Crash of a Boeing 737-2H4 in Caracas

Date & Time: Oct 16, 2008 at 1530 LT
Type of aircraft:
Operator:
Registration:
YV162T
Survivors:
Yes
Schedule:
Puerto Ordaz – Caracas
MSN:
23055/970
YOM:
1983
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 28R at Caracas-Maiquetía-Simón Bolívar Airport, the aircraft deviated to the left. It eventually veered off runway to the left and went down a slope, coming to rest with its nose gear torn off. All 54 occupants evacuated safely and aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 300 in Lukla: 18 killed

Date & Time: Oct 8, 2008 at 0731 LT
Operator:
Registration:
9N-AFE
Survivors:
Yes
Schedule:
Kathmandu – Lukla
MSN:
720
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
8185
Captain / Total hours on type:
7180.00
Copilot / Total flying hours:
556
Copilot / Total hours on type:
341
Circumstances:
The aircraft departed Kathmandu-Tribhuvan Airport at 0651LT on a regular schedule service to the Lukla-Tenzing-Hillary Airport. On approach to runway 06, the crew encountered poor visibility due to foggy conditions. Despite the pilot did not establish any visual contact with the ground, he continued the approach when, on short final, the aircraft struck a rock and crashed just below the runway 06 threshold, bursting into flames. The captain was seriously injured while 18 other occupants were killed, among them 12 Germans, 2 Australians and 5 Nepalese.
Probable cause:
Controlled flight into terrain after the captain decided to continue the approach under VFR mode in IMC conditions.

Crash of a Boeing 737-3Y0 in Kaliningrad

Date & Time: Oct 1, 2008 at 2318 LT
Type of aircraft:
Operator:
Registration:
EI-DON
Survivors:
Yes
Schedule:
Barcelona - Kaliningrad
MSN:
23812/1511
YOM:
1988
Flight number:
KNI794
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5372
Captain / Total hours on type:
1258.00
Copilot / Total flying hours:
1010
Copilot / Total hours on type:
1010
Aircraft flight hours:
48514
Aircraft flight cycles:
39949
Circumstances:
The accident aircraft Boeing 737-3Y0 EI-DON, was operated by KD Avia on a flight from Kaliningrad, Russia to Barcelona, Spain and return. Flight KD793 to Barcelona was uneventful. The return flight, KD794, departed at 16:18 with 138 passengers and six crew members on board. The copilot was Pilot Flying, the captain was Pilot Monitoring. The en route part of the flight was uneventful. As the flight was descending to Kaliningrad at night in heavy rains and with gusty crosswind. During the descent flaps were first selected at 1° and thereafter to 5°. As the flaps were transitioning to this position, a flap asymmetry warning caught the attention of the crew. At 19:00 hours the captain took over control and selected flaps to 2°, the position at which there was no asymmetry warning. The crew then contacted the controller at Kaliningrad and reported that they had flap problems. As the descent was continued, the copilot performed the necessary calculations for a landing with flaps at 2°. At 19:09 the cabin crew was warned to prepare for a high-speed landing. Using the QRH to work the flap issue, the co-pilot activated the 'flap inhibit' and 'gear inhibit' switches. This "incorrect" action effectively disconnected the ground-proximity warning system (GPWS). At 19:11 it was established that the landing speed would be Vref +30, leading to a planned landing speed of 161 knots. At 19:14 the Landing Gear Warning Horn sounded due to the combination of power and flaps setting with the fact that the landing gear had not been selected down. This warning was cancelled by the crew. When the engine power was reduced to idle, the Landing Gear Warning Horn sounded again. This time the crew did not pay attention to the warning and continued to land. The airplane performed a gear up landing, sliding for 1440 m before coming to rest on the runway. The flap asymmetry issue was caused by a faulty Flap Position Transmitter. The flaps had extended to the commanded position, but the system incorrectly detected an asymmetry issue. This issue had occurred previously on EI-DON. The sensor had been replaced prior to departure from Kaliningrad that same day.
Probable cause:
The crash was caused by aircraft landing with not extended landing gear that resulted in aircraft structure and engines damage and it was caused by combination of the following adverse factors:
- Erroneous deactivation of GPWS gear warning (voice) system that was caused by failure to perform QRH recommendations on flaps warning deactivation during their asymmetrical extension;
- Presence of QRH manual on board of Boeing-737-300 EI-DON aircraft containing in Additional Deferred Item clause of Trailing Edge Flap Asymmetry chapter recommendation to the crew which are not specialized for the board configuration;
- Violation of the "Crew operating procedure of Boeing-737-300 aircraft" and non-compliance with QRH recommendations («LANDING CHECKLIST» section) with the result that the crew did not extend landing gear and did not monitor their position;
- Stereotyping on actuation of Landing Gear Warning Horn aural warning during approach as a result of which the crew deactivated it repeatedly without monitoring of landing gear position;
- Inadequate coordination of the crew resulted in lack of monitoring of compliance with FCOM and QRH requirements at occurrence and development of abnormal situation;
Appropriate safety recommendations based on the investigation results were developed.
Following this accident, both pilots lost their licence and KD Avia's AOC was revoked by Russian authorities in September 2009. The same month, KD Avia bankrupted.
Final Report:

Crash of a Pilatus PC-12 in Santa Fe: 1 killed

Date & Time: Sep 29, 2008 at 2216 LT
Type of aircraft:
Registration:
N606SL
Flight Type:
Survivors:
No
Schedule:
New York - Lubbock - Santa Fe
MSN:
1020
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2437
Captain / Total hours on type:
86.00
Aircraft flight hours:
130
Circumstances:
The pilot was approaching his home airport under dark night conditions. He reported that he was five miles from the airport and adjusted the airport lighting several times. He made no further radio calls, though his normal practice was to report his position several times as he proceeded in the landing pattern. The airplane approached the airport from the southeast in a descent, continued past the airport, and adjusted its course slightly to the left. One witness reported observing the airplane enter a left turn, then pitch down, and descend at a steep angle. The airplane impacted terrain in a steep left bank and cart wheeled. An examination of the airframe, airplane systems, and engine revealed no pre-impact anomalies. Flight control continuity was confirmed. The pilot had flown eight hours and 30 minutes on the day of the accident, crossing two time zones, and had been awake for no less than 17 hours when the accident occurred. The accident occurred at a time of day after midnight in the pilot's departure time zone. Post-accident toxicology testing revealed doxylamine and amphetamine in the pilot's tissues. The pilot had been diagnosed with attention deficit hyperactivity disorder (ADHD) almost five years prior to the accident and had taken prescription amphetamines for the disorder since that diagnosis. The FAA does not medically certify pilots who require medication for the control of ADHD. At the time of the accident, the pilot's blood level of amphetamines may have been falling, and he may have been increasingly fatigued and distracted. The use of doxylamine (an over-the-counter antihistamine, often used as a sleep aid) could suggest that the pilot was having difficulty sleeping.
Probable cause:
The pilot's incapacitation due to fatigue resulting in an in-flight collision with terrain.
Final Report:

Crash of a De Havilland DHC-5D Buffalo in Lokichoggio

Date & Time: Sep 29, 2008
Type of aircraft:
Registration:
5Y-OPL
Flight Type:
Survivors:
Yes
MSN:
84
YOM:
1978
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Lokichoggio Airport, the airplane banked right, causing the right propeller and the right wing to struck the runway surface. The aircraft slid for few dozen metres before coming to rest. There were no injuries while the aircraft was damaged beyond repair.
Probable cause:
It is believed that the right main gear was stuck in its wheel well because the door was blocked.

Crash of an Antonov AN-24RV in Tbilisi

Date & Time: Sep 18, 2008 at 2127 LT
Type of aircraft:
Operator:
Registration:
4L-MJX
Survivors:
Yes
MSN:
1 73 070 04
YOM:
1971
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Tbilisi Airport by night, the aircraft's speed was excessive while passing over the inner marker at a height of 204 feet. Upon landing, the aircraft hit the ground with a positive aerodynamic force estimated between 1,81 and 1,97 G. The aircraft bounced several times and eventually hit the ground with a positive aerodynamic force of 4,82 G. The nose gear collapsed and punctured the cockpit floor. Then the aircraft slid for few dozen metres before coming to rest. There were no injuries while the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration and excessive speed upon landing. It appears that the approach speed over the inner marker was 224 km/h instead of 170-180 km/h according to procedures. Also, the aircraft's attitude upon landing was incorrect.

Crash of a Piper PA-60 Aerostar (Ted Smith 602P) in Kremmling: 2 killed

Date & Time: Sep 18, 2008 at 2024 LT
Registration:
N97TS
Flight Type:
Survivors:
No
Schedule:
North Las Vegas – Kremmling
MSN:
60-8265-036
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
500
Aircraft flight hours:
2786
Circumstances:
According to radar and Global Positioning System data, the pilot overflew the airport from the southwest and turned to the west to maneuver into position for landing on runway 9. Several witnesses observed the airplane to the west of the airport at a low altitude, appearing to enter a turn that was followed by a "rapid descent" and impact with the ground. The ground scars and
damage to the airplane were consistent with a near-vertical descent and impact. An examination of the airplane and its systems revealed no preaccident anomalies. The moon was obscured by an overcast sky and dark night conditions were prevalent.
Probable cause:
The pilot’s failure to maintain aircraft control, resulting in an aerodynamic stall and spin.
Final Report:

Crash of a Boeing 737-505 in Perm: 88 killed

Date & Time: Sep 14, 2008 at 0510 LT
Type of aircraft:
Operator:
Registration:
VP-BKO
Survivors:
No
Schedule:
Moscow - Perm
MSN:
25792/2353
YOM:
1992
Flight number:
AUL821
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
88
Captain / Total flying hours:
3900
Captain / Total hours on type:
1190.00
Copilot / Total flying hours:
8900
Copilot / Total hours on type:
236
Aircraft flight hours:
44533
Aircraft flight cycles:
35104
Circumstances:
On September 13, 2008 an Aeroflot –Nord flight crew (Captain and copilot), were conducting a scheduled domestic passenger flight n°AFL821 on a B737-505 aircraft, registration VP-BKO, from Moscow (Sheremetyevo, UUEE) to Perm (Bolshoye Savino, USPP). Apart from the two-member flight crew there were 4 flight attendants and 82 passengers on board, which makes a total of 88 people, including 66 citizens of the Russian Federation, 8 citizens of Azerbaijan, 1 citizen of Byelorussia, 1 of Germany, 1 of Italy, 1 of China, 1 of Latvia, 1 of Turkey, 1 of Uzbekistan, 5 citizens of Ukraine and 2 of France. According to the load sheet, the aircraft payload (cargo and passengers) was 8079 kg. The takeoff weight was ~54000 kg (with the max TOW of 60554 kg), the CG was at 20.61 % MAC, which was within the B-737-500 FCOM limitations. The calculated landing weight was 49700 kg (with the maximum of 49895 kg), and the CG was at 21.9 % MAC, which was also within the B737-500 FCOM limitations. The pre-flight briefing was conducted in due time and in compliance with the standard procedures. All the crew members passed medical check at the medical office of Aeroflot – Russian Airlines on September 13, 2008 at 1948 hrs and got permissions to fly. On the basis of the dispatch information (aircraft condition, aeronautical information, weather information, aircraft load data and operational flight plan) the PIC at 1955 hrs made a decision to fly. The takeoff was performed at 2113 without delay. The climb and level flight at FL290, 9,100 metres were conducted without any deviations. At 2245 hrs the crew started descent from the flight level to waypoint Mendeleyevo (940 MN). After passing over Mendeleyevo, in compliance with the Perm Approach Control instruction, the aircraft flew via the outer marker (705 PX) of Runway 21 which is the initial approach fix (IAF) for Runway 21 (heading 212° magnetic). After passing over the RWY with heading 110° M, the crew, following the Controller’s instruction, turned right for back course and started maneuvering for ILS approach to Runway 21. After the base turn, approaching the landing course at 600 m with both autopilot and autothrottle disengaged, the aircraft started climbing up to 1300 m, rolled 360° over the left wing and collided with the ground. The aircraft was totally destroyed and partly burnt in the ground fire. All passengers and crew members on board died due to the ground impact. The accident occurred at 2310 hrs 12.4 km from aerodrome reference point (ARP) of Perm Airport, azimuth 60° M. Accident site elevation is 153 m.
Probable cause:
The immediate cause of the accident was spatial disorientation of the crew, especially the Captain who was the pilot flying at the final stage of the flight, which led to the left flip-over, a steep descent and the crash of the aircraft. The spatial disorientation was experienced during the night time operation in clouds, with both autopilot and autothrottle disengaged. Contributing to the development of the spatial disorientation and failure to recover from it was a lack of proficiency in aircraft handling, crew resource management and of skills associated with upset recovery using "western"-type attitude indications that are found on foreign and modern Russian made aircraft. This type of indication differs from the one used on aircraft types previously flown by the crew (Tupolev 134, Antonov 2). The cause above was determined on the basis of flight recorders and ATC recorder data analysis, examination of the airframe and engine wreckage, results of the accident flight simulation, findings of the independent expertise conducted by test pilots from State Research Institute of Civil Aviation and Gromov Flight Research Institute as well as line pilots, and also on the basis of all the works conducted with participation of experts from Bermuda, France, Russia, UK and USA in the course of the investigation. The systemic cause of the accident was insufficient management by the airline of flight and maintenance operations of the Boeing 737 type of aircraft. These deficiencies in the aircraft maintenance also revealed through safety inspections conducted by the Russian Transport Oversight Authority and the Russian CAA after the accident. Deficiencies in the aircraft maintenance led to a situation when flights were performed for a long time with a throttle stagger that exceeded the limitations in the AMM and when the maintenance staff did not follow the AMM recommended troubleshooting procedures. The need to manage the throttle stagger during the approach increased crew workload. The forensic medical examination performed in the State Healthcare Center of Special Status “Perm Regional Forensic Expertise Bureau” confirmed the presence of ethyl alcohol in the Captain’s body before his death. The captain’s recent work schedule during the time period before the accident was conducive to fatigue and did not comply with national regulations.
Final Report:

Crash of a De Havilland DHC-4A Caribou in Efogi

Date & Time: Sep 5, 2008
Type of aircraft:
Operator:
Registration:
A4-285
Flight Type:
Survivors:
Yes
MSN:
285
YOM:
1969
Location:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Damaged beyond repair following structural failure due to fatigue upon landing at Efogi, PNG. There were no injuries but the aircraft was damaged beyond repair and dismantled.

Crash of a Beechcraft 1900C-1 near Bukavu: 17 killed

Date & Time: Sep 1, 2008 at 1600 LT
Type of aircraft:
Operator:
Registration:
ZS-OLD
Flight Type:
Survivors:
No
Site:
Schedule:
Kinshasa - Mbandaka - Kisangani - Bukavu - Goma
MSN:
UC-137
YOM:
1900
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total flying hours:
2031
Circumstances:
The aircraft departed Kinshasa on a humanitarian flight to Goma with intermediate stops in Mbandaka, Kisangani and Bukavu. While approaching Bukavu-Kamembe Airport, the crew encountered poor visibility due to bad weather conditions. At an altitude of about 10,800 feet, the aircraft struck the slope of Mt Kahuzi located some 15 km northwest of Bukavu. The wreckage was found a day later in a wooded area. All 17 occupants were killed, among them emissaries.
Probable cause:
Controlled flight into terrain after the crew initiated the descent prematurely. The lack of visibility was a contributing factor.