Crash of a Boeing E-3C Sentry at Nellis AFB

Date & Time: Aug 28, 2009 at 1800 LT
Type of aircraft:
Operator:
Registration:
83-0008
Flight Type:
Survivors:
Yes
Schedule:
Tinker AFB - Nellis AFB
MSN:
22836/962
YOM:
1983
Crew on board:
4
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a Red Flag exercice from Tinker AFB, the aircraft was returning to Nellis AFB. Upon landing, the nose gear collapsed and the aircraft slid on the runway for few dozen metres before coming to rest, bursting into flames. All 32 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The nose gear collapsed upon landing for unknown reasons.

Crash of an Antonov AN-12BK in Brazzaville: 6 killed

Date & Time: Aug 26, 2009 at 0500 LT
Type of aircraft:
Registration:
TN-AIA
Flight Type:
Survivors:
No
Schedule:
Pointe-Noire – Brazzaville
MSN:
6 3 446 07
YOM:
1966
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft departed Pointe-Noire Airport at 0400LT on a cargo flight to Brazzaville, carrying one passenger, five crew members and a load consisting of food, one minibus and three cars. On final approach by night to Brazzaville-Maya Maya Airport, at an altitude of about 2,000 feet, the four engine aircraft went out of control and crashed near Nganga Lingolo, 11 km short of runway 05. The aircraft was totally destroyed and all six occupants were killed.

Crash of a Britten-Norman BN-2A-6 Islander off Caracas

Date & Time: Aug 16, 2009 at 1806 LT
Type of aircraft:
Registration:
YV212T
Survivors:
Yes
Schedule:
Los Roques – Caracas
MSN:
171
YOM:
1970
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
10187
Circumstances:
The twin engine airplane departed Los Roques on a charter flight to Caracas with nine passengers and one pilot on board. While approaching Caracas-Maiquetía-Simón Bolívar Airport, at a distance of about 13 km, the pilot was cleared to descend to 1,500 feet where he completed two circuits. After being cleared to descend to 1,000 feet, he flew two other circuits as he was n°7 on approach. While descending at an altitude of 600 feet, both engines failed simultaneously. The pilot ditched the aircraft some 4 km off the airport. All 10 occupants were rescued, among them three were injured. The aircraft was damaged beyond repair.
Probable cause:
Double engine failure on approach caused by a fuel exhaustion. Poor flight preparation and planning on part of the pilot who miscalculated the fuel consumption for the required trip.
Final Report:

Crash of a Beechcraft 99 Airliner in Évora: 2 killed

Date & Time: Aug 14, 2009 at 1908 LT
Type of aircraft:
Operator:
Registration:
F-BTME
Survivors:
No
Site:
Schedule:
Évora - Évora
MSN:
U-79
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
22993
Aircraft flight cycles:
17449
Circumstances:
The aircraft, a Beechcraft model BE-99, s/n U79, with French registration F-BTME, belonging to the operator “Avioarte Serviços Aéreos, Lda”, was involved all that day, 14th of August, 2009, flying locally, carrying parachutists for skydiving exercises, in the vicinity of Évora aerodrome (LPEV), working for the enterprise “Skydive”. With twelve full equipped parachutists and one pilot on board, the aircraft took-off on runway 01 at 18:47, intending to climb to an altitude of 13000ft (4000m), at which altitude the jumping would take place. When passing about 9500ft (2900m), left engine (#1) flame-out and respective propeller was automatically feathered. The pilot stop climb at around 10500ft (3200m), informed the parachutists that one engine had stopped and they should jump a little lower than it was expected, while he would proceed for landing at same aerodrome, with one engine inoperative. All parachutists left the aircraft, on sequence, but one, who, after being next to the exit, returned to the cockpit and remained on board, with the pilot. The aircraft started a dive, turning around the field, and the pilot contacted the tower on left base leg for runway 01, but said nothing about the inoperative engine or any assistance required. He was told to report on final, which he never did. He continued the approach for runway 01, with landing gear down and flaps at initial setting (13º), but keeping high speed. The aircraft made a low pass, over all runway length, without the wheels touching the ground. Once passing runway end it continued flying, the pilot increased power on right engine (#2) and the aircraft started deviating to the left, with wings levelled and without showing significant climb tendency. Observers, at the aerodrome, lost the sight of the aircraft for some moments and saw it reappearing close to Almeirim residential quarter (in the outskirts of Évora). One testimony, sited at the aerodrome, referred seeing the aircraft executing a sudden manoeuvre, like a left roll, pointing the wheels up to the sky. Moments later a collision sound was heard, the engine became silent and some flames and a black smoke cloud appeared. The aircraft collided with a residential building, in Maria Auxiliadora street, Almeirim residential quarter, sited about 1160m far from runway end, on track 330º. After the collision with the building, the aircraft fell to the ground, upside-down, a fire sparked immediately and the plane was engulfed by flames. Fire brigades from Évora, Viana do Alentejo, Montemor-o-Novo and Arraiolos arrived at the scene, promptly, but it took some time for the fire to be extinguished (after burning all aircraft fuel) and the burned bodies recovered from the wreckage.
Probable cause:
Primary Cause:
Primary cause for this accident was pilot inability, as he was not qualified to fly this class of aircraft, to carry a single engine landing or maintain directional control during go-around with one engine inoperative.
Contributory Factors:
The following were considered as Contributory factors:
- The pilot was not qualified to operate multi-engine aircrafts and had no knowledge and training to fly this kind of aircraft;
- Unsuitable fuel monitoring and omission on manufacturer recommended procedures accomplishment;
- Inadequate flying technique, without consideration to the airplane special flying characteristics;
- Inadequate supervision, by the competent authorities, on flying activities carried by pilots and aircrafts with foreign licenses and registrations, inside Portuguese territory.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Kokoda: 13 killed

Date & Time: Aug 11, 2009 at 1114 LT
Operator:
Registration:
P2-MCB
Survivors:
No
Site:
Schedule:
Port Moresby - Kokoda
MSN:
441
YOM:
1975
Flight number:
CG4684
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
2270
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
2150
Copilot / Total hours on type:
1940
Aircraft flight hours:
46700
Circumstances:
On 11 August 2009, a de Havilland Canada DHC-6 Twin Otter aircraft, registered P2-MCB, with two pilots and 11 passengers, was being operated on a scheduled regular public transport service from Port Moresby to Kokoda Airstrip, Papua New Guinea (PNG). At about 1113, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5,780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors. Prior to the accident the crew were manoeuvring the aircraft within the Kokoda Gap, probably in an attempt to maintain visual flight in reported cloudy conditions. The investigation concluded that the accident was probably the result of controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, involving a de Havilland Canada DHC-6-300 Twin Otter aircraft, registered P2-MCB, and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• Visual flight in the Kokoda Gap was made difficult by the extensive cloud coverage in the area.
• The crew attempted to continue the descent visually within the Kokoda Gap despite the weather conditions not being conducive to visual flight.
• It was probable that while manoeuvring at low level near the junction of the Kokoda Gap and Kokoda Valley, the aircraft entered instrument meteorological conditions.
• The aircraft collided with terrain in controlled flight.
Other safety factors:
• The copilot was assessed during normal proficiency checks for instrument approach procedures but was not qualified for flight in instrument meteorological conditions.
• The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
• The Civil Aviation Safety Authority Papua New Guinea surveillance of the operator did not identify the operations by the operator in contravention of Rule 91.112.
• The lack of a reliable mandatory occurrence reporting arrangement minimized the likelihood of an informed response to Papua New Guinea-specific safety risks.
• There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG).
• The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Other key findings:
• The investigation was unable to discount the possible incapacitation of the copilot as a factor in the accident.
• Although not required by the aviation rules at the time of the accident, the adoption of threat and error management training for flight crews, and of the methodology by operators would provide a tool to identify and mitigate operational risk as follows:
– by flight crews, when flight planning and during flight; and
– by operators, when developing their operational procedures.
Final Report:

Crash of an ATR72-212A in Koh Samui: 1 killed

Date & Time: Aug 4, 2009 at 1430 LT
Type of aircraft:
Operator:
Registration:
HS-PGL
Survivors:
Yes
Schedule:
Krabi – Koh Samui
MSN:
670
YOM:
2001
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
68
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following an uneventful flight from Krabi, the crew started the approach to Koh Samui Airport. Conditions at destination were marginal with stormy weather, winds and turbulences. Upon landing on runway 35, the aircraft bounced then landed a second time. It deviated from the centerline to the left, veered off runway, rolled through a grassy area and eventually collided with the concrete structure of the airport tower. The captain was killed and the copilot was seriously injured as the cockpit area was destroyed upon impact. 26 other people were injured.

