Crash of a Beechcraft 350 Super King Air in Porto Seguro: 14 killed

Date & Time: May 22, 2009 at 2053 LT
Registration:
PR-MOZ
Flight Type:
Survivors:
No
Schedule:
São Paulo – Porto Seguro
MSN:
FL-237
YOM:
1999
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
20000
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
357
Copilot / Total hours on type:
107
Circumstances:
The twin engine aircraft departed São Paulo-Congonhas Airport at 1831LT on a private flight to Porto Seguro, carrying 12 passengers and two pilots, among them the Brazilian Businessman Roger Wright, his wife, children and grandchildren. On approach to Porto Seguro-Terravista Golf Club Airport, the crew encountered poor weather conditions and the visibility was low due to the night. On final approach to runway 15, the aircraft impacted trees located 900 metres from the runway threshold. The aircraft continued for about 700 metres then struck others trees and crashed 200 metres short of runway, bursting into flames. The aircraft was totally destroyed and all 14 occupants were killed.
Probable cause:
The crew's decision to continue the approach in poor weather conditions following a high motivation to land at destination.
The following contributing factors were identified:
- The crew failed to follow the published procedures,
- The crew did not take the bad weather conditions into consideration and took the decision to land,
- Limited visibility due to rain falls and night,
- Weather conditions affected the perception of the pilots who suffered a loss of situational awareness,
- Poor judgment of the situation and flight conditions on part of the crew,
- The crew continued the approach under VFR mode in IMC conditions,
- The crew carried out an improvised VFR approach via a GPS system,
- Excessive approach speed,
- Poor crew coordination,
- Lack of crew discipline.
Final Report:

Crash of a Lockheed C-130H Hercules in Madiun: 100 killed

Date & Time: May 20, 2009 at 0630 LT
Type of aircraft:
Operator:
Registration:
A-1325
Flight Type:
Survivors:
Yes
Schedule:
Jakarta – Madiun
MSN:
4917
YOM:
1982
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
98
Pax fatalities:
Other fatalities:
Total fatalities:
100
Circumstances:
The four engine aircraft departed Jakarta-Halim Perdana Kusuma Airport on a flight to Madiun, carrying Indonesian soldiers/officers and family members. On final approach to Madiun-Iswahyudi Airport, the crew failed to realize his altitude was too low when the aircraft collided with four houses and eventually crashed in a rice paddy field. 98 occupants as well as two people on the ground were killed while 14 other occupants were seriously injured.

Crash of a BAe 3212 Jetstream 32 in Útila: 1 killed

Date & Time: May 10, 2009 at 0200 LT
Type of aircraft:
Operator:
Registration:
YV1467
Flight Type:
Survivors:
Yes
MSN:
927
YOM:
1991
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While cruising in bad weather conditions, the crew apparently lost his orientation and decided to divert to Útila Airport. On approach, both engines failed due to fuel exhaustion. The aircraft stalled and crashed in a dense wooded area. A pilot was killed while both other occupants were injured. The aircraft was destroyed. A load of 1,500 kilos of cocaine was found in the cabine.
Probable cause:
Double engine failure on final approach due to fuel exhaustion. Illegal flight.

Crash of a McDonnell Douglas MD-90-30 in Riyadh

Date & Time: May 8, 2009 at 1558 LT
Type of aircraft:
Operator:
Registration:
HZ-APW
Flight Type:
Survivors:
Yes
Schedule:
Jeddah - Riyadh
MSN:
53513/2257
YOM:
1999
Flight number:
SVA9061
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Saudi Arabian Airlines MD-90 was substantially damaged during a runway excursion accident Riyadh (RUH). The seven crew members escaped unhurt. The airplane operated on a repositioning flight from Jeddah. During the flight, the captain discussed the use of manual spoilers during landing with the first officer. He further stated that; as he "had only around 400 hours in the aircraft" as a captain, he wanted to "see the effect' of landing with manual spoilers. He further explained that the flight provided an opportunity to "do it manually" (use manual spoilers) as it was a repositioning flight and, the weather and dry runway conditions were ideal. As such, he discussed the procedure with the first officer and elected to land with the auto ground spoiler system unarmed. The flight was uneventful. During the approach to Riyadh the Landing Checklist was completed, which included the arming of the auto ground spoiler system for landing. After the Landing Checklist was completed, the captain disarmed the auto ground spoiler system with the intention of applying manual ground spoilers after landing. The auto braking system was also not armed prior to landing. The final approach and touchdown to runway 15 Left at Riyadh were uneventful. The touchdown airspeed was 135 knots calibrated air speed (CAS). On touchdown, the captain manually extended the spoiler/speed brake lever, but did not latch it in the fully extended (EXT) position (fully aft and latched upwards). The captain then removed his right hand from the speed brake lever in order to deploy the thrust reversers. The first officer noted the movement of the spoiler/speed brake lever and called "Spoilers Deployed". Since the spoiler/speed brake lever was not fully pulled aft and latched upwards, the lever automatically returned to the forward retracted (RET) position. This movement of the spoiler/speed brake lever was not noticed by the captain and the first officer. In response, the ground spoilers re-stowed before being fully deployed and, a speed brake/flap configuration (SPD BRK/FLP CONFIG) Level 1 Amber Alert occurred. This alert occurred as the aircraft was not yet fully weight on wheels (WOW) and the aircraft still sensed a flight condition with speed brakes deployed and flaps extended beyond six degrees. Six seconds after touchdown on the right main landing gear, the nose gear touched down and the aircraft transferred to a ground condition (WOW on nose gear and main wheel spin up). The SPD BRK/FLP CONFIG alert extinguished when the nose gear oleo actuated ground shift on landing. After touchdown, the aircraft banked to the right and began to drift right of the runway centerline. In response, he applied left rudder, deployed the thrust reversers and applied left aileron. But this did not have any noticeable effect. The captain saw the approaching G4 taxiway exit and in an attempt to keep the aircraft from leaving the runway surface beyond the G4 taxiway exit, he decided to direct the aircraft towards the taxiway. He then applied a right rudder input which caused the aircraft to commence a rapid sweeping turn to the right towards the G4 taxiway exit. The aircraft left the runway at high speed, traversed the full width of the G4 taxiway, and exited the surface at its southern edge. The aircraft then entered a sand section and travelled the distance infield between the edge of the G4 taxiway and the adjacent section of taxiway GOLF. The left main landing gear collapsed during this time. The aircraft came to rest on taxiway GOLF. There was no post impact fire.
Probable cause:
Cause Related Findings
1. The Captain decided to land with manual ground spoilers when the auto ground spoiler system was fully operational.
2. The initiative by the Captain to conduct this improvised exercise contravened the Standard Operating Procedures (SOPs) and the Flight Operations Policy Manual (FOPM).
3. The auto ground spoiler system was disarmed prior to landing.
4. The spoiler/speed brake lever was partially applied manually after landing.
5. The spoiler/speed brake lever was released before it was fully extended and latched.
6. The spoiler/speed brake lever automatically retracted as per design.
7. The ground spoilers never fully deployed.
8. The loss of lift and aircraft deceleration were greatly reduced by the lack of ground spoiler deployment.
9. Brakes were not used in an attempt to control or slowdown the aircraft.
10. The Captain applied a large right rudder input with the intention of directing the aircraft onto the G4 taxiway exit.
11. The aircraft exited the runway at high speed and was travelling too fast to successfully negotiate the right turn onto the G4 taxiway.

Crash of a Douglas DC-10-30ER in Baltimore

Date & Time: May 6, 2009 at 1302 LT
Type of aircraft:
Operator:
Registration:
N139WA
Survivors:
Yes
Schedule:
Leipzig – Baltimore
MSN:
46583/292
YOM:
1979
Flight number:
WOA8535
Crew on board:
12
Crew fatalities:
Pax on board:
168
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
193.00
Copilot / Total flying hours:
6300
Copilot / Total hours on type:
373
Aircraft flight hours:
107814
Circumstances:
The flight was conducting a straight-in approach during visual meteorological conditions. The approach was backed up by an ILS and was stable at 500 feet above touchdown. The initial touchdown was firm and main landing gear rebounded, possibly bouncing slightly off the runway. Control column input and possibly momentum from the touchdown resulted in a rapid pitch down and hard nose gear impact with the runway. Wing spoilers likely did not deploy due to the main gear bounce and/or throttle position. Following the nose gear impact, the airplane pitched up as expected and the column was held in a slightly forward position. Airspeed rapidly decayed, and engine power began to increase as the airplane pitch reversed to a downward motion for a second time. One of the crew, likely the FO, called “flare flare” and the column recorded a rapid nose up input, followed by a rapid nose down input, and the nose gear again struck the runway very hard, likely causing the majority of the damage at that point. Following the second nose gear impact, column inputs stabilized at a slightly nose up command, power was set on all three engines, and the go-around was successfully executed. A slight lag in the power increase on engine number 3 may have contributed to the nose down motion leading to the second nose gear impact, although the large forward (airplane nose down) column movement appears to be a much more significant contributor. It is unclear why the engine was slower to increase. Throttle lever angle was not recorded, but the engine operated as expected for all other phases of the flight, including after the impact, therefore it is possible the pilot did not advance the number 3 throttle concurrently with the others. The captain’s flight and duty schedule complied with Federal Aviation regulations, but he experienced a demanding 10-day trip schedule prior to the incident involving multiple time zone crossings and several long duty periods, and reported difficulties sleeping prior to the accident leg. The captain was likely further affected by a digestive system upset during the accident flight. It is likely that the captain’s performance was degraded by fatigue and some degree of physical discomfort brought on by a short-term illness. The captain had recently completed upgrade training to DC-10, having previously been flying as an MD-11 first officer. The training program was fragmented over approximately ten months, and while in accordance with FAA regulations, may have adversely affected his consolidation of skills and experience.
Probable cause:
The captain’s inappropriate control inputs following a firm landing, resulting in two hard nose-gear impacts before executing a go-around. Contributing to the inappropriate control inputs was the captain’s fatigue and physical discomfort; and a possible lack of practical consolidation of skills and experience due to a protracted and fragmented training period.
Final Report:

Crash of an Antonov AN-2 at Seongnam AFB

Date & Time: May 4, 2009 at 1430 LT
Type of aircraft:
Operator:
Flight Type:
Survivors:
Yes
Schedule:
Seongnam - Seongnam
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a training flight at Seongnam AFB. On approach, the single engine aircraft stalled and crashed in a vineyard and was destroyed by a post impact fire. Both crew members escaped with minor injuries.

Crash of a PZL-Mielec AN-2T in Pokrovsk: 3 killed

Date & Time: Apr 30, 2009 at 2325 LT
Type of aircraft:
Operator:
Registration:
RF-00842
Flight Type:
Survivors:
No
Schedule:
Krasnoyarsk - Lensk - Yakutsk
MSN:
1G195-55
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was completing a positioning flight from Krasnoyarsk to Yakutsk with an intermediate stop in Lensk. The intended destination was in fact Prokovsk located about 70 km southwest of Yakutsk but the airfield was not suitable for night movements. On approach to Yakutsk-Magan Airport, the crew continued to Prokovsk where several cars were parked along the runway with their lights ON. Due to low visibility caused by night and snow falls, the crew was unable to establish a visual contact with the ground and two approaches were missed. During a third attempt to land, the aircraft collided with pine trees and power cables and crashed in an open field, bursting into flames. All three occupants were killed.
Probable cause:
The decision of the crew to land on an airfield that was not equipped for night movements.

Crash of a Boeing 737-2K9 in Guadalajara

Date & Time: Apr 27, 2009 at 1800 LT
Type of aircraft:
Operator:
Registration:
XA-MAF
Survivors:
Yes
Schedule:
Cancún – Guadalajara
MSN:
22505/815
YOM:
1981
Flight number:
GMT585
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Guadalajara-Miguel Hidalgo y Costilla Airport, the pilots encountered technical problems with the landing gear and elected to perform a low pass in front of the tower. ATC confirmed that the landing gear were not fully deployed and locked. The captain decided to perform a wheels up landing. After touchdown on runway 28, the aircraft slid for few dozen metres before coming to rest. The left engine was destroyed by fire and the aircraft was damaged beyond repair. All 116 occupants escaped uninjured.

Crash of a BAe 146-300 in Wamena: 6 killed

Date & Time: Apr 9, 2009 at 0743 LT
Type of aircraft:
Operator:
Registration:
PK-BRD
Flight Type:
Survivors:
No
Schedule:
Jayapura - Wamena
MSN:
E3189
YOM:
1990
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
8305
Captain / Total hours on type:
958.00
Copilot / Total flying hours:
12389
Copilot / Total hours on type:
191
Aircraft flight hours:
22225
Circumstances:
On the morning of 9 April 2009, a British Aerospace BAe 146-300 aircraft, registered PK-BRD, was being operated by PT. Aviastar Mandiri Airlines as a scheduled passenger and cargo flight from Sentani Airport to Wamena Airport, Papua. The crew consisted of two pilots, two flight attendants, an engineer, and a load master. The aircraft performed a go-around from the initial landing approach on runway 15 at Wamena. The flight crew positioned the aircraft on a right downwind leg for another landing approach. As the aircraft was turned towards the final approach for the second landing approach at Wamena it impacted terrain and was destroyed. All of the occupants were fatally injured. The Enhanced Ground Proximity Warning System (EGPWS) manufacturer performed simulations using data from the flight recorders, and two separate terrain data sources. The manufacturer informed the investigation that “the GPWS/EGPWS alerts recorded in the CVR were issued as designed”. However the enhanced Look-Ahead function appeared to have been inhibited following the go around. There was no evidence from the CVR that the crew had deliberately inhibited the terrain function of the EGPWS. The investigation determined that the EGPWS issued appropriate warnings to the flight crew, in the GPWS mode. The pilot in command did not take appropriate remedial action in response to repeated EGPWS warnings. The investigation concluded that flight crew’s lack of awareness of the aircraft’s proximity with terrain, together with non conformance to the operator’s published operating procedures, resulted in the aircraft’s impact with terrain. As a consequence of this accident, the operator took safety action to address deficiencies in its documentation for missed approach procedures at Wamena. As a result of this accident, the National Transportation Safety Committee (NTSC) also issued safety recommendations to the operator and to the Directorate General Civil Aviation (DGCA) to ensure that relevant documented safety procedures are implemented. During the investigation, safety issues were identified concerning modification of aircraft and DGCA approval of those modifications. While those safety issues did not contribute to the accident, they nevertheless are safety deficiencies. Accordingly, the NTSC report includes recommendations to address those identified safety issues.
Probable cause:
The crew did not appear to have awareness of the aircraft’s proximity with terrain until impact with terrain was imminent. The flight crew did not act on the Enhanced Ground Proximity Warning System aural warnings, and did not conform to the operator’s published operating procedures. Together, those factors resulted in the aircraft’s impact with terrain.
Final Report:

Crash of a Fokker F27 Friendship 400M in Bandung: 24 killed

Date & Time: Apr 6, 2009 at 1230 LT
Type of aircraft:
Operator:
Registration:
A-2703
Survivors:
No
Schedule:
Bandung - Bandung
MSN:
10538
YOM:
1976
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
24
Circumstances:
The aircraft was performing a paratroopers/skydiving mission in the region of Bandung, taking part to a military program with members of the Special Forces on board. While approaching runway 29 with 20 knots crosswind, the aircraft went out of control and crashed onto a hangar, bursting into flames. All 24 occupants were killed, among them 17 paratroopers, one instructor and 6 crew members.