Crash of an Airbus A310-204 in Surat Thani: 101 killed

Date & Time: Dec 11, 1998 at 1910 LT
Type of aircraft:
Operator:
Registration:
HS-TIA
Survivors:
Yes
Schedule:
Bangkok - Surat Thani
MSN:
415
YOM:
1988
Flight number:
TG261
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
132
Pax fatalities:
Other fatalities:
Total fatalities:
101
Aircraft flight hours:
23028
Aircraft flight cycles:
22031
Circumstances:
Thai Airways International flight 261, an Airbus A310, left Bangkok-Don Mueang International Airport, Thailand at 17:54 hours local time for a domestic flight to Surat Thani. At 18:26 hours, the copilot first established contact with the Surat Thani approach controller while the aircraft was 70 nautical miles away from Surat Thani Airport. The controller radioed that the crew could expect a VOR/DME instrument approach to runway 22. At that time surface wind was calm with a visibility of 1500 meters, light rain and a cloud base of 1800 feet. At 18:39 hours the copilot contacted Surat Thani aerodrome controller and reported over the Intermediate Fix (IF). The controller informed him that the precision approach path indicators (PAPI) on the right side of runway 22 were unserviceable while the left lights were in use. At 18:41 hours, the copilot reported passing final approach fix (FAF). The controller informed the pilot that the aircraft was not in sight but it was cleared to land on runway 22. The surface wind was blowing from 310 degrees at a velocity of 5 knots so the pilots should be careful or the slippery runway. At 18:42 hours, the copilot reported that the runway was in sight and later on the controller also had the aircraft in sight. The pilot decided to go-around. The controller asked the pilot about the distance where the runway could be seen. The copilot reported that it could be seen at 3 nautical miles and requested for the second approach. The controller requested to report over FAF . When the copilot reported that the flight was over the FAF again, the controller cleared the flight to land although he again could not see the runway. When the flight crew failed to observe the runway lights, the captain decided to go around again. Again the controller instructed the flight to report over the FAF and reported that visibility had decreased to 1,000 meters in light rain. At 19:05, after reporting over the FAF, the flight was cleared to land on runway 22. The flight maintained the Minimum Descent Altitude (MDA) but the crew were unable to see the runway. The autopilot was disconnected and a little later the captain decided to go around. The pitch attitude increased continuously. The pitch attitude reached approximately 40°, when the pilot applied the elevator decreasing the pitch attitude to 32-33°. When he discontinued applying elevator the pitch increased to 47-48°. Consequently the speed decreased to 100 knots. The captain was not aware of the attitude due to stress and the expectation that the go around was flown exactly like the first two go-arounds. The airplane lost altitude until it impacted terrain to the left of the runway. 45 people survived and 101 others were killed, including 11 crew members.
Probable cause:
After careful consideration. the Aircraft Accident Investigation Committee of the Kingdom of Thailand ultimately came to the conclusion that the accident occurred because the aircraft entered into stall condition which might be caused by the followings:
1. The pilot attempted to approach the airport in lower than minimum visibility with rain.
2. The pilot could not maintain the VOR course as set forth in the approach chart. The aircraft flew left of VOR course on every approach.
3. The pilots suffered from the accumulation of stress and were not aware of the situation until the aircraft emerged into the upset condition.
4. The pilots had not been informed of the document concerning the wide-body airplane upset recovery provided by Airbus Industrie for using in pilot training.
5. The lighting system and approach chart did not facilitate the low visibility approach.
6. Stall warning and pitch trim systems might not fully function as described in the FCOM and AMM.

Crash of a Britten-Norman BN-2A-26 Islander off Baie-Comeau: 7 killed

Date & Time: Dec 7, 1998 at 1111 LT
Type of aircraft:
Operator:
Registration:
C-FCVK
Flight Phase:
Survivors:
Yes
Schedule:
Baie-Comeau – Rimouski
MSN:
2028
YOM:
1981
Flight number:
ASJ501
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
1000
Captain / Total hours on type:
400.00
Aircraft flight hours:
9778
Circumstances:
Air Satellite=s Flight 501 was scheduled to fly from the airport at Baie-Comeau, Quebec, to Rimouski. After a five-hour delay because of adverse weather conditions, the Britten-Norman aircraft, serial number 2028, took off at 1109 eastern standard time. Eight passengers and two pilots were on board. The reported ceiling was 800 feet, the sky was obscured, and visibility was 0.5 statute mile in moderate snow showers. Shortly after take-off, the aircraft, which was climbing at approximately 500 feet above sea level, pitched up suddenly and became unstable when the flaps were retracted while entering the cloud layer. The pilot-in-command pushed the control column down to level the aircraft. After deciding that the aircraft could not safely continue the flight, he began turning left to return to Baie-Comeau. While turning, the aircraft rolled rapidly to the left and began to dive. The aircraft crashed into the St. Lawrence River approximately 0.5 nautical mile from shore and less than 1 nautical mile from the airport. Four passengers were fatally injured in the crash. Two passengers died while awaiting rescue, which came 98 minutes after take-off. The body of the co-pilot was carried away by the current and has not been recovered. The pilot-in-command and two passengers sustained serious injuries.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft took off with contaminated surfaces, without an inspection by the pilot-in-command. This contamination contributed to reducing the aircraft' performance and to the subsequent stall.
2. At take-off, the aircraft was more than 200 pounds over the maximum allowable take-off weight. This added weight contributed to reducing the aircraft's performance.
3. During the initial climbout, the pilot-in-command did not follow the recommended procedure when he entered an area of wind shear. Consequently, the aircraft lost more speed, contributing to the stall.
4. Insufficient altitude was available for the pilot to recover from the stall and avoid striking the water.
5. The co-pilot's shoulder harness was not installed properly. The co-pilot received serious head injuries because she was not restrained.
Findings as to Risk
1. The crew's lack of experience in the existing conditions was not conducive to effective decision making during the pre-flight planning and the flight.
2. The stall warning system was defective and, in other circumstances, could not have alerted the crew of an impending stall.
3. The crew did not transmit an emergency message after the pilot-in-command decided to return to Baie-Comeau for landing. This lack of a message delayed the rescue operation.
4. The emergency signal was not received by the Mont-Joli Flight Service Station because the Baie-Comeau remote communications outlet (RCO) was not equipped with the 121.5 MHz emergency frequency. The RCO was not required to be equipped with the emergency frequency.
5. The emergency locator transmitter (ELT) was not installed in accordance with Britten-Norman's instructions. The ELT's installation on the floor of the aircraft increased the risk of damage.
6. Transport Canada did not comply with its established audit standards for regulatory audits of the operator, thus increasing the risk that training and operational deficiencies would not be identified.
7. The emergency signal probably ceased after the ELT was ejected from its mounting plate and the antenna connection contacted the water. The ejection contributed to reducing the signal and
prevented the SARSAT (search and rescue satellite-aided tracking) system from validating the
8. One of the occupants might have had a greater chance of survival had lifejackets been on-board the aircraft. Existing regulations did not require life jackets to be carried on board.
9. The aircraft had numerous mechanical deficiencies that should have been detected by Air Satellite's staff.
10. According to the Baie-Comeau airport emergency plan, a helicopter could be used only after confirmation of a crash in water. The emergency response time was therefore longer than it could
have been.
11. The configuration of the instrument panel made it difficult to read and interpret the flight instruments from the co-pilot's seat.
12. Air Satellite's manual of standard operating procedures did not promote effective crew coordination.
13. The pilot-in-command and the co-pilot had not taken courses in crew resource management or pilot decision making. These courses would have promoted effective crew coordination but were not required under existing regulations.
14. The high turnover of flight personnel and the repeated changes in the position of company chief pilot did not allow adequate supervision of operations.
Final Report:

Crash of an Avro 748-335-2A in Iqaluit

Date & Time: Dec 3, 1998 at 1536 LT
Type of aircraft:
Operator:
Registration:
C-FBNW
Flight Phase:
Survivors:
Yes
Schedule:
Iqaluit - Igloolik
MSN:
1759
YOM:
1978
Flight number:
FAB802
Location:
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
2143
Copilot / Total hours on type:
117
Circumstances:
At approximately 1536 eastern standard time, First Air flight 802, a Hawker Siddeley HS-748-2A, serial number 1759, was on a scheduled flight from Iqaluit to Igloolik, Nunavut. On board were two flight crew, one flight attendant, one loadmaster, and three passengers. During the take-off run on runway 36, at the rotation speed (VR), the captain rotated the aircraft; however, the aircraft did not get airborne. Approximately seven seconds after VR, the captain called for and initiated a rejected take-off. The aircraft could not be stopped on the runway, and the nose-wheel gear collapsed as the aircraft rolled through the soft ground beyond the end of the runway. The aircraft hit the localizer antenna and continued skidding approximately 700 feet. It came to rest in a ravine in a nose-down attitude, approximately 800 feet off the declared end of the runway. The flight attendant initiated an evacuation through the left, main, rear cabin door. The two pilots evacuated the aircraft through the cockpit windows and joined the passengers and the flight attendant at the rear of the aircraft. The flight attendant was slightly injured during the sudden deceleration of the aircraft. The aircraft was substantially damaged.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The captain rejected the take-off at a speed well above the engine-failure recognition speed (V1) with insufficient runway remaining to stop before the end of the runway.
2. The far-forward position of the centre of gravity contributed to the pilot not rotating the aircraft to the normal take-off attitude.
3. The aircraft never achieved the required pitch for take-off. The captain=s inability to accurately assess the pitch attitude was probably influenced by the heavier than normal elevator control forces and the limited nighttime visual references.
4. The loadmaster did not follow the company- and Transport Canada-approved procedures to evaluate the excess baggage added to the aircraft, which led to a discrepancy of 450 pounds and a C of G position further forward than expected.
5. The performance analysis suggested that the aircraft was under-rotated as a result of a forward C of G loading and the generated lift never exceeded the aircraft=s weight during the take-off attempt.
Findings as to Risk:
1. The aircraft was approximately 200 pounds over maximum gross take-off weight.
2. The aircraft accelerated more slowly than normal, probably because of the snow on the runway.
3. Although atmospheric conditions were conducive to contamination and the aircraft was not de-iced, it could not be determined if contamination was present or if it degraded the aircraft performance during the attempted take-off.
4. Water methanol was not used for the occurrence take-off. Use of water methanol may have reduced the consequences of the rejected take-off.
5. The captain did not call for the overrun drill, and none of the items on the checklist were covered by the crew.
6. The co-pilot did not follow the emergency checklist and call air traffic control to advise of the rejected take-off or call over the public address system to advise the passengers to brace.
7. The aircraft lost all its electrical systems during the impact with the large rocks, rendering the radios unserviceable.
8. No HS-748 simulator exists that could be used to train pilots on the various take-off and rejected take-off scenarios.
9. There was confusion regarding the aircraft=s location. The flight service station, fire trucks, and intervening teams were not using an available grid map for orientation.
10. There is a risk associated with not de-icing aircraft before take-off in weather conditions such as those on the day of the accident.
11. There is a risk associated with not calculating the WAT limit and performance of an aircraft during an engine-out procedure in an environment with obstacles.
Other Findings
1. The aircraft=s brakes, anti-skid system, and tires functioned properly throughout the rejected take-off.
Final Report:

Crash of a Swearingen SA226AC Metro II in Río Gallegos

Date & Time: Nov 23, 1998 at 1445 LT
Type of aircraft:
Registration:
LV-WDV
Survivors:
Yes
Schedule:
Lago Argentino - Río Gallegos
MSN:
TC-271
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Lago Argentino Airport, a red warning light came on in the cockpit panel, informing the crew about the incomplete retraction of the left main gear. The crew proceeded to a visual inspection and after confirmation that the left main gear was properly secured in its wheel well, the crew decided to continue to Río Gallegos. On approach, the left main gear did not deploy. After the crew failed to extend it manually, he raised the other landing gear and completed a belly landing. On short final, just prior to flare, both engines were shut down and their propellers were feathered. The aircraft landed on its belly, slid for few dozen metres and came to rest. All seven occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
The crew completed a belly landing after it was impossible to extend the left main gear due to the deformation and fracture of the brace support of the gear's extension system. The following contributing factors were reported:
- The left main gear suffered previous incident,
- Marginal weather conditions with rain falls and unfavorable wind component,
- The crew started operations with know deficiencies,
- Inappropriate maintenance and technical controls.

Crash of a Cessna 207A Skywagon in Koror: 9 killed

Date & Time: Nov 17, 1998
Registration:
RP-C606
Survivors:
No
MSN:
207-0105
YOM:
1969
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The single engine airplane was completing a charter flight with seven passengers and two pilots on board. While approaching Koror Airport, the crew encountered poor weather conditions with limited visibility due to heavy rain falls. The crew decided to abandon the approach and made a go-around procedure. Few minutes later, a second attempt to land was also abandoned, as well as a third and a fourth attempt. During the fifth approach, the aircraft crashed few km from the airport, killing all nine occupants. It was reported that the crew was trying to land under VFR mode in IMC conditions.

Ground collision of an Ilyushin II-62M in Anchorage

Date & Time: Nov 11, 1998 at 0133 LT
Type of aircraft:
Operator:
Registration:
RA-86564
Flight Phase:
Survivors:
Yes
Schedule:
Anchorage - San Francisco
MSN:
4934734
YOM:
1979
Crew on board:
12
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Ilyushin II-62M was parked at gate with its 12 crew members on board, awaiting the passengers for the next leg to San Francisco. An Asiana Boeing 747-400 (HL7414) was taxiing to gate N6 for a refueling stop on the flight Seoul - New York (flight 211). While trying to make a U-turn, the Boeing's n°1 engine struck the wing of the Ilyushin. Then the left winglet struck the base of the Ilyushin's tail. The Asiana crew added more power causing the wing to cut through nearly half of the tail of the Russian aircraft. The maximum ground speed recorded by the on-board recorders was 16 knots, while according to the company flight manual it should have been "10 knots or below (5 knots if wet or slippery)".
Probable cause:
The excessive taxi speed by the pilot of the other aircraft. A factor associated with the accident was the other pilot's inadequate maneuver to avoid the parked airplane.

Crash of a Boeing 737-2P6 in Atlanta

Date & Time: Nov 1, 1998 at 1848 LT
Type of aircraft:
Operator:
Registration:
EI-CJW
Survivors:
Yes
Schedule:
Atlanta - Dallas
MSN:
21355
YOM:
1977
Flight number:
FL867
Crew on board:
5
Crew fatalities:
Pax on board:
100
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
4976
Copilot / Total hours on type:
167
Aircraft flight hours:
45856
Aircraft flight cycles:
49360
Circumstances:
The first officer of AirTran Airways flight 890, which preceded AirTran flight 867 in the accident airplane, identified and reported a leak from the right engine of the Boeing 737-200 during a postflight inspection at William B. Hartsfield Atlanta International Airport (ATL), Georgia. AirTran mechanics at ATL identified the source of the leak as a chafed hydraulic pressure line to the right thrust reverser. They found the part in the illustrated parts catalog (IPC), which was not designed as a troubleshooting document and does not contain sufficient detail for such use. One of the mechanics telephoned an AirTran maintenance controller in Orlando, Florida, for further instructions. The mechanics who initially identified the source of the leak had little experience working on the Boeing 737 because they had worked for ValuJet Airlines, which flew DC-9s only, until ValuJet and AirTran merged in September 1997. On the basis of the information provided by the mechanic, and without questioning his description of the line or verifying the part number that he had provided against the IPC or some other appropriate maintenance document, the maintenance controller instructed the mechanic to cap the leaking line and deactivate the right thrust reverser in accordance with AirTran's Minimum Equipment List procedures. However, instead of capping the hydraulic pressure line, the mechanics capped the right engine hydraulic pump case drain return line. The mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems; no leaks were detected. Although the mechanics were not required by company procedures to test their repair by running the engines, this test would have alerted the mechanics that they had incorrectly capped the hydraulic pump case drain line, which would have overpressurized the hydraulic pump and caused the hydraulic pump case seal to rupture. However, because the mechanics did not perform this test, the overpressure and rupture occurred during the airplane's climb out, allowing depletion of system A hydraulic fluid. Depletion of system A hydraulic fluid activated the hydraulic low-pressure lights in the cockpit, which alerted the flight crew that the airplane had a hydraulic problem. The crew notified air traffic control that the airplane would be returning to ATL and subsequently declared an emergency. The flight crew's initial approach to the airport was high and fast because of the workload associated with performing AirTran's procedures for the loss of hydraulic system A and the limited amount of time available to perform the procedures. Nevertheless, the crew was able to configure and stabilize the airplane for landing. However, depletion of system A hydraulic fluid disabled the nosewheel steering, inboard flight spoilers, ground spoilers, and left and right inboard brakes. The flight crew was able to land the airplane using the left thrust reverser (the right thrust reverser was fully functional but intentionally deactivated by the mechanics), outboard brakes (powered by hydraulic system B), and rudder. The flight crew used the left thrust reverser and rudder in an attempt to control the direction of the airplane down the runway, but use of the rudder pedals in this manner had depleted the system A accumulator pressure, which would have allowed three emergency brake applications. The use of the right outboard brake without the right inboard brake at a higher-than-normal speed (Vref for 15-degree flaps is faster than Vref for normal landing flaps) and with heavy gross weight (the airplane had consumed only 4,650 pounds of the 28,500 pounds of fuel on board at takeoff) used up the remaining friction material on the right outboard brake, causing it to fail. (The left outboard brake was still functional at this point.) The lack of brake friction material on the right outboard brake caused one of the right outboard brake pistons to overtravel and unport its o-ring, allowing system B hydraulic fluid to leak out; as a result, the left outboard brake also failed. Loss of the left and right inboard and outboard brakes, loss of nosewheel steering, and use of asymmetric thrust reverse caused the flight crew to lose control of the airplane, which departed the left side of the runway and came to rest in a ditch.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
(1) the capping of the incorrect hydraulic line by mechanics, which led to the failure of hydraulic system A;
(2) the mechanics' lack of experience working with the Boeing 737 hydraulic system; and
(3) the maintenance controller's failure to ascertain more information regarding the leaking hydraulic line before instructing the mechanics to cap the line and deactivate the right thrust reverser.
Contributing to the cause of the accident were:
(1) the asymmetric directional control resulting from the deactivation of the right thrust reverser;
(2) the depletion of the left and right inboard brake accumulator pressure because of the flight crew's use of the rudder pedals with only the left thrust reverser to control the direction of the airplane down the runway;
(3) the failure of the right outboard brake because the airplane was slowed without the use of the left and right inboard brakes and was traveling at a higher-than-normal speed and with heavy gross weight;
(4) the failure of the right outboard brake after one of the right outboard pistons overtraveled and unported its o-ring, allowing system B hydraulic fluid to deplete and the left outboard brake to fail; and
(5) the mechanics' improper use of the illustrated parts catalog for maintenance and troubleshooting and the maintenance controller's failure to use the appropriate documents for maintenance and troubleshooting.
Final Report:

Crash of a PZL-Mielec AN-2R on Mt Masin

Date & Time: Oct 12, 1998
Type of aircraft:
Operator:
Registration:
RA-33668
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Sibay - Ufa
MSN:
1G234-17
YOM:
1989
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Sibay Airport with 13 passengers and a crew of three including one inspector. Despite marginal weather conditions, the crew initiated the flight under VFR mode. After takeoff, the crew failed to follow the departure route and deviated from the published one. About half an hour into the flight, weather conditions deteriorated with low clouds. After the aircraft entered clouds, the captain decided to return to Sibay but this decision was taken too late. At this time, the aircraft was off course by 45 km to the northeast of the initial route. While making a turn to the left, still in the clouds, the crew failed to realize his altitude was too low when, at an altitude of 980 metres, the aircraft collided with trees and crashed on the slope of Mt Masim (1,040 metres high). All 16 occupants were rescued, among them three passengers were injured.
Probable cause:
The following findings were identified:
- Poor flight planning and preparation,
- The crew decided to continue the flight under VFR mode in IMC conditions,
- The crew deviated from the initial course and then continued over mountainous terrain below the minimum prescribed altitude,
- The flight inspector failed to verify that the crew prepared the flight according to published procedures,
- Lack of ATC assistance,
- Lack of visibility due to low clouds.

Crash of a Boeing 747SP-44 in Maputo

Date & Time: Oct 5, 1998 at 0955 LT
Type of aircraft:
Operator:
Registration:
ZS-SPF
Flight Phase:
Survivors:
Yes
Schedule:
Maputo - Lisbon
MSN:
21263
YOM:
1977
Country:
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Maputo Airport, while climbing, the engine n°3 failed, exploded and caught fire. Debris struck the engine n°4 and punctured the right wing and a fuel tank, causing a severe fire. The crew was cleared for an immediate return. Following a normal approach and landing, the aircraft was stopped on the main runway and all 66 occupants evacuated safely. The aircraft was considered as damaged beyond repair.

Crash of an Antonov AN-24RV off Iranativu Island: 55 killed

Date & Time: Sep 29, 1998 at 1354 LT
Type of aircraft:
Operator:
Registration:
EW-46465
Flight Phase:
Survivors:
No
Schedule:
Palaly - Colombo
MSN:
27307901
YOM:
1972
Flight number:
LNS602
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
48
Pax fatalities:
Other fatalities:
Total fatalities:
55
Aircraft flight hours:
42442
Circumstances:
The aircraft departed Palaly Airport at 1340LT on a schedule flight to Colombo, carrying 48 passengers and seven crew members. While climbing to an altitude of 8,000 feet, the captain contacted ATC and reported a cabin depressurization following an explosion. The aircraft entered an uncontrolled descent and crashed in the sea some 2 km south of Iranativu Island, 45 km south of Jaffna. The aircraft disintegrated on impact and all 55 occupants were killed. About 30% of the debris were found in May 2013.
Probable cause:
It was determined that the aircraft was shot down by a LTTE (Liberation Tigers of Tamil Eelam) rebels surface-to-air missile.