Crash of a Boeing 777-236ER in London

Date & Time: Jan 17, 2008 at 1242 LT
Type of aircraft:
Operator:
Registration:
G-YMMM
Survivors:
Yes
Schedule:
Beijing - London
MSN:
30314/342
YOM:
2001
Flight number:
BA038
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12700
Captain / Total hours on type:
8450.00
Copilot / Total flying hours:
9000
Copilot / Total hours on type:
7000
Aircraft flight hours:
28675
Aircraft flight cycles:
3957
Circumstances:
G-YMMM was on a scheduled return flight from Beijing, China, to London (Heathrow) with a flight crew consisting of a commander and two co-pilots; the additional co-pilot enabled the crew to take in-flight rest. There had been no reported defects with G-YMMM during the outboard flight from London (Heathrow) to Beijing, China. The flight plan for the return sector, produced by the aircraft’s operator, required an initial climb to 10,400 m (FL341) with a descent to 9,600 m (FL315) because of predicted ‘Extreme Cold’ at POLHO (a waypoint that lies on the border between China and Mongolia). Having checked the flight plan and the weather in more detail the crew agreed on a total fuel load for the flight of 79,000 kg. The startup, taxi, takeoff at 0209 hrs and the departure were all uneventful. During the climb, Air Traffic Control (ATC) requested that G-YMMM climb to an initial cruise altitude of 10,600 m (FL348). The crew accepted this altitude and, due to the predicted low temperatures, briefed that they would monitor the fuel temperature en route. The initial climb to altitude was completed using the autopilot set in the Vertical Navigation (VNAV) mode. Approximately 350 nm north of Moscow the aircraft climbed to FL380; this step climb was carried out using the Vertical Speed (VS) mode of the autoflight system. Another climb was then carried out whilst the aircraft was over Sweden, this time to FL400, and again this was completed in VS mode. During the flight the crew monitored the fuel temperature displayed on the Engine Indication and Crew Alerting System (EICAS) and noted that the minimum indicated fuel temperature en route was -34˚C. At no time did the low fuel temperature warning annunciate. The flight continued uneventfully until the later stages of the approach into Heathrow. The commander was flying at this time and during the descent, from FL400, the aircraft entered the hold at Lambourne at FL110; it remained in the hold for approximately five minutes, during which it descended to FL90. The aircraft was radar vectored for an Instrument Landing System (ILS) approach to Runway 27L at Heathrow and subsequently stabilised on the ILS with the autopilot and autothrottle engaged. At 1,000 ft aal, and 83 seconds before touchdown, the aircraft was fully configured for the landing, with the landing gear down and flap 30 selected. At approximately 800 ft aal the co-pilot took control of the aircraft, in accordance with the briefed procedure. The landing was to be under manual control and the co-pilot intended to disconnect the autopilot at 600 ft aal. Shortly after the co-pilot had assumed control, the autothrottles commanded an increase in thrust from both engines. The engines initially responded but, at a height of about 720 ft, 57 seconds before touchdown, the thrust of the right engine reduced. Some seven seconds later, the thrust reduced on the left engine to a similar level. The engines did not shut down and both engines continued to produce thrust above flight idle, but less than the commanded thrust. At this time, and 48 seconds before touchdown, the co-pilot noted that the thrust lever positions had begun to ‘split’. On passing 500 ft agl there was an automatic call of the Radio Altimeter height, at this time Heathrow Tower gave the aircraft a landing clearance, which the crew acknowledged. Some 34 seconds before touchdown, at 430 ft agl, the commander announced that the approach was stable, to which the co-pilot responded “just”. Seven seconds later, the co-pilot noticed that the airspeed was reducing below the expected approach speed of 135 kt. On the Cockpit Voice Recorder (CVR) the flight crew were heard to comment that the engines were at idle power and they attempted to identify what was causing the loss of thrust. The engines failed to respond to further demands for increased thrust from the autothrottle and manual movement of the thrust levers to fully forward. The airspeed reduced as the autopilot attempted to maintain the ILS glide slope. When the airspeed reached 115 kt the ‘airspeed low’ warning was annunciated, along with a master caution aural warning. The airspeed stabilised for a short period, so in an attempt to reduce drag the commander retracted the flaps from flap 30 to flap 25. In addition, he moved what he believed to be an engine starter/ignition switch on the overhead panel. The airspeed continued to reduce and by 200 ft it had decreased to about 108 kt. Ten seconds before touchdown the stick shaker operated, indicating that the aircraft was nearing a stall and in response the co-pilot pushed the control column forward. This caused the autopilot to disconnect as well as reducing the aircraft’s nose-high pitch attitude. In the last few seconds before impact, the commander attempted to start the APU and on realising that a crash was imminent he transmitted a ‘MAYDAY’ call. As the aircraft approached the ground the co-pilot pulled back on the control column, but the aircraft struck the ground in the grass undershoot for 27L approximately 330 m short of the paved runway surface and 110 m inside the airfield perimeter fence. During the impact and short round roll the nose landing gear (NLG) and both the main landing gears (MLG) collapsed. The right MLG separated from the aircraft but the left MLG remained attached. The aircraft came to rest on the paved surface in the undershoot area of Runway 27L. The commander attempted to initiate an evacuation by making an evacuation call, which he believed was on the cabin Passenger Announcement (PA) system but which he inadvertently transmitted on the Heathrow Tower frequency. During this period the co-pilot started the actions from his evacuation checklist. Heathrow Tower advised the commander that his call had been on the tower frequency so the commander repeated the evacuation call over the aircraft’s PA system before completing his evacuation checklist. The flight crew then left the flight deck and exited the aircraft via the escape slides at Doors 1L and 1R. The cabin crew supervised the emergency evacuation of the cabin and all occupants left the aircraft via the slides, all of which operated correctly. One passenger was seriously injured, having suffered a broken leg, as a result of detached items from the right MLG penetrating the fuselage. Heathrow Tower initiated their accident plan, with a crash message sent at 1242:22 hrs and fire crews were on scene 1 minute and 43 seconds later. The evacuation was completed shortly after the arrival of the fire vehicles. After the aircraft came to rest there was a significant fuel leak from the engines and an oxygen leak from the disrupted passenger oxygen bottles, but there was no fire. Fuel continued to leak from the engine fuel pipes until the spar valves were manually closed.
Probable cause:
Whilst on approach to London (Heathrow) from Beijing, China, at 720 feet agl, the right engine of G-YMMM ceased responding to autothrottle commands for increased power and instead the power reduced to 1.03 Engine Pressure Ratio (EPR). Seven seconds later the left engine power reduced to 1.02 EPR. This reduction led to a loss of airspeed and the aircraft touching down some 330 m short of the paved surface of Runway 27L at London Heathrow. The investigation identified that the reduction in thrust was due to restricted fuel flow to both engines. It was determined that this restriction occurred on the right engine at its FOHE. For the left engine, the investigation concluded that the restriction most likely occurred at its FOHE. However, due to limitations in available recorded data, it was not possible totally to eliminate the possibility of a restriction elsewhere in the fuel system, although the testing and data mining activity carried out for this investigation suggested that this was very unlikely. Further, the likelihood of a separate restriction mechanism occurring within seven seconds of that for the right engine was determined to be very low.
The investigation identified the following probable causal factors that led to the fuel flow restrictions:
1) Accreted ice from within the fuel system released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines.
2) Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the ‘sticky range’.
3) The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below -10°C and a fuel flow above flight idle.
4) Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time.
Final Report:

