Crash of a Cessna 340A in Angel Fire

Date & Time: Aug 31, 2008 at 2045 LT
Type of aircraft:
Registration:
N397RA
Flight Type:
Survivors:
Yes
Schedule:
Tomball – Angel Fire
MSN:
340A-0009
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4725
Captain / Total hours on type:
625.00
Aircraft flight hours:
6507
Circumstances:
The pilot reported that he was cleared for a GPS approach and broke out of the clouds at 1,800 feet. He entered a left hand traffic pattern and his last recollection was turning base. He woke up in the crashed airplane which was on fire. The airplane was destroyed. An examination of airplane systems revealed no anomalies.
Probable cause:
Controlled flight into terrain for unknown reasons.
Final Report:

Crash of a Boeing 737-2H6 in Jambi: 1 killed

Date & Time: Aug 27, 2008 at 1634 LT
Type of aircraft:
Operator:
Registration:
PK-CJG
Survivors:
Yes
Schedule:
Jakarta - Jambi
MSN:
23320/1120
YOM:
1985
Flight number:
SJY062
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7794
Captain / Total hours on type:
6238.00
Copilot / Total flying hours:
5254
Copilot / Total hours on type:
4143
Aircraft flight hours:
49996
Aircraft flight cycles:
54687
Circumstances:
On 27 August 2008, a Boeing 737-200 aircraft, registered PK-CJG, was being operated on a scheduled passenger service from Soekarno-Hatta International Airport, Jakarta to Sultan Thaha Airport, Jambi with flight number SJY062. On board the flight were two pilots, four flight attendants, and 124 passengers. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight time from Jakarta to Jambi was estimated to be about one hour and the aircraft was dispatched with approximately 4 hours of fuel endurance. The number one electrical engine driven generator was unserviceable, as such the Auxiliary Power Unit (APU) generator was used during the flight to maintain two generators operation. Prior to descent into Jambi, the PIC conducted the crew briefing and stated a plan for Makinga straight-in approach to runway 31 with flap 40°, reviewed the go-around procedures and stated that Palembang was the alternate airport.There was no abnormality recorded nor reported until the PIC commenced the approach to Jambi. At 09:18 UTC, the SIC contacted Thaha Tower controller and reported that the aircraft was descending and passing FL160 and had been cleared by Palembang Approach control to descend to 12,000 feet. The Thaha Tower controller issued a clearance to descend to 2500 feet and advised that runway 31 was in use. The SIC asked about the weather conditions and was informed that the wind was calm, rain over the field and low cloud on final approach to runway 31. The PIC flew the aircraft direct to intercept the final approach to runway 31. While descending through 2500 feet, and about 8 miles from the VOR, the flap one degree and flap 5° were selected. Subsequently the landing gear was extended and flap 15° was selected. 13 seconds after flap 15 selection, the pilots noticed that the hydraulic system A low pressure warning light illuminated, and also the hydraulic system A quantity indicator showed zero. The PIC commanded the SIC to check the threshold speed for the existing configuration of landing, weight and with flap 15°. The SIC called out that the threshold speed was 134 kts and the PIC decided to continue with the landing. The PIC continued the approach and advised the SIC that he aimed to fly the aircraft slightly below the normal glide path in order to get more distance available for the landing roll. The aircraft touched down at 0930 UTC and during the landing roll, the PIC had difficulty selecting the thrust reversers. The PIC the applied manual braking. During the subsequent interview, the crew reported that initially they felt a deceleration then afterward a gradual loss of deceleration. The PIC reapplied the brakes and exclaimed to the SIC about the braking condition, then the SIC also applied the brakes to maximum in responding to the situation. The aircraft drifted to the right of the runway centre line about 200 meters prior to departing off the end of the runway, and stopped about 120 meters from the end of the runway 31 in a field about 6 meters below the runway level. Three farmers who were working in that area were hit by the aircraft. One was fatally injured and the other two were seriously injured. The pilots reported that, after the aircraft came to a stop, they executed the Emergency on Ground Procedure. The PIC could not put both start levers to the cut-off position, and also could not pull the engines and APU fire warning levers. The PIC also noticed that the speed brake lever did not extend. The radio communications and the interphone were also not working. The flight attendants noticed a significant impact before the aircraft stopped. They waited for any emergency command from the PIC before ordering the evacuation. However, the passengers started to evacuate the aircraft through the right over-wing exit window before commanded by the flight attendants. The flight attendants subsequently executed the evacuation procedure without command from the PIC. The left aft cabin door was blocked by the left main landing gear that had detached from the aircraft and the flight attendants were unable to open the door. The right main landing gear and both engines were also detached from the aircraft. The Airport Rescue and Fire Fighting (ARFF) come to the crash site and activated the extinguishing agent while the passengers were evacuating the aircraft. The PIC, SIC and FA1 were the last persons to evacuate the aircraft. The APU was still running after all passengers and crew evacuation completed, afterward one company engineer went to the cockpit and switched off the APU. All crew and passengers safely evacuated the aircraft. No significant property damage was reported.
Probable cause:
Contributing Factors:
- When the aircraft approach for runway 31, the Loss of Hydraulic System A occurred at approximately at 1,600 feet. At this stage, there was sufficient time for pilots to conduct a missed approach and review the procedures and determine all the consequences prior to landing the aircraft.
- The smooth touchdown with a speed 27 kts greater than Vref and the absence of speed brake selection, led to the aircraft not decelerating as expected.
Final Report:

Crash of a Boeing 737-219 in Bishkek: 65 killed

Date & Time: Aug 24, 2008 at 2044 LT
Type of aircraft:
Operator:
Registration:
EX-009
Survivors:
Yes
Schedule:
Bichkek - Tehran
MSN:
22088/676
YOM:
1980
Flight number:
IRC6895
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
85
Pax fatalities:
Other fatalities:
Total fatalities:
65
Captain / Total flying hours:
18250
Captain / Total hours on type:
2337.00
Copilot / Total flying hours:
4531
Copilot / Total hours on type:
881
Aircraft flight hours:
60014
Aircraft flight cycles:
56196
Circumstances:
On 24 August, 2008 the Boeing 737-200 aircraft registered ЕХ-009 and operated by a crew including a PIC and a Co-pilot of Itek Air was flying a scheduled passenger flight IRC 6895 from Bishkek to Tehran. Also on board there was the cabin crew (3 persons) as well as 85 passengers including two service passengers: a maintenance engineer and a representative of the Iran Aseman Airlines. Flight IRC 6895 was executed in compliance with the leasing agreement No. 023/05 of 15 July, 2005 for the Boeing 737-200 ЕХ-009 between the Kyrgyz airline, Itek Air, and the Iran Aseman Airlines. The crew passed a medical examination in the ground medical office of Manas Airport. The crew did not have any complaints of their health. The crew received a complete preflight briefing. The weather at the departure airport Manas, the destination airport and at alternate aerodromes was favourable for the flight. Total fuel was 12000 kg, the takeoff weight was 48371 kg with the CG at 24,8% MAC, which was within the B737-200 AFM limitations. After the climb to approximately 3000 m the crew informed the ATC about a pressurization system fault and decided to return to the aerodrome of departure. While they were descending for visual approach the aircraft collided with the ground, was damaged on impact and burnt. As a result of the crash and the following ground fire 64 passengers died. The passenger who was transferred on 29 August, 2008 to the burn resuscitation department of the Moscow Sklifasovsky Research Institute died of burn disease complicated by pneumonia on 23 October, 2008, two months after he got burn injuries. Thus, his death is connected with the injuries received due to the accident.
Probable cause:
The cause of the Itek Air B737-200 ЕХ-009 accident during the air-turn back due to the cabin not pressurizing (probably caused by the jamming of the left forward door seal) was that the crew allowed the aircraft to descend at night to a lower than the minimum descent altitude for visual approach which resulted in the crash with damage to the aircraft followed by the fire and fatalities. The combination of the following factors contributed to the accident:
- Deviations from the Boeing 737-200 SOP and PF/PM task sharing principles;
- Non-adherence to visual approach rules, as the crew did not keep visual contact with the runway and/or ground references and did not follow the prescribed procedures after they lost visual contact;
- Loss of altitude control during the missed approach (which was performed because the PIC incorrectly evaluated the aircraft position in comparison with the required descent flight path when he decided to perform visual straight-in approach);
- Non-adherence to the prescribed procedures after the TAWS warning was triggered.
Final Report:

Crash of a De Havilland DHC-8-301 in Barranquilla

Date & Time: Aug 23, 2008 at 1715 LT
Operator:
Registration:
HK-3952
Survivors:
Yes
Schedule:
Willemstad – Barranquilla
MSN:
169
YOM:
1989
Flight number:
ARE051
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7003
Captain / Total hours on type:
6691.00
Copilot / Total hours on type:
781
Aircraft flight hours:
31260
Circumstances:
Following an uneventful flight from Willemstad-Hato Airport, the crew started the approach to Barranquilla-Ernesto Cortissoz Airport runway 23. The aircraft landed 770 metres past the runway threshold. After touchdown, the crew noticed vibrations coming from the right side of the aircraft when the right main gear collapsed. The aircraft slid for few dozen metres before coming to rest on the main runway. All 31 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Fracture of the ring of the mechanical stop of the shock absorber on the right main gear, turning the whole gear into a solid structure incapable of absorbing the landing loads, due to the non-incorporation of the Airworthiness Directive AD-2006-14 in the general repair of the main gear.
Final Report:

Crash of a Cessna 402 in Coventry: 4 killed

Date & Time: Aug 17, 2008 at 1136 LT
Type of aircraft:
Operator:
Registration:
G-EYES
Flight Type:
Survivors:
No
Schedule:
Coventry - Coventry
MSN:
402-0008
YOM:
1979
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1627
Captain / Total hours on type:
125.00
Copilot / Total flying hours:
2281
Copilot / Total hours on type:
339
Circumstances:
Cessna 402C aircraft G-EYES was engaged in flight calibration training and was making an ILS approach to Runway 23 at Coventry Airport when it was involved in a mid-air collision with a Rand KR-2 aircraft, G-BOLZ, operating in the visual circuit. The collision occurred in Class G (uncontrolled) airspace. The four occupants of G-EYES and the single occupant of G-BOLZ received fatal injuries.
Probable cause:
The investigation identified the following primary causal factor:
The two aircraft collided because their respective pilots either did not see the other aircraft, or did not see it in time to take effective avoiding action.
The investigation identified the following contributory factors:
1. The likelihood that the crew of G-EYES would see G-BOLZ in time to carry out effective avoiding action was reduced by the small size of G-BOLZ, its position relative to G-EYES and the high rate of closure between the aircraft.
2. Insufficient or inaccurate information was provided to the pilots, which did not assist them in fulfilling their duty to take all possible measures to avoid collisions with other aircraft.
3. The Aerodrome Controller’s sequencing plan, which was based on an incomplete understanding of the nature of G-EYES’ flight, was unlikely to have been successful. By the time the risk of a collision was identified, it was too late to devise an effective method of resolving the situation.
4. There were no effective measures in place to give G-EYES priority over traffic in the visual circuit
Final Report:

Crash of a Piper PA-31-310 Navajo in Tukums: 1 killed

Date & Time: Aug 16, 2008 at 1030 LT
Type of aircraft:
Operator:
Registration:
YL-CCX
Flight Type:
Survivors:
Yes
Schedule:
Riga - Tukums
MSN:
31-647
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine aircraft departed Riga on a flight to Tukums with eight people on board to take part to an airshow. Several others aircraft were also en route to Tukums but most of the pilots returned to their departure point due to the deterioration of the weather conditions. On approach to Tukums Airport runway 32, the pilot encountered poor visibility. Unable to establish a visual contact with the runway, he initiated a go-around procedure. After several circuits, he attempted a second approach under VFR mode. Too low, the aircraft struck a hill and eventually crashed in a private garden, coming to rest broken in two. All eight occupants were injured, some seriously. Few hours later, the pilot died from his injuries.

Crash of a Fokker F27 Friendship 500 in K50: 3 killed

Date & Time: Aug 13, 2008 at 0450 LT
Type of aircraft:
Operator:
Registration:
5Y-BVF
Flight Type:
Survivors:
No
Schedule:
Nairobi – K50
MSN:
10627
YOM:
1982
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft departed Nairobi-Jomo Kenyatta Airport on a cargo flight to the K50 Airstrip located about 35 km southwest of Mogadishu, carrying three crew members and a load of 5,4 tons of khat. On approach by night, the crew was unable to establish a visual contact with the runway due to foggy conditions. The captain initiated a go-around and the crew attempted a second approach to land. Too low, the airplane collided with a 60 metres high communication antenna and crashed 2 km from the airport. All three occupants were killed.

Crash of a Lockheed C-130H Hercules at Bagram AFB

Date & Time: Aug 5, 2008
Type of aircraft:
Operator:
Registration:
1212
Flight Type:
Survivors:
Yes
MSN:
4985
YOM:
1983
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft was completing a humanitarian mission to Bagram AFB. After landing in poor weather conditions, the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest, bursting into flames. There were no injuries among the crew but the aircraft was destroyed.

Crash of a Beechcraft A90 King Air in Pitt Meadows

Date & Time: Aug 3, 2008 at 1524 LT
Type of aircraft:
Registration:
N17SA
Survivors:
Yes
Schedule:
Pitt Meadows - Pitt Meadows
MSN:
LJ-164
YOM:
1966
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4800
Captain / Total hours on type:
1290.00
Aircraft flight hours:
13257
Circumstances:
The Bill Dause Beech 65-A90 King Air (United States registration N17SA, aircraft serial number LJ-164) took off from Pitt Meadows Airport, British Columbia, with the pilot and seven parachutists for a local sky diving flight. At 1521 Pacific daylight time, as the aircraft was climbing through 3900 feet above sea level, the pilot reported an engine failure and turned back towards Pitt Meadows Airport for a landing on Runway 08R. The airport could not be reached and a forced landing was carried out in a cranberry field, 400 metres west of the airport. On touchdown, the aircraft struck an earthen berm, bounced, and struck the terrain again. On its second impact, the left wing dug into the soft peat, spinning the aircraft 180 degrees. Four of the parachutists received serious injuries and the aircraft was substantially damaged. There was no fire and the occupants were evacuated. The emergency locator transmitter functioned at impact and was turned off by first responders.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The general condition of the aircraft, the engine time before overhaul (TBO) over-run and the missed inspection items demonstrated inadequate maintenance that was not detected by regulatory oversight.
2. The TBO over-run and missed inspections resulted in excessive spline wear in the left engine-driven fuel pump going undetected.
3. The left engine lost power due to mechanical failure of the engine fuel pump drive splines.
4. The horizontal engine instrument arrangement and the lack of recent emergency training made quick engine malfunction identification difficult. This resulted in the pilot shutting down the wrong engine, causing a dual-engine power loss and a forced landing.
5. Not using the restraint devices contributed to the seriousness of injuries to some passengers.
Finding as to Risk:
1. There is a risk to passengers if Transport Canada does not verify that holders of Canadian Foreign Air Operator Certificates-Free Trade Agreement meet airworthiness and operational requirements.
Final Report:

Crash of a Cessna 550 Citation II in Reading

Date & Time: Aug 3, 2008 at 1519 LT
Type of aircraft:
Operator:
Registration:
N827DP
Flight Type:
Survivors:
Yes
Schedule:
Pottstown - Reading
MSN:
550-0660
YOM:
1990
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12100
Captain / Total hours on type:
2690.00
Copilot / Total flying hours:
1779
Copilot / Total hours on type:
65
Aircraft flight hours:
5008
Circumstances:
The air traffic controller, with both ground and local (tower) responsibilities, cleared the accident airplane to land when it was about 8 miles from the runway. Another airplane landed in front of the accident flight, and the controller cleared that pilot to taxi to the hangar. The controller subsequently cleared a tractor with retractable (bat wing) mowers, one on each side, and both in the “up” position, to proceed from the terminal ramp and across the 6,350-foot active runway at an intersection about 2,600 feet from the threshold. The controller then shifted his attention back to the airplane taxiing to its hangar, and did not see the accident airplane land. During the landing rollout, the airplane’s left wing collided with the right side of the tractor when the tractor was “slightly” left of runway centerline. Calculations estimated that the airplane was about 1,000 feet from the collision point when the tractor emerged from the taxiway, and skid marks confirmed that the airplane had been steered to the right to avoid impact. Prior to the crossing attempt, the tractor operator did not scan the runway, and was concentrating on the left side bat wing. Federal Aviation Administration publications do not adequately address the need for ground vehicle operators to visually confirm that active runways/approaches are clear, prior to crossing with air traffic control authorization, thus overlooking an additional means to avoid a collision.
Probable cause:
The air traffic controller’s failure to properly monitor the runway environment. Contributing to the accident was the tractor operator’s failure to scan the active runway prior to crossing, and the Federal Aviation Administration’s inadequate emphasis on vehicle operator visual vigilance when crossing active runways with air traffic control clearance.
Final Report: