requesting for its Bangladesh ADC number which was recently made mandatory a few weeks ago by Bangladesh authority for all international outbound flights. The crew provided the ADC number as 2177 as provided in the Flight Plan. The Ground Controller again asked the crew if they had the ADC for Bangladesh. At 0642, PIC then contacted the Operations to confirm the Bangladesh ADC number. As per the CVR records, changes in the PIC’s vocal pitch and language used indicated that he was agitated and experiencing high levels of stress at the time while communicating with Dhaka Ground Control and airlines operations. The aircraft finally took off at 0651. As the aircraft was in a climb phase, the PIC overheard a communication between Operations and another US Bangla aircraft regarding the fuel onboard but the PIC without verifying whether the message was meant for him or not, engaged in some unnecessary conversation with the Operations staff. The Captain's vocal pitch and language used indicated that he was very much emotionally disturbed and experiencing high level of stress. The aircraft established its first contact with Kathmandu Control at 0752:04. At 0807:49 the First Officer contacted Kathmandu Control and requested for descent. Kathmandu Control gave descend clearance to FL160 with an estimated approach time of 0826 which was acknowledged by the First Officer. At 0810 the flight was handed over to Kathmandu Approach. At 0811, Kathmandu Approach instructed the aircraft to descend to 13,500 ft and hold over GURAS. The crew inserted the HOLD in the Flight Management System. At 0813:41 Kathmandu Approach further instructed the aircraft to reduce its speed and descend to 12500 ft. At 0816 Kathmandu Approach instructed the aircraft to further descend to 11500 ft., and cleared for VOR approach RWY 02 maintaining minimum approach speed. Both the crew forgot to cancel the hold on the FMS as they were engaged in some unnecessary conversation. Upon reaching GURAS, the aircraft turned left to enter the holding pattern over GURAS, it was noticed by PIC and FO and immediately PIC made correction and simultaneously this was alerted to the crew by Approach Control also. Once realizing the aircraft flying pattern and ATC clearance, the PIC immediately selected a heading of 027° which was just 5° of interception angle to intercept the desired radial of 202° inbound to KTM. The spot wind recorded was westerly at 28kt. The aircraft continued approach on heading mode and crossed radial 202° at 7 DME of KTM VOR. The aircraft then continued on the same heading of 027° and deviated to the right of the final approach course. Having deviated to the right of the final approach path, the aircraft reached about 2-3 NM North east of the KTM VOR and continued to fly further northeast. At 0827, Kathmandu Tower (TWR) alerted the crew that the landing clearance was given for RWY 02 but the aircraft was proceeding towards RWY 20. At 0829, Tower Controller asked the crew of their intention to which the PIC replied that they would be landing on RWY 02. The aircraft then made an orbit to the right. The Controller instructed the aircraft to join downwind for RWY 02 and report when sighting another Buddha Air aircraft which was already on final for RWY 02. The aircraft instead of joining downwind leg for RWY 02, continued on the orbit to the right on a westerly heading towards Northwest of RW 20. The controller instructed the aircraft to remain clear of RWY 20 and continue to hold at present position as Buddha air aircraft was landing at RW 02 (from opposite side) at that time. After the landing of Buddha Air aircraft, Tower Controller, at 08:32 UTC gave choice to BS211 to land either at RW 20 or 02 but the aircraft again made an orbit to the right, this time northwest of RWY 20. While continuing with the turn through Southeastern direction, the PIC reported that he had the runway in sight and requested tower for clearance to land. The Tower Controller cleared the aircraft to land but when the aircraft was still turning for the RWY it approached very close to the threshold for RWY 20 on a westerly heading and not aligned with the runway. At 08:33:27 UTC, spotting the aircraft maneuvering at very close proximity of the ground and not aligned with the RWY. Alarmed by the situation, the Tower Controller hurriedly cancelled the landing clearance of the aircraft by saying, "Takeoff clearance cancelled". Within the next 15-20 seconds, the aircraft pulled up in westerly direction and with very high bank angle turned left and flew over the western area of the domestic apron, continued on a southeasterly heading past the ATC Tower and further continued at a very low height, flew over the domestic southern apron area and finally attempted to align with the runway 20 to land. During this process, while the aircraft was turning inwards and momentarily headed towards the control tower, the tower controllers ducked down out of fear that the aircraft might hit the tower building. Missing the control tower, when the aircraft further turned towards the taxi track aiming for the runway through a right reversal turn, the tower controller made a transmission by saying, "BS 211, I say again...". At 08:34 UTC the aircraft touched down 1700 meters down the threshold with a bank angle of about 15 degrees and an angle of about 25 degrees with the runway axis (approximately heading Southeast) and to the left of the center line of runway 20, then veered southeast out of the runway through the inner perimeter fence along the rough down slope and finally stopped about 442 meters southeast from the first touchdown point on the runway. All four crew members (2 cockpit crew and 2 cabin crew) and 45 out of the 67 passengers onboard the aircraft were killed in the accident. Two more passengers succumbed to injury later in hospital during course of treatment. The aircraft caught fire after 6 seconds of touchdown which engulfed major portions of the aircraft.
Probable cause:
The Accident Investigation Commission determines that the probable cause of the accident is due to disorientation and a complete loss of situational awareness in the part of crewmember. Contributing to this the aircraft was offset to the proper approach path that led to maneuvers in a very dangerous and unsafe attitude to align with the runway. Landing was completed in a sheer desperation after sighting the runway, at very close proximity and very low altitude. There was no attempt made to carry out a go around, when a go around seemed possible until the last instant before touchdown on the runway.
The following contributing factors were reported:
- Improper timing of the pre-flight briefing and the commencement of the flight departure in which the operational pre-flight briefing was given in early morning but the flight departure time was around noon and there were four domestic short flights scheduled in between.
- The PIC, who was the pilot flying, seemed to be under stress due to behavior of a particular female colleague in the company and lack of sleep the preceding night.
- A very steep gradient between the crew.
- Flight crew not having practiced visual approach for runway 20 in the simulator.
- A poor CRM between the crew.

An investigation into the captain's behaviour showed that he had history of depression while serving in the Bangladesh Air Force in 1993 and was removed from active duty after evaluation by a psychiatrist. He was re-evaluated by a psychiatrist in January 2002 and was declared to be fit for flying. Examinations in successive annual medical checks were not focused on his previous medical condition of depression, possibly because this was not declared in the self-declaration form for annual medicals. During the flight the captain was irritable, tensed, moody, and aggressive at various times. He was smoking during the flight, contrary to company regulations. He also used foul language and abusive words in conversation with the junior female first officer. He was engaged in unnecessary conversation during the approach, at a time when sterile cockpit rules were in force. The captain seemed very unsecure about his future as he had submitted resignation from this company, though only verbally. He said he did not have any job and did not know what he was going to do for living.
Final Report:

Crash of an ATR72-212 on Mt Dena: 66 killed

Date & Time: Feb 18, 2018 at 0931 LT
Type of aircraft:
Operator:
Registration:
EP-ATS
Flight Phase:
Survivors:
No
Site:
Schedule:
Tehran – Yasuj
MSN:
391
YOM:
1993
Flight number:
EP3704
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
60
Pax fatalities:
Other fatalities:
Total fatalities:
66
Captain / Total flying hours:
17926
Captain / Total hours on type:
12519.00
Copilot / Total flying hours:
1880
Copilot / Total hours on type:
197
Aircraft flight hours:
28857
Aircraft flight cycles:
28497
Circumstances:
Iranian ATR72 aircraft registered EP-ATS operated by Iran Aseman Airlines was assigned to perform a domestic scheduled passenger flight from Tehran to Yasuj on 07:55 local time. The aircraft took off from Tehran Mehrabad International Airport (0III) at 04:35 UTC. (08:05 LMT) and the flight was the first flight of the day for aircraft and the crew. The cruise flight was conducted at FL210 on airway W144 and no abnormal situation was reported by the crew and the flight was continued on Tehran ACC frequency till the time the first officer requested latest weather information of the destination by contact to Yasuj tower then requested to leave FL210 to FL170 from Tehran ACC. When the aircraft was descending to FL170 and crew calling YSJ tower the aircraft descending was continued to altitude of 15000 ft. The aircraft was approved to join overhead of the airport and perform “circling NDB approach “to land on RWY 31 at the destination aerodrome. Finally the aircraft collided with a peak lee of DENA Mountains about 8.5 miles at North far from the airport and involved accident on 06:01 UTC. The aircraft was completely destroyed as a result of collision with the mountain at the altitude of approximately 13,300 ft.
Probable cause:
The accident was happened due to many chains of considered causes but the “Human Factor” had main roll for the conclusion of the scenario. The Cockpit Crew action which has caused dangerous conditions for the flight is considered as main cause. Based on provided evidences, the errors of cockpit crew were as follows:
- Continuing to the Yasouj airport for landing against Operation manual of the Company, due to low altitude ceiling of the cloud and related cloud mass. They should divert to alternate airport,
- Descending to unauthorized altitude below minimum of the route and MSA,
- Lack of enough CRM during flight,
- Failure to complete the stall recovery (flap setting, max RPM),
- Inappropriate use of Autopilot after Stall condition,
- Inadequate anticipation for bad weather based on OM (Clouds, Turbulence, and Icing ...),
- Quick action to switch off anti-ice system and AOA,
- Failure to follow the Check lists and standard call out by both pilots.
Contributing Factors:
The contributive factors to this accident include but are not limited to the following:
- The airline was not capable to detect systematic defectives about :
- Effectiveness of crew training about Meteorology, OM, SOP,
- Enough operational supervision on pilot behaviors,
- The lack of SIGMET about Mountain Wave or Severe Mountain wave,
- Unclear procedure for stall recovery in FCOM,
- Lack of warning in aircraft manuals by manufacturer for flight crew awareness about mountain wave.
- Lack of APM System to alert crew about performance degradation.
Other Deficiencies and Short Comes:
In the process of the accident investigation, some detailed deficiencies and short comes were found and should be considered as latent conditions by related authorities:
- AD accomplishment and related monitoring,
- Sanction on aviation industries and effect on Flight safety,
- Non-standard communication between ATC and crew,
- Unclear definition of the Fully Qualified Pilot and qualified copilot in Aircrew regulation.
- Weather forecast (TAF) in the airports based on annex 3 procedure in the Civil Aviation Organization for approving alternative method of compliance for aircraft AD,s
- Search and rescue Coordination with local authorities for aviation accidents,
- Time setting of aircraft flight data recording(FDR) either by technician or pilots.
Final Report:

Crash of an Antonov AN-148-100B in Stepanovskoye: 71 killed

Date & Time: Feb 11, 2018 at 1427 LT
Type of aircraft:
Operator:
Registration:
RA-61704
Flight Phase:
Survivors:
No
Schedule:
Moscow – Orsk
MSN:
27015040004
YOM:
2010
Flight number:
6W703
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
65
Pax fatalities:
Other fatalities:
Total fatalities:
71
Captain / Total flying hours:
5039
Captain / Total hours on type:
1323.00
Copilot / Total flying hours:
860
Copilot / Total hours on type:
720
Aircraft flight hours:
16249
Aircraft flight cycles:
8397
Circumstances:
The twin engine aircraft departed runway 14R at Moscow-Domodedovo Airport at 1421LT. Six minutes later, while climbing to an altitude of 6,000 feet in light snow showers, the airplane descended then disintegrated in a snow covered field located in Argunovo, about 37 km southeast of the Airport, one minute later. The aircraft was totally destroyed and debris were scattered on more than one km. All 71 occupants were killed. Both recording systems have been recovered. A day after the crash, Russian Authorities confirmed that the aircraft was intact until the final impact with the ground. Preliminary reports indicates speed variations on all three ASI's three minutes after rotation. 50 seconds after the automatic pilot was disconnected, the airplane experienced vertical loads between 0,5 and 1,5 G. then pitched down to an angle of 35°. Five seconds prior to impact, the airplane banked right to 25°. Preliminary investigations shows that the incorrect data on ASI's was caused by icing of the Pitot tubes as the heating systems was off, apparently because the crew failed to activate it.
Probable cause:
The accident was the consequence of erroneous actions on part of the crew while climbing in instrument meteorological conditions at unreliable readings of instrument speed caused by icing (blockage with ice) of all three Pitot tubes. This caused the aircraft to become uncontrollable, enter a dive and eventually collide with the ground. The accident was then considered as a loss of control in flight (LOC-I). The investigation revealed systemic weaknesses in the identification of hazards and risk control, the inoperability of the airline's flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels, which led to the issuance of certificates of aviation personnel and the admission to the flights of the crew, which did not fully meet the qualification requirements. The following contributing factors were reported:
- Hurry of the crew in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" with the time,
- Skipping by the crew of the operation to switch on the Pitot tube heating before takeoff and failing to comply with the section of the check list "BEFORE TAKE-OFF", which provides for the control of this action,
- Design features of the An-148 aircraft in terms of the restrictions on the duration of Pitot tube heating operation on the ground, which led to the need to carry out operations to control the inclusion of Pitot tube heating and compliance with the principle of "dark cockpit" in a separate section of the "BEFORE THE FLIGHT" check list, which is performed immediately before the start of the takeoff run, which creates additional risks of missing these operations. These actions are provided in the section "ON THE RUNWAY START",
- Systematic failure of the airline's crews to comply with the "dark cockpit" principle and the requirements of the radar, which contributed to "getting used" to the takeoff with the presence of emergency and warning messages on the Integrated system and alarm indicator (KISS) and did not allow to identify the fact that the Pitot tube heating was not included. In the accident flight before takeoff, six warning messages were displayed on the KISS, including three messages about the absence of Pitot tube heating,
- Design features of the An-148 aircraft, connected with the impossibility to disable the display of a number of warning messages on the KISS even when performing the whole range of works provided for by the MMEL while ensuring the flight with delayed defects,
- Low safety culture in the airline, which was manifested in: systematic failure to record in the flight log the failures detected during the flight, as well as in the performance of flights with the failures not eliminated and/or not included in the list of delayed failures, accompanied by the corresponding messages on the KISS,
- Failure to take necessary measures in case of detection of previous facts of untimely activation of Pitot tube heating by crews based on the results of express analysis of flight information,
- Unreadiness of the crew to take actions in case of triggering the alarm "Speed of Emergency" due to the lack of appropriate theoretical training in the airline and the impossibility to work out this special situation on the flight simulation device and / or during airfield training and, as a consequence, failure to comply with the procedures provided for after triggering of this alarm,
- Absence of federal aviation regulations for certification of flight simulators, the development of which is provided for by the Air Code of the Russian Federation,
- Approval for the existing AN-148 flight simulators of the IFC Training LLC and the CTC of the Saint-Petersburg State University of Civil Aviation without taking into account their actual capabilities to reproduce special flight cases, as well as the provisions of FAR-128,
- Absence of specific values of flight parameters (engine operation mode, pitch and roll angles, etc.) in the aircraft's flight manual, which must be maintained by the crew of the airspeed alarm system, as well as absence of the situation with unreliable instrument speed readings (Unreliable Airspeed Procedure) in the list of special flight cases,
- Increased psycho-emotional tension of crew members at the final stage of the flight due to inability to understand the causes of speed fluctuations and, as a consequence, the captain falling under the influence of the "tunnel effect" with the formation of the dominating factor of speed control according to the "own" (left) airspeed indicator without a comprehensive assessment of flight parameters,
- Insufficient training of pilots in the field of human factor, methods of threat and error control and management of crew resources,
- Individual psychological peculiarities of pilots (for the captain - reduction of intellectual and behavioral flexibility, fixation on their own position with the inability (impossibility) to "hear" prompts from the second pilot; for the second pilot - violation of the organization and sequence of actions), which in a stressful situation in the absence of proper level of management of the crew resources came to the fore; loss of the captain's psychological performance (psychological stupor, psychological incapacitation), which resulted in complete loss of spatial orientation and did not allow reacting to correct prompts and actions of the co-pilot, including when triggering the PULL UP warning of the EGPWS system,
- Absence of psychological incapacitation criteria in the airline's AFM, which prevented the second pilot from taking more drastic measures,
- High annual leave arrears for special conditions, which could lead to fatigue and negatively affect the performance of the captain,
- Operation of the aircraft control system in the longitudinal channel in the reconfiguration mode with unreliable signals of instrument speed, not described in the operational documentation, related to a double increase in the transfer coefficient from the hand wheel to the steering wheel in the flight configuration and constant deviation of the steering wheel for diving (without deviation of the steering wheel) for about 60 seconds, which reduced the time required for the crew to recognize the situation.
Final Report:

Crash of a Boeing 737-82R in Trabzon

Date & Time: Jan 13, 2018 at 2325 LT
Type of aircraft:
Operator:
Registration:
TC-CPF
Survivors:
Yes
Schedule:
Ankara – Trabzon
MSN:
40879/4267
YOM:
2012
Flight number:
PC8622
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
162
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane departed Ankara-Esenboğa Airport at 2233LT bound for Trabzon. Following an uneventful flight, the crew started the approach by night to runway 11 and the landing was completed in heavy rain falls at 2325LT. After touchdown at a speed of 143 knots, the airplane rolled for about 2,400 metres then veered off runway to the left, went through a grassy area then down a steep slope. It lost its right engine and came to rest few metres above the sea. All 168 occupants evacuated safely. The right engine was sheared off and fell into the sea. According to first report, it is believed something went wrong with the right engine after touchdown (unintentional forward thrust and asymmetrical thrust).