Crash of an Ilyushin II-62M in Mashhad: 16 killed

Date & Time: Jul 25, 2009 at 1805 LT
Type of aircraft:
Operator:
Registration:
UP-I6208
Survivors:
Yes
Schedule:
Tehran - Mashhad
MSN:
19 51 5 2 5
YOM:
1989
Flight number:
IRX1525
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
14200
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
8294
Copilot / Total hours on type:
1319
Aircraft flight hours:
13573
Aircraft flight cycles:
3987
Circumstances:
At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline with registration, UP-I6208 and flight IRX1525 of Aria Airline flight with 169 passengers from Mehrabad International Airport/ Tehran, and it has landed at 18:05 local time on RWY 13 L in Mashhad International Airport; then it has run off from end of the runway, without considerable reduction in aircraft speed and it collided with wall of the airport and it was stopped after approximately 185 m. The mentioned aircraft has been leased by Aria Airline as ACMI, according to contract No. 002/IL-62M/ACMI. Subsequently, the ground safety unit of the airport has attended in place of occurring accident, by breaking protective fences and barbed wires of the airport, and then they evacuated passengers and extinguished fire outside of aircraft by carrying out necessary actions. 16 people were killed, 11 crew members and five passengers. All other occupants were rescued, among them 30 were injured. Accident site inspection revealed that the aircraft position had coordinates N 36,218º E 59,666º, at a road in the vicinity of the aerodrome, 1km away from the RWY-31R threshold (130º MH or 133, 5º TH) of the Mashhad airport with the azimuth of 125º (true). Power line along the road was destroyed by the right aircraft wing. Wing fuel tanks of the right wing were damaged evidenced by fuel leaking. Main and emergency exits were open. An inflatable slide was dropped down from the port side. No evidences of fire on board and at the accident site were found. First tracks of intensive braking (black tire tracks) were found at the concrete at a distance of 550 m from the departure threshold of RWY31R. The track of the main gear wheels was going along the RWY in its left part, and diverging further to the right beyond the departure threshold. At about 100m away from the threshold at the end portion of the braking way, a net barrier was found (textile aerodrome emergency braking unit).The aircraft ran over the RWY when moving along the right side of the stop way, 300m long. Beyond the end of the RWY landing gear wheels track could be clearly seen passing over a rough partly grassed surface, and crossing a dirt road. At a distance of 100m from the RWY end, where the right gear crossed the road, a destroyed tire tube was found, which presumably belonged to the right gear front wheel. At a distance of 160m from the RWY end smashed approach lights were found, and after that point the gear wheel track started to diverge to the left from the RWY centerline. The front gear wheel track further merged with the left gear wheel track and extended joining the forward airframe track. At a distance of 320 m from the RWY end another line of broken approach lights were found. Airframe structures were found before the approach lights (along the aircraft way). From that point small aircraft structure pieces were found along the whole aircraft path. 40m past the destroyed approach lights line a ditch of 0,5…1m in depth was found (with an underground pipeline) which was crossing this area from the south to the north. The south-eastern part of the aerodrome was fenced with a brick wall of 2,5m high and 0,4m thick with a concrete strip foundation. It went along the RWY there. The aircraft collided with the fence at a distance of 820m from the departure threshold (520m past the stop way end) with a heading of 105 degrees. The fence was destroyed throughout 70m. Debris of the nose part of the airframe, cockpit, passenger seats, aircraft cabin parts were found behind the fence. Earlier aerodrome employees, police and medical services found at the site and evacuated crew bodies, as well as killed and injured passengers. After the collision with the fence the aircraft kept moving for 160 m with a heading of 105 degrees and came to a stop at the road.
Probable cause:
The following findings were identified:
- The crew was not trained &acquainted with flight conditions in the Iran territory with an Iranian instructor pilot and the operation unit of Aria Airline has acted so weak regarding those mentioned subjects.
- The approach speed of aircraft was higher than recommended available airport charts & aircraft weight, however it was controllable if the crew could proceed to land correctively.
- The crew had not done correct procedure according to the aircraft Standard Operation Procedure (SOP) to use related check lists. (Descend-Approach-Landing)
- There was lack of precise coordination between flight crew on their self responsibility during the approach and landing.
- The flight crew did not pay attention to EGPWS warning, and did not take corrective action.
- The crew did not use engine reverser and spoiler systems correctly to reduce aircraft speed during the landing and consequently it caused to loose long Runway distance.
- The flight crew had not good English language proficiency. And they were poor in England language conversation.
- The Capitan of the aircraft as the pilot in command had not sufficient force and efficient management in the cockpit. (lack of Cockpit Resource Management).
- There were unauthorized actions of flight engineer for shifting engine reversers as well as lack of mutual oversight by crew members in checklist accomplishment during approach and landing.
- The crew has had disagreement about “Go around” due to unsuitable landing situations.
- Presence of General Director of airline in the cockpit had adverse psychological effect on crew efficiency behaviors.
- The DETA airline did not use correct procedure to extend engines No; 1-2-4 life time from Ukrainian company (Aerotechservice co.) and the technical manager of ARIA airline did not control and
supervise the matter accordingly.

Main Cause :
Considering those items in factual information and analysis, the main cause of this accident is “weak Cockpit management between the crew” to use correct landing techniques same as releasing Engine trust reversers – Engine shut down in unsuitable time - ….

Contributive Factors :
Some of contributive factors for this accident occurrence are noted as:
- The copilot and the flight engineer had self activity& decision without the (PIC) coordination.
- The cockpit crew was careless and not paying proper attention toward EGPWS warning.
- Psychological adverse effect on cockpit crew because of presence of General Director of Aria airline

Violation & other deficiencies:
The accident investigation team encountered some violations and deficiencies with ICAO Standards and Iran Local Authority regulation (CAO) which are descript as:
- Poor and in-sufficient supervision controlled of operation &technical manger of Aria Airline.
- The DETA airline has not used proper procedure to receive life time extension of engine and has not passed necessary information to Iranian and Kazakhstan Authorities.
- It has not been designed a headset for flight engineer to make more coordination between the crew, by the aircraft design bureau.
- The crew was not familiar with Iranian AIP completely.
- The total on board persons was not according to written load sheet.
Final Report:

Crash of a Noorduyn Norseman IV in Akiachak

Date & Time: Jul 11, 2009 at 1300 LT
Type of aircraft:
Operator:
Registration:
N225BL
Survivors:
Yes
Schedule:
Bethel – Tuluksak
MSN:
542
YOM:
1944
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
100.00
Aircraft flight hours:
15729
Circumstances:
The airline transport pilot was on a Title 14, CFR Part 135 passenger flight. The pilot said during cruise flight he heard a loud bang, and the engine started running rough. He said he diverted to the nearest airport, but the engine quit completely, and he was unable to reach the runway. The airplane subsequently collided with terrain, sustaining substantial damage to both wings and the fuselage. An examination of the engine revealed that a locking screw had backed out of one of the anti-vibration counterweights on the crankshaft, scoring the interior back surface of the engine case. The unsecured counterweight then moved from its position in the crankshaft, and was likely struck by the engine's master rod, which shattered the weight, and liberated it from its normal location. The liberated counterweight was struck by internal moving parts, creating several component failures, and ultimately an engine seizure.
Probable cause:
The loss of engine power due to the failure of a crankshaft component, resulting in an off airport landing.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Vancouver: 2 killed

Date & Time: Jul 9, 2009 at 2208 LT
Operator:
Registration:
C-GNAF
Flight Type:
Survivors:
No
Schedule:
Vancouver – Nanaimo – Victoria – Vancouver
MSN:
31-8052130
YOM:
1980
Flight number:
APEX511
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2300
Copilot / Total flying hours:
400
Circumstances:
The Canadian Air Charters Piper PA-31-350 Chieftain (registration C-GNAF, serial number 31-8052130) was operating under visual flight rules as APEX 511 on the final leg of a multi-leg cargo flight from Vancouver to Nanaimo and Victoria, British Columbia, with a return to Vancouver. The weather was visual meteorological conditions and the last 9 minutes of the flight took place during official darkness. The flight was third for landing and turned onto the final approach course 1.5 nautical miles behind and 700 feet below the flight path of a heavier Airbus A321, approaching Runway 26 Right at the Vancouver International Airport. At 2208, Pacific Daylight Time, the target for APEX 511 disappeared from tower radar. The aircraft impacted the ground in an industrial area of Richmond, British Columbia, 3 nautical miles short of the runway. There was a post-impact explosion and fire. The 2 crew members on board were fatally injured. There was property damage, but no injuries on the ground. The onboard emergency locator transmitter was destroyed in the accident and no signal was detected.
Probable cause:
Findings as to Causes and Contributing Factors:
1. APEX 511 turned onto the final approach course within the wake turbulence area behind and below the heavier aircraft and encountered its wake, resulting in an upset and loss of control at an altitude that precluded recovery.
2. The proximity of the faster trailing traffic limited the space available for APEX 511 to join the final approach course, requiring APEX 511 not to lag too far behind the preceding aircraft.
Findings as to Risk:
1. The current wake turbulence separation standards may be inadequate. As air traffic volume continues to grow, there is a risk that wake turbulence encounters will increase.
2. Visual separation may not be an adequate defence to ensure that appropriate spacing for wake turbulence can be established or maintained, particularly in darkness.
3. Neither the pilots nor Canadian Air Charters (CAC) were required by regulation to account for employee duty time acquired at other non-aviation related places of employment. As a result, there was increased risk that pilots were operating while fatigued.
4. Not maintaining engine accessories in accordance with manufacturers’ recommendations can lead to failure of systems critical to safety.
Other Finding:
1. APEX 511 was not equipped with any type of cockpit recording devices, nor was it required to be. As a result, the level of collaboration and decision making discussion between the 2 pilots remains unknown.
Final Report:

Crash of a PZL-Mielec AN-28 in Sarif-Umra

Date & Time: Jul 6, 2009 at 0950 LT
Type of aircraft:
Operator:
Registration:
ST-TYB
Flight Type:
Survivors:
Yes
Schedule:
Al Fashir - Sarif-Umra
MSN:
1AJ006-02
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10144
Captain / Total hours on type:
1269.00
Copilot / Total flying hours:
5500
Copilot / Total hours on type:
950
Aircraft flight hours:
2180
Aircraft flight cycles:
2113
Circumstances:
The flight progress strip at Al Fashir aerodrome control tower illustrate that on the 6th of July 2009 – ST-TYB, AN-28 departed Al Fashir at time 0601 UTC, estimated time to arrive destination Sarif-Umra was 0650 UTC, persons on board were two (crew only), intended flight level was 085 (VFR) re-cleared later FL105, fuel endurance was 3,5 hours, load on board as indicated on the cargo manifest was 1511 k.gm (food stuff) destined for the UNAMID forces. Aircraft center of gravity was organized. Calculated actual take off weight was 6335 k.gm and the actual landing weight was 6035 k.gm as reported by the pilot. The aircraft proceeded normally to destination at FL 105, when it reached the airfield, the pilot stated that, they started descend gradually at a speed of 250 km/h willing to check the strip serviceability and to specify the direction of landing from the located wind sock. They detected that, the strip was clear, dry and the wind was favorable to the direction of 23 (strip 23/05). As the crew established a speed of 210 km/h at an altitude of 60 meters on final approach, they saw a dust devil storm on their right crossing the air strip, to avoid this phenomena, they decided to go around for another approach. Eye witnesses confirmed the occurrence of the storm at the time the aircraft commenced the final approach. The crew reported that, they started a right turn and applied full power to gain height, but they felt that there was no response from the engines and the aircraft was influenced by a wind shear and began to sink. The crew managed to control the aircraft, but in few minutes its altitude decreased rapidly. At time 0650 UTC the aircraft impacted with the ground and rolled, there after struck a small rock and bounced, finally the aircraft impacted the ground by the left main gear and nose, and stopped at a distance of 1,850 meters from the beginning of strip 05 coordinates N 13 29.527 ـــــــ E 023 16.794. Crews (2) were safe and the aircraft sustained substantial damage.
Probable cause:
The unexpected weather phenomena at destination, and environmental conditions, wind shear and CB down drafts caused the accident.
Final Report: