Landing (descent or approach)

Flight Type:

Training

Survivors:

Site:

Schedule:

Iquitos - Iquitos

MSN:

720

YOM:

1974

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The single engine aircraft was completing a local training flight at Iquitos-Moronacocha Airport, carrying five pilots. On short final, the single engine airplane lost height, struck the ground and crashed near the runway threshold. All five occupants were injured and the aircraft was damaged beyond repair.

Crash of a PZL-Mielec AN-28 in Benzdorp: 19 killed

Date & Time: Apr 3, 2008 at 1100 LT

Type of aircraft:

PZL-Mielec AN-28

Operator:

Registration:

PZ-TSO

Flight Phase:

Embraer EMB-820 Navajo/Carajá

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Mountains

Schedule:

Paramaribo – Lawa

MSN:

1AJ007-17

YOM:

1990

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

While approaching Lawa-Antino airport, the crew was informed that another airplane was on the runway at that time. The crew initiated a go-around procedure when the aircraft hit a wooded hillside and crashed, bursting into flames. All 19 occupants were killed.

Crash of an Embraer EMB-820C Carajá in Lençóis: 2 killed

Date & Time: Mar 31, 2008 at 0630 LT

Type of aircraft:

Operator:

Registration:

PT-VCI

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Salvador – Lençóis

MSN:

820-144

YOM:

1986

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

25000

Captain / Total hours on type:

1769.00

Copilot / Total flying hours:

750

Copilot / Total hours on type:

195

Aircraft flight hours:

7293

Circumstances:

The twin engine aircraft departed Salvador Airport at 0525LT on a cargo flight to Lençóis, carrying two pilots and a load of bank documents. On final approach to Lençóis Airport, the crew encountered limited visibility due to marginal weather conditions. The captain decided to continue the approach and completed a turn to the left when the aircraft crashed 2 km from the runway threshold, bursting into flames. The aircraft was totally destroyed and both pilots were killed.

Probable cause:

The decision of the captain to continue the approach under VFR mode in IMC conditions to an airport that was not suitable for IFR operations. The following contributing factors were identified:
- The lack of ground references may have contributed to the commander's spatial disorientation,
- Although the weather conditions made it impossible to land under VFR conditions, the captain insisted on landing, neglecting IFR procedures,
- The captain ignored the copilot's advice and continued with the approach procedure,
- The captain put the aircraft in an attitude that caused it to stall,
- Poor judgment on part of the captain,
- Despite the implementation of a CRM program, the operator was unable to identify that the captain was violating the published procedures.

Final Report:

Ground fire of a Boeing 747-357 in Dhaka

Date & Time: Mar 25, 2008 at 0827 LT

Type of aircraft:

Boeing 747-300

Operator:

Registration:

TF-ARS

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Dhaka-Hazrat Shahjalal (ex Zia Ul-Haq)

Schedule:

Madinah - Dhaka

MSN:

22996/586

YOM:

1983

Flight number:

SV810

Location:

Dhaka

Country:

Bangladesh

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

307

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

18137

Captain / Total hours on type:

5637.00

Copilot / Total flying hours:

7161

Copilot / Total hours on type:

261

Aircraft flight hours:

99327

Aircraft flight cycles:

18779

Circumstances:

