Crash of a Beechcraft 200 Super King Air in Recife: 2 killed

Date & Time: Nov 23, 2008 at 1115 LT
Operator:
Registration:
PT-OSR
Survivors:
Yes
Site:
Schedule:
Teresina - Recife
MSN:
BB-784
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10000
Circumstances:
Following an uneventful flight from Teresina, the crew started the approach to Recife-Guararapes Airport runway 18. On final, both engines failed simultaneously. The aircraft stalled and crashed in a residential area located 5 km from the runway threshold. A passenger and a pilot were killed while eight others occupants were injured. There were no victims on the ground while the aircraft was destroyed.
Probable cause:
Double engine failure caused by a fuel exhaustion. The following contributing factors were identified:
- Poor flight planning,
- The crew failed to add sufficient fuel prior to departure from Teresina Airport,
- The fuel quantity was insufficient for the required distance,
- The crew failed to follow the published procedures,
- Overconfidence from the crew,
- Poor organisational culture on part of the operator,
- Lack of discipline and poor judgment on part of the crew,
- Lack of supervision.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Marshfield: 3 killed

Date & Time: Nov 22, 2008 at 2309 LT
Operator:
Registration:
N67TE
Flight Type:
Survivors:
No
Schedule:
Green Bay – Marshfield
MSN:
46-97364
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
749
Captain / Total hours on type:
60.00
Aircraft flight hours:
153
Circumstances:
Witnesses reported that the airplane appeared to be making a normal approach for landing when it suddenly rolled to the left, descended, and impacted the terrain about one-half mile from the runway. On arrival at the scene, the witnesses saw the airplane fully engulfed in flames. The flight was operating in night visual meteorological conditions and the runway lights were illuminated at the time of the accident. The pilot communicated no problems or difficulties while in contact with air traffic control (ATC) during the accident flight. A postaccident examination of the airframe and engine did not reveal any anomalies associated with a pre-impact failure or malfunction. Radar track data and weather observations indicated that the pilot climbed through an overcast cloud layer without the required ATC clearance, en route to his intended destination. The pilot previously had been issued a private pilot certificate with single and multi-engine airplane ratings upon successful completion of the prescribed practical tests. He was subsequently issued a commercial pilot certificate, which included the addition of an instrument airplane rating, based on military flight experience. However, a review of military records and statements from his family indicated that the pilot had never served in the military. The pilot's medical history and toxicology testing showed he had a history of back pain and was taking medication for that condition that commonly causes impairment. However, the time proximity for the pilot having taken the medication prior to the accident flight and any possible impairment, could not be determined.
Probable cause:
The pilot's failure to maintain control of the airplane during final approach for landing in night, visual meteorological conditions for undetermined reasons.
Final Report:

Crash of a Beechcraft 100 King Air in Stony Rapids

Date & Time: Nov 11, 2008 at 1817 LT
Type of aircraft:
Registration:
C-GWWQ
Flight Type:
Survivors:
Yes
Schedule:
Uranium City – Stony Rapids
MSN:
B-76
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft made a wheels up landing and skidded on runway at Stony Rapids Airport before coming to rest. Both pilots were uninjured while the aircraft was damaged beyond repair.
Probable cause:
Gear up landing for undetermined reason.

Crash of a Boeing 737-8AS in Rome

Date & Time: Nov 10, 2008 at 0756 LT
Type of aircraft:
Operator:
Registration:
EI-DYG
Survivors:
Yes
Schedule:
Hahn - Rome
MSN:
33639/2557
YOM:
2008
Flight number:
FR4102
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9883
Captain / Total hours on type:
6045.00
Copilot / Total flying hours:
600
Copilot / Total hours on type:
400
Aircraft flight hours:
2419
Aircraft flight cycles:
1498
Circumstances:
The airplane departed Hahn Airport at 0630LT on a flight to Rome-Ciampino Airport, carrying 14 passengers and a crew of 8. The first officer was the Pilot Flying on the leg whilst the captain was the Pilot Monitoring. The flight was uneventful until the approach phase at the destination airport. The aircraft established the first radio contact with Ciampino Tower, communicating that it was 9 NM from the runway and stabilised on the ILS for runway 15. The aircraft, authorized and configured for the approach, was proceeding for landing, when, at a height of 136 ft and a distance of about 300 m from the runway, the captain noticed birds on the flight trajectory. He stated "Ahi", repeated in rapid sequence. At a distance of about 100 m from the runway, the TO/GA pushbutton was activated. The first officer acknowledged: "Go around, flaps 15", setting the go around attitude. At the same time as the TO/GA was activated, the aircraft collided with a thick flock of some 90 starlings. A loud bang was heard and both engines stalled. The aircraft climbed to 173 feet and then continued to lose height, despite the nose-up command. There was a progressive speed reduction and an increase of the angle of attack until the activation of the stick shaker, which was recorded at 21 feet. The aircraft hit the ground in aerodynamic stall conditions, near taxiway AC, about half way along the total length of the runway at a vertical acceleration of 2.66g. First contact with the runway occurred with the main landing gear properly extended and with the lower part of the fuselage tail section. The left main landing gear detached from its attachment during the landing run and the lower part of the left engine nacelle came into contact with the runway. The aircraft stopped near the threshold of runway 33. The fire brigade sprayed extinguishing foam around the area where the engine nacelle had come into contact with the runway. The captain then arranged for the disembarkation of the passengers and crew using a ladder truck from the right front door, with the addition of the right rear slide, later activated and used.
Probable cause:
The accident has been caused by an unexpected loss of both engines thrust as a consequence of a massive bird strike, during the go-around manoeuvre. The loss of thrust has prevented the aircrew from performing a successful go around and has led the aircraft to an unstabilized runway contact. The following factors have contributed to the event:
- The inadequate effectiveness of bird control and dispersal measures put in place by the airport operator at the time of the accident,
- The captain decision to perform a go around, when the aircraft was at approximately 7 seconds from touchdown. The above decision was significantly influenced by:
- The lack of instructions to flight crew concerning the most suitable procedures to adopt in the case of single or multiple bird strikes in the landing phase,
- The absence of specific training in the management, by the flight crew, of the "surprise" and "startle" effects in critical phases of the flight.
Final Report:

Crash of an Antonov AN-12B in Pointe-Noire

Date & Time: Nov 10, 2008
Type of aircraft:
Registration:
UR-PLV
Flight Type:
Survivors:
Yes
MSN:
4 3 423 08
YOM:
1964
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Few minutes after takeoff from Pointe-Noire Airport, while flying 80 km away, the crew contacted ATC and declared an emergency after a fire erupted in the cargo compartment. The crew was able to return and after landing, the aircraft stopped on the main runway, bursting into flames. All six occupants escaped uninjured while the aircraft was destroyed by fire.
Probable cause:
It is believed that the fire started in the cargo bay near a generator.

Crash of a Partenavia P.68C in Gainesville: 3 killed

Date & Time: Nov 7, 2008 at 0246 LT
Type of aircraft:
Operator:
Registration:
N681KW
Flight Type:
Survivors:
No
Schedule:
Key West - Gainesville
MSN:
273
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8300
Captain / Total hours on type:
1500.00
Aircraft flight hours:
6971
Circumstances:
The pilot of the multiengine airplane was flying two passengers at night on an instrument-flight-rules flight plan. One of the passengers had been on an organ recipient waiting list and his wife was accompanying him. A viable matched organ was available at a distant hospital and the passenger had to arrive on short notice for surgery the following morning. All radio communications during the flight between the pilot and air traffic control (ATC), a flight service station (FSS), and a fixed-based operator (FBO) were routine. The pilot was aware of the weather at the destination airport, and had commented to ATC about 75 miles from the destination that the weather was "going up and down…like a real thin fog layer.” Additionally, better weather conditions prevailed at nearby suitable airports. The pilot mentioned one of those airports to ATC in the event he decided to divert. According to an employee at an FBO located at the destination airport, the pilot contacted him via radio and asked about the current weather conditions. The employee replied that the visibility was low due to fog and that he could not see the terminal lights from the FBO. The pilot then asked which of the two alternate airports was closer and the employee stated that he did not know. The employee then heard the pilot “click” the runway lights and contact the local FSS. about 5 miles from runway 29, just prior to the initial approach fix, the pilot radioed on the common traffic advisory frequency and reported a 5-mile final leg for runway 29. The FSS reported that the current weather was automated showing an indefinite ceiling of 100 feet vertical visibility and 1/4 mile visibility in fog. The pilota cknowledged the weather information. The weather was below the minimum published requirements for the instrument-landing-system (ILS) approach at the destination airport. Radar data showed that the flight intercepted and tracked the localizer, then intercepted the glideslope about 1 minute later. There were a few radar targets without altitude data due to intermittent Mode C transponder returns. The last recorded radar target with altitude indicated the airplane was at 600 feet, on glideslope and heading for the approach; however, the three subsequent and final targets did not show altitude information. The last recorded radar target was about 1.4 miles from the runway threshold. The airplane flew below glideslope and impacted 100-foot-tall trees about 4,150 feet from the runway 29 threshold. On-ground facility checks and a postaccident flight check of the ILS runway 29 approach conducted by the Federal Aviation Administration did not reveal malfunctions with the ILS. The cabin and cockpit area, including the NAV/COMM/APP, equipment were consumed by a postimpact fire which precluded viable component testing. Detailed examination of the wreckage that was not consumed by fire did not reveal preimpact mechanical malfunctions that may have contributed to the accident. Given that the pilot was aware of the weather conditions before and during the approach, it is possible that the pilot’s goal of expeditiously transporting a patient to a hospital for an organ transplant may have affected his decision to initiate and continue an instrument approach while the weather conditions were below the published minimum requirements for the approach.
Probable cause:
The pilot's failure to maintain the proper glidepath during an instrument-landing-system (ILS) approach. Contributing to the accident were the pilot's decision to initiate the ILS approach with weather below the published minimums, and the pilot's self-induced pressure to expeditiously transport an organ recipient to a hospital.
Final Report:

Crash of a Dornier DO328-100TP in Fakfak

Date & Time: Nov 6, 2008 at 1033 LT
Type of aircraft:
Operator:
Registration:
PK-TXL
Survivors:
Yes
Schedule:
Sorong - Fakfak
MSN:
3037
YOM:
1995
Flight number:
XAR9000
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10190
Captain / Total hours on type:
2365.00
Copilot / Total flying hours:
4673
Copilot / Total hours on type:
15
Aircraft flight hours:
24404
Aircraft flight cycles:
21916
Circumstances:
The aircraft touched down heavily approximately 5 meters before the touch-down area of runway 10 at Torea Airport, Fak-Fak at 01:33. The investigation found that the left main landing gear touched the ground first (5 meters before the end of the runway), and the right main landing gear touched the ground (4.5 meters from the end of the runway). It stopped on the runway, approximately 700 meters from the touch-down area. The left main landing gear fractured in two places; at the front pivot point, and the aft pivot point. The left fuselage contacted the runway surface 200 meters from the touch-down point and the aircraft slid with the left fuselage on the ground for a further 500 meters, before it stopped at the right edge of the runway. The wing tip and left propeller blade tips also touched the runway and were damaged. The passengers and crew disembarked normally; there were no injuries. Following an inspection of the landing gear and temporary replacement of the damaged left main landing gear, the aircraft was moved to the apron on 8 November 2008 at 04:00. The runway was closed for 5 days.
Probable cause:
The Digital Flight Data Recorder data showed evidence that the aircraft descended suddenly and rapidly when it was on short final approach before the aircraft was above the touchdown area. Propeller RPM was reduced suddenly and rapidly to 70% less than 10 seconds before ground contact. Given that the propellers are constant speed units, the sudden and rapid changes could not be explained other than the probability that a crew member had made the control inputs. The PIC (pilot monitoring/flight instructor) did not monitor the operation of the aircraft sufficiently to ensure timely and effective response to the pilot induced excessive sink rate.
Other Factors:
The airport did not meet the ICAO Annex 14 Standard with respect to the requirement to have runway end safety areas.
Final Report:

Crash of a Learjet 45 in Mexico City: 16 killed

Date & Time: Nov 4, 2008 at 1846 LT
Type of aircraft:
Registration:
XC-VMC
Flight Type:
Survivors:
No
Site:
Schedule:
San Luis Potosí – Mexico City
MSN:
45-028
YOM:
1999
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
4000
Captain / Total hours on type:
180.00
Copilot / Total flying hours:
11809
Copilot / Total hours on type:
57
Aircraft flight hours:
2486
Aircraft flight cycles:
2215
Circumstances:
Following an uneventful flight from San Luis Potosí, the crew was cleared to the MATEO VOR and for an ILS/DME approach to runway 05R at Mexico-Benito Juarez Intl Airport, then was instructed by ATC to increase their speed to 220 knots. The Learjet was trailing a Boeing 767-300 (Mexicana Flight 1692 from Buenos Aires), which was instructed to decrease speed to 160 knots to maintain separation with a preceding Airbus A318. At 18:41 a further instruction was given to slow down to an indicated airspeed of 150 knots. At 18:42 the Boeing 767 crossed MATEO VOR at a ground speed of 224 knots. The Learjet was following at 8 nautical miles (NM) at a ground speed of 272 knots. At 18:44 the controller instructed Mexicana Flight 1692 to slow down to the minimum approach speed. At that time, the Learjet 45 was crossing the MATEO VOR with a ground speed of 262 knots, approximately 5.7 NM behind. The controller then instructed the Learjet crew to reduce their airspeed to 180 knots. This was acknowledged but it took 16 seconds for the crew to take action. Separation between the Boeing 767 and Learjet had decreased to 3.8 NM and the Learjet entered the wake turbulence of the 767. Control was lost and the aircraft entered an uncontrolled descent, crashing on the Monte Pelvoux and Ferrocarril de Cuernavaca Avenues. The aircraft disintegrated on impact and all 9 occupants were killed as well as 7 people on the ground. Some buildings were damaged, about 20 cars were destroyed and 40 people on the ground were injured, some seriously. Among the passengers were:
Juan Camilo Mouriño Terrazo, Interior Minister,
José Luis Santiago Vasconcelos, General Attorney,
Miguel Monterrubio Cubas, Director for Social Communication.
Probable cause:
Loss of control at low altitude and subsequent impact of the aircraft with the ground after it encountered wake turbulence caused by a preceding aircraft.
The following contributing factors were identified:
- Lack of adequate crew training on Learjet 45,
- Delay of the crew to reduce the approach speed,
- Lack of Air Traffic Control to correct the excessive approach speed of the aircraft,
- Fatigue accumulated by ATC,
- Grant of flight capacity, administrative problems and probable corruption,
- Insufficient monitoring of the aircraft operator to provide maintenance and operation.
Final Report:

Crash of a Beechcraft C90 King Air in Chandigarh: 2 killed

Date & Time: Oct 29, 2008 at 1125 LT
Type of aircraft:
Operator:
Registration:
VT-EHY
Flight Type:
Survivors:
No
Schedule:
Chandigarh - Ludhiana
MSN:
LJ-1008
YOM:
1982
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3152
Captain / Total hours on type:
9.00
Copilot / Total flying hours:
664
Copilot / Total hours on type:
13
Aircraft flight hours:
6530
Circumstances:
On 29.10.2008 Punjab Government King Air C90 aircraft, VT-EHY met with an accident while operating flight from Chandigarh to Ludhiana. This accident was notified to DGCA by ATC at Ludhiana and Punjab Government officials shortly after the occurrence. The accident occurred when the aircraft was in the process of making second attempt for landing at Ludhiana Airport. The accident was investigated by Inspector of Accident under Rule 71 of Aircraft Rules, 1937. As per the obligations under ICAO Annex 13, notification was sent to USA, the country of aircraft manufacture, Canada, the country of engine manufacture and ICAO. Transport Safety Board Canada appointed an accredited representative and authorized engine manufacturer M/s P&W to associate with investigation of engines. Low visibility conditions were prevailing at Ludhiana at the time of accident. Due to which the crew located the runway late. They were estimating their position based on GPS. Though they did spot the runway at some stage of the approach, they lost sight of it again and were unable to locate it subsequently. They carried out orbits on the right side (East Side) of R/w 12 in an effort to visually locate the runway and then followed non standard procedure to land. Not comfortable with the approach, the crew decided to go around. Due to low visibility and that they probably did not want to lose the sight of the airfield, carried out non-standard go around. In their anxiety not to lose the sight of the field they descended in three orbits in the vicinity of the airfield on the west side of R/w 12, perhaps to land after making the short circuit from the right. However, due to smoke in the cockpit, severe disorientation, lack of qualification & experience on type of aircraft and on sighting the communication tower, the panic gripped the crew. In their anxiety, the control was lost and aircraft impacted the ground in the steep left bank. Aircraft was destroyed in the crash due to impact and post impact fire. Both the occupant on board died due to fire and collapsing aircraft structure.
Probable cause:
The accident occurred due to loss of control while in base leg for landing at R/W 12 after executing go around on R/W 12.
Contributory Factors:
1) Low visibility reduced the margin of safety, may have caused severe disorientation, influenced their decision and played on crew for use of non standard procedures.
2) Both the crew lacked qualification/experience and familiarity with the type of aircraft and terrain.
3) Smoke in the cockpit further reduced the margin of safety and distracted the attention of the crew.
4) Obstruction in the flight path made the crew to take severe action and led to loss of control.
5) Lack of operational control and supervision by the organisation.
Final Report:

Crash of a Lockheed P-3C-140-LO Orion at Bagram AFB

Date & Time: Oct 21, 2008
Type of aircraft:
Operator:
Registration:
158573
Flight Type:
Survivors:
Yes
MSN:
5582
YOM:
1972
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Bagram AFB, the crew encountered difficulties to decelerate properly. Unable to stop within the remaining distance, the aircraft overran, lost its right main gear and came to rest, bursting into flames. There were no injuries among the occupants and the aircraft was damaged beyond repair.