Crash of a Piper PA-31-350 Navajo Chieftain in Nome

Date & Time: Feb 19, 2009 at 1812 LT
Operator:
Registration:
N41185
Survivors:
Yes
Schedule:
Brevig Mission – Nome
MSN:
31-8553001
YOM:
1985
Flight number:
FTA8218
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
24850
Captain / Total hours on type:
7500.00
Aircraft flight hours:
10928
Circumstances:
The scheduled commuter flight was about 10 miles north of the destination airport, operating under a special visual-flight-rules clearance, and descending for landing in instrument meteorological conditions. According to the pilot he started a gradual descent over an area of featureless, snow-covered, down-sloping terrain in whiteout and flat light conditions. During the descent a localized snow shower momentarily reduced the pilot’s forward visibility and he was unable to discern any terrain features. The airplane collided with terrain in an all-white snow/ice field and sustained substantial damage. At the time of the accident the destination airport was reporting visibility of 1.5 statute miles in light snow and mist, broken layers at 900 and 1,600 feet, and 3,200 feet overcast, with a temperature and dew point of 25 degrees Fahrenheit. The pilot reported that there were no pre accident mechanical problems with the airplane and that the accident could have been avoided if the flight had been operated under an instrument-flight-rules flight plan.
Probable cause:
The pilot's continued flight into adverse weather and his failure to maintain clearance from terrain while on approach in flat light conditions.
Final Report:

Crash of a HESA IrAn-140-100 in Isfahan: 5 killed

Date & Time: Feb 16, 2009
Type of aircraft:
Operator:
Registration:
90-04
Flight Type:
Survivors:
No
Schedule:
Isfahan - Isfahan
MSN:
90-04
YOM:
2007
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew was performing a training flight on behalf of the Iranian constructor HESA (Iran Aircraft Manufacturing Industrial Company) which built the Antonov AN-140 under licence with the name HESA IrAn-140-100. On final approach to Isfahan-Shahin Shahr-HESA Airport, the aircraft crashed in unknown circumstances and was destroyed. All five occupants, one instructor and four pilots under training, were killed.

Crash of an Avro RJ100 in London-City

Date & Time: Feb 13, 2009 at 2040 LT
Type of aircraft:
Operator:
Registration:
G-BXAR
Survivors:
Yes
Schedule:
Amsterdam - London-City
MSN:
E3298
YOM:
1997
Flight number:
BA8456
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4730
Captain / Total hours on type:
2402.00
Circumstances:
Following a normal touchdown, the fracture of the nose landing gear main fitting allowed the nose gear to collapse rearwards and penetrate the lower fuselage, causing significant damage to the equipment bay and the battery to become disconnected. The penetration of the fuselage allowed smoke and fumes produced by the consequent release of hydraulic fluid to enter the cockpit and passenger cabin. With the battery disconnected and after the engines were shut down, all power to the aircraft PA systems was lost and the remote cockpit door release mechanism became inoperative. No pre-accident defects were identified with the manual cockpit door release mechanism or the PA system.
Probable cause:
The nose landing gear main fitting failed following the formation of multiple fatigue cracks within the upper section of the inner bore, originating at the base of machining grooves in the bore surface. These had formed because the improved surface finish, introduced by SB 146-32-150, had not been properly embodied at previous overhaul by Messier Services Inc, despite their overhaul records showing its incorporation. The operator had been in full compliance with the Service Bulletin relating to regular inspection of the main fitting, and embodiment of SB 146-32-150 at overhaul removed the requirement for these inspections by the operator.
Final Report:

Crash of a De Havilland Dash-8-Q402 in Buffalo: 50 killed

Date & Time: Feb 12, 2009 at 2217 LT
Operator:
Registration:
N200WQ
Survivors:
No
Site:
Schedule:
Newark - Buffalo
MSN:
4200
YOM:
2008
Flight number:
CO3407
Crew on board:
4
Crew fatalities:
Pax on board:
45
Pax fatalities:
Other fatalities:
Total fatalities:
50
Captain / Total flying hours:
3379
Captain / Total hours on type:
111.00
Copilot / Total flying hours:
2244
Copilot / Total hours on type:
774
Aircraft flight hours:
1819
Aircraft flight cycles:
1809
Circumstances:
On February 12, 2009, about 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post crash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.
Probable cause:
The captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.
Contributing to the accident were:
1) The flight crew’s failure to monitor airspeed in relation to the rising position of the low speed cue,
2) The flight crew’s failure to adhere to sterile cockpit procedures,
3) The captain’s failure to effectively manage the flight,
4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
Final Report:

Crash of a BAe 3201 Jetstream 31 in Heraklion

Date & Time: Feb 12, 2009 at 1723 LT
Type of aircraft:
Operator:
Registration:
SX-SKY
Survivors:
Yes
Schedule:
Rhodes – Heraklion
MSN:
829
YOM:
1988
Flight number:
SEH103
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
24000
Captain / Total hours on type:
570.00
Copilot / Total flying hours:
1800
Copilot / Total hours on type:
250
Aircraft flight hours:
13222
Aircraft flight cycles:
15349
Circumstances:
Flight SEH102/103 of 12 February 2009 was a scheduled passenger carrying flight performing the route Heraklion – Rhodes – Heraklion. The crew that was going to perform the flight reported for duty at 16:00 h. The aircraft had earlier on the same day performed, with a different flight crew, four routes (Heraklion – Rhodes – Heraklion and Heraklion – Samos – Heraklion), without any problems being reported. Nothing had been observed during the pre-flight check. The aircraft departed Heraklion at 16:55 h and landed at Rhodes at 17:35 h without incident. At 18:30 h the aircraft departed Rhodes for Heraklion, carrying three crew members and 15 passengers. The pilot flying (PF) this particular sector was the Pilot in Command (PIC). At a distance of 30 nm from Heraklion and at a altitude of 7700 ft on its descent to 3000 ft, the crew informed the Air Traffic Control that it had the runway in sight and requested and was granted clearance to perform a visual approach. The aircraft, fully configured for landing from a distance of 7nm, approached the airport for landing at runway 27. The wind information provided by the Air Traffic Control was 18 kt – 25 kt, from 210°. While approaching the runway, the PF asked the First Officer (FO) to check the angle of descent based on the APAPIs’ of the runway. The FO confirmed the correct angle of descent, saying “one white, one red”. The aircraft crossed the threshold with a speed of 112 kt and after flaring the PF reduced speed to Flight Idle and touched down with a speed of 86 kt. As the speed was being gradually reduced, the PF had difficulty with controlling the aircraft along its longitudinal axis and noticing that the aircraft was leaning somewhat to the right, reported to the FO that “the gear has broken”. Immediately afterwards, the blades of the right propeller of the aircraft struck the runway. As the aircraft continued to move with the left main landing gear wheel operating normally and the collapsed right main landing gear, folded backwards under the wing, being dragged along the runway, the crew stopped the engines, reported to the Airport Control Tower that the right landing gear had broken and requested evacuation. The aircraft stopped in the runway with its nose wheel at 4.6 m to the right of the center line, at a distance of 930 m from the point of the propeller’s first contact with the runway. Immediately afterwards the PF ordered the cabin crew to open the cabin door and evacuated the aircraft, and the FO, who observed some fuel leaking from the right engine, switched off the electrical systems and requested through the Airport Control Tower that the fire trucks, which were on their way, to throw foam on the right wing to prevent any fire being started. The passengers disembarked from the left aft door without any problems with the assistance of the cabin crew, while the fire trucks covered the right wing with foam as a preventive measure. The airport, applying the standing procedures, removed the aircraft and released the runway for operation at 22:30 h. During the period of time that runway 09/27 remained out of operation, two flights approaching the airport for landing were diverted to Chania Airport, and the departures of another three flights were delayed.
Probable cause:
CONCLUSIONS
Findings:
- The flight crew met all the requirements for the performance of the flight.
- The aircraft was airworthy.
- The aircraft’s landing gears have a life of 50,000 cycles (landings) and the interval between two overhauls is six years or 10,000 cycles, whichever comes sooner.
- The fractured landing gear had completed 23,940 cycles since new and had been subjected to an overhaul on 17.09.08. Since then and as of the date of the accident it had completed 148 cycles.
- The aircraft manufacturer had issued an SB, and the UK Civil Aviation Authority an AD, asking for tests and inspection applicable to Region “A” of the main landing gear cylinders.
- Said AD had been carried out without findings in the course of the landing gear overhaul of 17.09.08 by an EASA-Part 145 approved maintenance organization.
- On 02.01.09 a visual inspection of Region “A” of the main landing gear cylinders was carried out by the aircraft operator’s maintenance organization, in accordance with Part B of the SB, again without findings.
- On 07.02.09 and in the morning of 12.02.09 the aircraft made ‘heavy’ landings considering that vertical acceleration values of 2.8 g and 2.5 g, respectively, had been recorded. None of these landings had been recorded in the aircraft’s log in order to trigger the inspection prescribed in the aircraft’s maintenance manual after a ‘heavy’ landing.
- According to the technical examination of the fractured parts, the first crack developed in Region “A” (fracture surface “A2-B2”) increasing the loading upon the cylinder material surrounding the threaded fasteners, sites of stress concentration. The second and third cracks then initiated at the site of stress concentration and propagated within the cylinder to form fracture surfaces “A1” - “B1” in the region surrounding the threaded fasteners. The cracks and the fracture resulted from the ductile overload of the undercarriage cylinder which is likely to have resulted from a ‘heavy’ landing made by the aircraft.
Probable Causes:
Landing gear cylinder failure because of ductile overload resulting from a ‘heavy’ landing made by the aircraft.
Final Report:

Crash of a Dassault Falcon 100 in Samedan: 2 killed

Date & Time: Feb 12, 2009 at 1612 LT
Type of aircraft:
Operator:
Registration:
VP-BAF
Flight Type:
Survivors:
Yes
Schedule:
Vienna - Samedan
MSN:
210
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17269
Captain / Total hours on type:
739.00
Copilot / Total flying hours:
2591
Copilot / Total hours on type:
119
Aircraft flight hours:
6386
Circumstances:
On 12 February 2009, the Marcel Dassault/Bréguet Aviation Falcon 10 aircraft, registration VP-BAF, took off at 14:06 UTC from Vienna (LOWW) on a private flight under instrument flight rules (IFR) and an ATC flight plan Y, to Samedan (LSZS). Two crew members and one passenger were on board. After an uneventful flight, the IFR flight plan was cancelled at 14:56:32 UTC and the flight continued under visual flight rules (VFR). Over Samedan the crew were informed by the Samedan airport flight information service officer (FISO) that snow clearance work would be taking place on the runway and that they should expect a ten-minute delay. After approximately 15 minutes the crew initiated the approach. On landing, the aircraft made first contact with the ground by scraping the right wing on the left half of the runway and subsequently touched down with the right, and then the left main landing gear. It then drifted to the left and the left wing tip scraped a bank of snow running parallel to the runway. As a result it rotated anti-clockwise around its vertical axis and crashed into a frozen bank of snow about four metres high. The aircraft broke into two pieces as a result of the force of the impact. The two pilots suffered fatal injuries on the impact. The passenger was seriously injured. The aircraft was destroyed. Fire did not break out.
Probable cause:
The accident is attributable to the fact that the crew wanted to make a landing with inadequate visual references from an unfavorable initial position and as a result, after touchdown the aircraft collided with a snowbank running along the runway.
The following factors contributed to the accident:
• The rapidly changing weather conditions on the mountain aerodrome of Samedan were misjudged by the crew.
• A coordinated crew working method in terms of crew resource manage-ment was missing.
• The deactivation of the EGPWS, which meant that acoustic messages con-cerning the aircraft’s height above ground and bank angle were no longer available in the final phase of the approach up to the first contact with the runway.
• A snowbank up to four metres high ran along the edge of the runway.
Final Report:

Crash of a Cessna 208B Grand Caravan in Boma

Date & Time: Feb 11, 2009
Type of aircraft:
Operator:
Registration:
5Y-BUQ
Flight Type:
Survivors:
Yes
Schedule:
Juba – Boma
MSN:
208B-0366
YOM:
1993
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was completing a humanitarian flight from Juba to Boma on behalf of the World Food Program, carrying one passenger and two pilots. Upon landing at Boma Airstrip, one of the landing gear collapsed. The aircraft slid for few dozen metres before coming to rest, bursting into flames. All three occupants escaped uninjured while the aircraft was destroyed by fire.

Crash of an Embraer EMB-110P1 Bandeirante off Santo Antônio: 24 killed

Date & Time: Feb 7, 2009 at 1324 LT
Operator:
Registration:
PT-SEA
Survivors:
Yes
Schedule:
Coari - Manaus
MSN:
110-352
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
24
Captain / Total flying hours:
18870
Captain / Total hours on type:
7795.00
Copilot / Total flying hours:
1011
Copilot / Total hours on type:
635
Aircraft flight hours:
12686
Circumstances:
The twin engine aircraft departed Coari Airport at 1240LT on a charter flight to Manaus-Eduardo Gomes Airport, carrying 26 passengers and two pilots. About 30 minutes into the flight, while cruising at FL115, the crew informed ATC that the left engine failed and elected to divert to the unused Manacapuru Airfield. While approaching runway 08, the aircraft rolled to the left to an angle of 30° then crashed in the Rio Manacapuru. 24 people were killed while 4 passengers were slightly injured.
Probable cause:
The following factors were identified:
- At takeoff from Coari Airport, the total weight of the aircraft was 6,414 kg, which means 744 kg over the MTOW,
- On board were 26 passengers including 8 children while the aircraft was certified for 19 passengers,
- The left engine fuel pump was completely burnt during the accident but it could not be determined if it failed during the flight or not,
- The crew was not sufficiently trained for emergency situations,
- Poor work organisation,
- Lack of supervision from the operator concerning crew's decisions before and during flights,
- Poor crew coordination,
- Lack of crew communication,
- Non compliance with management techniques,
- Incomplete execution of the actions provided by the emergency checklist.
Final Report:

Crash of an ATR42-320 in Lubbock

Date & Time: Jan 27, 2009 at 0437 LT
Type of aircraft:
Operator:
Registration:
N902FX
Flight Type:
Survivors:
Yes
Schedule:
Fort Worth - Lubbock
MSN:
175
YOM:
1990
Flight number:
FX8284
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13935
Captain / Total hours on type:
2052.00
Copilot / Total flying hours:
2109
Copilot / Total hours on type:
130
Aircraft flight hours:
28768
Aircraft flight cycles:
32379
Circumstances:
Aircraft was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude.
Contributing to the accident were:
-the flight crew’s failure to follow published standard operating procedures in response to a flap anomaly,
-the captain’s decision to continue with the unstabilized approach
-the flight crew’s poor crew resource management,
-fatigue due to the time of day in which the accident occurred and a cumulative sleep debt which likely impaired the captain’s performance.
Final Report:

Crash of a Beechcraft F90-1 King Air in Mamuno

Date & Time: Jan 21, 2009
Type of aircraft:
Operator:
Registration:
A2-AHV
Survivors:
Yes
MSN:
LA-212
YOM:
1983
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Mamuno Airstrip, the pilot decided to initiate a go-around procedure. After the undercarriage were raised, the twin engine aircraft continued to descent and hit the runway surface. It slid for few dozen metres then veered off runway to the left and came to rest in a grassy area. The high engine temperature set the grass on fire and the aircraft was destroyed by fire. There were no injuries among the occupants.