Landing (descent or approach)

Following a crop spraying flight, the crew was returning to Novobratskoye when the captain suddenly died on final approach. As the copilot was unable to regain control in time, the aircraft entered a dive and crashed, bursting into flames. The copilot was injured and the captain was killed.

After touchdown on runway 05, the aircraft went out of control, veered off runway and came to rest. There were no injuries while the aircraft was damaged beyond repair as the left engine and the undercarriage were torn off.

The aircraft was completing a day VFR flight from Durham Tees Valley Airport to Denham Airfield. As the pilot turned on to the final approach for Runway 06, the right engine ran down. The pilot attempted to increase power on the left engine but it did not appear to respond. The airspeed decayed and the right wing dropped. The aircraft descended into a wooded area short of the runway, seriously injuring all those on board. The investigation identified that fuel starvation of both engines was the cause of the accident.

The airport's instrument approach procedures included a very high frequency, omnidirectional range (VOR) approach, and a global positioning system (GPS) approach that was not an overlay. The VOR approach procedure included an inbound course to the VOR, and after passage, a descent along the same course to a missed approach point. The missed approach point was defined as 6 nautical miles beyond the VOR, as well as by timing. The pilot twice attempted the VOR approach in instrument meteorological conditions. He flew the first approach to the missed approach point, initiated a missed approach, contacted the controller, and requested a second VOR approach. He then received vectors to rejoin the approach course inbound to the VOR. The airplane subsequently passed over the VOR, on course, about 100 feet above the minimum altitude. However, instead of descending as described in the procedure, the airplane maintained that altitude until reaching the airport, then began a descent. The airplane continued to travel outbound along the same approach course until it impacted rising terrain about 6.5 miles beyond the airport. There was no dedicated distance measuring equipment (DME) onboard the airplane. Instead, distance was determined by the use of an instrument flight rules (IFR)-approved GPS unit. Due to the non-storage capability of the unit, historical waypoint selection could not be determined. The pilot could have selected the airport as a "direct to" waypoint, or, if he had entered flight plan waypoints, the unit would have sequenced from the VOR to the airport during the first approach. In either case, unless the pilot reprogrammed the unit, the last waypoint entered would have remained at the airport, rather than the VOR. The pilot then most likely mistook the airport position for the VOR position, and displaced the beginning of the descent by 6 nautical miles. Also noted, was that once the airplane passed over the VOR en route to the airport, the HSI would have indicated a change of "to" to "from". There were no medical anomalies noted with the pilot and no mechanical anomalies noted with the airplane.

While descending to Bukavu-Kamembe Airport, the crew encountered stormy weather with limited visibility due to rain falls. Too low, the twin engine aircraft impacted trees and crashed on hilly and wooded terrain located about 15 km from Bukavu Airport. The aircraft was destroyed and all 17 occupants were killed.

The crew of the missing airplane was conducting a local area familiarization flight under Title 14, CFR Part 91. At the time of the flight, visual meteorological conditions prevailed, with occasional moderate turbulence forecast for the area. The airplane was routinely contracted for animal and bird counts, and the flight was to include low level flight simulating such a mission. The three occupants of the airplane were the pilot, company check pilot, and another company pilot riding along as a passenger. Both the pilot and the check pilot held airline transport certificates, and were experienced in the make and model of the accident airplane. The airplane was equipped with a satellite position reporting device that updated position, groundspeed, and altitude every 2 minutes. Radar and GPS track information indicated the accident airplane was flying low and slow along a peninsula coast over a saltwater inlet, and turned toward the center of the inlet. The track stopped about 3 miles offshore. The data indicated that while flying along the inlet, the airplane descended to 112 feet above ground level (water), and climbed as high as 495 feet, which was the airplane's altitude at the last data point. The airplane's groundspeed varied between 97 and 111 knots. The area of the presumed crash site experiences extreme tides and strong currents, with reduced visibility due to a high glacial silt content. An extensive search was conducted, but the airplane and its occupants have not been located. An examination of the airplane's maintenance logs did not disclose any unresolved maintenance issues.

The approach and landing were stabilized and within specified limits. Recorded data indicates that the loads experienced by the landing gear at touchdown were within the certification limits for an intact landing gear without any pre-existing cracks or flaws. The weather and runway conditions did not affect the landing. The application of braking by the accident crew, and the overall effect of the carbon brake modification did not initiate or contribute to the landing gear fracture. Post-accident modifications to the MD-10 carbon brake system were implemented due to investigative findings for the purposes of braking effectiveness and reliability. Post accident emergency response by the flight crew and ARFF was timely and correct. The left main landing gear (LMLG) outer cylinder on the accident airplane had been operated about 8 ½ years since its last overhaul where stray nickel plating likely was introduced in the air filler valve hole. Nickel plating is a permissible procedure for maintaining the tolerances of the inner diameter of the outer gear cylinder, however the plating is not allowed in the air filler valve bore hole. Literature and test research revealed that a nickel plating thickness of 0.008" results in a stress factor increase of 35%. At some point in the life of the LMLG, there was a load event that compressively yielded the material in the vicinity of the air filler valve hole causing a residual tension stress. During normal operations the stress levels in the air filler valve hole were likely within the design envelope, but the addition of the residual stress and the stress intensity factor due to the nickel increased these to a level high enough to initiate and grow a fatigue crack on each side of the air filler valve hole. The stresses at the air filler valve hole were examined via development of a Finite Element Model (FEM) which was validated with data gathered from an instrumented in-service FedEx MD-10 airplane. The in-service data and FEM showed that for all of the conditions, the stress in the air filler valve hole was much higher than anticipated in the design of the outer cylinder. Fatigue analysis of the in service findings and using the nickel plating factor resulted in a significantly reduced fatigue life of the gear cylinder compared with the certification limits. During the accident landing the spring back loads on the LMLG were sufficient to produce a stress level in the air filler valve hole that exceeded the residual strength of the material with the fatigue cracks present.

