Scheduled Revenue Flight

The first instrument landing system (ILS) approach to runway 1 appeared to be proceeding normally until the first officer (the pilot flying) transitioned from instrument references inside the flight deck to outside references. During a postaccident interview, the first officer stated that he expected to see the runway at that time but instead saw “white on white” and a structure with an antenna that was part of the runway environment but not the runway itself. The captain (the pilot monitoring) stated that she saw a tower and called for a go-around. (Both flight crewmembers were most likely seeing the automated weather observing system wind sensor pole, which was located about 325 ft to the right of the runway 1 centerline and about 870 ft beyond the runway threshold, and the damage to the lightning arrester at the top of the wind sensor pole was likely due to contact with the accident airplane as it flew over the pole.) According to the cockpit voice recorder (CVR), after the go-around, the first officer asked the captain if she saw the runway lights during the approach. The captain responded that she saw the lights but that “it’s really white down there that’s the problem.” Airport personnel stated that snow plowing operations on the runway had finished about 10 minutes before the first approach. The CVR recorded the flight crew’s discussion about turning on the pilot-controlled runway lights and sounds similar to microphone clicks before and after the discussion. However, the PQI maintenance foreman stated that, after the first approach, the runway lights were not on. Thus, the investigation could not determine, based on the available evidence, whether the flight crew had turned on the runway lights during the first approach. The captain thought that the airplane had drifted off course when the first officer transitioned from flight instruments to the outside, so she instructed the first officer to remain on the instruments during the second approach until the decision altitude (200 ft above ground level [agl]). The second approach proceeded normally with no problems capturing or maintaining the localizer and glideslope. During this approach, the captain asked airport maintenance personnel to ensure that the runway lighting was on, and the PQI maintenance foreman replied that the lights were on “bright”(the high-intensity setting). Thus, the flight crew had a means to identify the runway surface even with the reported snow cover at the time. As the airplane approached the decision altitude, the captain instructed the first officer to disconnect the autopilot, which he did. About nine seconds later, the airplane reached the decision altitude, and the captain called, “runway in sight twelve o’clock.” This callout was followed by the first officer’s statement, “I’m stayin’ on the flight director ‘cause I don’t see it yet.” A few seconds later, while the airplane was below 100 ft agl, the captain and the first officer expressed confusion, stating “what the [expletive]” and “I don’t know what I'm see in’,” respectively, but neither called for a go-around. The airplane subsequently impacted the snow-covered grassy area between runway 1 and a parallel taxiway. During a postaccident interview, the first officer stated that, when he transitioned from flight instruments to the outside during the second approach, he again saw “white on white” as well as blowing snow and that the airplane touched down before he could determine what he was seeing. The maintenance foreman estimated that, at the time of the accident, the runway had about 1/8 inch of snow with about 20% to 25% of the runway visible.

The airplane departed Lima on a schedule service to La Paz with an intermediate stop in Cuzco, carrying 122 passengers and a crew of five. Following an uneventful flight from Cuzco-Alejandro Velasco Astete Airport, the crew completed the approach to La Paz-El Alto Airport. After touchdown, the crew started the braking procedure when both main landing gear collapsed. The airplane slid on its belly for few dozen metres before coming to rest on runway 10. All 127 occupants evacuated safely and no one was injured. It was reported that the touchdown was considered as normal. The airplane was damaged beyond repair.

On 9th November 2018, a Boeing B757-200 aircraft, registration N524AT operating as FJA256, departed SYCJ, Timehri, East Bank Demerara, Guyana, at 06:10 hrs with one hundred and twenty passengers, eight Crew Members; and eight hours and one minute of fuel on board. The aircraft was destined for CYYZ, Toronto, Canada. At approximately 06:21 hrs, when the aircraft was 75 nm northwest of SYCJ, at an altitude of 20,000 feet, the Captain reported a loss of hydraulic fluid. He requested Air Traffic Control clearance to stop climb at 20,000 feet and indicated the intention to return to SYCJ for a landing. The Captain's request was approved. He did not declare an emergency. However, after advising the Captain, the Air Traffic Controller on duty activated local emergency stand-by at the airport. The aircraft returned to SYCJ 'Holding Area' where it was configured for landing. The aircraft landed at 06:53 hrs. The final approach and touchdown appeared to be normal. As indicated by the FDR, the aircraft slowed to a speed of 60 kts. Halfway down the runway, the aircraft veered towards the right, departed the runway, and came to a stop approximately 1,400 ft beyond the end of, and perpendicular to, the active runway. The nose of the aircraft was extended over the airport fence and its nose wheel was about 30 ft short of a steep 'drop off.' The aircraft was stopped when its starboard undercarriage became embedded in thick, loose sand that was being used for the ongoing runway expansion project. The Aerodrome Rescue and Fire Fighting Service was on standby and responded immediately. The aircraft sustained major (significant) structural damages. The aircraft was evacuated via the aircraft Slides. There were reports of ten passengers suffering minor injuries and one elderly passenger subsequently died five days after the accident.

The single engine airplane departed Arkhangelsk-Vaskovo Airport on a flight to Mezen with intermediate stops in Soyana and Dolgoshchel’e, carrying 12 passengers (11 adults and one child) and two pilots. En route, weather conditions deteriorated with drizzle. The crew reduced his altitude from 400 to 300 metres when frost formed on the windshield. The captain decided to return to Arkhangelsk but the aircraft' speed dropped from 170 to 120 km/h. Unable to maintain the speed and altitude, the crew attempted an emergency landing when the aircraft collided with trees and crashed in a wooded area located about 50 km northeast of Arkhangelsk-Talaghy Airport. All 14 occupants were rescued, among them two passengers were injured. The aircraft was destroyed.

The aircraft departed runway 25L at Jakarta-Soekarno-Hatta Airport at 0621LT bound for Pangkal Pinang, carrying 181 passengers and 8 crew members. The crew was cleared to climb but apparently encountered technical problems and was unable to reach a higher altitude than 5,375 feet. At this time, the flight shows erratic speed and altitude values. The pilot declared an emergency and elected to return to Jakarta when control was lost while at an altitude of 3,650 feet and at a speed of 345 knots. The airplane entered a dive and crashed 12 minutes after takeoff into the Kerawang Sea, about 63 km northeast from its departure point. The airplane disintegrated on impact and few debris were already recovered but unfortunately no survivors. It has been reported that the aircraft suffered various technical issues during the previous flight on Sunday night but was released for service on Monday morning. Brand new, the airplane was delivered to Lion Air last August 18. At the time of the accident, weather conditions were considered as good. The Cockpit Voice Recorder (CVR) was found on 14 January 2019. In the initial stages of the investigation, it was found that there is a potential for repeated automatic nose down trim commands of the horizontal stabilizer when the flight control system on a Boeing 737 MAX aircraft receives an erroneously high single AOA sensor input. Such a specific condition could among others potentially result in the stick shaker activating on the affected side and IAS, ALT and/or AOA DISAGREE alerts. The logic behind the automatic nose down trim lies in the aircraft's MCAS (Maneuvering Characteristics Augmentation System) that was introduced by Boeing on the MAX series aircraft. This feature was added to prevent the aircraft from entering a stall under specific conditions. On November 6, 2018, Boeing issued an Operations Manual Bulletin (OMB) directing operators to existing flight crew procedures to address circumstances where there is erroneous input from an AOA sensor. On November 7, the FAA issued an emergency Airworthiness Directive requiring "revising certificate limitations and operating procedures of the airplane flight manual (AFM) to provide the flight crew with runaway horizontal stabilizer trim procedures to follow under certain conditions.

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.