Crash of a Cessna 207 Skywagon in Aniak

Date & Time: Jan 16, 2008 at 1215 LT
Operator:
Registration:
N1701U
Flight Type:
Survivors:
Yes
Schedule:
Crooked Creek - Aniak
MSN:
207-0301
YOM:
1975
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9455
Captain / Total hours on type:
1914.00
Aircraft flight hours:
18448
Circumstances:
The commercial certificated pilot was returning from a remote village after a round robin flight of about 130 miles over a frozen and snow-covered river. He was in cruise flight about 500 feet agl, but then circled while holding between 6 or 7 miles east of his destination airport, awaiting a special VFR (SVFR) clearance. The weather condition in that area was about 1 mile visibility, with a ceiling of about 1,000 feet agl. After receiving his SVFR clearance, the pilot flew toward the airport, but the engine fuel pressure began fluctuating. The engine rpm began decreasing, along with the airplane's altitude. The pilot switched fuel tanks, selected full flaps, and prepared for a forced landing. He said the weather was near white-out conditions, but he could see the bank of the river. After switching fuel tanks from the left to the right tank, the engine power suddenly returned to full power. He applied forward flight control pressure to prevent the airplane from climbing too fast, but the airplane collided with the surface of the river. The airplane sustained structural damage to the wings and fuselage. At the time of the accident, the ceiling at the airport was 600 feet obscured, with a visibility of 1/2 mile in snow. Neither the fuel status of the accident airplane, nor the mechanical condition of the engine, were verified by either the NTSB or FAA.
Probable cause:
A partial loss of engine power for an undetermined reason. Contributing to the accident were the pilot's inadvertent encounter with IMC conditions, and a whiteout during his attempted go around from an emergency landing approach.
Final Report:

Crash of a Beechcraft C90B King Air in Port Said: 2 killed

Date & Time: Jan 15, 2008 at 1320 LT
Type of aircraft:
Registration:
SU-ZAA
Flight Type:
Survivors:
No
Schedule:
Cairo - Port Said
MSN:
LJ-1353
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew departed Cairo-Intl Airport in the morning on a training flight to Port Said. Following four successful touch-and-go manoeuvres, the crew completed a 5th circuit. On approach, the aircraft apparently caught fire (engine explosion?), lost height and crashed in an open field, bursting into flames. Both pilots were killed.

Crash of a Beechcraft 1900C in Lihue: 1 killed

Date & Time: Jan 14, 2008 at 0508 LT
Type of aircraft:
Operator:
Registration:
N410UB
Flight Type:
Survivors:
No
Schedule:
Honolulu - Lihue
MSN:
UC-070
YOM:
1989
Flight number:
AIP253
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3098
Captain / Total hours on type:
1480.00
Aircraft flight hours:
19123
Circumstances:
The pilot was flying a night, single-pilot, cargo flight over water between two islands. He had routine contact with air traffic control, and was advised by the controller to maintain 6,000 feet at 0501 hours when the airplane was 11 miles from the destination airport. Two minutes later the flight was cleared for a visual approach to follow a preceding Boeing 737 and advised to switch to the common traffic advisory frequency at the airport. The destination airport was equipped with an air traffic control tower but it was closed overnight. The accident flight's radar-derived flight path showed that the pilot altered his flight course to the west, most likely for spacing from the airplane ahead, and descended into the water as he began a turn back toward the airport. The majority of the wreckage sank in 4,800 feet of water and was not recovered, so examinations and testing could not be performed. As a result, the functionality of the altitude and attitude instruments in the cockpit could not be determined. A performance study showed, however, that the airspeed, pitch, rates of descent, and bank angles of the airplane during the approach were within expected normal ranges, and the pilot did not make any transmissions during the approach that indicated he was having any problems. In fact, another cargo flight crew that landed just prior to the accident airplane and an airport employee reported that the pilot transmitted that he was landing on the active runway, and was 7 miles from landing. Radar data showed that when the airplane was 6.5 miles from the airport, at the location of the last recorded radar return, the radar target's mode C altitude report showed an altitude of minus 100 feet mean sea level. The pilot most likely descended into the ocean because he became spatially disoriented. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the visual approach. This increased the importance of monitoring flight instruments to maintain awareness of the airplane attitude and altitude. The pilot's tasks during the approach, however, included maintaining visual separation from the airplane ahead and lining up with the destination runway. These tasks required visual attention outside the cockpit. These competing tasks probably created shifting visual frames of reference, left the pilot vulnerable to common visual and vestibular illusions, and reduced his awareness of the airplane's attitude, altitude and trajectory.
Probable cause:
The pilot's spatial disorientation and loss of situational awareness. Contributing to the accident were the dark night and the task requirements of simultaneously monitoring the cockpit instruments and the other airplane.
Final Report:

Crash of a Cessna 340 in Port Clinton: 4 killed

Date & Time: Jan 12, 2008 at 1239 LT
Type of aircraft:
Operator:
Registration:
N2637Y
Flight Type:
Survivors:
No
Schedule:
Mansfield - Port Clinton
MSN:
340-0013
YOM:
1971
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1160
Captain / Total hours on type:
13.00
Aircraft flight hours:
6820
Circumstances:
During the landing approach, a witness saw the twin-engine airplane slow and stall. The airplane crashed short of the runway, in a residential backyard. An airport manager flew with the pilot 8 days before the accident. The manager reported that during his flight the pilot flew the approach and landing with the aural stall warning horn activated. The manager advised the pilot of the aural warning, however no corrective action was taken by the pilot during that flight. An on-scene investigation revealed no preimpact mechanical anomalies. The pilot had about 12.6 hours of flight time in the accident airplane, of which 7.7 hours were dual instruction. Due to the lack of any mechanical problems with the airplane, the pilot's minimal experience in twin-engine airplanes, and his history of flying the airplane too slow, it is probable that he allowed the airspeed to decay below a safe speed, and inadvertently stalled it.
Probable cause:
The pilot's failure to maintain sufficient airspeed to avoid a stall during the landing approach.
Final Report:

Crash of a Britten-Norman BN-2A-6R Islander in Bahia Piña

Date & Time: Jan 3, 2008 at 1125 LT
Type of aircraft:
Registration:
SAN-208
Flight Type:
Survivors:
Yes
MSN:
256
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a flight to Bahia Piña Airport on behalf of the Ministry of Social Development to pickup a woman and her child. Approaching the destination, the crew encountered engine problems when the aircraft crashed near Punta Caracoles. Both pilots were injured and the aircraft was destroyed.

Crash of a NAMC YS-11A-500 in Masbate

Date & Time: Jan 2, 2008 at 0735 LT
Type of aircraft:
Operator:
Registration:
RP-C3592
Survivors:
Yes
Schedule:
Manila - Masbate
MSN:
2108
YOM:
1969
Flight number:
RIT321
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Masbate Airport, the twin engine aircraft was unable to stop within the remaining distance. It overran, veered to the right and collided with a concrete wall. All 47 occupants escaped uninjured while the aircraft was damaged beyond repair. At the time of the accident, wind was from 040 at 11 knots gusting to 14 knots.

Crash of a GAF Nomad N.22B off Sabang: 5 killed

Date & Time: Dec 30, 2007 at 1130 LT
Type of aircraft:
Operator:
Registration:
P-833
Survivors:
Yes
Schedule:
Sabang - Medan
MSN:
168
YOM:
1983
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Sabang-Maimum Saleh airport at 1110LT on a maritime survey flight to Medan. About 15 minutes into the flight, the crew informed ATC about engine problems and elected to return to Sabang. On final approach in poor weather conditions, the aircraft crashed in the sea and sank about 200 metres offshore. Two people were rescued while five others were killed.

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

Date & Time: Dec 10, 2007 at 0755 LT
Operator:
Registration:
N925TT
Survivors:
Yes
Schedule:
Salmon - Boise
MSN:
BB-746
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
14500
Captain / Total hours on type:
75.00
Aircraft flight hours:
10885
Circumstances:
The pilot removed the airplane from a hangar that was kept heated to about 60 degrees Fahrenheit, and parked it on the ramp while awaiting the arrival of the passengers. The outside temperature was below freezing, and a steady light to moderate snow was falling. The airplane sat in the aforementioned ambient conditions for at least 45 minutes before the initiation of the takeoff roll. Prior to attempting the takeoff, the pilot did not remove the accumulated snow or the snow that had melted on the warm airframe and then refroze as ice. The surviving passengers said that the takeoff ground run was longer than normal and the airplane lifted off at 100 knots indicated and momentarily touched back down, and then lifted off again. Almost immediately after it lifted off the second time, the airplane rolled into a steep right bank severe enough that the surviving passengers thought that the wing tip might contact the ground. As the pilot continued the takeoff initial climb, the airplane repeatedly rolled rapidly to a steep left and right bank angle several times and did not seem to be climbing. The airplane was also shuddering, and to the passengers it felt like it may have stalled or dropped. The pilot then lowered the nose and appeared to attain level flight. The pilot made a left turn of about 180 degrees to a downwind for the takeoff runway. During this turn the airplane reportedly again rolled to a steeper than normal bank angle, but the pilot successfully recovered. When the pilot initiated a left turn toward the end of the runway, the airplane again began to shake, shudder, and yaw, and started to rapidly lose altitude. Although the pilot appeared to push the throttles full forward soon after initiating the turn, the airplane began to sink at an excessive rate, and continued to do so until it struck a hangar approximately 1,300 feet southwest of the approach end of runway 35. No pre-impact mechanical malfunctions or failures were identified in examinations of the wreckage and engines.
Probable cause:
An in-flight loss of control due to the pilot's failure to remove ice and snow from the airplane prior to takeoff. Contributing to the accident were the pilot's improper preflight preparation/actions, falling snow, and a low ambient temperature.
Final Report:

Crash of a Cessna T303 Crusader in Bratislava: 3 killed

Date & Time: Dec 10, 2007
Type of aircraft:
Operator:
Registration:
9A-DGV
Survivors:
No
Schedule:
Zagreb – Bratislava
MSN:
303-00186
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On approach to Bratislava-Ivanka-Milan Ratislav Štefánik Airport, the twin engine aircraft crashed in an open field located few kilometres from the airport, bursting into flames. All three occupants were killed. Weather conditions were marginal at the time of the accident.