The airplane was managed by and listed on the certificate of Jackson Air Charter, Inc. (JAC), a 14 Code of Federal Regulations (CFR) Part 135 on-demand operator; however, because the owner of the airplane was using it for personal use, the accident flight was flown under 14 CFR Part 91 regulations. The right-seat pilot, who was the chief pilot for JAC, was the flying pilot for the flight. The right-seat pilot had about 13,312 total flight hours, 833 hours of which were in Cessna 560 airplanes. The left-seat pilot, who was the nonflying pilot for the flight and had only worked for JAC for a little over a month, had not yet completed the company's Part 135 training but was scheduled to do so. The left-seat pilot had about 11,607 total flight hours, 557 hours of which were in Cessna 560 airplanes. The flight was planned to land at Rochester International Airport (RST), Rochester, Minnesota. The flight crew attempted to circumnavigate severe weather conditions and continue the planned descent for about 15 minutes even though a Minneapolis Air Route Traffic Control Center controller stated that the flight would have to deviate 100 miles or more to the north or 80 miles to the south to do so. The RST approach controller subsequently told the flight crew that there was "weather," including wind gusts, along the final approach course, and on-board radar and weather advisories also showed severe thunderstorms and wind gusts in the area. Given the overwhelming evidence of severe weather conditions around RST, the flight crew exhibited poor aeronautical decision-making by attempting to continue the preplanned descent to RST despite being aware of the severe weather conditions and by not diverting to a suitable airport earlier in the flight. The cockpit voice recorder (CVR) recorded the flight crew begin discussing an alternate destination airport about 3 minutes after contacting RST approach; however, the CVR did not record the left-seat pilot adequately communicate to air traffic control that the flight was going to divert. CVR evidence also showed that neither pilot took a leadership role during the decision-making process regarding the diversion. As a result, the flight crew chose an alternate airport, Ellen Church Field Airport (CJJ), Cresco, Iowa, from either looking at a map or seeing it out the cockpit window. The flight crew was not familiar with the airport, which did not have weather reporting capabilities. CVR evidence indicates that the flight crew did not use the on-board resources, such as the flight management system and navigational charts, to get critical information about CJJ, including runway direction and length. Further, the flight crew did not use on-airport resources, such as the wind indicator located on the left side of runway 33. During the approach and landing, the enhanced ground proximity warning system (EGPWS) alerted in the cockpit. However, the flight crew did not recognize or respond to the EGPWS warning, which alerted because the EGPWS did not recognize the runway since it was less than 3,500 feet long. CVR evidence indicated that the flight crew incorrectly attributed the warning to the descent rate. Further, the runway was not depicted on an on-board non-navigational publication, which only contained runways that were 3,000 feet or more long, and this was referenced and noted by the flight crew. In addition, the flight crew visually recognized during the final approach that the runway was shorter than the at least 5,000 feet they originally believed it to be (as stated by the right-seat pilot earlier in the flight). Despite all of these indications that the runway was not long enough to land safely, the flight crew continued the descent and landing. (After the accident, Cessna computed the landing distance for the accident conditions, which indicated that about 5,200 feet would have been required to stop the airplane on a wet runway with a 10-knot tailwind. Runway 33 is only 2,949 feet long. Further, the Cessna Aircraft Flight Manual does not recommend landing on precipitation covered runways with any tailwind component.) Because the flight crew did not look up the runway length and did not heed indications that the runway was too short, both of which are further evidence of the flight crew's poor aeronautical decision-making, they landed with inadequate runway length to either land the airplane on the runway or abort the landing. Subsequently, the airplane exited the runway and continued about 1,700 feet beyond its end. The airplane had sufficient fuel to have proceeded to an airport with a suitable runway length. In addition to the poor decision-making, the flight crew did not exhibit adequate crew resource management (CRM) throughout the flight. For example, the flight crew exhibited poor communication and decision-making skills, did not effectively use the available on-board resources to get information about the landing runway, and neither pilot took a leadership role during the flight. JAC did not have and was not required to have an approved CRM training program although, according to company pilots, some CRM training was incorporated into the company's simulator training. On December 2, 2003, the National Transportation Safety Board issued Safety Recommendation A-03-52, which asked the Federal Aviation Administration (FAA) to require that 14 CFR Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement an FAA-approved CRM training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. On May 2, 2006, Safety recommendation A-03-52 was reiterated and classified "Open-Unacceptable Response" pending issuance of a final rule. Although the accident flight was operated under Part 91, if JAC, as an on-demand Part 135 operator, had provided all of its pilots CRM training, the benefits of such training would extend to the company's Part 91 flights. In November 2007, the Safety Board placed Safety Recommendation A-03-52 on its Most Wanted List of Transportation Safety Improvements because of continued accidents involving accident flight crew members. As a result of this accident, the Safety Board reiterated Safety Recommendation A-03-52 on May 1, 2008. The right-seat pilot had in his possession multiple prescription and nonprescription painkillers, nonprescription allergy and anti-acid medications, and one prescription muscle relaxant. None of these medications are considered illicit drugs and would not have been reportable on drug testing required under 49 CFR Part 40. The right-seat pilot was known to have problems with back pain, although no medical records of treatment for the condition could be located. On his most recent application for airman medical certificate, the pilot had reported no history of or treatment for any medical conditions and no use of any medications. Toxicology testing revealed recent use of a prescription muscle relaxant, which might have resulted in impairment. It is also possible that the right-seat pilot was impaired or distracted by the symptoms for which he was taking the muscle relaxant; however, it could not be determined what role the muscle relaxant or the physical symptoms might have played in this accident.

The crew was completing a local training flight at Semarang-Ahmad Yani Airport. On final approach, the twin engine aircraft crashed in unknown circumstances in a pond located 500 metres short of runway 13. Both pilots were killed.

The aircraft was completing a flight to Geneina, carrying an unknown number of people and a load consisting of 30 tons of ammunitions. After touchdown at Geneina Airport, the four engine aircraft was unable to stop within the remaining distance. It overran and came to rest few dozen metres further in a field, broken in several pieces. There were no casualties.