TF-ARS (B747-300) was on a scheduled flight from Medina (Saudi Arabia) to Dhaka (Bangladesh), flight number SVA810. The flight crew consisted of a commander, copilot and a flight engineer. The cabin crew consisted of 15 crew members including one senior cabin attendant. Additionally to the cabin crew, one “off duty” cabin crew member was in the cabin. According to the commander, the flight from Medina and the landing at Dhaka was uneventful. During the landing roll, approximately 50 seconds after touchdown, the flight crew received a call from the tower controller where the tower controller inquired whether the aircraft was under control. The flight crew responded to the call by stating that the aircraft was completely under control and asked what the problem seemed to be. The controller then informed the flight crew that fire was observed at the right wing area. At this point the Aerodrome Fire Operator had already activated the fire fighters as well as the rescue team. As soon as the controller had informed the flight crew about the fire, the flight crew received a No. 3 engine fire alarm. The co-pilot immediately discharged the first engine fire bottle and the flight crew requested firefighter assistance and shut down all engines. The co-pilot waited 20 seconds until the second fire bottle was discharged. At this time the commander called the senior cabin attendant to the flight deck using the public address system (PA). This command was followed by a command to the cabin crew to remain seated. The commander informed the senior cabin attendant of the situation and instructed him to evaluate the situation and to evacuate the passengers if necessary. The senior cabin attendant went back down to the main deck and saw the smoke and the fire through the windows. He then commanded the cabin crew as well as passengers, by using a megaphone, to evacuate the aircraft. The cabin attendant at location L2 (see figure 6-7, page 21) had already operated the emergency exit and started evacuating the passengers. Cabin attendants at locations L1 and R2 (see figure 6-7, page 21) also operated their respective emergency exits. After realizing that smoke and fire were at the right hand side, the emergency exit at R2 was blocked by one of the cabin attendants. All passengers managed to evacuate without serious injuries and the fire department at Zia International Airport managed to extinguish the fire successfully. The damage to the aircraft was later evaluated as beyond economical repair.

Probable cause:

When TF-ARS was decelerating after landing on runway 14 at Zia International Airport, fuel leak at engine No. 3 resulted in a fire within the strut. The cause of the fire was that fuel was leaking through the flexible half coupling to the hot surface of the engine. The fuel leak was because the O-ring and retaining rings were not properly assembled within the coupling and one retaining ring was missing. The IAAIB considers unclear instructions in the aircraft maintenance manual (AMM) to be a contributing factor of the incorrect installation. Another incorrect installation was also found at the flexible half coupling at the front spar for engine No. 1. However there were no signs of a fuel leak in that area, most likely due to the fact that both the retaining rings and the O-ring were within the coupling even though they were incorrectly placed. During the investigation, it was not possible to determine the quantity of the fuel leak. However it is likely that the draining system within the strut of engine No. 3 could not manage the fuel leak. According to the manufacturer, the intention of the draining system is to drain drips or small running leaks. Furthermore the drain was clogged by debris, but IAAIB believes that this was a result of the fire. Two out of six suitable emergency exits on the left side were used (L1 and L2) to evacuate most of the passengers during the emergency evacuation. The reason for not opening doors at location L3, L4 and L5 initially was most likely due to the fact that the commander ordered the cabin crew to remain seated prior to the emergency evacuation. The cabin crew members at locations L3 to L5 most likely did not hear the emergency evacuation command from the senior cabin crew member as he was only using a megaphone. Furthermore these exits were not opened later since the passengers moved aggressively to the opened exits, L1 and L2. The reason for not opening emergency exit UDL at the upper deck was evaluated by the crew to be too risky for the passengers. The flight crew discharged both fire bottles for engine No. 3 without managing to extinguish the fire. The flight crew did not discharge fire bottles on other engines. According to the passenger evacuation checklist (see Appendix 2), the crew should discharge all fire bottles before evacuation.
Findings as to causes and contributing factors:
- Incorrect assembly of the flexible half coupling at the front spar of engine No. 3.
- Retaining ring missing in flexible half coupling at the front spar engine No. 3.
- Lock wire fastened in such a way that the coupling nut might rotate slightly.
Findings as to risk:
- Unclear command made to the cabin crew to start emergency evacuation.
- Cabin crew did not open all suitable emergency exits.
- Flight crew did not follow company’s procedure regarding evacuation.
Other findings:
- Retaining rings and O-ring incorrectly inserted in the flexible half coupling on engine No. 1.
- Pliers used to tighten or loosen the coupling nuts, even though maintenance manual instructs to only hand tight the nuts.

Final Report:

Crash of a Dornier DO328-110 in Mannheim

Date & Time: Mar 19, 2008 at 1745 LT

Type of aircraft:

Dornier DO328

Operator:

Registration:

D-CTOB

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Berlin - Mannheim

MSN:

3107

YOM:

1999

Flight number:

RUS1567

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5000

Captain / Total hours on type:

1700.00

Copilot / Total flying hours:

320

Copilot / Total hours on type:

130

Aircraft flight hours:

13029

Aircraft flight cycles:

13185

Circumstances:

Following an uneventful flight from Berlin-Tempelhof Airport, the crew started a LOC/DME approach to runway 27 at Mannheim Airport. The copilot was the pilot-in-command and reported to the captain he has difficulties to land in Mannheim. On approach, the aircraft descended below the prescribed altitude of 5,000 feet. At an altitude of 3,800 feet, some 100 feet below the Minimum Sector Altitude (MSA), the captain instructed the copilot to arrest the descent and climb back to 5,000 feet. After he was established on the localizer, the crew continued the approach. Shortly before landing, the aircraft floated over the runway and the touchdown zone and landed too far down the runway, about 530 metres past the runway threshold. After touchdown, the aircraft encountered difficulties to decelerate and was unable to stop within the remaining distance of 480 metres. It overran at a speed of 50 knots, lost its left main gear and came to rest against an embankment. All 27 occupants evacuated safely and the aircraft was damaged beyond repair.

Probable cause:

The following findings were identified:
- The throttle, after placement by the PIC (PF), could not be moved into 'ground idle' or reverse,
- The landing was not aborted after the plane had flown over the touchdown zone,
- The crew failed to initiate a go-around procedure,
- During the flare for landing, the engine throttles were not selected to 'flight idle', which was not noted by both pilots,
- The flight crew flew the approach not in accordance with SOPs, and thereby pushing and even exceeding the limits.
The following factors contributed to the accident:
- Many non-precision approaches and landings at Mannheim City were not performed according to air carriers OMs,
- The TRs and FOIs of the aircraft manufacturer were not incorporated into the OM/B and D of the air carrier,
- The practical training of the flight crew by the air carrier was inadequate in terms of preventing an erroneous operation of the throttle control on the basis of the manufacturer of the Do 328-100 issued instructions,
- The flight crew conducted a non-precision approach, which did not meet the procedural requirements of the OM of the air carrier and the AIP,
- The design of the power lever was not forgiving enough,
- The risks of existing problems in the operation of the power levers were not correctly identified and eliminated by by the relevant authorities and the relevant type certificate holder, in spite of several relevant events and various safety recommendations,
- The touchdown zone in Mannheim was not marked,
- The size and design of the safety area at the end of runway 27 was not sufficient to guarantee the operation of the flight within the safety levels set by ICAO and the legislator.

Final Report:

Crash of a Raytheon Premier in Udaipur

Date & Time: Mar 19, 2008 at 1507 LT

Type of aircraft:

Raytheon 390 Premier I

Operator:

Ran Air Services

Registration:

VT-RAL

Flight Phase:

Executive/Corporate/Business

Flight Type:

Survivors:

Site:

Schedule:

Jodhpur - Udaipur

MSN:

RB-23

YOM:

2001

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2900

Captain / Total hours on type:

40.00

Copilot / Total flying hours:

896

Copilot / Total hours on type:

Aircraft flight hours:

989

Aircraft flight cycles:

812

Circumstances:

The aircraft, after necessary met and ATC briefing took off at 0940 UTC from Jodhpur on direct route W58 at cruise FL 100 and sector EET 20 minutes as per Flight Plan. No abnormality was reported / recorded by the pilot during take off from Jodhpur. The crewmember of the aircraft while operating Jodhpur–Udaipur were the same who operated flight Delhi-Jodhpur on 18.3.2008. There were five passengers also on board the aircraft. The aircraft climbed to the assigned level where the pilot was experiencing continuous turbulence at FL100. The pilot communicated the same to the ATC Jodhpur and requested for higher level which was not granted and advised to continue at same level and contact ATC Udaipur for level change. It came in contact with Udaipur at 0944 UTC, approx 50 NM from Udaipur. At 0948 the weather passed by ATC was winds 180/07 kts. Vis 6 km. Temp 34, QNH 1006 Hpa and advised for ILS approach on runway 26. Consequently the pilot requested to make right base Rwy 26 visual approach, which was approved by the ATC. Aircraft did not report any defect/snag. Pilot further stated that during approach to land at Udaipur when flap 10 degree was selected, the flap didn’t respond and ‘Flaps-Fail’ message flashed. Thereafter he carried out the check list for flapless landing. At 1004 UTC when the aircraft reported on final the ATC cleared the aircraft to land on runway 26 with prevailing wind 230/10 Kts. The same was acknowledged by the crew and initiated landing. At about 20 to 30 feet above ground the pilot stated to have experienced sudden down-draft thereby the aircraft touched down heavily on the runway. The touch-down was on the centerline, at just before the touchdown Zone (TDZ), on the paved runway, after the threshold point. Consequent to the heavy impact both the main wheel tyre got burst; first to burst was right tyre. The aircraft rolled on the runway centerline for a length of about 1,000 feet in the same condition. Thereafter it gradually veered to the right of the runway 26 at distance of approx 2,200 feet runway length from the threshold of the runway. The aircraft left the runway shoulder and after rolling almost straight for another 90 ft it stopped after impact with the airport boundary wall.

Probable cause:

The approach speed for flapless landing was about 149 knots against the calculated speed 130-135 knots approx. Incident occurred as the aircraft impacted runway with higher speed while carrying out flapless approach and landing.

Final Report:

Crash of a Boeing 737-408 in Batam

Date & Time: Mar 10, 2008 at 1020 LT

Type of aircraft:

Boeing 737-400

Operator:

Registration:

PK-KKT

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Jakarta - Batam

MSN:

24353/1721

YOM:

1989

Flight number:

DHI292

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

171

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

On 10 March 2008, a Boeing Company 737-400 aircraft, registered PK-KKT, was being operated by Adam SkyConnection Airlines (Adam Air) as scheduled passenger flight with flight number DHI292. The flight departed Soekarno – Hatta Airport, Jakarta at 01:30 UTC with destination Hang Nadim Airport, Batam and the estimated time of arrival was 03:05 UTC. On board in this flight were 177 people consisted of two pilots, four flight attendants, and 171 passengers. The Pilot in Command (PIC) acted as pilot flying (PF) and the Second in Command (SIC) acted as pilot monitoring (PM). The flight until commencing descend was uneventful. Prior to descend, the flight crew received weather information indicating that the weather was fine. At 0302 UTC the flight crew contacted Hang Nadim tower controller and informed them that the visibility was 1,000 meters and they were sequence number three for landing runway 04. The flight crew of the aircraft on sequence number two informed to Hang Nadim tower controller that the runway was insight at an altitude of about 500 feet. The Hang Nadim tower controller forwarded the information to the flight crew of DHI 292, and followed this by issuing landing clearance, and additional information that the wind velocity was 360 degrees at 8 knots and heavy rain. The DHI 292 flight crew acknowledged the information. The landing configuration used flaps 40 degrees with landing speed of 136 knots. The flight crew were able to see the runway prior to the Decision Altitude (DA), however the PIC was convinced that continuing the approach to landing was unsafe and elected to go around. The Hang Nadim tower controller instructed the flight crew to climb to 3000 feet, maintain runway heading, and contact Singapore Approach. At 0319 UTC, DHI 292 was established on the localizer runway 04, and the Hang Nadim tower controller informed them that the visibility improved to 2,000 meters. While on final approach, the flight crew DHI 292 reported that the runway was in sight and the Hang Nadim tower controller issued a landing clearance. On touchdown, the crew felt that the main wheels barely touch the runway first. During the landing roll, as the ground speed decreased below 30 knots, the aircraft yawed to the right. The flight crew attempted to steer the aircraft back to centerline by applying full left rudder. The aircraft continued yaw to the right and came to stop on the runway shoulder at approximately 40 meters from the right side of the runway edge, and 2,760 meters from the runway 04 threshold. No one was injured in this accident. The aircraft was seriously damaged with the right main landing gear assembly detached and collapsing backward and damaging the right wing and flaps. The right engine was displaced from its attachment point.

Probable cause:

The Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR) data were downloaded. The CVR data showed that the aircraft was flying below the correct glide path indicated by a glide slope aural warning, and the crew had difficulty in recovering the condition. The CVR also recorded landing gear warning after touchdown which indicated the landing gear had collapsed. The FDR data showed that the vertical acceleration during landing was 2.97 g, however this amount of vertical acceleration should not damage the landing gear. The FDR data showed that just after touchdown, the right main landing gear collapsed. The FDR also recorded that the aircraft experienced hard landing and had bounced on a previous flight, and the value of the vertical acceleration recorded was 1.78 g. It was most likely that the hard landing and bounce had affected the strength of the landing gear. The examination of the failed landing gear also found corrosion on the fracture surface of the right main landing gear strut.

Final Report:

Ground fire of a Transall C-160NG in Wamena

Date & Time: Mar 6, 2008 at 0920 LT

Type of aircraft:

Transall C-160

Operator:

Registration:

PK-VTQ

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Jayapura – Wamena

MSN:

F235

YOM:

1985

Location:

Wamena

Special Region of Papua

Country:

Indonesia

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

On 6 March 2008, a Transall C-160 aircraft, registered PK-VTQ, operated by PT. Manunggal Air, was on an unscheduled freight flight from Sentani Airport, Jayapura, to Wamena Airport, Papua. There were seven people on board; two pilots, two engineers, and three flight officers. The pilots reported that the approach and landing were normal. However, they told the investigators that both Beta lights did not illuminate during the landing roll, so they could not use reverse thrust. They reported that they used maximum brakes to slow the aircraft, and rolled through to the end of runway 15. During the 180-degree right turn at the end of the runway, they felt the left brakes grabbing, and had to use increased thrust on the left engine to assist the turn. After completing the turn, the pilots backtracked the aircraft towards taxiway “E”, about 450 meters from the departure end of runway 15. The air traffic controller informed the Transall crew that heavy smoke was coming from the left main wheels, and that they should proceed to taxiway “E” and stop on the taxiway. Before the aircraft entered taxiway “E”, the controller activated the crash alarm. The pilots stopped the aircraft on taxiway “E”, and the occupants disembarked and attempted to extinguish the wheel-bay fire with a hand held extinguisher. The airport rescue fire fighting service (RFFS) arrived at the aircraft 10 minutes after the aircraft came to a stop on taxiway “E”. It took a further 5 minutes to commence applying foam. The attempts to extinguish the fire were unsuccessful, and the fire destroyed the aircraft and its cargo of fuel in drums. Investigators found molten metal on the runway along the left wheel track for about 16 meters, about 100 meters from taxiway “E”, between taxiway “E” and the departure end of runway 15. There was also molten metal along the left wheel track on taxiway “E”.

Probable cause:

The aircraft’s left main wheels’ brakes overheated during the landing roll and a fire commenced in the brake assembly of one or more of the left main landing gear wheels. The evidence indicated that a brake cylinder and/or hydraulic line may have failed. It is likely that brake system hydraulic fluid under pressure, was the propellant that fed the fire. There was no Emergency Response Plan at Wamena. The RFFS delay in applying fire suppressant resulted in the fire engulfing the aircraft.

Final Report:

Crash of a Beechcraft 1900D in Kayenta

Date & Time: Feb 22, 2008 at 0745 LT

Type of aircraft:

Beechcraft 1900D

Operator:

Registration:

N305PC

Flight Phase:

Executive/Corporate/Business

Flight Type:

Survivors:

Site: