Scheduled Revenue Flight

Following an uneventful flight from Ulan-Ude, the crew initiated the approach to Yakutsk-Platon Oyunsky Intl Airport Runway 23L. Due to work in progress, the runway 05R threshold was displaced by 1,150 metres, reducing the landing distance to 2,248 metres for the runway 23L on which the touchdown zone lighting system was unserviceable. On approach, the crew was informed by ATC that the friction coefficient was 0,45. The crew completed the landing on runway 23L with a slight tailwind component of 4 knots and started the braking procedure. Unable to stop within the remaining distance, the aircraft overran, entered the construction area and collided with the junction of a concrete section under reconstruction, causing both main landing gear to collapse (the left main gear was torn off). The aircraft slid for another 250 metres before coming to rest. All 92 occupants evacuated safely and the aircraft was damaged beyond repair.

On 28 September 2018, at 23:24:19 UTC2 (09:24 local time), a Boeing 737-8BK aircraft, registered P2-PXE (PXE), operated by Air Niugini Limited, was on a scheduled passenger flight number PX073, from Pohnpei to Chuuk, in the Federated States of Micronesia (FSM) when, during its final approach, the aircraft impacted the water of the Chuuk Lagoon, about 1,500 ft (460 m) short of the runway 04 threshold. The aircraft deflected across the water several times before it settled in the water and turned clockwise through 210 deg and drifted 460 ft (140 m) south east of the runway 04 extended centreline, with the nose of the aircraft pointing about 265°. The pilot in command (PIC) was the pilot flying, and the copilot was the support/monitoring pilot. An Aircraft Maintenance Engineer occupied the cockpit jump seat. The engineer videoed the final approach on his iPhone, which predominantly showed the cockpit instruments. Local boaters rescued 28 passengers and two cabin crew from the left over-wing exits. Two cabin crew, the two pilots and the engineer were rescued by local boaters from the forward door 1L. One life raft was launched from the left aft over-wing exit by cabin crew CC5 with the assistance of a passenger. The US Navy divers rescued six passengers and four cabin crew and the Load Master from the right aft over-wing exit. All injured passengers were evacuated from the left over-wing exits. One passenger was fatally injured, and local divers located his body in the aircraft three days after the accident. The Government of the Federated States of Micronesia commenced the investigation and on 14th February 2019 delegated the whole of the investigation to the PNG Accident Investigation Commission. The investigation determined that the flight crew’s level of compliance with Air Niugini Standard Operating Procedures Manual (SOPM) was not at a standard that would promote safe aircraft operations. The PIC intended to conduct an RNAV GPS approach to runway 04 at Chuuk International Airport and briefed the copilot accordingly. The descent and approach were initially conducted in Visual Meteorological Conditions (VMC), but from 546 ft (600 ft)4 the aircraft was flown in Instrument Meteorological Conditions (IMC). The flight crew did not adhere to Air Niugini SOPM and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed. The RNAV approach specified a flight path descent angle guide of 3º. The aircraft was flown at a high rate of descent and a steep variable flight path angle averaging 4.5º during the approach, with lateral over-controlling; the approach was unstabilised. The Flight Data Recorder (FDR) recorded a total of 17 Enhanced Ground Proximity Warning System (EGPWS) alerts, specifically eight “Sink Rate” and nine “Glideslope”. The recorded information from the Cockpit Voice Recorder (CVR) showed that a total of 14 EGPWS aural alerts sounded after passing the Minimum Descent Altitude (MDA), between 307 ft (364 ft) and the impact point. A “100 ft” advisory was annunciated, in accordance with design standards, overriding one of the “Glideslope” aural alert. The other aural alerts were seven “Glideslope” and six “Sink Rate”. The investigation observed that the flight crew disregarded the alerts, and did not acknowledge the “minimums” and 100 ft alerts; a symptom of fixation and channelised attention. The crew were fixated on cues associated with the landing and control inputs due to the extension of 40° flap. Both pilots were not situationally aware and did not recognise the developing significant unsafe condition during the approach after passing the Missed Approach Point (MAP) when the aircraft entered a storm cell and heavy rain. The weather radar on the PIC’s Navigation Display showed a large red area indicating a storm cell immediately after the MAP, between the MAP and the runway. The copilot as the support/monitoring pilot was ineffective and was oblivious to the rapidly unfolding unsafe situation. He did not recognise the significant unsafe condition and therefore did not realise the need to challenge the PIC and take control of the aircraft, as required by the Air Niugini SOPM. The Air Niugini SOPM instructs a non-flying pilot to take control of the aircraft from the flying pilot, and restore a safe flight condition, when an unsafe condition continues to be uncorrected. The records showed that the copilot had been checked in the Simulator for EGPWS Alert (Terrain) however there was no evidence of simulator check sessions covering the vital actions and responses required to retrieve a perceived or real situation that might compromise the safe operation of the aircraft. Specifically sustained unstabilised approach below 1,000 ft amsl in IMC. The PIC did not conduct the missed approach at the MAP despite the criteria required for visually continuing the approach not being met, including visually acquiring the runway or the PAPI. The PIC did not conduct a go around after passing the MAP and subsequently the MDA although:
• The aircraft had entered IMC;
• the approach was unstable;
• the glideslope indicator on the Primary Flight Display (PFD) was showing a rapid glideslope deviation from a half-dot low to 2-dots high within 9 seconds after passing the MDA;
• the rate of descent high (more than 1,000 ft/min) and increasing;
• there were EGPWS Sink Rate and Glideslope aural alerts; and
• the EGPWS visual PULL UP warning message was displayed on the PFD.
The report highlights that deviations from recommended practice and SOPs are a potential hazard, particularly during the approach and landing phase of flight, and increase the risk of approach and landing accidents. It also highlights that crew coordination is less than effective if crew members do not work together as an integrated team. Support crew members have a duty and responsibility to ensure that the safety of a flight is not compromised by non-compliance with SOPs, standard phraseology and recommended practices. The investigation found that the Civil Aviation Safety Authority of PNG (CASA PNG) policy and procedures of accepting manuals rather than approving manuals, while in accordance with the Civil Aviation Rules requirements, placed a burden of responsibility on CASA PNG as the State Regulator to ensure accuracy and that safety standards are met. In accepting the Air Niugini manuals, CASA PNG did not meet the high standard of evidence-based assessment required for safety assurance, resulting in numerous deficiencies and errors in the Air Niugini Operational, Technical, and Safety manuals as noted in this report and the associated Safety Recommendations. The report includes a number of recommendations made by the AIC, with the intention of enhancing the safety of flight (See Part 4 of this report). It is important to note that none of the safety deficiencies brought to the attention of Air Niugini caused the accident. However, in accordance with Annex 13 Standards, identified safety deficiencies and concerns must be raised with the persons or organisations best placed to take safety action. Unless safety action is taken to address the identified safety deficiencies, death or injury might result in a future accident. The AIC notes that Air Niugini Limited took prompt action to address all safety deficiencies identified by the AIC in the 12 Safety Recommendations issued to Air Niugini, in an average time of 23 days. The quickest safety action being taken by Air Niugini was in 6 days. The AIC has closed all 12 Safety Recommendations issued to Air Niugini Limited. One safety concern prompting an AIC Safety Recommendation was issued to Honeywell Aerospace and the US FAA. The safety deficiency/concern that prompted this Safety Recommendation may have been a contributing factor in this accident. The PNG AIC is in continued discussion with the US NTSB, Honeywell, Boeing and US FAA. This recommendation is the subject of ongoing research and the AIC Recommendation will remain ACTIVE pending the results of that research.

On 31.08.2018 Boeing 737-800 VQ-BJI operated by UTAir Airlines conducted the scheduled flight UT 579 from Moscow (Vnukovo airport) to Sochi (Adler airport). During the preflight briefing (at 19:50) the crew was provided with the necessary weather information. At 20:15, the crew had passed the medical examination at Vnukovo airport mobile RWY medical unit. The Daily Check line maintenance (DY) was done on 30.08.2018 at Vnukovo airport by UTG aviation services, ZAO; job card # 11465742. The A/C takeoff weight was 68680 kg and the MAC was 26.46 %, that was within the AFM limitations for the actual conditions. At 21:33 the takeoff from Vnukovo airport was performed. The flight along he prescribed route was performed on FL350 in auto mode and without any issues. The F/O acted as the pilot flying (PF). When approaching the Sochi aerodrome traffic control area, the flight crew was provided by the aerodrome approach control with the approach and descending conditions, as well as with the weather conditions near the aerodrome. After descending to the height specified by Sochi Approach, the pilot contacted Sochi Radar, waited for the weather that met his minimum and was cleared for landing. In course of the first approach to landing (from the altitude about 30 m) when RVR got down because of heavy showers, the PIC took controls and performed the go-around. In course of the second approach, the crew performed the landing but failed to keep the airplane within the RWY. The airplane had landed at about 1285 m from the RWY threshold, overrun the threshold, broke through the aerodrome fencing, and came to rest in Mzymta river bed. This ended with the fire outbreak of fuel leaking from the damaged LH wing fuel tank. The crew performed the passenger evacuation. The aerodrome alert measures were taken and the fire was brought under control. Eighteen occupants were injured while all other occupants were unhurt. The aircraft was damaged beyond repair.

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.

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.

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.

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.

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.

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.

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.